Valvular heart disease Flashcards
Describe the stages of valvular heart disease
- A - at risk: patients with rish factors for VHD development ^[can detect and categorise quite early i.e. pre-symptoms]
- B - progressive: patients wtih progressive VHD (mild to moderate, asymptomatic)
- C - asymptomatic severe: C1 - asymptomatic, severe VHD, LV or RV remains compensated, OR, C2 - asymptomatic, severe VHD with decompensation of Lv or RV
- D - symptomatic severe: symptoms devleop as a resilt of VHD
Describe the timeline of Echo follow up
- mild: every 3 years
- moderate: every year
- asymptomatic severe: every 6-12 months
Describe the causes and symptoms of aortic stenosis
Cause:
- Calcific degeneration
- Bicuspid aortic valve (or three developed, but two stuck together)
- Rheumatic fever
Symptoms – can be more or less obvious:
- Exertional dyspnoea
- Chest pain or tightness
- Syncope (later on, because decreased CO) ie. feeling faint, or fainting on exertion
- palpitations
- rediced physical activity
- fatigue
- LV hypertrophy
Describe the investigations indicated in aortic stenosis
Chest X ray:
Normal heart size
Echo:
Thickened, calcified leaflets
Reduced valve opening
High velocity through valve (higher velocity, greater severity of stenosis)
Assessment:
- Clinical signs of severity: loud systolic murmur, slow-rising carotid pulse, systolic thrill, heart failure
- Echo evidence of severity: peak velocity >4 m/s, mean gradient: >40 mmHg
- In patients with reduced LV function, peak velocity and gradient may underestimate AS severity
Describe management of aortic stenosis
Mment:
- AVR recommended for:
- Symptomatic patients with severe AS
- Asymptomatic patients with very severe AS and reduced exercise tolerance
- Moderate AS in patients undergoing cardiac surgery
- Aortic valve replacement: bio-prosthetic or mechanical valve ^[mechanical generally lasts longer, requires warfarin, blood test]
- Consider Tran-cutaneous Aortic Valve Implantation (TAVI) in high surgical risk patients (trans-catheter) ^[via femoral access, care not to block aortic sinuses and coronary artery opening]
Note: prevalent disease, one in eight over 75 – auscultation is the key
Describe the prognosis of aortic stenosis
Prognosis
- 50%
- severe stenosis: prognosis worse than some cancers
Describe the prescription of TAVI vs SAVR
TAVI vs SAVR in intermediate risk patients
- 2000 intermediate risk patients
- severe, symptomatic aortic stenosis
- randomised to TAVI or SAVR and followed up for 5 years
- primary endpoint: death or disabling stroke
- result about the same
- valve gradient also about the same
TAVI vs SAVR in low risk patients
- primary endpoint: composite of death, stroke or rehospitalisation after 1 year
- TAVI performed better on primary end-point, one metric not stat sig. (death any cause)
US Aortic Stenosis Guidelines ^[based on longevity of valve]
- over 8-0 any risk: TAVI
- under 65: SAVR
- 65-80: either or - discussion with heart team, patient preference
Describe the causes and symptoms of aortic regurgitation
Cause:
- Bicuspid aortic valve
- Calcific valve disease
- Rheumatic fever
- Infective endocarditis
- Dilation of the aortic root (e.g., hypertension)
Symptoms:
- Dyspnoea on exertion
- Chest pain/tightness
- Heart failure
- LV hypertrophy
- Cardiomegaly on chest X-ray
Describe the investigation, assessment and management of aortic regurgitation
ECG:
- LV hypertrophy
CXR
- cardiomegaly
Echo:
- diastolic regurgitant jet
- possibly dilated LV, dilated aortic root in advanced disease
Assessment:
- Signs of severity:
- Wide regurgitant jet (echo)
- Holo-diastolic flow reversal in abdominal aorta (Echo)
- Dilated LV
- Reduced LV function
Management:
- Aortic valve replacement indicated for:
- Symptomatic severe AR
- Asymptomatic severe AR with LV dysfunction
- Severe AR in patients undergoing cardiac surgery
- TAVI not suitable for aortic regurgitation
Describe the cause and symptoms of mitral stenosis
Cause:
- Rheumatic fever**
- Mitral annulus calcification (Aging, renal failure)
Symptoms:
- Dyspnea on exertion
- Atrial fibrillation
- Heart failure
Describe the investigations, assessment and management of mitral stenosis
ECG
- LA enlargement
- possibly AF
CXR:
- LA enlargement
- possibly heart failure
Echo
- thickened and calcified mitral leaflets
- reduced opening
- possibly hockey stick deformity
- dilated LA
- in severe MS: valve area less than 1.5 cm2, PG 6-10 mmHg
Assessment:
- LA enlargement, possible atrial fibrillation
- Left atrial enlargement, possible heart failure
- Thickened and calcified mitral leaflets, reduced opening, possible hockey stick deformity
- Dilated LA
- Severe MS: valve area <1.5cm2, PG 6-10 mmHg
Management:
- Percutaneous mitral balloon commissurotomy for favorable valve morphology in the absence of left atrial thrombus or >moderate MR
- Surgical mitral commissurotomy or replacement
- Anticoagulation for atrial fibrillation
Describe the causes and symptoms of mitral regurgitation*
Aetiology:
- Degenerative (primary); e.g., mitral valve prolapse caused by abnormalities of leaflets, chords, pap muscle, annulus
- Functional (secondary) MR, caused by LV dilatation (MI, cardiomyopathy) ^[linked to binge drinking]. Dilated left ventricle causes papillary muscle displacement, which in turn results in leaflet tethering with associated annular dilation that prevents coaptation
Symptoms:
- Dyspnea on exertion
- Congestive heart failure
- Atrial fibrillation
Describe management of mitral regurgitation
Management:
- Mitral valve repair ^[tighten loose leaflet, repair it] is preferable to replacement if possible
- Primary MR:
- Surgery is indicated for symptomatic patients with severe MR
- Secondary MR ^[not useful if ventricle is issue]:
- Mitral valve surgery is reasonable for patients with chronic severe secondary MR who are undergoing CABG or AVR
- Repair or replacement may be considered for severely symptomatic patients with chronic severe secondary MR who have persistent symptoms despite optimal medical therapy for heart failure
Note Mitraclip - reduces degree of regurgitation, creates small degree of stenosis but not a problem, for people who are not surgical candidates
Describe the causes and clinical features of tricuspid regurgitation
- Mild degrees of TR commonly detected, of no physiological consequence
- Approximately 80% of cases of significant TR are functional in nature and related to tricuspid annular dilation and leaflet tethering in the setting of RV enlargement
- Primary disorders of the tricuspid apparatus that can lead to more significant degrees of TR include rheumatic disease, prolapse, congenital disease (Ebstein’s), infective endocarditis ^[cancer patient], radiation, carcinoid
Clinical Features:
- Edema
- Elevated JVP
- Pleural effusion
- Abdominal discomfort
^aka symptoms of right heart failure
Describe the management of tricuspid regurgitation
Management:
- Treat right heart failure:
- Salt and fluid restriction
- Diuretics
- Tricuspid valve surgery is recommended for patients with severe TR undergoing left-sided valve surgery ^[prevents coaptation of leaflets]
- Tricuspid valve surgery can be beneficial for patients with symptoms due to severe primary TR that are unresponsive to medical therapy
(clip not much clinical utility: no change in outcomes, some improvement in symptoms)
