Valvular Heart Disease Flashcards
Aortic Regurgitation Types
Type 1- dilated aortic root with impaired coaption and central jet
Type 2 - cusp prolapse with eccentric jet
Type 3 - retraction with poor cusp tissue quality with large central or eccentic jet
Severe Aortic Regurgitation Echo Criteria
- Qualitative
Valve morphology - abnormal / flail / large coaptation defect
Colour flow regurgitant jet area - large in central jets, variable in eccentric jets
CW doppler signal - dense
Other - holodiastolic flow reversal in descending aorta (EDV >20cm/s) - Semi-quantitative
Vena contra width - >6mm
Pressure half time - <200ms - Quantitative
EROAmm2 - ≥30
Regurgitant Volume ≥60
LV dilatation
Indications for Aortic Valve Replacement in Severe Aortic Regurgitation
- Symptomatic patients regardless of LV function
- Asymptomatic patients with: LVESD > 50mm, LVESD/BSA >25mm/m2 in small patients (<BSA 1.68m2), LVEF ≤50%
- Symptomatic or asytmptomaic severe AR undergoing CABG or other valve surgery
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Consider in asymptomatic LVESD≥20mm/m2 or LVEF <55% if low risk surgery
5.Consider repair in experienced centres - Consider when LVEDD >65mm
Indications for Aortic Root or Tubular Ascending Aorta Surgery
- Valve sparing root replacement surgery in young patients in experienced centres
- Marfans with ascending aorta maximum diameter ≥50mm
- Consider in all patients with maximum aortic diameter ≥55mm in all patients; ≥45mm in patients with Marfans and additional risk (>3mm per year, want pregnancy, FHx aortic dissection, prev vascular dissection, sev AR or MR or uncontrolled HTN), or patients with TGFBR1 or 2 (inc Loeys-Dietz); ≥50mm in biscuspid with additional risk or coarctation
- If surgery indicated for valve, consider root replacement if ≥45mm
- Turners - ≥25mm/m2 + RF (HTN, biscuspid valve, elongation of the transverse aorta, coarctaton) - surgery
- Coarctation repair with gradient ≥20mmHg - preference for stenting
Severe Aortic Regurgitation - Medical Therapy
- For symptoms in patients who can’t have surgery - ACEi or DHP-CCB
- Post surgery but ongoing heart failure - ACEi and BB
- Marfan’s pre or post surgery - BB (or ARBs)
- Biscuspid Valve pre or post surgery - BB (or ARBs)
Aortic Regurgitation - Serial Testing
- Asymptomatic severe AR - at least yearly
- Asymptomatic severe AR, first presentation, significant change or borderline LV - 3-6 monthly. Significant LV dilatation (LVEDD >65mm or progressive LV dysfunction -> surgery
- Mild - moderate AR - review annually, echo every 2 years
- Aorta >40mm - CT or CMR to confirm. Follow up with echo / CMR. If >3mm growth, confirm with CT/CMR
Aortic Regurgitation - Special Populations
- If severe primary or secondary MR - MVR in same operation
- If moderate AR having CABG or MVR, consider AVR with heart team, consider cause of AR (generally slow AR progression in absence of root dilatation)
- Biscuspid valve - echo screening for first degree relatives
- Aortic aneurysm with connective tissue disease - imaging and genetics of first degree relatives
Aortic Stenosis - High Flow, High Gradient
- Mean gradient - ≥40mmHg
- Peak velocity (Vmax) - ≥4m/s
- Valve area ≤1.0cm2 or ≤0.6cm2/m2)
Aortic Stenosis - Low Flow (SVi <35ml/m2), Low Gradient, Reduced LVEF
- Mean gradient <40mmHg
- Valve Area ≤1.0cm2
- LVEF <50%
- SVi <35ml/m2
- Low dose dobutamine stress echo recommended to distinguish between true severe and pseudo severe AS and identify patients with no (or low) contractile reserve
Aortic Stenosis - Low flow (SVi <35ml/m2), Low Gradient, Preserved LVEF
- Mean gradient <40mmHg
- Valve Area ≤1.0cm2
- LVEF >50%
- SVi <35ml/m2
Usually elderly, hypertensive patients with marked LVH and low LV cavity volume.
Also other low stroke volume states: severe MR, severe TR, severe MS, large VSD, severe RV dysfunction
CT calcium score useful
High Likely = men >3000, women >1600
Likely = men >2000, women >1200
Unlikely = men <1600, women <800
Aortic Stenosis - Normal Flow, Low Gradient
- Mean Gradient <40mmHg
- Valve Area <1.0cm2
- SVi >35ml/m2
- LVEF >50%
These patients usually only have moderate aortic stenosis
Aortic Stenosis - Indications for intervention - SYMPTOMATIC
- Severe, high gradient - intervene
- Severe, low flow, low gradient, LVEF <50%, contractile reserve - intervene
- Severe, low flow, low gradient, LVEF <50%, NO contractile reserve - consider intervention, esp if CT calcium score confirms severe
- Severe, low flow, low gradient, LVEF >50% - consider intervention after confirming AS is truly severe
Aortic Stenosis - Indications for intervention ASYMPTOMATIC
- Intervene if LVEF <50% if no other cause
- Intervene if symptoms on exercise testing
- Consider if LVEF <55% if no other cause
- Consider if SBP drop >20mmHg on exercise testing
- Consider if LVEF >55%, low procedural risk AND: very severe AS (mean gradient >60mmHg or Vmax >5m/s), severe valve calcification on CT and progression of >0.3m/s/year, very high BNP >3x ULN)
Aortic Stenosis - Mode of Intervention
- SAVR - <75 AND STS/Prom/EUROScoreII <4%, or operable and unsuitable for TAVI
- TAVI in ≥75 AND STS/Prom/EUROScoreII >8%
- Remaining patients SAVR or TAVI depending on patient factors
- Consider non-femoral TAVI if inoperable and TF TAVI not suitable
- Consider BAV if haemodynamically unstable as a bridge to TAVI or SAVR or for patients recuiring urgent non-cardiac surgery
- SAVR for patients with severe AS undergoing CABG
- Consider SAVR for patients with moderate AS undergoing CABG
Aortic Stenosis - Serial Testing
- Severe, asymptomatic, normal LVEF - education (prompt symptoms reporting), regular follow up (6 months or earlier)
- Moderate AS - at least annually
- Mild AS, young patients, low valve calification - 2-3 yearly
Severe Mitral Regurgitation Criteria
Primary Mitral Regurgitation - indications for intervention in severe PMR
- MV repair is prefered technique where durable results expected
- Surgery is indicated when symptomatic, operable and non-high risk, LVEF >30%
- Surgery is indicated in asymptomatic patients with LV dysfunction (LVESD ≥45mm and or LVEF ≤60%)
- Consider in asymptomatic, preserved LV and AF secondary to MR OR pulmonary HTN (SPAP at rest >50mmHg)
- Consider in asymptomatic patients with preserved LV if low-risk , durable repair likely, performed in Heart Valve Centre and at least 1 of (1) dilated LA (volume ≥60mm2/m2 or dimension ≥55mm) or (2) flail leaflet
- Consider if symptomatic, severe LV dysfunction (LVEF <30%), LVESD >55mm, refractory to medical therapy when high likelihood successful repair and comorbidity low
- Consider TEER in patients who fulfill echo criteria but inoperable but procedure not futile
Primary Mitral Regurgitation - Serial Testing
- Asymptomatic severe PMR, LVEF ≥60% - 6 month follow up with echo. Extra data with BNP, CMR, Holter, exercise echo for risk stratification
- Asymptomatic moderate PMR, LVEF ≥60% - yearly follow up, echo every 1-2 years
Primary Mitral Regurgitation - Management
Secondary Mitral Regurgitation - Management
- Intervention only indicated in severe SMR in patients who remain symptomatic despite GDTM including CRT where indicated
- Surgery for SMR recommended if need concomittant CABG - If not fit for surgery consider PCI and TEER
- Consider TEER if not fit for surgery and fit COAPT criteria (more severe MR with less dilated LV)
Rheumatic Mitral Stenosis - Management
Contraindications to PMC in rheumatic MS
* MVA ≥1.5cm2
* LA thrombus
* More than mild MR
* Severe or bicommisural calcification
* Absence of commisural fusion
* Severe concomitant valve or coronary disease requiring surgery
Unfavourable PMC characteristics - clinical:
- Old age
- Previous PMC
- NYHA IV
- pulmonary HTN
- Permanent AF
Unfavourable PMC characteristics - anatomical:
- Echo score 8
- Cromier 3
- Very small MVA
- Severe TR
Rheumatic Mitral Stenosis - Medical Therapy
- Symptoms - diuretics, BBs, Non-DHP CCBs, Ivarbradine
- Mod-severe MS with AF - Warfarin - INR 2-3
- DONT do AF ablation or DCCV before valve intervention as AF recurs
- If sinus rhythm but system embolism or spontaneous echo contrast or significant LA enlargement (LA volume ≥60ml/m2 or M mode diameter >50mm) consider warfarin
Serial testing
Asymptomatic, severe - annual
Asymptomatic, moderate - 2-3 years
Degenerative Mitral Stenosis with Mitral Annular Calcification
- Poor prognosis, LA and LV remodelling
- Can have MVR after Heart Team
- Transmitral gradient may persist post MVR due to LA and LV remodelling
- TAVI in MAC may be an option in appropriate centres
Tricuspid Regurgitation - Echo Criteria
Causes of Primary TR - Carcinoid, infective endocarditis, iatrogenic, rheumatic heart disease, Myxomatous disease, Congenital (Ebstein’s Anomaly), endomyocardial fibrosis, AF
Secondary TR - left heart disease (valve or myocardial)
