Secondary Prophylaxis for
• Accepted tool to predict the risk of a surgical operation.
• STS – Society of Thoracic Surgeons
• PROM – Predicted Rate Of Mortality
STS database 2000 -2010
• Frailty – ability to perform activites of daily living.
PROM MEAN MORTALITY
80% <4% 1.4%
14% 4%-8% 5.1%
6% >8% 11.1%
SEVEN FRAILTY INDICES
Katz Activities of daily living
• Independence in feeding
• Urinary continence
Independence in ambulation
• No walking aid or
Assist required or
Walk 5 meter < 6 sec.
PROCEDURE SPECIFIC IMPEDIMENT
Heavily calcified ascending aorta,
Chest deformity,arterial coronary graft adherent to chest wall,
MAJOR ORGAN SYSTEM COMPROMISE
• Severe LV systolic
• Severe LV diastolic
• RV dysfunction
• Fixed pulmonary HTN
• CKD stage 3 or more
• Pulmonary dysfunction with
FEV1 <50%,DLCO2 <50%
of predicted value
• CNS dysfunction
• Alzhemiers disease
• Parkinson’s disease
• CVA with persistent physical
• GI dysfunction
• Crohn’s disease
• Serum albumin <3.0 gm/dl
• Cancer –active malignancy
• Liver –cirrhosis,variceal bleed
• Elevated INR
Does all patients need intervention?
• Life expectancy less than 1 yr.
• Chance of survival with benefit <25% at 2yrs.
• Improvement of NYHA by one class
-Stages of Valvular Heart Disease
Diagnosis and follow up
Diagnostic testing – initial diagnosis
Diagnostic testing – changing signs or symptoms
Diagnostic testing – routine follow up
Diagnostic testing – cardiac catheterisation
Diagnostic testing – exercise testing
Timing of intervention
Choice of intervention
Bicuspid Aortic valve and Aortopathy
Tricuspid valve disease
Pulmonic valve disease
Mixed valve disease
Pregnancy and VHD
Non cardiac surgery in patients with VHD
Evidence gaps and future directions
Special Sub groups
• Some patients with AS have a low transaortic volume flow rate due
to either LV systolic dysfunction with a low LV ejection fraction
(LVEF) or due to a small hypertrophied left ventricle with a low
• Diagnostic and management challenge.
• D2 (with a low LV EF)
• D3 ( with a normal LVEF).
INDICATION CLASS RECOMMENDATION
ECHO I B Signs or symptoms of AS /bicuspid AV for ∆ ,cause,
severity, LVsize ,function, systolicfunction, prognosis,
timing of intervention.
IIa B Low dose DBS – D2AS calcified,
EF<50%,1.0cm2area ,velocity <4m/sec, MPG - 40 mmHg.
IIaB Asymptomatic pts >4m/sec , MPG >40 mmHg.
III B Symptomatic pts with >4m /sec , MPG>40 mmHg
I B HTN in pts at risk, asymptomatic ,according to
GDMT, low dose to start with
IIb C Vasodilator therapy in acute RX of decompensated
severe AS with NYHA class IV HF symptoms
III A Statin therapy is not indicated for hemodynamic
progression of AS in pts with mild to moderate AS
Dobutamine Stress Echocardiography
• To be done in patients with severe AS(due to small valve area)
and concurrent LV systolic dysfunction.(usually have MPG
• 1.Severe AS with LV systolic dysfunction due to afterload
• 2.Primary myocardial dysfunction with only moderate AS and
reduced leaflet opening due to low flow rate.
SEVERE /MODERATE AS
CONTRACTILE RESERVE PRESENT/ABSENT.
• 5 mcg/kg/min – increments of 5 ug/kg/min(max 20 ug/kg/min)
• AJV,MPG,LVEF,valve area
• Pts who donot have true anatomically severe AS - increase in valve
area with only a modest increase in transaortic velocity or gradient as
transaortic stroke volume increases.
• Patients with severe AS – relatively fixed area even with an increase
in LV contractility and flow rate.
• EAE/ASE – Severe AS - >4m/sec, valve area <1.0cm2 at any point
during test protocol.
• Fail to increase in SV >20% with dobutamine – lack of Contractile
• Very poor prognosis with either medical or surgical therapy.
What is the rate of progression of
AORTIC STENOSIS PROGRESSION/EVENT FREE
Severe AS (asymptomatic –
Event free survival 30-50% at 2yrs
Moderate AS (3.0-3.9m/sec) 0.3m/sec/yr,7mmhg/yr,0.1cm2/yr
Aortic sclerosis 10% in 2 yrs
Progression of AS more rapid in older patients and those with more leaflet calcification
What are the symptoms in favour of
AS in ExerciseTesting?
• 1.Exercise induced angina
• 2.Excessive dyspnea early in exercise
• 5.abnormal BP response(<20 mm Hg increase)
• 6.ST-T abnormalities .
Studies on Aortic Stenosis
TRIAL NAME DRUGS USED RESULT
1 SEAS SIMVASTATIN,EZETIMIBE NO BENEFIT
2 SALTIRE HIGH DOSE ATORVASTATIN NO BENEFIT
3 ASTRONOMER ROSUVASTATIN NO BENEFIT
4 SCOPE -AS ENALAPRIL BENEFIT
• SIMVASTATIN EZETIMIBE IN AORTIC STENOSIS
• RCT ,Simvastatin 40 mg and Ezetimibe 10 mg did not reduce
aortic valve events (AVEs), while ischemic cardiovascular events
(ICEs) were significantly reduced in the overall study population.
• the impact of baseline AS severity on treatment effect has not
• rates of AVEs and ICEs increased with increasing baseline
severity of AS.
• Higher baseline peak aortic jet velocity predicted higher rates of
AVEs and ICEs in all tertiles (all p values < 0.05) and in the
total study population (p < 0.001).
Simvastatin-ezetimibe treatment was not associated with a
statistically significant reduction in AVEs in any individual tertile.
A significant quantitative interaction between the severity of AS
and simvastatin-ezetimibe treatment effect was demonstrated for
ICEs (p < 0.05) but not for AVEs (p = 0.10).
In conclusion, the SEAS study results demonstrate a strong
relation between baseline the severity of AS and the rate of
cardiovascular events but no significant effect of lipid-lowering
treatment on AVEs, even in the group with the mildest AS.
AORTIC STENOSIS PROGRESSION OBSERVATION
MEASURING EFFECTS OF ROSUVASTATIN
• 168 patients (56 ± 13 years), AS severity was categorized
based on peak velocity at baseline (Group I: 2.5-3.0 m/s; Group
II: 3.1-3.5 m/s; Group III: 3.6-4.0 m/s).
• Baseline and follow-up hemodynamics, LV dimensions and
diastolic functional parameters were evaluated in all three
• There was increased diastolic dysfunction from baseline to
follow-up in each of the placebo and rosuvastatin groups.
• In patients with increasing severity of AS in Groups I and II,
the lateral E' was lower and the E/E' (as an estimate of
increased LVEDP) was higher at baseline (p < 0.05).
• However, treatment with rosuvastatin did not affect the
progression of diastolic dysfunction from baseline to 3.5 year
follow-up between patients in any of the three predefined
Choice of Surgical or Transcatheter intervention
• TAVI VIDEO
• Dr Alain Cribier pioneered the first transcatheter aortic valve
implantation (TAVI) procedure in 2002
Antegrade – Acute MR
Transaortic surgical retrograde approach
Two types of stent-valve devices
Balloon-expandable valves (Edwards SAPIEN and SAPIEN XT,
which have replaced the Cribier-Edwards valve)
Self-expanding valve (Medtronic CoreValve)
thesubclavian/axillary artery , direct aortic access via either
ministernotomy or right anterior thoracotomy.
C/I for TAVR/TAVI
• Bicuspid or unicuspid or noncalcified aortic valve
• Severe AR (>3+)
• Native aortic annulus size as measured by echo <18 mm or > the largest
annulus size for which a TAVR device is available (eg, 29 mm for the largest
• HOCM. LVEF < 20 %.
• Severe PAH and RV dysfunction.
• Renal insufficiency (eg, creatinine >3.0 mg/dL) and/or ESRD
• MRI confirmed CVA or TIA within six months (180 days) of the procedure.
• Estimated life expectancy <12 months due to noncardiac comorbid
• Severe MR
• Thoracic or abdominal aortic aneurysm (luminal diameter ≥5 cm), marked
tortuosity (hyperacute bend), Aortic arch atheroma (especially if >5 mm
thick, protruding, or ulcerated) ,Narrowing (especially with calcification and
surface irregularities) of the abdominal or thoracic aorta ,
Case scenario 1
A 50 yr old male,hypertensive since 15 yrs ,came with
complaints of SOB on exertion.class III NYHA.
• On examination his pulse – 68/min, normal volume,regular ,BP
160/100 mm Hg,CVS – apex in 5th ICS left side,heaving ,S1 ,S2
normal an ESM 4/6 at right 2nd ICS heard.
• ECG- LV strain
• ECHO – aortic valve calcified, valve area 1.0 cm2,AJV – 3.6m/sec ,
mean gradient 38 mm Hg, LVEF – 45%,grade I LVDD,conc LVH.
• What is the diagnosis?
• What would be the next investigation in management of patient?
• Finally will he be posted for surgery or not ,how, why?
• Severe Asymptomatic aortic stenosis with LV
• Dobutamine stress echo
• See for contractile reserve
• Even if reserve absent ,Take him for surgery
• Benefit is present.
A 38 yr old male,labourer by occupation,k/c/o RHD on regular
penicillin prophylaxis was evaluated by echo on routine follow
• His echo showed thickened mitral valve,no MS.
• Aortic valve tricuspid,thickened,calcified
• Aortic valve area 0.9cm2
• AJV – 4.5m/sec,MPG – 81mmHg.
• LVEF - 50%,grade I LVDD.
• What is the stage of VHD?
• Plan of management?
• Asymptomatic severe AS (C1)
• Exercise stress test
• Look for symptoms,exercise tolerance
• If present,decreased exercise tolerance
• Take him for surgery.
A 65 yr old male,hypertensive, having prostatic carcinoma
been referred to cardiologist for evaluation of cardiac status.
• On evaluation ,he had aortic valve calcified,valve area
0.8cm2,AJV – 5.4m/sec, MPG – 116 mm Hg.
• LVH present.
• LVEF -40%
• Grade II LVDD
• What would be the plan of management?
• Should he be posted for surgery or VHD corrected ?
• If so ,why?
• He would have high surgical risk
• He should be taken for TAVI.
A 60 yr old male,hypertensive,diabetic,with diabetic
neuropathy culminating in lower limb loss was referred
to cardiologist for evaluation of cardiac function.
• h/o CVA rt hemiparesis in the past.
• Mitral annular calcification present
• Aortic valve calcified,
• AJV – 4.2 m/sec, mean gradient – 48 mm Hg, AVA -0.8 cm2,
• What would be the plan of management?
• He would not be benefited by surgery
• Increased risk of mortality,morbidity as there are other
organ system compromise
• Medical management
INDICATION CLASS RECOMMENDATION
ECHO I B Pts with symptoms of AR ,cause,severity,
LV size , function, intervention timing.
I B In pts with dilated aortic sinuses,asc aorta
for presence, severity of AR.
I B CMR - moderate to severe AR.
Medical therapy I B HTN (SBP > 140 mmHg) in pts with
chronic AR ---- CCB,ACEI./ARBS
II a B Medical therapy with ACEI/ARBs ,BB in
pts with LVD when surgery not performed.
Vasodilator therapy in AR
• Effective in reducing SBP in patients with chronic AR.
• Improve hemodynamic abnormalities,forward flow.
Donot alter the natural h/o of asymptomatic pts
with chronic severe AR and normal LV function..
Nifedipine Fioretti et al.,Am J Cardiol;1982:49:1728-32
Felodipine Sondergard L et al .,
Am Heart Journal 2000;139:667-74
Enalapril vs Hydralazine J Am Coll Cardiol.1994:24:1046-53
Nifedipine vs Captopril JACC 1993
mmHg ) for
CLASS I B
with ACEI/ARBs in
pts with severe AR
and LV dysfunction
when surgery is not
CLASS II a B
Vasodilator therapy is
useful to improve
compensation in Acute
Vasodilator therapy in
symptomatic pts with
chronic primary MR
LVEF< 60%,in whom
surgery is not
Class II aB
C/ I in
Reasonable if used with
in acute management of
pts with severe
decompensated AS (Stage
D)NYHA CLASS IV
II b C
INDICATION CLASS RECOMMENDATION
ECHO I B Pts with bicuspid AV ,to know severity of
AS/AR,shape , diameter of aortic sinuses, ascending
MRI/CT angio I B MRI,CT angio when the above cannot be assessed by
I B Serial evaluation is needed in BAV, aortic diameter
>4.0 cm ,frequency determined by progression of
dilation(annually if >4.5 cm).
No proven therapies.(previously B Blockers,ARBs)
Intervention I B If diameter of aortic sinuses or Asc aorta >5.5 cm.
II a B If diameter of aortic sinuses or asc. Aorta >5.0
cm,risk for dissection present (family h/o)rate being
IIa B Replacement of Asc aorta if pts having severe
AS/AR when Asc aorta >4.5 cm
• Incidence of aortic dilation is higher in patients with fusion of
right or left and the non coronary cusps than the more common
phenotype of fusion of the right and left non coronary
cusps.(68% vs 40% ).
• Report of a patient with BAV – aortic measurements at the aortic
annulus,sinuses,sinotubular junction and mid –ascending aorta.
• Aortic diameters by MRI/CT typically are 1 mm to 2mm larger
than by 2d echo – inclusion of aortic wall in measurement.
• 20-30% of pts with BAV ,other family members also have
bicuspid aortic valve /aortopathy –specific gene not been
identified, patterns of inheritance variable.
• Mean rate of diameter progression was 0.5 mm/yr at the sinuses of
valsalva,0.5 mm/yr at the sinotubular junction,0.9 mm/yr at the
proximal ascending aorta.
• Previous guidelines recommended surgery when diameter >5.0cm at
• Surgery is recommended presently if diameter is 5.1-5.5 cm only if
there is a family h/o aortic dissection or rapid progression of
dilation(>0.5cm/yr). (in all others >5.5 cm).
• Does not recommend the application of formulas to adjust diameter to
• Replacement of sinuses of valsalva when considering asc aorta
replacement, is not necessary in all cases (pts with BAV and AS/AR).
Bicuspid Aortic Valve M Mode Echo
NORMAL – 1.0 -1.5
BAV – 1.5-5.6
INDICATION CLASS RECOMMENDATION
ECHO I B Diagnosis, quantify hemodynamic severity , assess concomitant
valvular lesions, and demonstrate valve morphology.
I B Assess the presence or absence of left atrial thrombus and to
further evaluate the severity of MR.
I C Evaluate the response of the mean mitral gradient and
pulmonary artery pressure in patients with MS when there is a
discrepancy between resting Doppler echocardiographic
findings and clinical symptoms or signs.
I B Anticoagulation MS with AF,MS with prior embolic event
.,MS and left atrial thrombus
II a C Heart rate control can be beneficial in patients with MS and
AF and fast ventricular response.
II b B Heart rate control may be considered for patients with MS in
normal sinus rhythm and symptoms associated with exercise
• Definition of severe MS is based on the severity at which
symptoms occur as well as the severity at which intervention will
improve symptoms.(MVA <1.5cm2 is considered severe).
• Transmitral gradient of >5-10 mm Hg at normal heart rate.
• DPHT is dependent not only on mitral obstruction,also on
compliance of LA,LV.
• Doppler hemodynamics (apical 4 C view)- peak and mean TVG
–averaged from 3-5 beats in SR,5-10 in AF.
• Heart rate should always to be included in the report.
• RVSP >60-70mm Hg on exercise.
• 30-40% pts with MS will develop AF.
• A reduction in the diastolic interval from 604 milliseconds to
219 msec as heart rate increased from 60-120 bpm,indicating a
63% reduction in total diastolic time.for maintaining same
cardiac output a 38% increase in mean flow rate during
diastole ,which by bernoulli equation ,requires an increase in
mean mitral gradient by 90%.
• Moderate to severe MS – 0.09cm2/yr.
• Usually takes the form of a parachute mitral valve(mitral
chordae are attached to a single or dominant papillary
Form a component of shone complex
• Supramitral rings
• Valvular or subvalvular AS
• Aortic coarctation
Why does murmur of acute MR
• The rapid systolic rise in LA pressure with a concomitant fall in
LV systolic pressure limits the pressure gradient driving MR to
early systole. – short and unimpressive MR.
• Torrential MR – no murmur – rapid equalisation of LA and LV
• Vasodilator therapy
• IABP –by lowering systolic aortic pressure,decreases LV
afterload,increases forward output
• Increases diastolic mean aortic pressure –systemic circulation
• Chordae tendinae –repair
TTE I B LV size and function, RV function and left atrial size,
PAP, severity of primary MR (stages A to D)
CMR I B Assess LV and RV volumes, function, or MR severity when not satisfactorily
addressed by TTE
TEE I B Establish the anatomic basis for chronic primary MR (stages C
and D) and to guide repair
I C When noninvasive imaging provides nondiagnostic information about severity of
MR, mechanism of MR, and/or status of LV function.
EST II a
Exercise hemodynamics reasonable in symptomatic patients with chronic
primary MR ,in discrepancy between symptoms and the severity of MR at rest
Exercise treadmill testing can be useful in patients with chronic primary MR to
establish symptom status and exercise tolerance
RX II a
Medical therapy for systolic dysfunction is reasonable in symptomatic patients
with chronic primary MR (stage D) and LVEF less than 60% in whom surgery is
III B Vasodilator therapy is not indicated for normotensive asymptomatic patients with
chronic primary MR (stages B and C1) and normal systolic LV function
Described by Alfieri
Originally for MR with MVP
EVEREST II trial
TTE I C
PAP ,PVR invasive I C
CMR ,3D echo IIb C
Exercise testing IIb C
diuretics IIa C
Reduce PAP (functional TR) IIb C
TTE I C Assess the anatomy,evaluate
sided valve disease
II b C Symptoms and noninvasive data are
Medical therapy Loop diruetics
Intervention I C Severe TS at the time of operation for
left sided valve disease
I C Isolated symptomatic severeTS
II b C PBTV in absence of TR
TTE I B Evaluation of valve hemodynamics after
implantation(6 weeks to 3 months)
Repeat TTE I C change in symptoms
TEE I C Prosthetic valve dysfuncton(accurate for
mitral valve dysfunction)
Annual TTE II a C Bioprosthetic valves after the first 10
rupture of a valve
Present with HF
Acute or chronic
Earlier evaluation may be prudent in selected patients at risk of
early bioprosthetic valve degeneration –
• Renal impairement
• Diabetes mellitus
• Abnormal calcium metabolism
• Systemic inflammatory disease
• Patients <60 yrs of age.
• Patients are usually asymptomatic until valve dysfunction is
Rahimtoola et al,J Am Coll Cardiol.2010;55:2413-26
Kappetein et al,J Thorac Cardiovasc Surg,2009;137:881-5
• Patient – prosthetic mismatch.
• Aortic annular enlarging procedures.
• Risk of need for reoperation with a bioprosthetic valve is
inversely related to the patient’s age at the time of implantation.
20 yrs of age at the
time of implantation
70 yrs of age at time of
Rate of structural deterioration 15-20 yrs
Pibarot et al,Circulation 2009;119:1034-48
Pibarot et al,Circulation2006;92:1022-29
Bioprosthetic valve vs Mechanical valve
• Prospective randomized study , 1977 and 1982
• 575 pts
• Older generation mechanical vs bioprosthetic valve
replacement (Bjork-Shiley spherical disc mechanical
prosthesis or a Hancock porcine bioprosthetic valve).
• Overall survival was similar at 15 yrs in both groups.
AVR 26% 0% 0.0001
MVR 44% 4 %
VETERANS AFFAIRS randomized trial. J Am Coll Cardiol2000;36:1152-8.
structural deterioration and
Age at the time of implantation and primary
structural deterioration in
BIOPROSTHETIC VALVE IMPLANTATION
RahimtoolaSH et al ,J Am Coll Cardiol .2010;55:2413-26
Edinburgh Heart Valve Study
• Outcomes are similar with implantation of either a bioprosthetic
or mechanical valve for patients between 60 -70 yrs of age.
• 533 pts
• Mean age 54.4 +/-10.4 yrs.
• Bjork Shiley mechanical prosthesis or a porcine prosthesis
• No difference in long term survival(p=0.39)
Wheatley DJ et al,Heart 2003;89:715-21
• 310 pts
• 55-70 yrs of age
• No difference in overall survival at 13 yrs
• Thromboembolism,bleeding,IE,and major adverse prosthesis
related events were no different between the two valve types.
• Valve failures (p= 0.0001) ,reoperations were more frequent in
the bioprosthetic group (p=0.0003)
Banbury MK,et al Long-term results of the Carpentier-Edwards pericardial aortic valvee: a 12 year follow-up.
Ann Thorac Surg 1998;66Suppl:73– 6.
Society for Cardiothoracic Surgery
in the Great Britain and Ireland
• 2004-2009,Bioprosthesis at the time of valve replacement
• 41,227 pts
60-65 yrs 65-70 yrs >70 yrs
Dunning et al,J Thorac Cardiovascular Surg 2011;142:776-82
Replacement of the aortic valve with a pulmonary autograft,
Replacing the pulmonary valve with a homograft.
• Requires an experienced surgical team
Failure is most often due to regurgitation of the pulmonary
autograft (the neoaortic valve ) in the second decade after the
• Regurgitation is typically due to
• leaflet prolapse ( if implanted in the subcoronary position )
• Aortic sinus dilation (if implanted starting at the aortic sinuses)
• Placing the pulmonary valve within a dacron conduit.
• Neoaortic valve in subcoronary position with a reinforced native
Anticoagulation with a VKA and INR monitoring is recommended
in pts with a mechanical prosthetic valve
CLASS I A
Anticoagulation with VKA to achieve INR 2.5 is recommended in
mechanical AVR ,no riskfactors for thromboembolism
CLASS I B
VKA ,INR -3.0 in pts with mechanical AVR ,additional risk factors for
thromboembolism,older generation mechanical AVR
CLASS I B
VKA,INR -3.0 in mitral mechanical valve pts CLASS I B
Aspirin 75-100 mg in addition to VKA in mechanical prosthesis pts CLASS I A
Aspirin 75-100 mg in all pts with bioprosthetic aortic or mitral valve CLASS II a B
Anticoagulation with VKA – INR 2.5 reasonable in bioprosthetic
MVR or repair ,first 3 months
CLASS II a C
Anticoagulation with VKA – INR 2.5 reasonable after bioprosthetic
CLASS II b B
Clopidogrel 75 mg daily may be reasonable for first 6 months after
TAVR in addition to life long aspirin 75-100mg daily
CLASS II b C
Anticoagulation with oral direct thrombin inhibitors or anti Xa agents
should not be used in mechanical prosthesis patients
Strive to attain the single INR value.
• It is preferable to specify a single INR target in each patient,
recognizing that the acceptable range is 0.5 INR units on each
side of this target, this is preferable because it avoids patients
having INR values consistently near the upper or lower edge of
• Fluctuations in INR are assosciated with increased incidence of
complications in pts with prosthetic valves.
• Rate of thromboembolism in patients with bileaflet mechanical AVR
on VKA and antiplatelet regimen in 0.53% per patient year over the
INR range of 2.0 -4.5.
LOWERING –IT trial ,Am H J 2010;160:171-8
Adverse events increased if INR was >4.0.
• New generation AVR ,without other risk factors for
thromboembolism , risk of thromboembolism was similar,
risk of hemorrhage is lower in group with an INR of 2.0 -3.0 vs INR
3.0- 4.5(p<0.01) Chest 2005;127:53-9.
• INR 1.5-2.5 vs INR 2.0 -3.0 – noninferior ,quality of evidence was
AREVA trial ,Circulation,1996;94:2107-12
• Preferred INR is 2.5 – bileaflet and single tilting disc in aortic position
(low thromboembolic risk pts)
Preferred target INR
CONDITION INR RANGE
AVR bileaflet ,current generation single tilting
disc (Medtronic hall)
2.5 2.0 -3.0
Additional risk factors for
Ball in cage valve (Starr Edwards valve) 3.0 2.5-3.5
MVR All types of mechanical valves 3.0 2.5-3.5
G erman Experience with Low Intensity Anticoagulation
• Mechanical mitral prosthesis (St Jude Medical valve)
• Low INR (2.0 -3.5) was assosciated with lower survival rates
than a higher target INR range (2.5-4.5) in those with a
• Patient compliance is challenging with higher INR goals
INR WITHIN RANGE
2.0 -3.5 74.5%
3.0 -4.5 44.5%
Role of Aspirin
• Aspirin is recommended in all patients with prosthetic heart
valves (incl. mechanical valves with VKA therapy)
• Risk of thromboembolism with VKA – 1 -2%/yr.
EVENTS VKA VKA plus aspirin p value
8.5% 1.9% < 0.001
Stroke rate 4.2% 1.3% <0.027
Overall mortality 7.4% 2.8% <0.01
Risk of minor
Major bleeding 6.6% 8.5% 0.43
LIWACAP study ,Clin Appl Thrombo hemostst 2007;13:241-8.
The risk of GI irritation and hemorrhage with Aspirin
dose dependent over the range of 100mg-1,000 mg /day,
but the antiplatelet effects
independent of dose over this range.
LIWACAP study;Clin Appl Thromb Hemost.2007;13:241-8
• Risk of clinical thromboembolism –average 0.7%/yr in pts
with biological valves in sinus rhythm.
• Mitral > Aortic (2.4% vs 1.9%)
• St JUDE MEDICAL EPIC heart valve bioprosthesis(AVR)
• Incidence of thromboembolic events,bleeding,death was
similar between those who received aspirin or warfarin.
• No studies examining the long term effects of antiplatelet
agents in patients with bioprosthetic MVR or mitral valve
WoA epic pilot trial.J Heart Valve Disease 2007;16:667-71
Risk of stroke after all types of
mitral valve surgery
30 days 180 days 5 years
Eur J Thoracic Surg1995;615-9
Risk of ischemic stroke
Surgery Within 30 days at 5 yrs P value
Mitral valve repair 1.5% 6.1% 0.9% <0.0001
Bioprosthetic 4.6% 8.0% 2.1%
Mechanical 1.3% 16.1% 2.7% <0.001
Anticoagulation with a VKA in bioprosthetic AVR
Anticoagulation with an INR target of 2.5 may be reasonable
for atleast 3 months
and perhaps as long as 6 months after bioprosthetic AVR
Not treated with VKA Treated with VKA
Strokes per 100 person
CV event rate at 6
Antiplatelet therapy after TAVR
• Small prospective RCT
• Single center study
• 79 pts with self expanding TAVR
Aspirin P value
Events at 30 days 13% 15% 0.71
6 months 18% 15% 0.85
RE ALIGN trial
• Randomized ,Phase II Study to Evaluate the Safety and
Pharmacokinetics of Oral Dabigatran Etexilate in Patients after
Heart Valve Replacement
• Stopped prematurely for excessive thrombotic complications in
• 252 pts
Ischemic stroke 9 pts (5%) nil
Composite end point of
15 pts (9%) 4 pts (5%)
Major bleeding episode 7 pts( 4%) 2 pts (2%)
Bleeding of any type 45 pts (27%) 10 pts (12%)
Am Heart J,2012;163:931-7.
Bridging therapy for prosthetic valves
VKA anticoagulation with
INR in range in pts with
I C Minor procedures (dental
Temporary interruption in
bridging in bileaflet
I C Invasive or surgical procedure
INR <1.5 (stop warfarin 2-4
days before procedure)
Mechanical AVR + thrombotic
risk factor, older generation
I C Invasive or surgical procedure
FFP or IV prothrombin II a C Emergency noncardiac
• Usually UFH ,or SC LMWH used
• Stop warfarin 2-4 days before surgery (INR<1.5),start 24
hrs after surgery.
• Start IV UFH (48 hrs before surgery )and stopped 4-6 hrs
(IVUFH)or 12 hrs (for SC LMWH )before the procedure.
• For procedures with a low bleeding risk,such as coronary
angiography from the radial approach,only slight
modification in VKA dosing is needed.
• With interventional procedures at higher risk,many prefer to
stop VKA anticoagulation and use bridging therapy as is
done for other surgical procedures.
ACCP ,Evidence based guidelines for thrombotic management,CHEST april 2012
Excessive anticoagualtion and serious
• INR >5.0 –risk of hemorrhage.
• Rapid decrease in INR below therapuetic range – risk of
• High dose vitamin K not given routinely,creates a
• 5-10 INR ,withold VKA,serial INR
• INR>10 ,not bleeding – 1-2.5 mg oral vitamin K1
(phytonadione) in addition to witholding VKA therapy.
• Emergency conditions –FFP,prothrombin complex –
• Mechanical valve 1-2%
• Bioprosthetic valve 0.7%
• Embolic events do occur even when in therapeutic range.
• AVR 2.5
• AVR+RISK FACTORS
(AF,previous TE, hypercoagulable condition ,older gen ,LVSD,
>1 mechanical valve ) 3.0
• MVR 3.0
• Time in therapuetic range is only 60-70%
• Increase INR 2.5 3.0 in AVR,
3.0 4.0 in MVR
PROSTHETIC VALVE THROMBOSIS
• Mechanical PVT – prevalence is 0.3% to 1.3% per pt yr in developed
• 6.1% per patient year in developing countries.
• TEE more sensitive for detection of valve thrombosis, mitral valve.
• Prior history of stroke,thrombosis area by TEE are independent
predictors of complications after thrombolysis.
• A thrombus area <0.8cm2 – lower risk of complications from
thrombolysis irrespective of NYHA classification.
• Fluoroscopy,CT imaging for prosthetic aortic valves.
CLASS II a B Fibrinolytic therapy is reasonable for patients with a
thrombosed left sided prosthetic heart valve ,recent onset
(<14 days) of NYHA class I –II symptoms and a small
CLASS II a B Fibrinolytic therapy is reasonable for right sided
prosthetic heart valves
CLASS I B Emergency surgery is recommended in pts with a
thrombosed left sided prosthetic heart valve with NYHA
CLASS IIa B Emergency surgery is reasonable for patients with a
thrombosed left sided prosthetic heart valve with a
mobile or large thrombus >0.8cm2
Factors that predict adverse outcomes
from fibrinolytic therapy
• Active internal bleeding
• History of hemorrhagic stroke
• Recent cranial trauma/neoplasm
• Diabetic hemorrhagic retinopathy
• Large thrombi
• Mobile thrombi
• Systemic hypertension (>200/120 mm Hg)
• NYHA III/IV
• Fibrinolytic therapy of a left sided obstructed prosthetic valve is
assosciated with an overall rate of thromboembolism and
bleeding of 17.8%,the degree of risk is directly proportional
to thrombus size.
• A mobile thrombus or a length of >5 -10 mm – increased
• >1.0 cm or 0.8cm2 area – 2.4 fold increase in embolism risk per
1.0cm2 increase in size.
rTPA 10 mg IV bolus – 90 mg infused IV over 2 hours.
Heparin,GPIIb/IIIa held,aspirin continued
20 mg IV bolus – 10 mg per hour for 3 hours
STREPTOKINASE 5,00,000 IU in 20 minutes – 15,00,000 IU over 10
UROKINASE Less effective
If fibrinolytic therapy is successful ,it is followed by IV UFH
until VKA achieves an INR of 3.0 -4.0 for aortic prosthetic
valves and 3.5-4.5 for mitral prosthetic valves
J Am Coll Cardiol 1997;30:1521-6
Surgery vs fibrinolytic therapy in
patients with left sided PHVT
• Success rate - 90% with surgery.
No difference in mortality between two groups.
THROMBOEMBOLISM 1.6% 16%
MAJOR BLEEDING 1.4% 5%
RECURRENT PVT 7.1% 25.4%
Karthikeyan et al,Eur Heart Journal,2013:34:1557-66
• Mortality rate was 17.6% pts with NYHA class IV, 4.7% in
pts with NYHA class I –III.
• Mortality was similar for removing the thrombus or replacing
the entire prosthetic valve.
• In pts with recent hemorrhagic stroke,surgery is a better option.
Guidelines for management of left sided prosthetic valve thrombosis,JACC,1997;30:1521-6
PROSTHETIC VALVE STENOSIS
• Mechanical valve - chronic thrombus or pannus
• Bioprosthetic valve ----- leaflet fibrosis ,calcification
• Patient –prosthesis mismatch – prosthesis functions normally.
Indexed effective orifice area <0.85cm2 for AV prosthesis.
Severe patient –prosthesis mismatch - <0.65cm2/m2
Detrimental in pts with low LVEF.
Can be avoided by adequate indexed orifice area (pts body
• No medical therapy for prevention
• Valve in valve approach.(not fully validated)
• For mechanical valve – consider bioprosthetic valve at reoperation,if
noncompliant is the cause
PROSTHETIC VALVE REGURGITATION
• TEE –clear images of the LA side of mitral
prosthesis,delineation,severity of paravalvular MR.
• No medical therapies.
• Intractable hemolysis or HF due to severe mechanical
Prosthetic/paraprosthetic valve regurgitation - surgery indicated (I
• Severe symptomatic or asymptomatic bioprosthetic regurgitation –
(II a C)
• Catheter based approaches in high risk for surgery -II a B
Procedural death <2%
• In hospital mortality rate - 15-20%
• 1 yr mortality rate - 40%
• Overall incidence of IE – 3-10/100,000 pt –yrs
• Higher prevalence in older patients.
• IE associated with prosthetic,intracardiac – 50 times more
compared to general population.
Class I C At least 2 sets of blood culture should be obtained in patients at risk of IE ,who
have unexplained fever for more than 48 hours,pts with a new diagnosis of left
sided valve regurgitation
Class I B Modified duke criteria for evaluation of pt with suspected IE.
Class I B Intraoperative TEE in pts undergoing valve surgery for IE
Class II a B TEE to diagnose IE in pts with Staph.aureus bacteremia without a known
Class II a B TEE in pts with prosthetic valve ,fever ,no murmur,no bacteremia
Class II a B Cardiac CT when echo not conclusive
Class II a B Temporarily discontinue anticoagulation in pts with IE who develop CNS
compatible with embolism/stroke regardless of indications for anticoagulation
Class I B Early surgery in pts with HF
Class I B Early surgery n left sided IE by S.aureus,fungal
Class I B Early surgery if there is heart block,annular or aortic abscess
• In patients with chronic (subacute ) – 3 sets of blood
• Blood cultures are positive 90% of pts with IE.
• 10% - serology.
• 3/4ths of pts with IE are diagnosed within 30 days of onset
of infection- classic features are absent.
In hospital mortality 15-20%
1 yr mortality rate 40%
Embolization other than stroke 22.6%
Intracardiac abscess 14.4%
Need for surgical therapy 48.2%
Arch Internal Med2009;169:463-73.
TTE sensitivity 50-90% 36-69%
TEE sensitivity 90-100% lower
PPV 90% 90%
1.Anterior aspect of a
prosthetic aortic valve
2.Aortic transvalvular gradient
3.Vegetations and perivalvular
4.Active and healed
5.Thickened valves or valvular
nodules and vegetations
Most vegetations 83.8% remain constant in size under therapy
and this does not worsen prognosis
Right sided pacemaker leads IE – intracardiac echo
• PVE – less incidence of vegetations(mechanical) ,higher
incidence of annular abscess and other paravalvular
• 15-35% of all pts with IE develop clinically evident
emboli.(CMR - >30%)
• MC cause of stroke in pts with IE – septic embolus
resulting in ischemia –with hemorrhagic transformation
later -11 days later also.
• Death may occur suddenly in pts with endocarditis induced
HF ,if aortic valve is involved.
IE pts with HF Rx with surgery Medical Rx
inhospital mortality 21% 45%
1 yr mortality 29.1% 58.4%
In complicated left heart NVE -4 baseline features
have been independently assosciated with 6 month mortality
Abnormal mental status
Moderate –to severe HF
Bacterial etiology other than viridans
Medical therapy alone
Reinfection is more common in injectable drug users (5-10% pts)
Repair better than replacement
EARLY <60 days of surgery Health care acquired
infection - S. aureus
INTERMEDIATE 60-365 days after surgery Health care +community
acquired – coagulase
2/3 cases of PVE
LATE >1 yr after surgery Resembles NVE
INJECTABLE DRUG USERS MORTALITY
Staphylococcus <5% *right sided 20-30%*left sided
• 20-40% pts with IE.
• Incidence decreases to 9-21% on antibiotic use
• New embolic event occurs if vegetation >10 mm,anterior mitral
• Risk of embolism is highest during the first days after initiation
of antibiotic treatment and decreases after 2 weeks.
• Surgical intervention is needed in case of staphylococcal PVE.
NATIVE VALVE STENOSIS
Medical therapy I C MS WITH AF
II a C Bblockers for rate control in AF(metoprolol)
II b C Diuretics in MS and HF
III ACEI/ARBS not to be given in pts with valve
Intervention I C Before pregnancy ,Severe symptomatic AS
I C Before pregnancy ,Severe symptomatic MS
Before pregnancy ,PBMV in asymptomatic severe
For pregnant pts ,with MS ,in HF despite medical
II a C Before pregnancy ,Severe asymptomatic AS
III Valve operation in absence of HF symptoms
AORTIC STENOSIS MITRAL STENOSIS
HF 10-44% 75%
Risk of arrhythmia 25% 75%
increased incidence of
Valve operation 30-40%
No ideal time
High pump flows and
NATIVE VALVE REGURGITATION
• Symptomatic pts - High risk of HF during pregnancy
• Valve repair is ideal.
• Threshold to be higher
CLASS I C Valve repair or replacement before pregnancy for symptomatic women
with severe valvular regurgitation
CLASS II a C Valve operation for pregnant with severe valvular regurgitation only if
there are refractory NYHA class IV HF symptoms
CLASS IIb C Valve repair Before pregnancy may be considered in asymptomatic pts
with severe MR
CLASS III Not to be performed in pregnancy in absence of HF symtpoms (NYHA
• Risk of embryopathy is dose dependent
• <3% - <5 mg/day
• >8% - >5mg/day
INTERVENTION FOR AF
Class II a C A concomitant MAZE procedure at time of MV
repair/replacement for Rx of chronic persistent AF.
Class II a B A full biatrial MAZE procedure
Class II b C Concomitant maze or pulmonary vein isolation in
patients with paroxsymal AF with h/o embolism on
Class II b C Concomitant maze or pulmonary vein isolation at time
of other cardiac surgeries with paroxysmal AF
Class III Catheter ablation in pts with severe MR in place of
combined maze procedure plus mitral repair.
MAZE I - initial incisons deep into the atrial wall,open sternotomy,CP bypass
MAZE II -
MAZE III – cut and sew (1992)
MAZE IV – cryoablative /radiofrequency
"Maze" refers to the series of incisions arranged in a maze -like pattern in the
atria. Today, various methods of minimally invasive maze procedures,
collectively named mini maze procedures, are used.
James Cox in 1987.
Non cardiac surgery in HVD
• Rate of cardiac complications in undiagnosed severe AS
undergoing noncardiac surgery is 10-30%.
• 30 day mortality high for pts with AS 2.1%
• HIGH risk of post operative MI in AS pts.
• Tachycardia to be avoided in AS. DC shock for conversiob in
• CCB s for HTN
• Phenylephrine is useful.
• High dilution neuraxial local anaesthetic
• MS – IV fluids cautious
• Regional anaesthesia in AR/MR
• Preload to be maintained
• 48-72 hrs post op
CLASS IIa B Moderate risk elective noncardiac surgery,
asymptomatic severe AS.
CLASS II a C Moderate risk elective noncardiac surgery,
CLASS II a C Moderate risk elective non cardiac surgery
asymtpomatic sevvere AR,normal LVEF
CLASS II b C Moderate risk in pts with asymptomatic severe MS ,not
favourable for PBMV
EVIDENCE GAPS AND FUTURE DIRECTIONS
• Vaccine development
• At risk of calcific aortic stenosis – therapies to prevent
• Values of measures of LV size,volumes,myocardial structure
immediately after intervention.