Cardiac Valve Cardiac Valve Replacement SurgeryReplacement Surgery

Jane HallamJane Hallam

RMHRMH

AnatomyAnatomy

3

ACC/AHA definition: ACC/AHA definition: Classification of recommendationsClassification of recommendations

IIIIIbIIaI

? Class I: Conditions for which there is evidence for and/or general agreement that a given procedure or treatment is beneficial, useful, and effective

? Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment

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

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

? Class III: Conditions for which there is evidence and/or general agreement that a procedure/treatment is not useful/effective and in some cases may be harmful

Class:

Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed March 22, 2006.

4

ACC/AHA definition: ACC/AHA definition: Level of evidenceLevel of evidence

?Level of evidence A: Data derived from multiple randomized clinical trials or meta-analyses

?Level of evidence B: Data derived from a single randomized trial or nonrandomized studies

?Level of evidence C: Only consensus opinion of experts, case studies, or standard of care

A

B

C

Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed March 22, 2006.

Indications for SurgeryIndications for Surgery Aortic ValveAortic Valve

StenosisStenosis – results from thickening, – results from thickening, calcification and/or fusion. Younger pt calcification and/or fusion. Younger pt congenital bicuspid, older pt degenerative congenital bicuspid, older pt degenerative changes. Impairment opening, pressure changes. Impairment opening, pressure overload, LVH, reduced ventricular overload, LVH, reduced ventricular compliance. compliance.

Grading - N 2.5-3.5, mild (AVA >1.5 cm2), Grading - N 2.5-3.5, mild (AVA >1.5 cm2), moderate (AVA =1.0 – 1.5), severe (AVA moderate (AVA =1.0 – 1.5), severe (AVA <1.0), critical (AVA <0.75)<1.0), critical (AVA <0.75)

More precise, indexed to pt size, critical AS More precise, indexed to pt size, critical AS when AVA Index <0.45cm2when AVA Index <0.45cm2

Average survival symptomatic AS 2-3 yrs.Average survival symptomatic AS 2-3 yrs.

Traditional indications presence of angina, Traditional indications presence of angina, CHF, syncope, resuscitation after cardiac CHF, syncope, resuscitation after cardiac arrest.arrest.

Surgery in asymptomatic controversial. Surgery in asymptomatic controversial. Presence of LV systolic dysfunction, Presence of LV systolic dysfunction, hypotension response exercise, VT or LVH hypotension response exercise, VT or LVH (>15mm), transvalvular peak gradient > (>15mm), transvalvular peak gradient > 50mmHg are poor prognostic signs, 50mmHg are poor prognostic signs, consider early surgery.consider early surgery.

Pts undergoing CABG’s with AVA <1.1cm2 Pts undergoing CABG’s with AVA <1.1cm2 should have replacement.should have replacement.

Indications for AVR in ASIndications for AVR in ASClass IClass I1 1 AVR is indicated for symptomatic patients with severe AS.* AVR is indicated for symptomatic patients with severe AS.* (Level of Evidence: (Level of Evidence:

B)B)

2 2 AVR is indicated for patients with severe AS* undergoing coronary artery AVR is indicated for patients with severe AS* undergoing coronary artery bypass graft surgery (CABG). bypass graft surgery (CABG). (Level of Evidence: C)(Level of Evidence: C)

3 3 AVR is indicated for patients with severe AS* undergoing surgery on the aorta AVR is indicated for patients with severe AS* undergoing surgery on the aorta or other heart valves. or other heart valves. (Level of Evidence: C)(Level of Evidence: C)

4 4 AVR is recommended for patients with severe AS* and LV systolic dysfunction AVR is recommended for patients with severe AS* and LV systolic dysfunction (ejection fraction less than 0.50). (ejection fraction less than 0.50). (Level of Evidence: C)(Level of Evidence: C)

Class IIaClass IIaAVR is reasonable for patients with moderate AS* undergoing CABG or surgery AVR is reasonable for patients with moderate AS* undergoing CABG or surgery

on the aorta or other heart valves (see Section 3.7 on combined multiple on the aorta or other heart valves (see Section 3.7 on combined multiple valve disease and Section 10.4 on AVR in patients undergoing CABG). valve disease and Section 10.4 on AVR in patients undergoing CABG). (Level (Level of Evidence: B)of Evidence: B)

Class IIbClass IIb1 1 AVR may be considered for asymptomatic patients with severe AS* and AVR may be considered for asymptomatic patients with severe AS* and

abnormal response to exercise (e.g., development of symptoms or abnormal response to exercise (e.g., development of symptoms or asymptomatic hypotension). asymptomatic hypotension). (Level of Evidence: C)(Level of Evidence: C)

2 2 AVR may be considered for adults with severe asymptomatic AS* if there is a AVR may be considered for adults with severe asymptomatic AS* if there is a high likelihood of rapid progression (age, calcification, and CAD) or if high likelihood of rapid progression (age, calcification, and CAD) or if surgery might be delayed at the time of symptom onset. surgery might be delayed at the time of symptom onset. (Level of Evidence: (Level of Evidence: C)C)

3 3 AVR may be considered in patients undergoing CABG who have mild AS* when AVR may be considered in patients undergoing CABG who have mild AS* when there is evidence, such as moderate to severe valve calcification, that there is evidence, such as moderate to severe valve calcification, that progression may be rapid. progression may be rapid. (Level of Evidence: C)(Level of Evidence: C)

4 4 AVR may be considered for asymptomatic patients with extremely severe AS AVR may be considered for asymptomatic patients with extremely severe AS (aortic valve area less than 0.6 cm2, mean gradient greater than 60 mm Hg, (aortic valve area less than 0.6 cm2, mean gradient greater than 60 mm Hg, and jet velocity greater than 5.0 m per second) when the patient’s expected and jet velocity greater than 5.0 m per second) when the patient’s expected operative mortality is 1.0% or less. operative mortality is 1.0% or less. (Level of Evidence: C)(Level of Evidence: C)

Class IIIClass IIIAVR is not useful for the prevention of sudden death in asymptomatic patients AVR is not useful for the prevention of sudden death in asymptomatic patients

with AS who have none of the findings listed under the class IIa/IIb with AS who have none of the findings listed under the class IIa/IIb recommendations. recommendations. (Level of Evidence: B)(Level of Evidence: B)

Aortic ValveAortic Valve

RegurgitationRegurgitationResults from abN in AV leaflets such as Results from abN in AV leaflets such as

post inflammatory changes, bicuspid valve, post inflammatory changes, bicuspid valve, damage from endocarditis, or aortic root damage from endocarditis, or aortic root dilatation preventing coaptation.dilatation preventing coaptation.

Acute AR fr endocarditis or aortic dissection Acute AR fr endocarditis or aortic dissection produces LV failure, pul edema as ventricale produces LV failure, pul edema as ventricale unable to dilate to handle fluid overload. unable to dilate to handle fluid overload. Chronic AR pressure and volume overload of Chronic AR pressure and volume overload of LV, with progressive dilatation, wall stress, LV, with progressive dilatation, wall stress, hypertrophy, and symptoms left heart failure. hypertrophy, and symptoms left heart failure. Increased stroke volume will increase pulse Increased stroke volume will increase pulse pressure, increase SBP and evidence of pressure, increase SBP and evidence of hyperdynamic circulation.hyperdynamic circulation.

Class IClass I1 1 AVR is indicated for symptomatic patients with severe AR irrespective AVR is indicated for symptomatic patients with severe AR irrespective

of LV systolic function. of LV systolic function. (Level of Evidence: B)(Level of Evidence: B)

2 2 AVR is indicated for asymptomatic patients with chronic severe AR and AVR is indicated for asymptomatic patients with chronic severe AR and LV systolic dysfunction (ejection fraction 0.50 or less) at rest. LV systolic dysfunction (ejection fraction 0.50 or less) at rest. (Level of (Level of Evidence: B)Evidence: B)

3 3 AVR is indicated for patients with chronic severe AR while undergoing AVR is indicated for patients with chronic severe AR while undergoing CABG or surgery on the aorta or other heart valves. CABG or surgery on the aorta or other heart valves. (Level of (Level of Evidence: C)Evidence: C)

Class IIaClass IIaAVR is reasonable for asymptomatic patients with severe AR with normal AVR is reasonable for asymptomatic patients with severe AR with normal

LV systolic function (ejection fraction greater than 0.50) but with LV systolic function (ejection fraction greater than 0.50) but with severe LV dilatation (end-diastolic dimension greater than 75 mm or severe LV dilatation (end-diastolic dimension greater than 75 mm or end-systolic dimension greater than 55 mm).* end-systolic dimension greater than 55 mm).* (Level of Evidence: B)(Level of Evidence: B)

Class IIbClass IIb1 1 AVR may be considered in patients with moderate AR while undergoing AVR may be considered in patients with moderate AR while undergoing

surgery on the ascending aorta. surgery on the ascending aorta. (Level of Evidence: C)(Level of Evidence: C)

2 2 AVR may be considered in patients with moderate AR while undergoing AVR may be considered in patients with moderate AR while undergoing CABG. CABG. (Level of Evidence: C)(Level of Evidence: C)

3 3 AVR may be considered for asymptomatic patients with severe AR and AVR may be considered for asymptomatic patients with severe AR and normal LV systolic function at rest (ejection fraction greater than normal LV systolic function at rest (ejection fraction greater than 0.50) when the degree of LV dilatation exceeds an end-diastolic 0.50) when the degree of LV dilatation exceeds an end-diastolic dimension of 70 mm or end-systolic dimension of 50 mm, when there dimension of 70 mm or end-systolic dimension of 50 mm, when there is evidence of progressive LV dilatation, declining exercise tolerance, is evidence of progressive LV dilatation, declining exercise tolerance, or abnormal hemodynamic responses to exercise.* or abnormal hemodynamic responses to exercise.* (Level of Evidence: (Level of Evidence: C)C)

Class IIIClass IIIAVR is not indicated for asymptomatic patients with mild, moderate, or AVR is not indicated for asymptomatic patients with mild, moderate, or

severe AR and normal LV systolic function at rest (ejection fraction severe AR and normal LV systolic function at rest (ejection fraction greater than 0.50) when degree of dilatation is not moderate or severe greater than 0.50) when degree of dilatation is not moderate or severe (end-diastolic dimension less than 70 mm, end-systolic dimension less (end-diastolic dimension less than 70 mm, end-systolic dimension less than 50 mm).*than 50 mm).*(Level of Evidence: B)(Level of Evidence: B)

Mitral ValveMitral Valve StenosisStenosis MS is an obstruction to LV inflow at the level of the MV as a result of a MS is an obstruction to LV inflow at the level of the MV as a result of a

structural abnormality of the MV apparatus, which prevents proper structural abnormality of the MV apparatus, which prevents proper opening during diastolic filling of the left ventricle. opening during diastolic filling of the left ventricle.

The predominant cause of MS is rheumatic carditis. In patients with The predominant cause of MS is rheumatic carditis. In patients with MS due to rheumatic fever, the pathological process causes leaflet MS due to rheumatic fever, the pathological process causes leaflet thickening and calcification, commissural fusion, chordal fusion, or a thickening and calcification, commissural fusion, chordal fusion, or a combination of these processes. combination of these processes.

Acquired causes of MV obstruction, other than rheumatic heart Acquired causes of MV obstruction, other than rheumatic heart disease, are rare. These include left atrial myxoma, ball valve disease, are rare. These include left atrial myxoma, ball valve thrombus, mucopolysaccharidosis, and severe annular calcification. thrombus, mucopolysaccharidosis, and severe annular calcification.

The normal MV area is 4.0 to 5.0 cm2. Narrowing of the valve area to The normal MV area is 4.0 to 5.0 cm2. Narrowing of the valve area to less than 2.5 cm2 typically occurs before the development of less than 2.5 cm2 typically occurs before the development of symptoms. MV area greater than 1.5 cm2 usually does not produce symptoms. MV area greater than 1.5 cm2 usually does not produce symptoms at rest. However, if there is an increase in transmitral symptoms at rest. However, if there is an increase in transmitral flow or a decrease in the diastolic filling period, there will be a rise flow or a decrease in the diastolic filling period, there will be a rise in left atrial pressure and development of symptoms. in left atrial pressure and development of symptoms.

The first symptoms of dyspnea in patients with mild MS are usually The first symptoms of dyspnea in patients with mild MS are usually precipitated by exercise, emotional stress, infection, pregnancy, or precipitated by exercise, emotional stress, infection, pregnancy, or atrial fibrillation with a rapid ventricular response. As the atrial fibrillation with a rapid ventricular response. As the obstruction across the MV increases, decreasing effort tolerance obstruction across the MV increases, decreasing effort tolerance occurs. occurs.

Although MS is best described as a disease Although MS is best described as a disease continuum, and there is no single value that continuum, and there is no single value that defines severity, for these guidelines, MS severity defines severity, for these guidelines, MS severity is based on a variety of hemodynamic and natural is based on a variety of hemodynamic and natural history data using mean gradient, pulmonary history data using mean gradient, pulmonary artery systolic pressure, and valve area as follows: artery systolic pressure, and valve area as follows:

Mild (area greater than 1.5 cm2, mean Mild (area greater than 1.5 cm2, mean gradient less than 5 mm Hg, or pulmonary artery gradient less than 5 mm Hg, or pulmonary artery systolic pressure less than 30 mm Hg), systolic pressure less than 30 mm Hg),

Moderate (area 1.0 to 1.5 cm2, mean Moderate (area 1.0 to 1.5 cm2, mean gradient 5 to 10 mm Hg, or pulmonary artery gradient 5 to 10 mm Hg, or pulmonary artery systolic pressure 30 to 50 mm Hg), systolic pressure 30 to 50 mm Hg),

Severe (area less than 1.0 cm2, mean Severe (area less than 1.0 cm2, mean gradient greater than 10 mm Hg, or pulmonary gradient greater than 10 mm Hg, or pulmonary artery systolic pressure greater than 50 mm Hg). artery systolic pressure greater than 50 mm Hg).

Indications for Surgery for Mitral StenosisIndications for Surgery for Mitral StenosisClass IClass I1 1 MV surgery (repair if possible) is indicated in patients with MV surgery (repair if possible) is indicated in patients with

symptomatic (NYHA functional class III–IV) moderate or severe symptomatic (NYHA functional class III–IV) moderate or severe MS* when 1) percutaneous mitral balloon valvotomy is MS* when 1) percutaneous mitral balloon valvotomy is unavailable, 2) percutaneous mitral balloon valvotomy is unavailable, 2) percutaneous mitral balloon valvotomy is contraindicated because of left atrial thrombus despite contraindicated because of left atrial thrombus despite anticoagulation or because concomitant moderate to severe anticoagulation or because concomitant moderate to severe MR is present, or 3) the valve morphology is not favorable for MR is present, or 3) the valve morphology is not favorable for percutaneous mitral balloon valvotomy in a patient with percutaneous mitral balloon valvotomy in a patient with acceptable operative risk. acceptable operative risk. (Level of Evidence: B)(Level of Evidence: B)

2 2 Symptomatic patients with moderate to severe MS* who also Symptomatic patients with moderate to severe MS* who also have moderate to severe MR should receive MV replacement, have moderate to severe MR should receive MV replacement, unless valve repair is possible at the time of surgery. unless valve repair is possible at the time of surgery. (Level of (Level of Evidence: C)Evidence: C)

Class IIaClass IIaMV replacement is reasonable for patients with severe MS* and MV replacement is reasonable for patients with severe MS* and

severe pulmonary hypertension (pulmonary artery systolic severe pulmonary hypertension (pulmonary artery systolic pressure greater than 60) with NYHA functional class I–II pressure greater than 60) with NYHA functional class I–II symptoms who are not considered candidates for percutaneous symptoms who are not considered candidates for percutaneous mitral balloon valvotomy or surgical MV repair. mitral balloon valvotomy or surgical MV repair. (Level of (Level of Evidence: C)Evidence: C)

Class IIbClass IIbMV repair may be considered for asymptomatic patients with MV repair may be considered for asymptomatic patients with

moderate or severe MS* who have had recurrent embolic events moderate or severe MS* who have had recurrent embolic events while receiving adequate anticoagulation and who have valve while receiving adequate anticoagulation and who have valve morphology favorable for repair. morphology favorable for repair. (Level of Evidence: C)(Level of Evidence: C)

Class IIIClass III1 1 MV repair for MS is not indicated for patients with mild MV repair for MS is not indicated for patients with mild

MS. MS. (Level of Evidence: C)(Level of Evidence: C)

Mitral RegurgeMitral Regurge

Common causes of organic MR include rheumatic Common causes of organic MR include rheumatic heart disease, CAD, infective endocarditis, certain heart disease, CAD, infective endocarditis, certain drugs, and collagen vascular disease. drugs, and collagen vascular disease.

MR may also occur secondary to a dilated annulus MR may also occur secondary to a dilated annulus from dilatation of the left ventricle. from dilatation of the left ventricle.

In some cases, such as ruptured chordae In some cases, such as ruptured chordae tendineae, ruptured papillary muscle, or infective tendineae, ruptured papillary muscle, or infective endocarditis, MR may be acute and severe, endocarditis, MR may be acute and severe, resulting in cardiogenic shock and acute pul resulting in cardiogenic shock and acute pul edema. Alternatively, MR may worsen gradually edema. Alternatively, MR may worsen gradually over a prolonged period of time with LV over a prolonged period of time with LV dysfunction, dilatation and ^filling pressures. dysfunction, dilatation and ^filling pressures. These 2 ends of the spectrum have quite different These 2 ends of the spectrum have quite different clinical presentations. clinical presentations.

Ischaemic MR chronic or acute.Ischaemic MR chronic or acute.

Three different MV operations are Three different MV operations are currently used for correction of MR: currently used for correction of MR:

1) MV repair; 1) MV repair;

2) MV replacement with 2) MV replacement with preservation of part or all of the preservation of part or all of the mitral apparatus; and mitral apparatus; and

3) MV replacement with removal of 3) MV replacement with removal of the mitral apparatus.  the mitral apparatus. 

Indications for Mitral Valve OperationIndications for Mitral Valve OperationClass IClass I1 1 MV surgery is recommended for the symptomatic patient with acute severe MR.* MV surgery is recommended for the symptomatic patient with acute severe MR.* (Level of (Level of

Evidence: B)Evidence: B)

2 2 MV surgery is beneficial for patients with chronic severe MR* and NYHA functional class II, MV surgery is beneficial for patients with chronic severe MR* and NYHA functional class II, III, or IV symptoms in the absence of severe LV dysfunction (severe LV dysfunction is III, or IV symptoms in the absence of severe LV dysfunction (severe LV dysfunction is defined as ejection fraction less than 0.30) and/or end-systolic dimension greater than 55 defined as ejection fraction less than 0.30) and/or end-systolic dimension greater than 55 mm. mm. (Level of Evidence: B)(Level of Evidence: B)

3 3 MV surgery is beneficial for asymptomatic patients with chronic severe MR* and mild to MV surgery is beneficial for asymptomatic patients with chronic severe MR* and mild to moderate LV dysfunction, ejection fraction 0.30 to 0.60, and/or end-systolic dimension moderate LV dysfunction, ejection fraction 0.30 to 0.60, and/or end-systolic dimension greater than or equal to 40 mm. greater than or equal to 40 mm. (Level of Evidence: B)(Level of Evidence: B)

4 4 MV repair is recommended over MV replacement in the majority of patients with severe MV repair is recommended over MV replacement in the majority of patients with severe chronic MR* who require surgery, and patients should be referred to surgical centers chronic MR* who require surgery, and patients should be referred to surgical centers experienced in MV repair. experienced in MV repair. (Level of Evidence: C)(Level of Evidence: C)

Class IIaClass IIa1 1 MV repair is reasonable in experienced surgical centers for asymptomatic patients with MV repair is reasonable in experienced surgical centers for asymptomatic patients with

chronic severe MR* with preserved LV function (ejection fraction greater than 0.60 and chronic severe MR* with preserved LV function (ejection fraction greater than 0.60 and end-systolic dimension less than 40 mm) in whom the likelihood of successful repair end-systolic dimension less than 40 mm) in whom the likelihood of successful repair without residual MR is greater than 90%. without residual MR is greater than 90%. (Level of Evidence: B)(Level of Evidence: B)

2 2 MV surgery is reasonable for asymptomatic patients with chronic severe MR,* preserved LV MV surgery is reasonable for asymptomatic patients with chronic severe MR,* preserved LV function, and new onset of atrial fibrillation. function, and new onset of atrial fibrillation. (Level of Evidence: C)(Level of Evidence: C)

3 3 MV surgery is reasonable for asymptomatic patients with chronic severe MR,* preserved LV MV surgery is reasonable for asymptomatic patients with chronic severe MR,* preserved LV function, and pulmonary hypertension (pulmonary artery systolic pressure greater than function, and pulmonary hypertension (pulmonary artery systolic pressure greater than 50 mm Hg at rest or greater than 60 mm Hg with exercise). 50 mm Hg at rest or greater than 60 mm Hg with exercise). (Level of Evidence: C)(Level of Evidence: C)

4 4 MV surgery is reasonable for patients with chronic severe MR* due to a primary MV surgery is reasonable for patients with chronic severe MR* due to a primary abnormality of the mitral apparatus and NYHA functional class III-IV symptoms and abnormality of the mitral apparatus and NYHA functional class III-IV symptoms and severe LV dysfunction (ejection fraction less than 0.30 and/or end-systolic dimension severe LV dysfunction (ejection fraction less than 0.30 and/or end-systolic dimension greater than 55 mm) in whom MV repair is highly likely. greater than 55 mm) in whom MV repair is highly likely. (Level of Evidence: C(Level of Evidence: C))

Class IIbClass IIbMV repair may be considered for patients with chronic severe secondary MR* due to severe MV repair may be considered for patients with chronic severe secondary MR* due to severe

LV dysfunction (ejection fraction less than 0.30) who have persistent NYHA functional LV dysfunction (ejection fraction less than 0.30) who have persistent NYHA functional class III-IV symptoms despite optimal therapy for heart failure, including biventricular class III-IV symptoms despite optimal therapy for heart failure, including biventricular pacing. pacing. (Level of Evidence: C)(Level of Evidence: C)

Class IIIClass III1 1 MV surgery is not indicated for asymptomatic patients with MR and preserved LV function MV surgery is not indicated for asymptomatic patients with MR and preserved LV function

(ejection fraction greater than 0.60 and end-systolic dimension less than 40 mm) in (ejection fraction greater than 0.60 and end-systolic dimension less than 40 mm) in whom significant doubt about the feasibility of repair exists. whom significant doubt about the feasibility of repair exists. (Level of Evidence: C)(Level of Evidence: C)

2 2 Isolated MV surgery is not indicated for patients with mild or moderate MR. Isolated MV surgery is not indicated for patients with mild or moderate MR. (Level of (Level of Evidence: C)Evidence: C)

Tricuspid valve diseaseTricuspid valve disease Tricuspid valve dysfunction can occur with normal or abnormal valves. Tricuspid valve dysfunction can occur with normal or abnormal valves.

When normal tricuspid valves develop dysfunction, the resulting When normal tricuspid valves develop dysfunction, the resulting hemodynamic abnormality is almost always pure regurgitation. This hemodynamic abnormality is almost always pure regurgitation. This occurs with elevation of RV systolic and/or diastolic pressure, RV occurs with elevation of RV systolic and/or diastolic pressure, RV cavity enlargement, and tricuspid annular dilatation; RV systolic cavity enlargement, and tricuspid annular dilatation; RV systolic hypertension occurs in MS, pulmonic valve stenosis, and the various hypertension occurs in MS, pulmonic valve stenosis, and the various causes of pulmonary hypertension. RV diastolic hypertension occurs in causes of pulmonary hypertension. RV diastolic hypertension occurs in dilated cardiomyopathy, RV infarction, and RV failure of any cause. dilated cardiomyopathy, RV infarction, and RV failure of any cause. Pacemaker-induced severe TR is rare but may require intervention.Pacemaker-induced severe TR is rare but may require intervention.

Abnormalities of the tricuspid valve leading to TR can occur with Abnormalities of the tricuspid valve leading to TR can occur with rheumatic valvulitis, infective endocarditis, carcinoid, rheumatoid rheumatic valvulitis, infective endocarditis, carcinoid, rheumatoid arthritis, radiation therapy, trauma (such as repeated endomyocardial arthritis, radiation therapy, trauma (such as repeated endomyocardial biopsies), Marfan syndrome, tricuspid valve prolapse, tricuspid biopsies), Marfan syndrome, tricuspid valve prolapse, tricuspid annular dilatation, or congenital disorders such as Ebstein’s anomaly annular dilatation, or congenital disorders such as Ebstein’s anomaly or a cleft tricuspid valve as part of atrioventricular canal or a cleft tricuspid valve as part of atrioventricular canal malformations. Anorectic drugs may also cause TR.malformations. Anorectic drugs may also cause TR.

Tricuspid stenosis is most commonly rheumatic in origin. On very rare Tricuspid stenosis is most commonly rheumatic in origin. On very rare occasions, infective endocarditis (with large bulky vegetations), occasions, infective endocarditis (with large bulky vegetations), congenital abnormalities, carcinoid, Fabry’s disease, Whipple’s congenital abnormalities, carcinoid, Fabry’s disease, Whipple’s disease, or previous methysergide therapy may be implicated. Right disease, or previous methysergide therapy may be implicated. Right atrial mass lesions represent a nonvalvular cause of obstruction to the atrial mass lesions represent a nonvalvular cause of obstruction to the tricuspid orifice and may also over time destroy the leaflets and cause tricuspid orifice and may also over time destroy the leaflets and cause regurgitation. Rheumatic tricuspid involvement usually results in both regurgitation. Rheumatic tricuspid involvement usually results in both stenosis and regurgitation.stenosis and regurgitation.

  clinical features of tricuspid stenosis include a giant a clinical features of tricuspid stenosis include a giant a wave and diminished rate of y descent in the jugular wave and diminished rate of y descent in the jugular venous pulse, a tricuspid opening snap, and a murmur that venous pulse, a tricuspid opening snap, and a murmur that is presystolic as well as middiastolic and that increases on is presystolic as well as middiastolic and that increases on inspiration inspiration

clinical features of TR include abnormal systolic c and v clinical features of TR include abnormal systolic c and v waves in the jugular venous pulse, a lower left parasternal waves in the jugular venous pulse, a lower left parasternal systolic murmur (holosystolic or less than holosystolic, systolic murmur (holosystolic or less than holosystolic, depending on the severity of hemodynamic derangement) depending on the severity of hemodynamic derangement) that may increase on inspiration (Carvallo’s sign), a that may increase on inspiration (Carvallo’s sign), a middiastolic murmur in severe regurgitation, and systolic middiastolic murmur in severe regurgitation, and systolic hepatic pulsation. In rare instances, severe TR may hepatic pulsation. In rare instances, severe TR may produce systolic propulsion of the eyeballs, pulsatile produce systolic propulsion of the eyeballs, pulsatile varicose veins, or a venous systolic thrill and murmur in varicose veins, or a venous systolic thrill and murmur in the neck. Other associated clinical features are related to the neck. Other associated clinical features are related to the cause of TR. Moderate or severe TR may be present the cause of TR. Moderate or severe TR may be present without the classic clinical features. without the classic clinical features.

ManagementManagementClass IClass ITricuspid valve repair is beneficial for severe TR in patients Tricuspid valve repair is beneficial for severe TR in patients

with MV disease requiring MV surgery. with MV disease requiring MV surgery. (Level of (Level of Evidence: B)Evidence: B)

Class IIaClass IIa1 1 Tricuspid valve replacement or annuloplasty is reasonable Tricuspid valve replacement or annuloplasty is reasonable

for severe primary TR when symptomatic. for severe primary TR when symptomatic. (Level of (Level of Evidence: C)Evidence: C)

2 2 Tricuspid valve replacement is reasonable for severe TR Tricuspid valve replacement is reasonable for severe TR secondary to diseased/abnormal tricuspid valve leaflets secondary to diseased/abnormal tricuspid valve leaflets not amenable to annuloplasty or repair. not amenable to annuloplasty or repair. (Level of (Level of Evidence: C)Evidence: C)

Class IIbClass IIbTricuspid annuloplasty may be considered for less than Tricuspid annuloplasty may be considered for less than

severe TR in patients undergoing MV surgery when there severe TR in patients undergoing MV surgery when there is pulmonary hypertension or tricuspid annular is pulmonary hypertension or tricuspid annular dilatation. dilatation. (Level of Evidence: C)(Level of Evidence: C)

Class IIIClass III1 1 Tricuspid valve replacement or annuloplasty is not Tricuspid valve replacement or annuloplasty is not

indicated in asymptomatic patients with TR whose indicated in asymptomatic patients with TR whose pulmonary artery systolic pressure is less than 60 mm Hg pulmonary artery systolic pressure is less than 60 mm Hg in the presence of a normal MV. in the presence of a normal MV. (Level of Evidence: C)(Level of Evidence: C)

2 2 Tricuspid valve replacement or annuloplasty is not Tricuspid valve replacement or annuloplasty is not indicated in patients with mild primary TR. indicated in patients with mild primary TR. (Level of (Level of Evidence: C)Evidence: C)

Pulmonary ValvePulmonary Valve Stenosis Stenosis Pulmonary valve is the least likely valve to be affected by acquired Pulmonary valve is the least likely valve to be affected by acquired

heart disease, virtually all cases of pulmonary valve stenosis are heart disease, virtually all cases of pulmonary valve stenosis are congenital in origin.  congenital in origin. 

Symptoms are unusual in children or adolescents with pulmonary Symptoms are unusual in children or adolescents with pulmonary valve stenosis even when severe. valve stenosis even when severe.

Adults with long-standing severe obstruction may have dyspnea Adults with long-standing severe obstruction may have dyspnea and fatigue secondary to an inability to increase cardiac output and fatigue secondary to an inability to increase cardiac output adequately with exercise. Exertional syncope or light-adequately with exercise. Exertional syncope or light-headedness may occur in the presence of severe pulmonic headedness may occur in the presence of severe pulmonic stenosis with systemic or suprasystemic RV pressures, with stenosis with systemic or suprasystemic RV pressures, with decreased preload or dehydration, or with a low systemic decreased preload or dehydration, or with a low systemic vascular resistance state (such as pregnancy). However, sudden vascular resistance state (such as pregnancy). However, sudden death is very unusual. Eventually, with long-standing untreated death is very unusual. Eventually, with long-standing untreated severe obstruction, TR and RV failure may occur. it appears that severe obstruction, TR and RV failure may occur. it appears that congenital mild pulmonary stenosis is a benign disease that congenital mild pulmonary stenosis is a benign disease that rarely progresses, that moderate or severe pulmonary stenosis rarely progresses, that moderate or severe pulmonary stenosis can be improved with either surgery or balloon valvotomy at can be improved with either surgery or balloon valvotomy at very low risk, and that patients who undergo surgery or balloon very low risk, and that patients who undergo surgery or balloon valvotomy have an excellent prognosis and a low rate of valvotomy have an excellent prognosis and a low rate of recurrence. recurrence.

Thus, the goal of the clinician is to ascertain the severity of the Thus, the goal of the clinician is to ascertain the severity of the disease, treat those in whom it is moderate or severe, and disease, treat those in whom it is moderate or severe, and infrequently follow up on those with mild disease  infrequently follow up on those with mild disease 

Pulmonary RegurgitationPulmonary Regurgitation

Pulmonary valve regurgitation is an uncommon Pulmonary valve regurgitation is an uncommon congenital lesion seen occasionally with what congenital lesion seen occasionally with what has been described as idiopathic dilation of the has been described as idiopathic dilation of the pulmonary artery or with connective tissue pulmonary artery or with connective tissue disorders. In this condition, the annulus of the disorders. In this condition, the annulus of the pulmonary valve dilates, which causes failure pulmonary valve dilates, which causes failure of the leaflets to coapt during diastole. of the leaflets to coapt during diastole.

Pulmonary regurgitation also commonly occurs Pulmonary regurgitation also commonly occurs after successful repair of tetralogy of Fallot.  after successful repair of tetralogy of Fallot. 

Most physicians would perform pulmonary Most physicians would perform pulmonary valve replacement in patients with NYHA class valve replacement in patients with NYHA class II or III symptoms and severe pulmonary II or III symptoms and severe pulmonary regurgitation, but not for asymptomatic regurgitation, but not for asymptomatic patients. patients.

Valve typesValve types

Bioprosthetic/TissueBioprosthetic/Tissue

No lifetime No lifetime warfarinwarfarin

Less durabilityLess durability

Mechanical valveMechanical valve

Need for warfarinNeed for warfarin

Better durabilityBetter durability

Need for anticoagulationNeed for anticoagulation Systemic embolization (predominantly cerebrovascular Systemic embolization (predominantly cerebrovascular

events) occurs at a frequency of approximately 0.7 to 1.0 events) occurs at a frequency of approximately 0.7 to 1.0 percent per patient per year in patients with mechanical percent per patient per year in patients with mechanical valves who are treated with warfarin. valves who are treated with warfarin.

In comparison, the risk is 2.2 percent per patient per In comparison, the risk is 2.2 percent per patient per year with year with aspirinaspirin and 4.0 percent with no anticoagulation. and 4.0 percent with no anticoagulation.

Patients with mitral valve prostheses are at Patients with mitral valve prostheses are at approximately TWICE the risk as those with aortic valve approximately TWICE the risk as those with aortic valve prostheses prostheses