Track 7: Prosthetic Valve Flashcards
Takes native pulmonary valve and replaces it in the aortic position
Take homograft or heterograft and put this in the pulmonary position
Ross procedure
Cons of mechanical valve
- Lifelong anticoagulation with warfarin
Pros of mechanical valve
- Lasts forever
Pros of bioprosthesis
- Only requires anticoagulation for 3 months (unless with concomitant AF)
- Option for transcatheter approach
Cons of bioprosthesis valve
- Breakdown/early degeneration (especially true in younger patients
- Ie 40 yo will like see degeneration in 8-10 years
- Older patient 70s-80s, might see slower degeneration. maybe 15-20 years
Pros and cons of Ross procedure
Pros
- Valve holds up well with time
Cons
- When valve does degenerate, not only do you have an aortic valve issue you may have pulmonary problems as well
- Traded in one valve problem for 2 valve problems
Aortic valve replacement
Age < 50
Patient can tolerate OAC
Valve?
- Mechanical valve (likely has survival benefit)
- Ross procedure
Aortic valve replacement
Age > 65
Valve?
- Bioprosthetic (degeneration will be slower in older patients)
- Won’t require lifelong OAC
At what age is a bioprosthetic aortic valve preferred over mechanical
> 65
if < 50 and can tolerate OAC then mechanical preferred
Aortic valve replacement
Age 50-65
Valve?
Shared decision making process
Mitral valve replacement
Age < 65
Valve?
Mechanical
Mitral valve replacement
Age > 65
Valve?
Bioprosthetic
“closing click” during closure
Mechanical prosthesis
no click
mild stenosis
Bioprosthetic valve
S1 normal
S2 crisp closing click
Mechanical aortic valve
S1 crisp closing click
S2 normal
Mechanical mitral valve
Normal S1, S2
Slight systolic ejection murmur
Bioprosthetic aortic valve
*Each replacement valve has small degree of intrinsic obstruction
Normal S2, S2
Slight early diastolic rumble
Bioprosthetic mitral valve
Mechanical valve
Lose closing click
Bad sign
Usually indicates thrombosis or something else is inhibiting valve closure
In a mechanical valve you always want to hear what?
closing click
bad sign if not hearing this
Mechanical aortic position
Loud systolic ejection murmur ≥ 3/6, extending to second heart sound
Bad sign
Usually indicates obstruction
Mechanical mitral position
Loud diastolic murmur
*Not should not hear a murmur with mechanical mitral
Indicates significant stenosis
Bioprosthesis aortic position
Very loud systolic murmur extending to S2
OR
Bioprosthesis mitral position
Very loud diastolic rumble
Bad sign
Suggests stenosis of bioprosthesis
You suspect something is wrong with the aortic prosthesis, what is your next line test?
You suspect something is wrong with the mitral prosthesis, what is your next line test?
Mechanical prosthesis you suspect is malfunctioning, next test?
TTE
TEE
- Because of acoustic shadowing, need to get TEE to clearly evaluate mitral prosthesis
Fluoroscopy or 3D CT scan
Mechanical OR bioprosthetic aortic prosthesis
Diastolic decrescendo murmur
Bad sign
Suspect regurgitation
Mechanical bioprosthetic mitral prosthesis
Holosytolic murmur present
Bad sign
Suspect regurgitation
Bioprosthetic aortic valve
What next test to evaluate if malfunction suspected?
TTE
Bioprosthetic mitral valve
What next test to evaluate if malfunction suspected?
TEE
(d/t acoustic shadowing, TTE will be nondiagnostic)
Mechanical mitral or aortic valve
What next test to evaluate if malfunction suspected?
Fluoroscopy or 3D CT scan
Low risk anticoagulation criteria for prosthetic valve
INR goal?
Bridging?
AVR
New generation (St judes, on-x)
No prior embolic event
NSR
Normal EF
Target INR 2.5
No longer require ASA unless indicated for other cause
Stop warfarin
Let INR drift
Once sub-therapeutic, surgery
Ideally restart the night of the surgery
High risk anticoagulation criteria for prosthetic valve
INR goal
MVR
Prior embolic event
AF
Decreased EF
Target 3.0
Low risk anticoagulation patient
INR goal
Target 2.5
High risk anticoagulation patient
INR goal
Target 3.0
On-X aortic valve
Trials have shown you can go as low as what INR?
1.5-2.0
Warfarin bridging in patient with low risk anticoagulation prosthetic valve
(AVR
New generation (St judes, on-x)
No prior embolic event
NSR
Normal EF)
Stop warfarin
Let INR drift
Once sub-therapeutic, surgery
Ideally restart the night of the surgery
Warfarin bridging in patient with high risk anticoagulation prosthetic valve
(MVR
Prior embolic event
AF
Decreased EF)
Stop warfarin
Once INR < 2.0 bridge with LMWH (outpatient) or UFH (inpatient)
At least 6 hours prior to operation stop UFH
At least 12 hours prior to operation stop LMWH
(if spinal surgery stop LMWH at least 24 hours)
Restart warfarin as soon as possible post surgery
For patient with AF and native valve heart disease (except rheumatic mitral stenosis) or who received a bioprosthetic valve > 3 months prior, what is the recommended anticoagulation?
DOAC is an effective alternative to VKA
Should be administered on the basis of the pt’s CHADS2-VASc
Class I
For patients with AF and rheumatic MS, what anticoagulation is recommended
Longterm VKA
Class I
For patients with new onset AF ≤ 3 months after surgical or transcatheter bioprosthetic valve replacement, anticoagulation with?
VKA
Class 2a (Moderate)
In patients with mechanical heart valves with or without AF who require long term anticoagulation, which anticoagulation is recommended and which is not recommended
VKA recommended
DOAC not recommended
Class III (Harm)
Under what circumstances should pt with VHD and AF be treated with VKA (DOAC unsafe)
Mechanical valve
Rheumatic mitral stensosis
DOAC is a reasonable option in patients with AF and native VHD with the exception of:
Rheumatic MS (then VKA indicated)
Patients with postoperative AF in the first 3 months after surgical or trancatheter bioprosthetic valve implantation should be anticoagulated with?
VKA
May be some evidence that DOACs are safe, but data still being compiled
Outline the OAC plan
Pt with VHD (rheumatic MS) and AF
VKA
Outline the OAC plan
Pt with VHD (native valve disease, NOT rheumatic MS) and AF
DOAC or VKA based on CHADS2VASc
Outline the OAC plan
- Pt with VHD (bioprosthetic valve) > 3 months after procedure and AF
- Pt with VHD (bioprosthetic valve) < 3 months after procedure and AF
- DOAC or VKA based on CHADs2VASC
- VKA
Pt with mechanical bileaflet or current-generation single-tilting disk AVR AND NO risk factors for thromboembolism
OAC plan?
VKA w/ INR of 2.5
(Class I)
Mechanical AVR and additional risk factors for thromboembolism (ie AF, previous thromboembolism, LV dysfunction, hypercoaguable state) or an older generation prosthesis (ie ball in cage)
OAC plan?
VKA w/ INR of 3.0
(Class I)
Mechanical mitral valve
OAC plan?
VKA w/ INR of 3.0
(Class I)
Bioprosthetic TAVI (3+ months out)
No other indications for anticoagulation
Plan?
ASA 75-100 mg
(Class 2a)
Bioprosthetic SAVR or mitral valve replacement and no other indications for anticoagulation
Plan?
ASA 75-100 mg
(Class 2a)
Bioprosthetic SAVR or mitral valve replacement and low risk for bleeding
Short term OAC plan?
VKA to achieve INR of 2.5 for at least 3 months and for as long as 6 months after surgical replacement
(Class 2a)
Mechanical SAVR or mitral valve replacement who are managed with VKA and have an indication for antiplatelet therapy
Plan?
Addition of ASA 75-100 mg so long as bleeding risk is low
Class 2b
Mechanical On-X AVR and no thromboembolic risk factors
OAC plan?
VKA w/ targeted lower INR (1.5-2.0) starting ≥ 3 months after surgery with continuation of ASA 75-100 mg
Class 2b
Bioprosthetic TAVI, low risk of bleeding
Plan?
Alternative plan?
DAPT w/ ASA 75-100 mg and clopidogrel 75 mg for 3-6 months after valve implantation
Class 2b
Anticoagulation with VKA w/ INR of 2.5 may be reasonable for 3 months after implantation
Class 2b
Mechanical valve prosthesis, anticoagulation with direct thrombin inhibitor, dabigitran?
Contraindicated
Class 3, Harm
Mechanical valve prosthesis, anticoagulation with anti-Xa direct oral anticoagulant?
Class 3, Harm
Has not been assessed yet and is not currently recommended
