Valvular Heart Disease: Ambulatory Monitoring and Surgical Referral Dr. Shane Shapera Previous version: Dr. Wassim Saad for AIMGP October 2006.

Valvular Heart Disease: Ambulatory Monitoring and Surgical

Referral

Dr. Shane ShaperaPrevious version: Dr. Wassim Saad

for AIMGP October 2006

Valvular Heart Disease Focus on:

Aortic stenosis Chronic mitral regurgitation Mitral Stenosis (extra slides if time permits)

Who should have an Echo? At first contact? Follow up? How do we interpret the results?

How should we follow patients? How often should they be seen in clinic? Are there options for medical management? When should we refer to a surgeon?

References New ACC/AHA Practice

Guidelines: ACC/AHA 2006 Practice Guidelines for

the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Valvular Heart Disease) JACC. 2006;48(3):598-675.

Reminder Class I: There is evidence and/or general agreement that

a given procedure or treatment is useful and effective

Class II: There is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment

IIa: Weight of evidence/opinion is in favor of usefulness/efficacy

IIb: Usefulness/efficacy is less well established by evidence/opinion.

Class III: There is evidence and/or general agreement that the procedure/treatment is not useful and in some cases may be harmful.

A new referral 62 year old man RFR: Family MD “heard a murmer” PMH: HTN and obesity Meds: ASA and Norvasc HPI:

Told he has a murmer 2 years ago No symptoms of CVS or respiratory nature Limited physical activity, but no limitations

A new referral O/E:

HR: 88 BP: 150/85 JVP normal Harsh midsystolic ejection murmer

(3/6) over aortic area – radiates to the clavicle

Normal pulses Remainder of physical exam normal

Questions to think about: Is a 2D-Echo appropriate in this

patient?

Which patients require an echo?

Are there any symptoms that need to be considered when deciding whether to order an echo?

Recommendations for Echocardiography in Asymptomatic

Patients With Cardiac Murmurs

Indication Class

Diastolic, Continuous, Holosystolic or late Systolic murmurs

I

Grade 3 or greater midsystolic murmurs I

Murmurs with ejection click or radiation to neck or back

I

Murmurs associated with abnormal physical findings on cardiac palpation or auscultation

IIa

Murmurs associated with an abnormal ECG or chest x-ray

IIa

≤Grade 2 midsystolic murmur (Innocent)

III

Recommendations for Echocardiography in Asymptomatic

Patients With Cardiac Murmurs

Indication Class

Diastolic, Continuous, Holosystolic or late Systolic murmurs

I

Grade 3 or greater midsystolic murmurs

I

Murmurs with ejection click or radiation to neck or back

I

Murmurs associated with abnormal physical findings on cardiac palpation or auscultation

IIa

Murmurs associated with an abnormal ECG or chest x-ray

IIa

≤Grade 2 midsystolic murmur (Innocent)

III

Recommendations for Echocardiography in Symptomatic Patients With Cardiac Murmurs

Indication Class

Signs / symptoms of CHF, MI, ischemia or syncope

I

Signs / symptoms of endocarditis I

Signs / symptoms of thromboembolism I

Signs/ symptoms likely due to noncardiac disease but cardiac disease not excluded by standard cardiovascular evaluation

IIa

Back to the case… CXR: normal ECG: LVH (aVL > 11mm) ECHO:

AVA 1.4cm2 with a mean gradient 30mmHg

Mild concentric LVH Grade I LV Final interpretation: moderate AS

Aortic Stenosis: Causes Two most common causes of AS:

Calcification of the valve Older patients Very similar to an atherosclerotic process

Bicuspid aortic valve Younger patients Mechanical abnormality leading to

degeneration

Aortic Stenosis: Natural History

Prognosis mnemonic: A-S-D

Aortic Stenosis: Classification

AVA Gradient Jet Velocity

Mild AS < 1.5 cm2 < 25 mmHg < 3 m/s

Moderate AS 1.0 – 1.5 cm2

25 – 40 mmHg

3 – 4 m/s

Severe AS < 1.0 cm2 > 40 mmHg > 4 m/s

Critical AS < 0.75 cm2 variable Variable, but often > 5 m/s

Questions to think about for our patient with moderate AS

What is his expected prognosis?

How should he be followed?

When should we offer a surgical intervention?

Is there medical therapy we can offer?

Aortic Stenosis: Follow-up Expect prolonged latency period

Low M&M while asymptomatic Progression of stenosis is highly variable

Treatment based largely on symptoms Average survival 2-3 yrs once symptoms Risk of sudden cardiac death once symptoms

Aortic Stenosis: Follow-up ACC Guidelines suggest “frequent

monitoring” of asymptomatic patients looking for: Symptoms of angina, syncope and

SOB Signs of CHF (raised JVP, SOA,

crackles)

Aortic Stenosis: Follow-up

When should you repeat an ECHO? Changing signs or symptoms Patient becomes pregnant Routine follow-up

Mild AS: q 3-5 years Moderate AS: q 1-2 years Severe AS: q 1 year

Aortic Stenosis: When to operate?

Indication for Aortic Valve Repair Class

Severe AS (AVA <1.0cm2) with symptoms I

Severe AS undergoing CABG or CVS surgery I

Severe AS and impaired LV function (LVEF < 50%) I

Moderate AS undergoing CABG or CVS surgery IIa

Asymptomatic patients: - critical AS if operative mortality very low (<1%) - severe AS with exercise induced hemodynamic changes - severe AS and risk of rapid progression (age, calcified, CAD)

IIbIIbIIb

Aortic Stenosis: Medical Therapy

Baloon Valvotomy Not an alternative to valve replacement Many complications (10%) Most get restenosis in 6 – 12 months Can be used as a bridge to OR Can be used for palliation in non-

operative pts

Aortic Stenosis: Medical Therapy No medical therapy prolongs life

Theoretical benefit of statins, but trials –ve so far

Treatment of CHF can reduce symptoms Diuretics, ACEi, Digoxin have all been used

Atrial fibrillation worsens symptoms Needs aggressive rate control or cardioversion

All patients should be considered for OR Age is NOT a contraindication to surgery, but

increases risk of complications

Back to the case… 62M with asymptomatic moderate AS

Annual history and physical exam Repeat Echo q 1-2 years or if symptoms Discuss prognosis and possibility of valve

replacement in future if symptoms develop

Cover with endocarditis prophylaxis for dental and surgical procedures

Next referral 68 year old woman

RFR: Murmur heard on routine physical exam

PMH: previous smoker x 20 pk yrs

Meds: Vitamin D and Calcium

HPI: Very poor physical fitness Occasional SOB while running for the bus No chest pain or pre-syncope Mild SOA and a couple of episodes of PND

Next referral O/E:

HR: 92 BP: 138/78 JVP normal Soft S1 with holosystolic murmer at the

apex (2/6) that radiates to the axilla Mild SOA Remainder of physical exam normal

Is a 2D-Echo appropriate in this patient?

Recommendations for Echocardiography in Asymptomatic

Patients With Cardiac Murmurs

Indication Class

Diastolic, Continuous, Holosystolic or late Systolic murmurs

I

Grade 3 or greater midsystolic murmurs I

Murmurs with ejection click or radiation to neck or back

I

Murmurs associated with abnormal physical findings on cardiac palpation or auscultation

IIa

Murmurs associated with an abnormal ECG or chest x-ray

IIa

≤Grade 2 midsystolic murmur (Innocent)

III

Recommendations for Echocardiography in Symptomatic Patients With Cardiac Murmurs

Indication Class

Signs/symptoms of CHF, MI, ischemia or syncope

I

Signs / symptoms of endocarditis I

Signs / symptoms of thromboembolism I

Signs/ symptoms likely due to noncardiac disease but cardiac disease not excluded by standard cardiovascular evaluation

IIa

Back to the case… CXR normal ECG normal PFT’s normal ECHO

Grade II LV with regional variability Severe MR Slightly dilated LA (42mm) LV end systolic dimension ~42mm RVSP 65mm Hg

Mitral Regugitation: Natural History

May be asymptomatic for many years Chronic severe MR tends to increase over time

Usually leads to symptoms within 6 – 10 years

Eventually develop overload with LV dysfunction Chronic volume overload state LV dysfunction Increased LV end-systolic volume LV dilatation and higher LV pressures Pulmonary congestion Symptoms of CHF

Mitral Regurgitation: Classification

No specific numbers to memorize

Multiple components go into determining severity (chamber sizes, LVEF, RVSP, visual assessment, etc…)

Final report: Mild, Moderate or Severe

Questions to think about for our patient with moderate MR What baseline tests should we do?

How should we follow her up? When should we reassess her symptoms? When should we repeat the Echo?

How can we treat her medically?

When should we refer her for surgery?

Mitral Regurgitation: Baseline Establish clear exercise tolerance

Be sensitive to subtle changes suggesting CHF

Baseline ECG and CXR Chamber enlargement and complications (Afib)

ECHO Assess severity and look for possible anatomical

causes of MR (Ischemic vs. functional)

Exercise testing Consider exercise measurements of PAP and MR if

exercise capacity can’t be established on history

Mitral Regurgitation: Follow-up

Asymptomatic mild MR (normal LVEF, chamber sizes & RVSP) Annual history and physical No repeat Echo unless symptoms develop

(Class III)

Asymptomatic moderate MR Annual history and physical Repeat Echo annually (Class I)

Mitral Regurgitation: Follow-up

Asymptomatic severe MR History and physical q6months

Watch carefully for development of symptoms Repeat Echo q6months (Class I)

Watch for Echo evidence of asymptomatic LV dysfunction which would be an indication for OR

Mitral Regurgitation: When to operate?

General Principles (Class I evidence)* MV repair is preferred over MV replacement Acute severe symptomatic MR needs surgical repair Chronic severe MR should be referred to CVSx if:

Symptomatic (NYHA≥II) and LV function preserved (LV ≥ Gr3) Symptomatic (NYHA≥II) and LV end-systolic dimension

enlarged Asymptomatic with any of the following: LV dysfunction,

LV dilatation, pulmonary HTN or new-onset atrial fibrillation Isolated MV surgery is not indicated for patients with

mild to moderate MR (Class III)

*please see guidelines for complete list of recommendations

Mitral Regurgitation: Medical Therapy

Asymptomatic chronic MR No specific therapy recommended No evidence for vasodilators (despite the logical appeal)

Chronic MR secondary to ischemic or dilated CM Preload reduction is beneficial (Lasix)

LV dysfunction present Usual therapies for LV failure (BB, ACEi, Biventricular

Pacing)

Atrial Fibrillation Usual therapy with rate control and anticoagulation

Back to the case… 68 year old woman

Minimal physical activity, but occasionally SOB on exertion

Severe MR with Grade 2 LV, regional wall motion abnormalities and pulmonary hypertension

Back to the case… History, physical, ECG and CXR done

Don’t add much to the picture

Further workup? Possible ischemic etiology?

Exercise tolerance unclear Regional wall motion abnormalities on

Echo

Stress echo MR worse with exercise with reversible

inferior wall motion abnormality

Back to the case… Management

Pt is a surgical candidate NYHA II with preserved LV function (Class I)

Refer for CVSx opinion, TEE & Cath Treat medically while waiting for OR

Rx for symptoms, underlying CAD and LV dysfunction with ASA, BB, ACEi, Statin & Lasix

Hold ASA 5 days pre-op

Summary History and physical exam guide decision

to do an Echo during first visit Many patients have valvular lesions for

years before they develop symptoms Patients should be followed clinically and

radiologically at intervals that vary according to the specific valve pathology and severity

Symptomatic or severe asymptomatic valvular lesions requires an early surgical opinion

Extras… If time permits, continue with

slides on mitral stenosis otherwise they can serve as a reference for residents

Last referral 57 year old man

RFR: Murmur heard on routine physical exam

PMH: No cardiac risk factors

Meds: None

HPI: Asymptomatic

O/E: Loud S1, Low pitched rumbling diastolic murmur with

pre-systolic accentuation at the apex. No opening snap.

Does this patient need an Echo?

Indication Class

Diastolic, Continuous, Holosystolic or late Systolic murmurs

I

Grade 3 or greater midsystolic murmurs I

Murmurs with ejection click or radiation to neck or back

I

Murmurs associated with abnormal physical findings on cardiac palpation or auscultation

IIa

Murmurs associated with an abnormal ECG or chest x-ray

IIa

≤Grade 2 midsystolic murmur (Innocent) III

Back to the case… The echo shows an MVA of 1.3cm2.

Chamber size and function are normal RVSP and gradient across valve

normal CXR and ECG normal Pt is asymptomatic

Questions about MS? What should you do at your initial

assessment? How should you follow up this

patient? When would you refer to a surgeon? When would you repeat the Echo? How can you manage these patients

medically?

Mitral Stenosis: Natural History

Asymptomatic patient with MS 10 yr survival >80% 60% have no progression of

symptoms Significant limiting symptoms

10 yr survival rate of 0-15% If severe pulmonary HTN

Mean survival <3 yr

Mitral Stenosis: Classification

Mild Moderate Severe

Valve area > 1.5 cm2 1.0 – 1.5 cm2 < 1.0 cm2

PAP < 30 mmHg

30 – 50 mmHg

> 50 mmHg

Mean Gradient

< 5 mmHg 5 – 10 mmHg > 10 mmHg

Mitral Stenosis: Initial Exam

Hx – dyspnea, hemoptysis, hoarseness, CHF, thromboembolism, endocarditis

P/E – evidence of Afib, pulmonary HTN, CHF

CXR – heart size, pulmonary edema

ECG – rhythm, LAE, RVH due to pulmonary HTN

Mitral Stenosis: Initial Echo Baseline Echocardiogram

Doppler to assess severity Determines valve area, RVSP and gradient

Visualize leaflets and commissures Determines timing and type of interventions Assesses for other valvular lesions

Chamber size & function Consider exercise Echo if clinical picture

doesn’t fit with Echo findings

Follow Up - Asymptomatic Mild MS (MVA > 1.5cm2)

Patients remain stable for years Should be seen annually and have CXR,

ECG

Modearte-Severe MS (MVA ≤ 1.5cm2) Initially, assess valve morphology & look

for pulmonary HTN (PAP > 50mmHg) If intervention is not appropriate, then

follow as for mild MS (above)

Follow up – When to re-Echo?

Repeat any time symptoms change

Routine follow-up Mild MS – repeat Echo q 3-5 years Mod MS – repeat Echo q 1-2 years Severe MS – repeat Echo q 1 year

Who Should be Referred to a Surgeon?

Indication Class

NYHA ≥ II with moderate or severe MS (MVA≤1.5cm2)

I

Asymptomatic patient with moderate or severe MS (MVA≤1.5cm2) who have pulmonary HTN (PAP>50)

I

Asymptomatic patient with moderate or severe MS (MVA≤1.5cm2) who have new onset atrial fibrillation

IIb

Interventions: balloon valvotomy, repair, replacement

Medical Management - MS CHF

Salt restriction and intermittent diuretics See MD immediately if sudden onset SOB

May have A-fib with flash pulmonary edema

Exertional symtpoms Consider –ve chonotropic agents (BB,CCB)

Atrial fibrillation Rate control and anticoagulation May consider anticoagulation if stroke w/o

Afib

Back to the case… 57 year old man Asymptomatic with mild MS (MVA

1.3cm2) Annual history and physical Repeat Echo q3-5yrs or sooner if symptoms Call EMS immediately if acute onset SOB Endocarditis prophylaxis for dental and

surgical procedures

Questions?