Valvular Heart Disease Aortic Stenosis - uniba.sk · Aortic Stenosis - Etiology •Young patient...

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



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)



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


Normal Bicuspid Ao V “Normal” geriatric

calcific valve Kardiologická klinika Lekárskej fakulty Univerzity Komenského a NÚSCH v Bratislave

Bicuspid Aortic Valve



Common Clinical Scenarios (systolic murmur)

• Younger people

– Functional murmur vs MVP vs bicuspid AV

• Older people

– Aortic sclerosis vs aortic stenosis




Etiology of Aortic Stenosis


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


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



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)



Innocent Murmurs

• Common in asymptomatic adults

• Characterized by

– Grade I – II at left sternal border

– Systolic ejection pattern


– Normal intensity & splitting of second sound (S2)

– No other abnormal sounds or murmurs

– No evidence of LVH, and no with Valsalva

S1 S2


Aortic Stenosis: Physical Findings


S1 S2 S1 S2

Mild-Moderate Severe


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



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



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


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



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



Echocardiogram


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



• High gradient – easy to confirm aortic stenosis

• Low/lower gradients do not exclude severe stenosis

- Low flow – low gradient

- Pseudostenosis


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



• Therapy - valve replacement

- Open chest surgery

- Transcatheter aortic valve replacement (TAVR)

transfemoral

transapical

• WHEN ??? (timing)

Risk from procedure balanced with risk of AoS


What nondrug therapies should clinicians recommend?

• Moderate-to-severe or severe aortic stenosis

– Avoid strenuous physical activity

– Avoid sports that demand high muscular effort


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


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


Methods of valve replacement

• Surgical

• Transcatheter


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…


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


Prosthetic Heart Valves



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



Problems after valve replacement

• Anticoagulation

• Valve trombosis

• Valve degeneration (bioprothesis)

• Paravalvular leak

• Infective endocarditis


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)


• 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


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


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



Aortic Stenosis: Prognosis

Symptom/Sign Live expectancy

Angina 5 years

Syncope 2-3 years

Congestive Heart Failure 1-2 years


Therapy: Valve replacement for severe aortic stenosis

Operative mortality (elderly) ~ 4-24%/Morbidity ~ 3-11%

Event rate in asymptomatic severe AS ~ 1%/year


Figure 4

Mayo Clinic Proceedings 2018 93, 488-508DOI: (10.1016/j.mayocp.2018.01.020)


Valvular Heart Disease Aortic Stenosis - uniba.sk · Aortic Stenosis - Etiology •Young patient...

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