Valvular heart disease Flashcards
Valvular heart diseases in adult patients?
- Mitral Stenosis
- Mitral Insufficiency
- Aortic Stenosis
- Aortic Insufficiency
- Tricuspid Insufficiency
- PCP & Cardiologist need to be alert to the presence of a systolic murmur in older patients with exertional dyspnea, chest pain, or dizziness
- Activity in itself may not be a good determining factor as many patients unintentionally limit activities to avoid symptoms
Diagnosis of Valvular heart disease?
- Patient History
- Physical Exam
- Echocardiogram – Surface / Trans-Thoracic Echocardiogram – T.E.E. – Trans-Esophageal Echocardiogram
- Cardiac Catheterization
- MRA / CTA
New York Heart association classifications of Valvular heart defects?
- Class I – No Symptoms, no limitation of activity
- Class II – Symptoms with Ordinary activity
- Class III – Symptoms with less than Ordinary activity
- Class IV – Symptoms at Rest, any activity causes symptoms
Treatment of Valvular heart defects?
- Observation – There are 15 to 20 million people with valve disease
- Medication
- Percutaneous Balloon Valvuloplasty – rarely utilized
- Percutaneous Valve Replacement & Repair
- Surgery – 106,000 valve procedures in U.S. (2016) – Valve Repair – Valve Replacement – Minimally Invasive
Mitral stenosis is what? Spares?
- Insidious Disease
- Gradual Progression
- Morbidity / Mortality – Pulmonary Edema – Pulmonary Hypertension – Right Sided Heart Failure – Systemic Embolization – Infective Endocarditis
- Spares the Left Ventricle
What are the etiologies of Mitral stenosis?
- Rheumatic Fever – Most Always – Often Asymptomatic for 10-20 Years – May Only Have Subtle Symptoms – Fusion of Valve Leaflets at Commissures
- Left Atrial Myxoma – Rare
- Congenital – Rare
Indications for surgery with mitral stenosis?
- N.Y.H.A. Class III or IV
- Valve Area 1.0 cm2 to 1.5 cm2 (or Less) –Normal Valve Area – 4 - 6 cm2
- Systemic Embolization
- Endocarditis with Failure of Medical Therapy
What are the surgeries for mitral stenosis?
• Repair
- Commissurotomy
– Open Versus Closed - Closed is Rare in the U.S.
– If No Calcification
– If No Insufficiency
– Best If : • Young • Female • No Hypertension
• Replacement - Most Common
Mitral insufficiency etiologies?
- Myxomatous Degeneration
- Ischemic cardiomyopathy
- Rheumatic Fever
- Myocardial Infarction
- Ruptured Cordae
- Papillary Muscle Dysfunction
- Mitral Valve Prolapse
- Bacterial Endocarditis
- Left Atrial Myxomarare
- Congenital - rare
Indications for surgery for Mitral stenosis?
- Significantly Limiting Symptoms – N.Y.H.A. Class III or IV – N.Y.H.A. Class II With Dilated Left Ventricle
- Increasing Ventricular Volumes
- Increasing Regurgitant Fraction
- Any Acute, Severe, Mitral Regurgitation
- Mild Regurgitation is Well Tolerated, “Can baby these along”
What are the surgeries for Mitral stenosis?
- Valve Repair and/or Annuloplasty –Most common
- Replacement –Less common
Minimally invasive:• Limited incision • Robotic assisted • Percutaneous
what is Aortic stenosis?
- A progressive disease
- End stage is characterized by obstruction of left ventricular outflow
- Disease results in: – Inadequate cardiac output – Decreased exercise capacity – Death
Etiology of Aortic Stenosis?
- Senile Degenerative Calcified Aortic Stenosis – Most Common in Patients > 65 Years – Collagen Disruption and Calcification • Rheumatic Fever – Fibrosis of Leaflets and Fusion of Commissures
- Congenital - Bicuspid Valve
- Endocarditis - rare
Symptoms of Aortic stenosis?
- Sudden Death may be the First “Symptom”
- Easy Fatigability
- Angina – Most Common Clinical Presentation
- Syncope – From Fixed Cardiac Output
- Dyspnea on Exertion – C.H.F.
Indications for surgery for Aortic stenosis?
- Any Symptoms: – Angina – Syncope – C.H.F.
- Peak Systolic Gradient 50 mm Hg or greater
- Valve Orifice Area of 1.0 cm2 or less – Valve Index 0.5 cm2/m2 or less
If Asymptomatic:
• Progressive Cardiac Enlargement
• Elevation of L.V.E.D.P. at Rest or with Exercise
• Need for other cardiac surgery and the presence of Aortic stenosis
What is the surgery for Aortic stenosis?
- 65,000 AVR in the U.S. in 2010 –Primarily for AS –70% on patients > 65 years
- Overall 30-day mortality < 3% for isolated AVR –4.5% for AVR with CABG
- Decalcification of Leaflets - rare
- Commissurotomy - rare
- Replacement – usual –Sternotomy –Minimally Invasive –Concomitant procedure
- Valve • CABG
- Percutaneous Valvuloplasty –Limited hemodynamic benefit –Recurrence in 6 months –Bridge to TAVR
- Percutaneous Replacement – TAVR • Trans-catheter Aortic Valve Replacement
