Valvular Heart Disease

Transcription

1 Case #1 Valvular Heart Disease Internal Medicine Board Review Niels Engberding, MD, FACC, FESC Assistant Professor of Medicine Division of Cardiology Emory University of School of Medicine 78 y/o female is admitted to hospital with pulmonary edema She has had 3 months of progressive dyspnea On exam she has a late-peaking systolic murmur with a single heart sound An echocardiogram reveals a heavily calcified/stenotic aortic valve (area of 0.8 cm 2 ) Which of the following is appropriate? Major types of aortic valve stenosis 1) ACE inhibitor therapy for heart failure 2) Coronary angiography followed by aortic valve replacement 3) Exercise thallium to evaluate for ischemia 4) Balloon valvuloplasty Braunwald s Heart Disease, 10 th ed. 2015; Elsevier Baumgartner et al. JASE 2009; 22(1):1 Aortic Stenosis Congenital Bicuspid Aortic Valve Associated with dilation of the aorta Can present with aortic regurgitation Typically presents in 40 s-50 s Acquired Rheumatic usually with coexisting mitral disease Senile age-related calcific degeneration Typically presents > 65 years Senile Aortic Stenosis Most common cause of Aortic Valve replacement in the U.S. Incidence is 2% among people over the age of 65 true AS not Aortic sclerosis. Pathophysiology may be related to atherosclerosis. 1

2 Pathophysiology AS - History Asymptomatic Small increased risk of sudden cardiac death Symptoms Angina Syncope Heart Failure Lilliy s Pathophysiology of Heart Disease, 4 th ed. 2007; Lippincott W &W Physical Examination Narrow Pulse Pressure Delayed Carotid Pulses Pulses (Parvus et Tardus) S4 Late-peaking crescendo-decrescendo murmur Single second heart sound Outcomes of aortic stenosis Ross et al. Circulation 1968; 38:61 Management for Severe AS Asymptomatic Consider exercise restriction Avoid vasodilators Caution with non-cardiac surgery Symptomatic - Surgery Main indications for aortic valve replacement Severe AS symptomatic asymptomatic LVEF < 50% Other cardiac surgery Nishimura et al. JACC 2014; 63(22):2438 2

3 Signs of Severe AS EKG LVH Echo Calcified Leaflets with reduced valve opening LVH Mean gradient of greater than 40mmHg Calculated valve area of less than 1.0 cm 2 Cath Confirm gradient Assess coronaries in patients at risk for CAD Which of the following is appropriate? 1) ACE inhibitor therapy for heart failure 2) Coronary angiography followed by aortic valve replacement 3) Exercise thallium to evaluate for ischemia 4) Balloon valvuloplasty CASE #2 A 42 y/o man with a history of a bicuspid aortic valve and a history of treated endocarditis. Echocardiography reveals severe aortic regurgitation He is asymptomatic. Which of the following is not appropriate 1) Nifedipine if left ventricular function is normal 2) Aortic valve replacement if the left ventricular end-diastolic diameter is >75 mm 3) All patients with severe chronic aortic regurgitation regardless of symptoms should undergo aortic valve replacement Chronic Aortic Regurgitation - Etiology Rheumatic Dilated Aortic Root Bicuspid Aortic Valve HTN Previous Endocarditis Chronic Aortic Regurgitation - other etiologies Ankylosing spondylitis Reiter s syndrome Syphilis Ehlers Danlos Osteogenesis imperfecta Pseudoxanthoma elasticum Marfan s 3

4 AR - Pathophysiology AR Hemodynamics Normal Severe acute AR Chronic compensated AR Chronic decompensated AR After AVR Braunwald s Heart Disease, 10 th ed. 2015; Elsevier Braunwald s Heart Disease, 10 th ed. 2015; Elsevier Chronic AR Physical Exam Timing of Surgery the importance of symptoms Widened Pulse Pressure Bounding pulses Austin-Flint murmur - a soft mid-diastolic murmur heard at the apex Displaced apical pulse Braunwald s Heart Disease, 10 th ed. 2015; Elsevier from: Dujardin et al. Circulation 1999;99:1851 Chronic AR - Indications for surgery Severe AR Chronic AR- Medical Therapy Asymptomatic patient Vasodilator therapy. ACE-I or Nifedipine Nifedipine is the only vasodilator proven in a clinical trial to slow progression of AR. A recent long-term trial did not show benefit in preventing surgery. Nishimura et al. JACC 2014; 63(22):2438 4

5 Acute AR Usually a medical and surgical emergency Etiologies Aortic dissection Endocarditis Trauma Which of the following is not appropriate 1) Nifedipine if left ventricular function is normal 2) Aortic valve replacement if the left ventricular end-diastolic diameter is >75 mm 3) All patients with severe chronic aortic regurgitation regardless of symptoms should undergo aortic valve replacement CASE #3 A 48 y/o recent immigrant from the Philippines presents with dyspnea and hemoptysis. No significant past medical history. On examination, there is a loud S1 and a low pitched sound in diastole Which is true about the opening snap of mitral stenosis 1) A short aortic closure sound (A 2 ) to opening snap interval indicates severe stenosis 2) It cannot be appreciated if you own an iphone 3) It is best appreciated in early systole Physical Exam of MS History Dyspnea, PND, Fatigue, Hemoptysis. Exam Loud S1, Opening snap, Diastolic rumble, Loud P2. Severe MS Short A2-opening snap interval. Pathophysiology Lilliy s Pathophysiology of Heart Disease, 4 th ed. 2007; Lippincott W &W 5

6 Diastolic LA LV pressure gradient Mitral Stenosis - EKG Atrial fibrillation is common Left atrial abnormality Rightward Axis/ RVH Braunwald s Heart Disease, 10 th ed. 2015; Elsevier Management of Mitral Stenosis Atrial fibrillation anticoagulation, Rate Control with digoxin, B-blockers, diltiazem, verapamil Surgical intervention if symptoms with heavy exertion (NYHA Class II) and moderate to severe stenosis Balloon valvuloplasty is alternative for pliable, noncalcified valve with minimal MR and no atrial clot Which is true about the opening snap of mitral stenosis 1) A short aortic closure sound (A 2 ) to opening snap interval indicates severe stenosis 2) It cannot be appreciated if you own an iphone 3) It is best appreciated in early systole In chronic mitral regurgitation which is not true? 1) ACE inhibitor therapy can decrease the degree of valve regurgitation acutely 2) Severe mitral regurgitation requires surgery if the LVESD is greater than 45mm 3) The operative approach for MR should always be valve replacement 4) Patients with mitral valve prolapse without regurgitation do not need SBE prophylaxis Pathophysiology Acute MR Chronic MR Lilliy s Pathophysiology of Heart Disease, 4 th ed. 2007; Lippincott W &W 6

7 Chronic MR - Etiologies Chronic MR History fatigue and dyspnea Exam hyperdynamic PMI, systolic murmur (late, holo, or early). Diastolic rumble can be heard in severe MR. EKG left atrial enlargement, LVH Lilliy s Pathophysiology of Heart Disease, 4 th ed. 2007; Lippincott W &W MITRAL REGURGITATION - THERAPY Severe surgery prior to decline in LVEF repair or replacement if LVESD > 40 mm or LVEF < 60% Repair is preferred over MVR when possible Acute afterload reduction may decrease severity of MR MITRAL VALVE PROLAPSE Generally benign women (20-50 y.o.) mild regurgitation Often progressive men (40 70 y.o.) myxomatous mitral disease, chordal rupture Midsystolic click in MVP Standing Valsalva Amyl nitrate Squatting Handgrip In chronic mitral regurgitation which is not true? 1) ACE inhibitor therapy can decrease the degree of valve regurgitation acutely 2) Severe mitral regurgitation requires surgery if the LVESD is greater than 45mm 3) The operative approach for MR should always be valve replacement 4) Patients with mitral valve prolapse without regurgitation do not need SBE prophylaxis Braunwald. Essential Atlas of Heart Diseases, 1997; Current Medicine 7

8 New Guidelines for Endocarditis Prophylaxis Procedures Dental Procedures Procedures of respiratory tract that involve biopsy or incision of mucosa Not for GU or GI procedures unless active infection Patients Prosthetic heart valves Prior endocarditis Heart Transplant patients Congenital Heart Disease Hard Question #1 During a patient exam, you hear a mid-diastolic rumble at the apex and a diastolic decrescendoblowing murmur at the LLSB. He has mild dyspnea on effort. The murmurs have been present for years. Which of the following features on examination suggests the apical diastolic murmur is Austin Flint and not Mitral Stenosis? Answers A) Increased S1 B) Atrial Fibrillation C) Presystolic accentuation of rumble D) BP 160/50 E) Opening Snap Answers A) Increased S1 B) Atrial Fibrillation C) Presystolic accentuation of rumble D) BP 160/50 E) Opening Snap Hard Question #2 Which of the following is the most reliable finding on physical examination to indicate that a severe degree of Aortic Regurgitation is present? A) Wide arterial pulse pressure B) Lateral displacement of PMI C) Grade 2 mid-to-late diastolic apical murmur D) Absent A2 E) Loud AR murmur Hard Question #2 Which of the following is the most reliable finding on physical examination to indicate that a severe degree of Aortic Regurgitation is present? A) Wide arterial pulse pressure B) Lateral displacement of PMI C) Grade 2 mid-to-late diastolic apical murmur D) Absent A2 E) Loud AR murmur 8

9 Hard Question #3 A 52 y/o male comes to clinic with moderate dyspnea on exertion. On examination he has n S3 and II/VI systolic ejection murmur. An echo shows and LVEF of 15% and aortic stenosis. The mean aortic valve gradient is 10mmHg and the calculated aortic valve area is 0.7 Answers A) Refer for emergent aortic valve replacement B) Refer for coronary angiography and valvuloplasty C) Order a dobutamine stress echocardiogram D) Order a transesophageal echocardiogram to review Answers A) Refer for emergent aortic valve replacement B) Refer for coronary angiography and valvuloplasty C) Order a dobutamine stress echocardiogram D) Order a transesophageal echocardiogram to review 9