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Valvular Heart Disease Aortic Stenosis
© Continuing Medical Implementation …...bridging the care gap
Kardiologická klinika
Lekárskej fakulty
Univerzity Komenského a NÚSCH v Bratislave
Figure 1
Mayo Clinic Proceedings 2018 93, 488-508DOI: (10.1016/j.mayocp.2018.01.020)
Epidemiológia chlopňových chýb
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Aortic Stenosis
• Etiology
• Physical Examination
• Diagnosis
• Assessing Severity
• Natural History
• Prognosis
• Timing of Surgery
© Continuing Medical Implementation …...bridging the care gap
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Aortic Stenosis - Etiology
• Young patient think congenital – Bicuspid
• 2% population
• 3:1 male:female distribution
• Co-existing coarctation 6% of patients
• Rarely – Unicuspid valve
– Sub-aortic stenosis • Discrete
• Diffuse (Tunnel)
• Middle aged patient(4&5th decades) think bicuspid or rheumatic disease
• Old patient think degenerative (6,7,8th decades)
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Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Imaging and biomarker assessments of stage of valvular stenosis and myocardial response to increased afterload.
Russell James Everett et al. Heart 2018;104:2067-2076
Copyright © BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved. Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Aortic Stenosis: Etiology
• Congenital bicuspid valve is the most common abnormality
• Rheumatic heart disease and degeneration with calcification are found as well
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Normal Bicuspid Ao V “Normal” geriatric
calcific valve Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Bicuspid Aortic Valve
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Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Common Clinical Scenarios (systolic murmur)
• Younger people
– Functional murmur vs MVP vs bicuspid AV
• Older people
– Aortic sclerosis vs aortic stenosis
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Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
© Continuing Medical Implementation …...bridging the care gap
Etiology of Aortic Stenosis
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
What symptoms or conditions should prompt clinicians to consider aortic
stenosis?
3 cardinal symptoms Angina
Dyspnea
Presyncope or syncope
Once these occur, risk of death increases From <1% per year to 2% per month
75% of symptomatic patients die within 3 years unless they receive a valve replacement
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Aortic Stenosis: Symptoms
• Cardinal Symptoms – Chest pain (angina)
• Reduced coronary flow reserve
• Increased demand-high afterload
– Syncope/Dizziness (exertional pre-syncope) • Fixed cardiac output
• Vasodepressor response
– Dyspnea on exertion & rest
– Impaired exercise tolerance
• Other signs of LV failure – Diastolic & systolic dysfunction
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Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Aortic Stenosis: Physical Findings
• Intensity DOES NOT predict severity
• Presence of thrill DOES NOT predict severity
• “Diamond” shaped, harsh, systolic crescendo-decrescendo
• Decreased, delay & prolongation of pulse amplitude
• S4 (with left ventricular hypertrophy and SR)
• S3 (with left ventricular failure)
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Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Innocent Murmurs
• Common in asymptomatic adults
• Characterized by
– Grade I – II at left sternal border
– Systolic ejection pattern
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– Normal intensity & splitting of second sound (S2)
– No other abnormal sounds or murmurs
– No evidence of LVH, and no with Valsalva
S1 S2
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Aortic Stenosis: Physical Findings
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S1 S2 S1 S2
Mild-Moderate Severe
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Common Murmurs and Timing
Systolic Murmurs
• Aortic stenosis
• Mitral insufficiency
• Mitral valve prolapse
• Tricuspid insufficiency
Diastolic Murmurs
• Aortic insufficiency
• Mitral stenosis
© Continuing Medical Implementation …...bridging the care gap S1 S2 S1 Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
An 83 year old man with exertional dyspnea
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Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Echocardiogram
• Etiology
• Valve gradient and area
• LVH
• Systolic LV function
• Diastolic LV function
• LA size
• Concomitant regional wall motion abnormalities
• Coarctation associated with bicuspid AV
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Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
What laboratory tests and imaging studies should clinicians use to evaluate patients
with suspected aortic stenosis?
• Echocardiography • Retrograde catheterization of the heart to image the
aortic valve and measure left ventricular pressure – Not recommended if noninvasive methods are adequate
• Hemodynamic criteria that indicate severe stenosis – Doppler velocity >4 m/s – Aortic valve area <1 cm2 (<0.6 cm2/m2 indexed to BSA) – Mean gradient >40 mm Hg
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Severity of Stenosis
• Normal aortic valve area 2.5-3.5 cm2
• Mild stenosis 1.5-2.5 cm2
• Moderate stenosis 1.0-1.5 cm2
• Severe stenosis < 1.0 cm2
• Onset of symptoms
~ 0.9 cm2 with CAD
~ 0.7 cm2 without CAD
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Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Other diagnoses/condition to consider in patients with possible
aortic stenosis?
• Systolic murmur – Mitral or tricuspid regurgitation
– Hypertrophic cardiomyopathy
– Hyperdynamic state
• Atherosclerotic lesions – Coronary artery disease if angina is prominent
– Stenoses of the magistral head/cerebral artheries, especially in patients with presyncope or syncope
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
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Echocardiogram
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Figure 1: Principles of the Use of Doppler Ultrasonography and the Continuity Equation in Estimating Aortic-Valve Area. For blood flow (A1 x V1) to remain constant when it reaches a stenosis (A2), velocity must increase to V2. Doppler examination of the stenosis detects the increase in velocity, which can be used to calculate the aortic-valve gradient or to solve the continuity equation for A2. A denotes area, and V velocity
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Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
• High gradient – easy to confirm aortic stenosis
• Low/lower gradients do not exclude severe stenosis
- Low flow – low gradient
- Pseudostenosis
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Natural History of Aortic Stenosis
• Heart failure reduces life expectancy to less than 2 years
• Angina and syncope reduce life expectancy between 2 and 5 years
• Rate of progression @ 0.1 cm2/year
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Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
• Therapy - valve replacement
- Open chest surgery
- Transcatheter aortic valve replacement (TAVR)
transfemoral
transapical
• WHEN ??? (timing)
Risk from procedure balanced with risk of AoS
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
What nondrug therapies should clinicians recommend?
• Moderate-to-severe or severe aortic stenosis
– Avoid strenuous physical activity
– Avoid sports that demand high muscular effort
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
What medications should clinicians use for treatment?
• Definitive management requires mechanical intervention
• No drug reverses aortic stenosis • Prescribe appropriate medical therapy for
associated risk factors or concurrent disease – Coronary artery disease – Atrial fibrillation – Diabetes mellitus – Heart failure – Hypertension (start at low dose and gradually titrate
up) – Hyperlipidemia
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
When should patients be considered for valve replacement?
• When symptoms develop – Death rate after symptoms start is ≥2%/month – Delay risks sudden death
• When asymptomatic patients have severe stenosis – risk for watchful waiting usually outweighs the
risk for intervention – valve replacement for patients with very severe
stenosis and low surgical risk – valve replacement for all patients with severe
stenosis and LV dysfunction
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Methods of valve replacement
• Surgical
• Transcatheter
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Which patients should have surgical aortic valve replacement (SAVR) ?
• Traditional, definitive, time-tested therapy • Increasing use of bioprosthetic valves instead of
mechanical valves • Full sternotomy is the most common approach • Partial sternotomy and mini-thoracotomy
approaches are increasingly popular • Surgical mortality is <3% overall; <2% in low-risk
patients • Common reasons for wanting to avoid SAVR:
advanced age; severe comorbidities; frailty
continued…
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Which patients should have transcatheter aortic valve replacement (TAVR)?
• Became available in 2011 • Equal or superior to SAVR in high-risk and
intermediate-risk patients • Usefulness in lower-risk patients remains
undetermined • Well-suited for patient with advanced age, extra-
cardiac comorbidities, or anatomical factors that would complicate an open surgical approach
• Transfemoral approach is the default • More long-term data are needed
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Prosthetic Heart Valves
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Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Prosthetic Valves
• MECHANICAL
– Durable
– Large orifice
– High thromboembolic potential
– Best in Left Side
– Chronic warfarin therapy
• BIO-PROSTHETIC – Not durable
– Smaller orifice/functional stenosis
– Low thromboembolic potential
– Consider in elderly
– Best in tricuspid position
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Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Problems after valve replacement
• Anticoagulation
• Valve trombosis
• Valve degeneration (bioprothesis)
• Paravalvular leak
• Infective endocarditis
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
How often should clinicians see patients in follow-up, and what should follow-up entail?
For patients with known aortic stenosis who do not yet meet the threshold for intervention
– Rigorous follow-up is essential to avoid delay should intervention become necessary
– Progression is more rapid in older patients, in those with more severe stenosis or denser leaflet calcification, and in those with a bicuspid valve
– Repeat transthoracic echocardiography warranted whenever signs or symptoms change
– Repeat transthoracic echocardiography also warranted if increased hemodynamic demand is anticipated (surgery, pregnancy, severe infection)
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
• For patients after aortic valve replacement
– Yearly follow-up
• Physical examination with detailed cardiovascular assessment
• Blood chemistries, lipid profile, and prothrombin time (for patients receiving warfarin)
• Electrocardiography
• Chest x-ray
– When new cardiac symptoms occur
• Examine patient to rule out malfunction of the valve prosthesis
• Perform echocardiography
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
When should clinicians hospitalize patients with aortic stenosis?
• Decompensated heart failure – Medical optimization in preparation for definitive
therapy
– Judicious intravenous diuresis
– Low cardiac output may require inotropic support or mechanical circulatory support
– Balloon aortic valvuloplasty may be considered for patients without significant aortic regurgitation
• Rapidly progressive or unstable symptoms – Consider admission
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Operative mortality of AVR in the elderly
• ~ 4-24%/year
• Risk factors for operative mortality
– Functional class
– Lack of sinus rhythm
– HTN
– Pre-existing LV dysfunction
– Aortic regurgitation
– Concomitant surgical procedures:CABG/MV surgery
– Previous bypass
– Emergency surgery
– CAD
– Female gender
© Continuing Medical Implementation …...bridging the care gap
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Aortic Stenosis: Prognosis
Symptom/Sign Live expectancy
Angina 5 years
Syncope 2-3 years
Congestive Heart Failure 1-2 years
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Therapy: Valve replacement for severe aortic stenosis
Operative mortality (elderly) ~ 4-24%/Morbidity ~ 3-11%
Event rate in asymptomatic severe AS ~ 1%/year
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave
Figure 4
Mayo Clinic Proceedings 2018 93, 488-508DOI: (10.1016/j.mayocp.2018.01.020)
Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave