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Valvular Heart Disease Mitral Stenosis
Valvular Heart Disease Mitral Stenosis
Yerizal Karani MD
Cardiology Division
Faculty of Medicine Andalas University
© Continuing Medical Implementation …...bridging the care gap
A 75 year old woman with loud first heart sound and mid-diastolic murmur
A 75 year old woman with loud first heart sound and mid-diastolic murmur
• Chronic dyspnea Class 2/4
• Fatigue• Recent orthopnea/pnd• Nocturnal palpitation• Pedal edema
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Mitral StenosisMitral Stenosis
• Etiology
• Symptoms
• Physical Exam
• Severity
• Natural history
• Timing of Surgery
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Mitral Stenosis: EtiologyMitral Stenosis: Etiology
• Primarily a result of rheumatic fever
(~ 99% of MV’s @ surgery show rheumatic damage )
• Scarring & fusion of valve apparatus• Rarely congenital• Pure or predominant MS occurs in approximately
40% of all patients with rheumatic heart disease• Two-thirds of all patients with MS are female.
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Mitral Stenosis:Pathophysiology
Mitral Stenosis:Pathophysiology
• Normal valve area: 4-6 cm2
• Mild mitral stenosis: – MVA 1.5-2.5 cm2
– Minimal symptoms
• Mod mitral stenosis– MVA 1.0-1.5 cm2 usually does not produce symptoms
at rest
• Severe mitral stenosis– MVA < 1.0 cm2
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Right Heart Failure:
Hepatic Congestion
JVD
Tricuspid Regurgitation
RA Enlargement
Pulmonary HTN
Pulmonary Congestion
LA Enlargement
Atrial Fib
LA Thrombi
LA Pressure
RV Pressure Overload
RVH
RV Failure LV Filling
Mitral Stenosis:Pathophysiology
Mitral Stenosis:Pathophysiology
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Mitral Stenosis: SymptomsMitral Stenosis: Symptoms
• Fatigue • Palpitations• Cough• SOB• Left sided failure
– Orthopnea
– PND
• Palpitation
• Afib• Systemic embolism• Pulmonary infection• Hemoptysis• Right sided failure
– Hepatic Congestion– Edema
• Worsened by conditions that cardiac output.– Exertion,fever, anemia,
tachycardia, Afib, intercourse, pregnancy, thyrotoxicosis
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Recognizing Mitral Stenosis
Recognizing Mitral Stenosis
Palpation:• Small volume pulse
• Tapping apex-palpable S1
• +/- palpable opening snap (OS)
• RV lift
• Palpable S2
ECG:• LAE, AFIB, RVH, RAD
Auscultation:• Loud S1- as loud as S2 in aortic
area
• A2 to OS interval inversely proportional to severity
• Diastolic rumble: length proportional to severity
• In severe MS with low flow- S1, OS & rumble may be inaudible
Wave Sound
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Mitral Stenosis: Physical ExamMitral Stenosis: Physical Exam
• First heart sound (S1) is accentuated and snapping• Opening snap (OS) after aortic valve closure• Low pitch diastolic rumble at the apex• Pre-systolic accentuation (esp. if in sinus rhythm)
S1 S2 OS S1
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Common Murmurs and Timing (click on murmur to play)
Common Murmurs and Timing (click on murmur to play)
Systolic Murmurs• Aortic stenosis• Mitral insufficiency• Mitral valve prolapse• Tricuspid insufficiency
Diastolic Murmurs• Aortic insufficiency• Mitral stenosis
S1 S2 S1
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Auscultation-Timing of A2 to OS Interval
Auscultation-Timing of A2 to OS Interval
• Width of A2-OS inversely correlates with severity
• The more severe the MS the higher the LAP the earlirthe LV pressure falls below LAP and the MV opens
Say Timing seconds
Severity of MS
Other HS’s
Prrr 0.06 Severe
Pada .07-.08 Mod-severe
Pata .08-.09 Mod
Papa 0.10 Mild PK 0.1-0.110
Tu-huh
.12 A2-S3 0.12-0.18
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Mitral Stenosis: Natural HistoryMitral Stenosis: Natural History
• Progressive, lifelong disease,
• Usually slow & stable in the early years.
• Progressive acceleration in the later years
• 20-40 year latency from rheumatic fever to symptom onset.
• Additional 10 years before disabling symptoms
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Mitral Stenosis: ComplicationsMitral Stenosis: Complications
• Atrial dysrrhythmias• Systemic embolization (10-25%)
– Risk of embolization is related to, age, presence of atrial fibrillation, previous embolic events
• Congestive heart failure • Pulmonary infarcts (result of severe CHF)• Hemoptysis
– Massive: 20 to ruptured bronchial veins (pulm HTN)– Streaking/pink froth: pulmonary edema, or infection
• Endocarditis• Pulmonary infections
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Mitral Stenosis: EKGMitral Stenosis: EKG
• LAE
• RVH• Premature contractions • Atrial flutter and/or fibrillation
freq. in pts with mod-severe MS for several years
– A fib develops in 30% to 40% of pts w/symptoms
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A 75 year old woman with loud first heart sound and mid-diastolic murmer
A 75 year old woman with loud first heart sound and mid-diastolic murmer
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Mitral Stenosis: Role of Echocardiography
Mitral Stenosis: Role of Echocardiography
• Diagnosis of Mitral Stenosis• Assessment of hemodynamic severity
– mean gradient, mitral valve area, pulmonary artery pressure
• Assessment of right ventricular size and function.• Assessment of valve morphology to determinesuitability for percutaneous mitral balloon valvuloplasty• Diagnosis and assessment of concomitant valvular lesions• Reevaluation of patients with known MS with changing
symptoms or signs.• F/U of asymptomatic patients with mod-severe MS
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Mitral Stenosis:TherapyMitral Stenosis:Therapy
• Medical– Diuretics for LHF/RHF– Digitalis/Beta blockers/CCB: Rate control in A
Fib– Anticoagulation: In A Fib– Endocarditis prophylaxis
• Balloon valvuloplasty– Effective long term improvement
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Mitral Stenosis:TherapyMitral Stenosis:Therapy
• Surgical– Mitral commissurotomy– Mitral Valve Replacement
• Mechanical
• Bioprosthetic
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Recommendations for Mitral Valve Repair for Mitral Stenosis
Recommendations for Mitral Valve Repair for Mitral Stenosis
• ACC/AHA Class I– Patients with NYHA functional Class III-IV symptoms, moderate
or severe MS (mitral valve area <1.5 cm 2 ),*and valve morphology favorable for repair if percutaneous mitral balloon valvotomy is not available
– Patients with NYHA functional Class III-IV symptoms, moderate or severe MS (mitral valve area <1.5 cm 2 ),*and valve morphology favorable for repair if a left atrial thrombus is present despite anticoagulation
– Patients with NYHA functional Class III-IV symptoms, moderate or severe MS (mitral valve area <1.5 cm 2 ),* and a non-pliable or calcified valve with the decision to proceed with either repair or replacement made at the time of the operation.
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Recommendations for Mitral Valve Repair for Mitral Stenosis
Recommendations for Mitral Valve Repair for Mitral Stenosis
• ACC/AHA Class IIB– Patients in NYHA functional Class I, moderate
or severe MS (mitral valve area <1.5 cm 2 ),* and valve morphology favorable for repair who have had recurrent episodes of embolic events on adequate anticoagulation.
ACC/AHA Class III– Patients with NYHA functional Class I-IV
symptoms and mild MS.*The committee recognizes that there may be a variability in the
measurement of mitral valve area and that the mean trans-mitral gradient, pulmonary artery wedge pressure, and pulmonary artery pressure at rest or during exercise should also be considered.
Valvular Heart Disease Mitral Regurgitation
Valvular Heart Disease Mitral Regurgitation
Yerizal Karani MD
Cardiology Division
Faculty of Medicine Andalas University
© Continuing Medical Implementation ® …...bridging the care gap
Mitral RegurgitationMitral Regurgitation
• Etiology
• Symptoms
• Physical Exam
• Severity
• Natural history
• Timing of Surgery
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An 80 year old woman with increasing dyspnea
An 80 year old woman with increasing dyspnea
• Longstanding heart murmur
• Increasing dyspnea & fatigue
• Recent ER visit Dx CHF
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Mitral Regurgitation:Etiology
Mitral Regurgitation:Etiology
• Valvular-leaflets– Myxomatous MV
Disease– Rheumatic– Endocarditis– Congenital-clefts
• Chordae– Fused/inflammatory– Torn/trauma– Degenerative– IE
• Annulus– Calcification, IE (abcess)
• Papillary Muscles– CAD (Ischemia,
Infarction, Rupture)– HCM– Infiltrative disorders
• LV dilatation & functional regurgitation
• Trauma
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MR Etiology:Surgical series MR Etiology:Surgical series
• MVP(20-70%)
• Ischemia (13-40%)
• RHD (3-40%)
• Infectious endocarditis(10-12%)
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MR PathophysiologyMR Pathophysiology
• Chronic LV volume overload -» compensatory LVE initially maintaining cardiac output
• Decompensation (increased LV wall tension) -»CHF
• LVE – » annulus dilation – » increased MR
• Backflow – » LAE, Afib, Pulmonary HTN
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MR SymptomsMR Symptoms
• Similar to MS
• Dyspnea, Orthopnea, PND
• Fatigue
• Pulmonary HTN, right sided failure
• Hemoptysis
• Systemic embolization in A Fib
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Recognizing ChronicMitral Regurgitation
Recognizing ChronicMitral Regurgitation
• Pulse:– brisk, low volume
• Apex:– hyperdynamic– laterally displaced– palpable S3 +/- thrill– late parasternal lift 2 to LA
filling
• S 1 soft or normal• S 2 wide split (early A2)
unless LBBB
• Murmer-Fixed MR:– pansystolic– loudest apex to axilla– no post extra-systolic
accentuation
• Murmer-Dynamic MR(MVP)– mid systolic– +/- click upright
• S 3 / flow rumble if severe
Wave Sound
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Recognizing Acute SevereMitral Regurgitation
Recognizing Acute SevereMitral Regurgitation
• Acute severe dyspnea, CHF & hypotension
• LV size normal• LV may/may not be
hyperdynamic• Loud S1• Systolic murmur may/may
not be pan-systolic• Inflow/rumble• S3 present-may be only
abnormality
• RV lift• TTE/TEE for diagnosis
– Chordal or papilllary muscle rupture/tear
– Infarction with papillary muscle ischaemia or tear
– Infectious endocarditis with leaflet perforation or disruption or chordal tear
– Flail MV segment
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Comparing AS and MRComparing AS and MR
Systolic Murmurs• Aortic stenosis• Mitral insufficiency• Mitral valve prolapse• Tricuspid insufficiency
Diastolic Murmurs• Aortic insufficiency• Mitral stenosis
S1 S2 S1
Wave Sound
Wave Sound
Wave Sound
Wave Sound
Wave Sound
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Assessing Severity of Chronic Mitral Regurgitation
Assessing Severity of Chronic Mitral Regurgitation
Measure the Impact on the LV:
• Apical displacement and size
• Palpable S3
• Longer/louder MR murmer (chronic MR)
• S3 intensity/ length of diastolic flow rumble
• Wider split S2 (earlier A2) unless HPT narrows the split
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Recognizing Mitral Regurgitation
Recognizing Mitral Regurgitation
• ECG:– LA enlargement– Afib– LVH (50% pts.
With severe MR)– RVH (15%)– Combined
hypertrophy (5%)
• CXR: LV LA pulmonary
vascularity– CHF– Ca++ MV/MAC
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MR EchocardiographyMR Echocardiography
• Baseline evaluation to identify etiology, quantify severity of MR
• Assess and quantify LV function and dimensions• Annual or semi-annual surveillance of LV
function, estimated EF and LVESD in asymptomatic severe MR
• To establish cardiac status after change in symptoms
• Baseline study post MVR or repair
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MR EchocardiographyMR Echocardiography
• Etiology: – flail leaflets (chord/pap rupture)
– thick (RHD)
– post mvt of leaflets (MVP)
– vegetations(IE)
• Severity: – regurgitant volume/fraction/orifice area
– LV systolic function
– increased LV/LA size, EF
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MR Echo/DopplerMR Echo/Doppler
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MR Pressure TracingMR Pressure Tracing
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MR StagesMR Stages
LV size and function defined by echo• Stage 1-compensated:
– End-diastolic dimension less 63mm, ESD less 42mm– EF more than 60
• Stage 2-transitional– EDD 65-68mm, ESD 44-45mm, EF 53-57
• Stage 3-decompensated– EDD more than 70mm, ESD more than 45mm, EF less
than 50
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Echo Indicators for Valve Replacement in Asymptomatic Aortic & Mitral Regurgitation
Echo Indicators for Valve Replacement in Asymptomatic Aortic & Mitral Regurgitation
Type of Regurgitation
LVESD mm
EF %
FS
Aortic > 55 < 55 <0.27
Mitral > 45 < 60 < 0.32
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RECOMMENDED FREQUENCY OF ECHOCARDIOGRAPHYIN PATIENTS WITH CHRONIC MITRAL REGURGITATION
AND PRIMARY MITRAL-VALVE DISEASE.
RECOMMENDED FREQUENCY OF ECHOCARDIOGRAPHYIN PATIENTS WITH CHRONIC MITRAL REGURGITATION
AND PRIMARY MITRAL-VALVE DISEASE.
SEVERITY OF
MITRAL
REGURGITATION
LEFT VENTRICULAR FUNCTION*
FREQUENCY OF
ECHOCARDIOGRA-PHIC FOLLOW-UP
Mild Normal ESD and EF Every 5 yr
Moderate Normal ESD and EF Every 1 –2 yr
Moderate ESD >40 mm or EF <0.65 Annually
Severe Normal ESD and EF Annually
Severe ESD >40 mm or EF <0.65 Every 6 mo
*ESD denotes end-systolic dimension and EF ejection fraction. Otto C.M. NEJM 345:10.
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Mitral Valve SurgeryMitral Valve Surgery
• Only effective treatment is valve repair/replacement
• Optimal timing determined:– Presence/absence of symptoms– Functional state of ventricle– Feasability of valve repair– Presence of Afib/PHTN– Preference/expectations of patient
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Surgical Therapy - TimingSurgical Therapy - Timing
• Surgery reduces morbidity and mortality from severe MR but exposes patient to risk of surgery and prosthetic valve
• Surgery should be performed before onset of severe symptoms or development of LV contractile dysfunction
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SymptomsSymptoms
• Class III or IV symptoms (even if transient) always indicate need for surgery
• Class II symptoms indicate need for surgery in patients with repairable valves
• ETT may reveal concealed symptoms
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Ejection Fraction (LVEF)Ejection Fraction (LVEF)
• Strongest predictor of outcome following surgery• Should be assessed quantitatively
– MUGA or Echo
• Surgery indicated if LVEF is below normal (60%)• If EF normal, follow every 6 to 12 months• If EF <30%, medical management (valve repair
experimental in this setting)
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Load-Independent Measures of LV Function
Load-Independent Measures of LV Function
• Complex measurements:– LV dP/dT– End-systolic stress-strain– Myocardial Elastance– Peak systolic pressure/end-systolic volume
• End-systolic diameter– LVIDs >45 predicts poor outcome
• End-systolic volume index– ESVI >50cc/m2 predicts poor outcome
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Other IndicationsOther Indications
• Flail mitral leaflet
• Left atrial dimension >45mm
• Paroxysmal atrial fibrillation
• Pulmonary hypertension
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Mitral RegurgitationACC/AHA recommendations
Mitral RegurgitationACC/AHA recommendations
Surgery Recommended in patients who are• Symptomatic• Asymptomatic with
– Any LV dysfunction– Atrial fibrillation– Pulmonary hypertension– Reparable valves– Recurrent VT
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Indications for Surgery Isolated,Severe Chronic MR
Indications for Surgery Isolated,Severe Chronic MR
• Definite (major criteria):– NYHA Class III or IV heart failure (any
duration)– EF <60%– EF >60% but decreasing on serial
measurements– LVIDs >45mm– ESVI >50cc/m2
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Indications for Surgery Isolated,Severe Chronic MR
Indications for Surgery Isolated,Severe Chronic MR
• Emerging (minor criteria):– Any symptoms of heart failure
or sub optimal exercise tolerance test– Flail mitral leaflet– Left atrial diameter >45mm– Paroxysmal atrial fibrillation– Abnormal exercise end-systolic volume index
or ejection fraction
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MV Repair vs. ReplacementMV Repair vs. Replacement
• Lower operative mortality
• Better late outcome
• Curative
• Avoids anticoagulation unless atrial fibrillation
• Open Afib ablation
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MV Repair vs. Replacement (2)MV Repair vs. Replacement (2)
• Valve replacement:– Mortality 2-7%– Anti-coagulation– Decreased LVEF
• Tissue prosthetic valve degeneration
• Mechanical prosthetic valve dysfunction/ thrombosis
• Valve repair
– Mortality 2-3%
– No anticoagulation (unless Afib)
– Preservation of LVEF
• Valve repair always preferable
– Feasible in 70-90% of patients
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Mitral Valve Replacement Other Issues
Mitral Valve Replacement Other Issues
• Mechanical valve – thromboembolism, bleed from anticoagulation
• Bioprosthetic valve– limited durability (degeneration)
• Chordal/subvalvular apparatus preservation– EF preop/postop 60% to 36% VS 63% to 61%
in a comparative study
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AcknowledgmentAcknowledgment
• Some slides adapted from Cardiology Rounds presentation by Stephane Moffett – R1 Anesthesia
AORTIC STENOSIS AORTIC STENOSIS
Yerizal Karani MDCardiology Division
Faculty of Medicine Andalas University
C D
VALVULAR AORTIC STENOSISVALVULAR AORTIC STENOSIS
Congenital Acquired Rheumatic
Degenerative(age related) Atherosclerotic Calcific AS associated with Paget’s Disease,
end-stage renal failure, rheumatoid arthritis,
etc.
•
AORTIC SCLEROSISAORTIC SCLEROSIS
• Irregular thickening of the valve leaflets seen on• echo but without significant obstruction. May• result in a systolic ejection murmur.
• Approx. 25% over age 65 and over 40% over 85• Evidence suggests Ao sclerosis does progress to• degenerative aortic stenosis.•
AORTIC SCLEROSISAORTIC SCLEROSIS• Cosmi et al studied 2000 pts with aortic • sclerosis and found 16% progressed to• aortic stenosis and 10% had mild, 3% moderate, and 2% severe obstruction. The average time for progression from ao sclerosis to severe stenosis was 8 years. Arch Int Med 2002; 62:2345
Degenerative Aortic StenosisDegenerative Aortic Stenosis
• Most common type of AS today and the usual cause for aortic valve replacement
• Shares common risk factors with mitral annular calcification
• Risk factors for calcific aortic stenosis are similar to those for vascular atherosclerosis
AORTIC STENOSISAORTIC STENOSIS
• NATURAL HISTORY• May be asymptomatic for many years• Gradual onset and slow progression• LVH allows large gradient to be • tolerated for years with little or no• reduction of cardiac output, left • ventricular dilatation, or symptoms
AORTIC STENOSISAORTIC STENOSIS
• Obstruction is progressive-but insidious
• Rate of progression is variable so difficult to• predict in an individual patient
On average: AVA decreases 0.12 cm2/yr• with average increase jet velocity of • 0.32 m/sec per year and mean gradient• increase of 7 mm Hg per year•
AORTIC STENOSISAORTIC STENOSIS
• Critical obstruction is associated with:
• Peak gradient >50 mm Hg in presence• of normal output• Effective oriface area <0.8 cm2
• Normal ao valve area=2.6-3.5 cm2
AORTIC STENOSISAORTIC STENOSIS
• In general:
• Mild Aortic Stenosis=1.5-2.0 cm2
• Moderate Stenosis=1-1.5 cm2
• Severe Aortic Stenosis=<1.0 cm2
• Critical Aortic Stenosis=<0.8 cm2
AORTIC STENOSISAORTIC STENOSIS
• Thickening and stiffening of the LV in the face of increasing obstruction results in
• Increased LVEDP
• Result=LAH and diastolic dysfunction
• Left atrium becomes critical in filling the
• ventricle and At Fib or AV dissociation
• are poorly tolerated
AORTIC STENOSISAORTIC STENOSIS
• In significant ao stenosis, the cardiac• output may be fairly well maintained at• rest but fails to augment with exercise• Late in the course of severe AS : cardiac • output, stroke volume, and the gradient• itself all decline……while the• Mean LA pressure, capillary wedge • pressure and P.A. pressure increase
AORTIC STENOSISAORTIC STENOSIS
• DIAGNOSIS:• Symptoms• Physical exam• Chest X-Ray• EKG• Echo-major diagnostic tool and means• of follow-up. Allows measurement of• gradient, LV function, associated lesions
AORTIC STENOSISAORTIC STENOSIS
• Symptoms:• Can be asymptomatic• Dyspnea on exertion• Angina• Syncope or “light spells”• Palpitations not listed as major • symptom, but common in significant• heart disease
AORTIC STENOSISAORTIC STENOSIS
• Implications of symptoms• With unrelieved obstruction survival is• approx 2 years after onset of failure,• 3 years after onset of syncope, and • 5 years after onset of angina• Recent data: symptomatic pts with • severe stenosis-average survival was• 2 years with only 20% survival at 5 yrs
AORTIC STENOSISAORTIC STENOSIS
• Physical Exam• Narrow pulse pressure, slow arterial • upstroke, carotid shudder• Sustained PMI and with failure it is• displaced laterally and inferiorly• S4 common, S1 soft, S2 may be single,• systolic ejection murmur best at the• base•
AORTIC STENOSISAORTIC STENOSIS
• MANAGEMENT
• Medical: medications and careful • follow-up
• Surgical: Valve replacement is• the best approach in most cases•
AORTIC STENOSISAORTIC STENOSIS
• Medical Management• Patient education• Medications-patients with associated• hypertension or CHF can be treated• with medications if AS is mild or • moderate. Caution if Severe AS, • especially with beta blockers and• dilator type agents• Favor use of statin drugs
AORTIC STENOSISAORTIC STENOSIS
• Management-2
• Periodic echo-if mild AS: echo every
• 2 years; for moderate AS every year,
• and for severe AS echo assessment
• every 6-8 months
• Question the role of SBE prophylaxis
AORTIC STENOSISAORTIC STENOSIS
• Management-3 (surgical and related)• Non-calcified congenital AS can be• managed with open commissural• incision at low risk• Some cases of adult AS can be • managed by Balloon Valvuloplasty-• often will need operative care in 2 yrs• Most adult calcific AS if severe or• progressive-symptomatic best care is AVR
AORTIC STENOSISAORTIC STENOSIS
• Management-4• AVA <1.0 cm2 whose symptoms are• believed to result from the stenosis• Asymptomatic patients if progressive• LV dysfunction, or if hypotensive• response to exercise• Threshold for AVR will likely lower in• the future
AORTIC STENOSISAORTIC STENOSIS
• Effects of successful AVR• Substantial clinical and hemodynamic• improvement• Ten year survival approx 85%• Exertional dyspnea improved as also• frequency and severity of angina• Impaired LV performance improves• toward normal often and LV mass • decreases toward normal-not normal
AORTIC STENOSIS AORTIC STENOSIS
• SUMMARY:• Aortic stenosis of varying degree is• common in adults• Diagnosis and management are• DEPENDENT on the internist, • hospitalist, and family physician• Follow up involves history, physical,• and especially the echo-Doppler• Valve replacement=best overall Rx
Valvular Heart Disease Aortic Regurgitation
Valvular Heart Disease Aortic Regurgitation
Yerizal Karani MD
Cardiology Division
Faculty of Medicine Andalas University
© Continuing Medical Implementation …...bridging the care gap
Aortic RegurgitationAortic Regurgitation
• Etiology
• Physical Examination
• Assessing Severity
• Natural History
• Prognosis
• Timing of Surgery
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Aortic Regurgitation:Etiology
Aortic Regurgitation:Etiology
• Any conditions resulting in incompetent aortic leaflets
• Congenital– Bicuspid valve
• Aortopathy– Cystic medial necrosis– Collagen disorders (e.g.
Marfan’s)– Ehler-Danlos– Osteogenesis imperfecta– Pseudoxanthoma elasticum
• Acquired– Rheumatic heart disease– Dilated aorta (e.g.
hypertension..)– Degenerative– Connective tissue disorders
• E.g. ankylosing spondylitis, rheumatoid arthritis, Reiter’s syndrome, Giant-cell arteritis )
– Syphilis (chronic aortitis)
• Acute AI: aortic dissection, infective endocarditis, trauma
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Aortic Regurgitation:Symptoms
Aortic Regurgitation:Symptoms
• Dyspnea, orthopnea, PND• Chest pain.
– Nocturnal angina >> exertional angina
– ( diastolic aortic pressure and increased LVEDP thus coronary artery diastolic flow)
• With extreme reductions in diastolic pressures (e.g. < 40) may see angina
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Peripheral Signs of Severe Aortic Regurgitation
Peripheral Signs of Severe Aortic Regurgitation
• Quincke’s sign: capillary pulsation
• Corrigan’s sign: water hammer pulse
• Bisferiens pulse (AS/AR > AR)
• De Musset’s sign: systolic head bobbing
• Mueller’s sign: systolic pulsation of uvula
• Durosier’s sign: femoral retrograde bruits
• Traube’s sign: pistol shot femorals
• Hill’s sign:BP Lower extremity >BP Upper extremity by – > 20 mm Hg - mild AR
– > 40 mm Hg – mod AR
– > 60 mm Hg – severe AR
Wave Sound
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Aortic Regurgitation: Physical Exam
Aortic Regurgitation: Physical Exam
• Widened pulse pressure – Systolic – diastolic
= pulse pressure
• High pitched, blowing, decrescendo diastolic murmur at LSB
• Best heard at end-expiration & leaning forward
• Hands & Knee position
S1 S2 S1
Wave Sound
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Central Signs of Severe Aortic Regurgitation
Central Signs of Severe Aortic Regurgitation
• Apex:– Enlarged– Displaced– Hyper-dynamic– Palpable S3 – Austin-Flint
murmur
• Aortic diastolic murmur– length correlates with
severity (chronic AR)
– in acute AR murmur shortens as Aortic DP=LVEDP
– in acute AR - mitral pre-closure
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Assessing Severity of AR
Assessing Severity of AR
• Assess severity by impact on peripheral signs and LV peripheral signs = severity LV = severity– S3– Austin -Flint– LVH– radiological cardiomegaly
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Aortic Regurgitation: Natural History
Aortic Regurgitation: Natural History
Asymptomatic %/Y• Normal LV function (~good prognosis)
– Progression to symptoms or LV dysfunction < 6– Progression to asymptomatic LV dysfunction < 3.5– 75% 5-year survival– Sudden death < 0.2
• Abnormal LV function– Progression to cardiac symptoms 25
• Symptomatic (Poor prognosis)– Mortality > 10
Bonow RO, et al, JACC. 1998;32:1486.
TX: Medical Surgery BEFORE LV dysfunction
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Echo Indications for Valve Replacement in Asymptomatic AR & MR
Echo Indications for Valve Replacement in Asymptomatic AR & MR
Type of Regurgitation
LVESD mm
EF %
FS
Aortic > 55 < 55 <0.27
Mitral > 45 < 60 < 0.32
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Indication for Valve Replacement in Aortic Regurgitation
Indication for Valve Replacement in Aortic Regurgitation
• ACC/AHA Class I– Symptomatic patients with preserved LVF (LVEF
>50%)– Asymptomatic patients with mild to moderate LV
dysfunction (EF 25-49%)– Patients undergoing CABG, aortic or other valvular
surgery
• ACC/AHA Class II a– Asymptomatic patients with preserved LVEF but severe
LV dilatation (EDD>75 mm or ESD > 55mm)
© Continuing Medical Implementation …...bridging the care gap
Indication for Valve Replacement in Aortic Regurgitation
Indication for Valve Replacement in Aortic Regurgitation
• ACC/AHA Class II b– Patients with severe LV dysfunction (EF < 25%)– Asymptomatic patients with normal systolic func-tion
at rest (EF >0.50) and progressi ve LV dilata-tion when the degree of dilatation is moderatelysevere (EDD 70 to 75 mm, ESD 50 to 55 mm).
• ACC/AHA Class III – Asymptomatic patients with normal systolicf
unction at rest (EF >0.50) and LV dilatation when the degree of dilatation is not severe (EDD <70 mm, ESD <50 mm).