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    1. 1. Dr.NagulaPraveen
    2. 2. Rick A.Nishimura,M.D.,FACC Catherine M.Otto,MD.,FACC
    3. 3. Introduction • Diagnosis and management of adults with valvular heart disease. • Original VHD guidelines in 1998 – revised in 2006 – updated in 2008. • Evidence based recommendations are made.
    5. 5. Frequency of Echocardiogram in Asymptomatic pts with VHD
    6. 6. Secondary Prevention of Rheumatic fever
    7. 7. Duration of Secondary Prophylaxis for Rheumatic Fever
    8. 8. STS PROM • 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. AORTIC VALVE OPERATIONS PROM MEAN MORTALITY RATE 80% <4% 1.4% 14% 4%-8% 5.1% 6% >8% 11.1%
    9. 9. SEVEN FRAILTY INDICES Katz Activities of daily living • Independence in feeding • Bathing • Dressing • Transferring • Toileting • Urinary continence Independence in ambulation • No walking aid or Assist required or Walk 5 meter < 6 sec. PROCEDURE SPECIFIC IMPEDIMENT Tracheostomy , Heavily calcified ascending aorta, Chest deformity,arterial coronary graft adherent to chest wall, Radiation damage
    10. 10. MAJOR ORGAN SYSTEM COMPROMISE • Cardiac- • Severe LV systolic dysfunction • Severe LV diastolic dysfunction • RV dysfunction • Fixed pulmonary HTN • CKD stage 3 or more • Pulmonary dysfunction with FEV1 <50%,DLCO2 <50% of predicted value • CNS dysfunction • Dementia • Alzhemiers disease • Parkinson’s disease • CVA with persistent physical limitation • GI dysfunction • Crohn’s disease • UC • Serum albumin <3.0 gm/dl • Cancer –active malignancy • Liver –cirrhosis,variceal bleed • Elevated INR
    11. 11. Does all patients need intervention? • http://riskcalc.sts.org/de.aspx NO • Life expectancy less than 1 yr. • Chance of survival with benefit <25% at 2yrs. • Improvement of NYHA by one class
    12. 12. -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 Medical therapy Timing of intervention Choice of intervention
    13. 13. Aortic Stenosis Aortic Regurgitation Bicuspid Aortic valve and Aortopathy Mitral Stenosis Mitral Regurgitation Tricuspid valve disease Pulmonic valve disease Mixed valve disease Prosthetic valves Infective Endocarditis Pregnancy and VHD Surgical considerations Non cardiac surgery in patients with VHD Evidence gaps and future directions
    15. 15. Stages of Valvular AS Each of these stages is defined by • Valve anatomy, • Valve hemodynamics, • The consequences of valve obstruction on left ventricle and vasculature, • Patient symptoms.
    16. 16. Hemodynamic severity is best characterized by the transaortic maximum velocity or Mean Pressure Gradient when the transaortic volume flow rate is normal.
    18. 18. Stages C1 and C2
    19. 19. 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 stroke volume. • Diagnostic and management challenge. Designated as • D2 (with a low LV EF) • D3 ( with a normal LVEF).
    20. 20. 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. Exercise testing IIaB Asymptomatic pts >4m/sec , MPG >40 mmHg. III B Symptomatic pts with >4m /sec , MPG>40 mmHg Medical therapy 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 calcific.
    21. 21. Dobutamine Stress Echocardiography • To be done in patients with severe AS(due to small valve area) and concurrent LV systolic dysfunction.(usually have MPG <40 mmHg). • 1.Severe AS with LV systolic dysfunction due to afterload mismatch. • 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
    22. 22. • 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 Reserve. • Very poor prognosis with either medical or surgical therapy.
    23. 23. What is the rate of progression of Aortic Stenosis? AORTIC STENOSIS PROGRESSION/EVENT FREE SURVIVAL Severe AS (asymptomatic – sympotmatic) 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
    24. 24. What are the symptoms in favour of AS in ExerciseTesting? • 1.Exercise induced angina • 2.Excessive dyspnea early in exercise • 3.dizziness • 4.syncope • 5.abnormal BP response(<20 mm Hg increase) • 6.ST-T abnormalities .
    26. 26. SEAS study • 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 been reported. • 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).
    27. 27. 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.
    28. 28. ASTRONOMER STUDY AORTIC STENOSIS PROGRESSION OBSERVATION MEASURING EFFECTS OF ROSUVASTATIN (ASTRONOMER) STUDY. • 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 groups. • There was increased diastolic dysfunction from baseline to follow-up in each of the placebo and rosuvastatin groups.
    29. 29. Conclusions • 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 groups.
    30. 30. I C II b C II b C
    31. 31. N N II b C
    32. 32. Choice of Surgical or Transcatheter intervention
    33. 33. TAVR • TAVI VIDEO • Dr Alain Cribier pioneered the first transcatheter aortic valve implantation (TAVI) procedure in 2002
    34. 34. TAVR PARTNER trial. FRANCE study. Antegrade – Acute MR Retrograde approaches Transfemoral approach Transapical approach 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.
    35. 35. 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 Medtronic CoreValve). • 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 conditions. • 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 ,
    36. 36. 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?
    37. 37. • Severe Asymptomatic aortic stenosis with LV dysfunction(StageC2) • Dobutamine stress echo • See for contractile reserve • Even if reserve absent ,Take him for surgery • Benefit is present.
    38. 38. Case 2 A 38 yr old male,labourer by occupation,k/c/o RHD on regular penicillin prophylaxis was evaluated by echo on routine follow up. • 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?
    39. 39. • Asymptomatic severe AS (C1) • Exercise stress test • Look for symptoms,exercise tolerance • If present,decreased exercise tolerance • Take him for surgery.
    40. 40. Case 3 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?
    41. 41. • He would have high surgical risk • He should be taken for TAVI.
    42. 42. Case 4 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?
    43. 43. • He would not be benefited by surgery • Increased risk of mortality,morbidity as there are other organ system compromise • Medical management
    45. 45. Stage D AR
    46. 46. 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.
    47. 47. 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.. DRUG REFERENCE 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 Hydralazine Circulation.1980:62:48-55 Nifedipine JACC,1984;4;902-7. Nifedipine vs Captopril JACC 1993
    48. 48. VASODILATOR THERAPY REGURGITANT LESIONS CHRONIC AORTIC REGURGITATION Treatment of hypertension (SBP>140 mmHg ) for chronic stage (Band C)with CCBs /ACEI/ARBs CLASS I B Medical therapy with ACEI/ARBs in pts with severe AR and LV dysfunction when surgery is not performed because of comorbidities CLASS II a B MITRAL Vasodilator therapy is useful to improve hemodynamic compensation in Acute MR Vasodilator therapy in symptomatic pts with chronic primary MR LVEF< 60%,in whom surgery is not preferred Class II aB C/ I in asymptom atic patients STENOTIC LESIONS AORTIC STENOSIS Reasonable if used with hemodynamic monittoring in acute management of pts with severe decompensated AS (Stage D)NYHA CLASS IV symtpoms II b C
    50. 50. INDICATION CLASS RECOMMENDATION ECHO I B Pts with bicuspid AV ,to know severity of AS/AR,shape , diameter of aortic sinuses, ascending aorta. MRI/CT angio I B MRI,CT angio when the above cannot be assessed by echocardiography. I B Serial evaluation is needed in BAV, aortic diameter >4.0 cm ,frequency determined by progression of dilation(annually if >4.5 cm). Medical therapy 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 0.5cm/year. IIa B Replacement of Asc aorta if pts having severe AS/AR when Asc aorta >4.5 cm N
    51. 51. • 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.
    52. 52. • 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 any level. • 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 body size. • Replacement of sinuses of valsalva when considering asc aorta replacement, is not necessary in all cases (pts with BAV and AS/AR).
    53. 53. Bicuspid Aortic Valve M Mode Echo NORMAL – 1.0 -1.5 BAV – 1.5-5.6
    55. 55. 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. Medical therapy 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
    56. 56. • 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.
    57. 57. • 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. •
    58. 58. Congenital MS • Usually takes the form of a parachute mitral valve(mitral chordae are attached to a single or dominant papillary muscle Form a component of shone complex Includes • Supramitral rings • Valvular or subvalvular AS • Aortic coarctation
    61. 61. Why does murmur of acute MR not holosystolic • 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 pressures. • Vasodilator therapy • IABP –by lowering systolic aortic pressure,decreases LV afterload,increases forward output • Increases diastolic mean aortic pressure –systemic circulation • Chordae tendinae –repair
    62. 62. 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 B Exercise hemodynamics reasonable in symptomatic patients with chronic primary MR ,in discrepancy between symptoms and the severity of MR at rest II a C Exercise treadmill testing can be useful in patients with chronic primary MR to establish symptom status and exercise tolerance RX II a B 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 not contemplated. III B Vasodilator therapy is not indicated for normotensive asymptomatic patients with chronic primary MR (stages B and C1) and normal systolic LV function
    63. 63. Mitra clip MITRACLIP VIDEO Described by Alfieri Originally for MR with MVP EVEREST II trial
    65. 65. 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
    66. 66. CLASS RECOMMENDATION TTE I C Assess the anatomy,evaluate severity,associated regurgitation,left sided valve disease Invasive hemodynamics II b C Symptoms and noninvasive data are discordant 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
    68. 68. • ..DocumentsTranscutaneous Pulmonary Valve implantation.mp4
    70. 70. CLASS RECOMMENDATIONS 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 years
    71. 71. PROSTHETIC VALVE DYSFUNCTION BIOPROSTHETIC VALVE DYSFUNCTION INSIDIOUS ONSET Exterional dyspnea, Louder systolic murmur New diastolic murmur ABRUPT ONSET Valve endocarditis Degenerative rupture of a valve cusp MECHANICAL VALVE DYSFUNCTION Present with HF symptoms Systemic thromboembolism Hemolysis Often acute/subacute Acute or chronic paravalvular regurgitation – IE,suture dehiscence
    72. 72. 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 severe. Rahimtoola et al,J Am Coll Cardiol.2010;55:2413-26 Kappetein et al,J Thorac Cardiovasc Surg,2009;137:881-5
    73. 73. IIa C 65 yrs
    74. 74. • 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 implantation 90% 10% Rate of structural deterioration 15-20 yrs after implantation Pibarot et al,Circulation 2009;119:1034-48 Pibarot et al,Circulation2006;92:1022-29
    75. 75. 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. PRIMARY VALVE FAILURE BIOPROSTHETIC VALVE MECHANICAL VALVE P VALUE AGE <65 yrs AVR 26% 0% 0.0001 MVR 44% 4 % VETERANS AFFAIRS randomized trial. J Am Coll Cardiol2000;36:1152-8.
    76. 76. 0% 20% 40% 60% 80% 100% 50 yrs 40 yrs 30 yrs 20 yrs 40% 55% 75% 90% structural deterioration and reoperation 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
    77. 77. 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
    78. 78. Italian study • 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.
    79. 79. Society for Cardiothoracic Surgery in the Great Britain and Ireland National Database • 2004-2009,Bioprosthesis at the time of valve replacement • 41,227 pts 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 60-65 yrs 65-70 yrs >70 yrs 37% 62% 87% 55% 78% 96% initial final Dunning et al,J Thorac Cardiovascular Surg 2011;142:776-82
    80. 80. Ross procedure 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 operation. • 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 aorta.
    82. 82. 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 AVR 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 CLASS III HARMIII HARM B
    83. 83. 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 the range. • Fluctuations in INR are assosciated with increased incidence of complications in pts with prosthetic valves.
    84. 84. Mechanical valves Thrombogenecity of prosthetic material intravascularly Zones of low flow Platelet activation Areas of high shear stress Effects of mechanical valve Valve thrombosis Embolic events
    85. 85. • 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 low. AREVA trial ,Circulation,1996;94:2107-12 • Preferred INR is 2.5 – bileaflet and single tilting disc in aortic position (low thromboembolic risk pts)
    86. 86. 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 thromboembolism (AF,LVD,prev.TE,hypercoagulability) 3.0 2.5-3.5 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
    87. 87. GELIA trial 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 mechanical valve. • Patient compliance is challenging with higher INR goals INR WITHIN RANGE 2.0 -3.5 74.5% 3.0 -4.5 44.5% CHEST ,2005:127:53-9.
    88. 88. 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 Major embolism/death 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 bleeding (epistaxis,bruising) increased Major bleeding 6.6% 8.5% 0.43 LIWACAP study ,Clin Appl Thrombo hemostst 2007;13:241-8.
    89. 89. The risk of GI irritation and hemorrhage with Aspirin is dose dependent over the range of 100mg-1,000 mg /day, but the antiplatelet effects are independent of dose over this range. LIWACAP study;Clin Appl Thromb Hemost.2007;13:241-8
    90. 90. • 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 repair. WoA epic pilot trial.J Heart Valve Disease 2007;16:667-71
    91. 91. Risk of stroke after all types of mitral valve surgery 2% 3% 8% 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 30 days 180 days 5 years % stroke Eur J Thoracic Surg1995;615-9
    92. 92. 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 years 7.00 2.69 CV event rate at 6 months 6.50 2.08
    93. 93. Antiplatelet therapy after TAVR • Small prospective RCT • Single center study • 79 pts with self expanding TAVR Clopidogrel +Aspirin Aspirin P value Events at 30 days 13% 15% 0.71 6 months 18% 15% 0.85
    94. 94. 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 dabigatran arm. • 252 pts DABIGATRAN WARFARIN Ischemic stroke 9 pts (5%) nil Composite end point of stroke,TIA,systemic embolism,MI 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.
    95. 95. Bridging therapy for prosthetic valves Medical therapy VKA anticoagulation with INR in range in pts with mechanical valves. I C Minor procedures (dental extractions ,cataract surgery,surgeries on skin,dental caries) Temporary interruption in VKA anticoagulation,INR being subtherapeutic,without bridging in bileaflet mechanical AVR I C Invasive or surgical procedure INR <1.5 (stop warfarin 2-4 days before procedure) Bridging anticoagulation Mechanical AVR + thrombotic risk factor, older generation AVR, tricuspid valve,mechanical MVR I C Invasive or surgical procedure FFP or IV prothrombin II a C Emergency noncardiac
    96. 96. BRIDGING THERAPY • 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.
    97. 97. • 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
    98. 98. Excessive anticoagualtion and serious bleeding • INR >5.0 –risk of hemorrhage. • Rapid decrease in INR below therapuetic range – risk of thromboembolism. • High dose vitamin K not given routinely,creates a hypercoagulable condition. • 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 – CLASS IIaB
    99. 99. THROMBOEMBOLIC EVENTS • 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
    100. 100. Management • Optimal anticoagulation • Antiplatelet therapy. • Improve patient compliance • Surgical intervention is rarely needed. • Replacement of prosthetic valve – stenosed/regurgitation/degenerated.
    101. 101. PROSTHETIC VALVE THROMBOSIS • Mechanical PVT – prevalence is 0.3% to 1.3% per pt yr in developed countries. • 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.
    102. 102. RECOMMENDATIONS 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 thrombus <0.8cm2 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 III-IV symptoms 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
    103. 103. 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) • Hypotension/shock • NYHA III/IV
    104. 104. • 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 embolic risk. • >1.0 cm or 0.8cm2 area – 2.4 fold increase in embolism risk per 1.0cm2 increase in size.
    105. 105. Fibrinolytic agent 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 hours.i.e.,1,50,000 U/hr 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
    106. 106. Surgery vs fibrinolytic therapy in patients with left sided PHVT • Success rate - 90% with surgery. 70%.-fibrinolytic therapy No difference in mortality between two groups. SURGERY FIBRINOLYTIC THERAPY THROMBOEMBOLISM 1.6% 16% MAJOR BLEEDING 1.4% 5% RECURRENT PVT 7.1% 25.4% RESTORING NORMAL VALVE FUNCTION 90% 70% Karthikeyan et al,Eur Heart Journal,2013:34:1557-66
    107. 107. • 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
    108. 108. 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 size,annular dimension) • 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
    109. 109. 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 B) • Severe symptomatic or asymptomatic bioprosthetic regurgitation – (II a C) • Catheter based approaches in high risk for surgery -II a B Success -80-85% Complications -9% Procedural death <2%
    111. 111. • 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.
    112. 112. 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 source. 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
    113. 113. • In patients with chronic (subacute ) – 3 sets of blood culture. • 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.
    114. 114. In hospital mortality 15-20% 1 yr mortality rate 40% Stroke 16.9% Embolization other than stroke 22.6% HF 32.3% Intracardiac abscess 14.4% Need for surgical therapy 48.2% Arch Internal Med2009;169:463-73. NVE PVE TTE sensitivity 50-90% 36-69% specificity >90% TEE sensitivity 90-100% lower specificity PPV 90% 90%
    115. 115. TTE TEE 1.Anterior aspect of a prosthetic aortic valve  2.Aortic transvalvular gradient  3.Vegetations and perivalvular complications  4.Active and healed vegetations 5.Thickened valves or valvular nodules and vegetations differentiation Most vegetations 83.8% remain constant in size under therapy and this does not worsen prognosis Right sided pacemaker leads IE – intracardiac echo
    116. 116. S.Aureus bacteremia Neurological complications 30% Paravalvular cardiac abscesses 30-40% HF 20-50% Mortality 19%-65% Systemic embolization 40%
    117. 117. • PVE – less incidence of vegetations(mechanical) ,higher incidence of annular abscess and other paravalvular complications. • 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.
    118. 118. ICE –PCS 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
    119. 119. PVE EARLY <60 days of surgery Health care acquired infection - S. aureus INTERMEDIATE 60-365 days after surgery Health care +community acquired – coagulase negative staphylococcus 2/3 cases of PVE LATE >1 yr after surgery Resembles NVE INJECTABLE DRUG USERS MORTALITY Staphylococcus <5% *right sided 20-30%*left sided Enterococcus 15-25% Pseudomonas aeruginosa Enterobacteriaciae >50%
    120. 120. Embolism • 20-40% pts with IE. • Incidence decreases to 9-21% on antibiotic use • New embolic event occurs if vegetation >10 mm,anterior mitral leaflet vegetations. • 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.
    122. 122. 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 stenosis Intervention I C Before pregnancy ,Severe symptomatic AS I C Before pregnancy ,Severe symptomatic MS I C IIa B Before pregnancy ,PBMV in asymptomatic severe MS. For pregnant pts ,with MS ,in HF despite medical therapy II a C Before pregnancy ,Severe asymptomatic AS III Valve operation in absence of HF symptoms
    123. 123. AORTIC STENOSIS MITRAL STENOSIS MATERNAL MORTALITY RATE 17% uncommon FETAL,NEONATAL MORTALITY RATE 32% 30% HF 10-44% 75% Risk of arrhythmia 25% 75% increased incidence of HTN emergencies Valve operation 30-40% fetal mortality Maternal -9% No ideal time High pump flows and normothermic perfusion
    124. 124. 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 CLASS III/IV)
    125. 125. • Risk of embryopathy is dose dependent • <3% - <5 mg/day • >8% - >5mg/day
    127. 127. 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 anticoagulation 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.
    128. 128. MAZE PROCEDURE 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. Mini maze Wolf maze
    129. 129. 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 acute setting. • 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
    130. 130. CLASS IIa B Moderate risk elective noncardiac surgery, asymptomatic severe AS. CLASS II a C Moderate risk elective noncardiac surgery, asymptomatic severeMR 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
    131. 131. EVIDENCE GAPS AND FUTURE DIRECTIONS • Vaccine development • At risk of calcific aortic stenosis – therapies to prevent progression. • Values of measures of LV size,volumes,myocardial structure immediately after intervention. • TAVI