Valvular heart disease Flashcards
(40 cards)
1
Q
Valvular heart diseases in adult patients?
A
- 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
2
Q
Diagnosis of Valvular heart disease?
A
- Patient History
- Physical Exam
- Echocardiogram – Surface / Trans-Thoracic Echocardiogram – T.E.E. – Trans-Esophageal Echocardiogram
- Cardiac Catheterization
- MRA / CTA
3
Q
New York Heart association classifications of Valvular heart defects?
A
- 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
4
Q
Treatment of Valvular heart defects?
A
- 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
5
Q
Mitral stenosis is what? Spares?
A
- Insidious Disease
- Gradual Progression
- Morbidity / Mortality – Pulmonary Edema – Pulmonary Hypertension – Right Sided Heart Failure – Systemic Embolization – Infective Endocarditis
- Spares the Left Ventricle
6
Q
What are the etiologies of Mitral stenosis?
A
- 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
7
Q
Indications for surgery with mitral stenosis?
A
- 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
8
Q
What are the surgeries for mitral stenosis?
A
• 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
9
Q
Mitral insufficiency etiologies?
A
- Myxomatous Degeneration
- Ischemic cardiomyopathy
- Rheumatic Fever
- Myocardial Infarction
- Ruptured Cordae
- Papillary Muscle Dysfunction
- Mitral Valve Prolapse
- Bacterial Endocarditis
- Left Atrial Myxomarare
- Congenital - rare
10
Q
Indications for surgery for Mitral stenosis?
A
- 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”
11
Q
What are the surgeries for Mitral stenosis?
A
- Valve Repair and/or Annuloplasty –Most common
- Replacement –Less common
Minimally invasive:• Limited incision • Robotic assisted • Percutaneous
12
Q
what is Aortic stenosis?
A
- A progressive disease
- End stage is characterized by obstruction of left ventricular outflow
- Disease results in: – Inadequate cardiac output – Decreased exercise capacity – Death
13
Q
Etiology of Aortic Stenosis?
A
- 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
14
Q
Symptoms of Aortic stenosis?
A
- 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.
15
Q
Indications for surgery for Aortic stenosis?
A
- 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
16
Q
What is the surgery for Aortic stenosis?
A
- 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
17
Q
Prognosis of Aortic stenosis?
A
Untreated:
• If Angina - 5 years
• If Syncope - 3 years
• If C.H.F. - 2 years
18
Q
Etiology of Aortic insufficiency?
A
- Rheumatic Fever – 30% - 50%
- Endocarditis – 25%
- Ascending Aortic Aneurysm
- Annulo-aortic Ectasia
- Congenital - Bicuspid Valve
- Trauma –Blunt Chest Trauma - Cusp Rupture –Penetrating
- Aortitis –Rheumatoid Arthritis –Ankylosing Spondylitis –Reiter’s Syndrome
19
Q
Indication for surgery for Aortic insufficiency?
A
- N.Y.H.A. Class III or IV
- N.Y.H.A. Class II with Ventricular Enlargement
- Increasing Ventricular Volumes of Decreasing Ejection Fraction
- Any Significant Acute Regurgitation
20
Q
What do we do in the surgery for Aortic insufficiency?
A
- Repair
* Replacement - usual
21
Q
What is the general information about valve surgery? indications?
A
• When to Operate ? –Better Sooner than Later • Replace or Repair ? –Trend is Towards Repair –Mitral Valves are typically Repaired –Aortic Valves are typically Replaced
Indications: • Relief of symptoms • Prevention of complications of the disease • Prevention of death
22
Q
Ideal prosthestic valve characteristic?
A
- Good hemodynamics • No thromboembolic problems • Durable • Resistant to infection • No hemolysis • Inert, Nontoxic
- Easy to insert • No impingement on other structures • Inexpensive • Reliable / manufacturer • Good quality control • Quiet
23
Q
Types of prosthesis?
A
- Two types of valve prosthesis
- Similar susceptibility to infection
- Mechanical – “Metal Valves”
- Biological – Tissue – “Pig Valves” – porcine – Bovine pericardium
24
Q
Advantages and disadvantages to the mechanical prosthesis?
A
- Very durable – may last a lifetime
- Better hemodynamics at smaller sizes
Disadvantages:
• Thrombogenic
• Requires full anticoagulation – Life long – Warfarin - Coumadin – Associated risks
• Risk of tissue, cordae or suture becoming caught in mechanism
25
Explain the ball and cage valve?
Ball and Cage:
• First type of mechanical valve prosthesis
• ‘Starr-Edwards’ - > 40 years
• Advantages: – Proven with time – Very Durable
• Disadvantages: – Poor hemodynamics – Requires full anticoagulation – Many Thromboembolic events reported
26
Explain the titling disc valve? aka?
* ‘Bjork-Shiley’
* ‘Medtronic-Hall’
* Advantage: – Fairly good hemodynamic – Durable
* Disadvantages: – Requires full anticoagulation – Strut fractures & Disc Embolization reported
27
Explain Bi-leaflet valves?
* St. Jude
* Advantages: – Durable – Pyrolite Carbon – Minimal Regurgitation – Less blood stagnation – Less thrombogenic – Superior Hemodynamic
• Disadvantages: – Requires full anticoagulation
28
Biological tissue valves advantages? Disadvantages?
* Tissue Valves • Most common type of valve used
* Advantages: –Generally does not require anticoagulation –But patient may require anticoagulation for other reasons
* Disadvantages:
* Poor hemodynamics at smaller sizes
* Less durable (but they have gotten better!) – Degeneration – Develop holes – Calcification
* May require re-replacement
* 8-15 years 20 years
29
Explain biological valves used?
‘Carpentier-Edwards’
• Excised porcine (“Pig”) Aortic valve –Tanned in Glutaraldehyde
• Pericardial valve –Bovine pericardium
30
What are homografts? used for? advantages? disadvantages?
* Cadaver
* Often used for endocarditis
* Advantages: –Durable
* Disadvantages: –Availability –High Cost
31
Stentless valves?
* Excised porcine Aortic Root
* Better hemodynamics
* Probably improved durability
* Can be used to replace the aortic root
32
Considerations with valve surgeries?
* Now There is an Iatrogenic Disease
* Prosthetic Valves are Susceptible to: –Thrombosis –Embolism –Valve Deterioration
• Complications of Anticoagulation
33
Hemodynamics of prosthetic valves?
* All prosthetic valves are inherently stenotic to some degree
* There is less area available for the flow of blood then the normal native valve –Reduced by the sewing ring and the support structures –Not usually a factor in larger sizes
34
Complications of valve surgery?
* Arrhythmias
* Endocarditis –Mortality 25% - 50%
* Prosthesis Malfunction
* Thrombosis / Thromboembolism
35
Mechanical valve complications?
* Perivalvular Leak
| * Mechanical Valve –Mechanical Failure –Thrombosis –Infection
36
Complications of a biological valve?
* Perivalvular Leak
| * Biologic Valve –Calcification –Tear –Thrombosis –Infection
37
Emobolic complications with valvular surgeries?
* All valves are predisposed
* Most commonly a late complication
* May be devastating – Major vessel obstruction – CVA – MI – Death
* True incidence is not known
* Mechanical valves > Biologic valves
38
Thrombotic complications?
* All valve prosthesis’ have been associated with thrombotic phenomena
* Mechanical valves > Biologic valves
* Can result in: –Hemodynamic compromise –D.I.C. –Sudden death
39
Who should be given a biologic valve?
* Must Be individualized
* Patients with contraindications to anticoagulation – GI bleed – Alcoholic – Malignant states – Females desiring pregnancy – Poor compliance
* Patients with a strong aversion to taking warfarin
* Older patients
40
Who should be given a mechanical valve?
* “Younger patients”
* Patients with a small annulus – Aortic < 19mm – Mitral < 23mm
* A strong aversion to re-operation – On the part of the patient or the surgeon
* Patient without a contraindication to anticoagulation
