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Aortic Stenosis

Aortic Stenosis

#AorticStenosis

#Valve

#Elderly

#Patients

#Helsinki

#Study

Calcific or degenerative aortic valve disease is the most common valvular abnormality seen in the elderly. The prevalence of at least moderate aortic stenosis (AVA <1.2 cm2 ) in patients aged 75–85 years old was 5% in the Helsinki Aging Study.

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Aortic Regurgitation

Aortic Regurgitation

#Aortic

#Regurgitation

#Valve

#Surgery

#Mortality

Aortic regurgitation is less common in the elderly than calcific aortic stenosis or mitral regurgitation and is most often associated with aortic stenosis or dilation of the ascending aorta from long-standing hypertension.

Although prophylactic aortic valve surgery is usually recommended for asymptomatic patients with severe aortic insufficiency (AI) and evidence of LV dysfunction, in the elderly (especially patients over the age of 80), it is recommended that aortic valve surgery be reserved for those patients with symptoms and severe AI, given the increased risk of operative and long-term mortality with increasing age

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Mitral Stenosis

Mitral Stenosis

#Mitral

#Stenosis

#Patients

#Younger

#Calcification

#Replacement

Mitral stenosis remains a disease primarily of younger patients, with rheumatic heart disease being the most common etiology. In elderly patients the most common cause of mitral stenosis is impingement on the mitral valve by mitral annular calcification.

The preferred surgical treatment for mitral stenosis is mitral commissurotomy. However, this is often not possible in the elderly, necessitating mitral valve replacement. The ideal treatment for those elderly patients with favorable valvular morphology is percutaneous valvotomy. However, the number of elderly patients who have valvular morphology amenable to this technique is quite limited.

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Mitral Regurgitation

Mitral Regurgitation

#Mitral

#Regurgitation

#Causes

#Acute

#Chronic

#Dysfunction

#Trauma

Causes

Acute

• Infective endocarditis

• Acute myocardial infarction (MI) (usually inferior wall) from papillary muscle dysfunction or acute rupture

• Trauma

Chronic

• Mitral valve prolapse

• Rheumatic heart disease

• Ischemic heart disease

• Left ventricular dilatation of any cause

• Hypertrophic cardiomyopathy

• Carcinoid syndrome

• Fen-phen valvulopathy

• Congenital lesions (i.e., cleft mitral valve).

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Aortic Root Disease

#Aortic

#Root

#Disease

#Dilation

#Hypertension

#Syphilis

#Biscuspid

#Valve

Dilatation, aneurysm, and dissection cause failure of coaptation of cusps. One may see diastolic cusp prolapse in dissection.

Causes

• Hypertension

• Marfan’s syndrome

• Osteogenesis imperfecta

• Syphilis

• Spondyloarthritides (ankylosing spondylitis, Reiter’s, etc.)

• Trauma

• Bicuspid aortic valve

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Valve Hemodynamics

Valve Hemodynamics

#Valve

#Hemodynamics

#Dimension

#OrificeArea

#Homografts

Different prosthetic valves have unique profiles and valve areas. For any given valve dimension, bioprosthetic valves and ball and cage valves have the smallest effective valve orifice area, and homografts have the largest valve area (comparable to native valve area).

https://drbhishmacardiologist.com/bicuspid-aortic-valve

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Hemolysis

Hemolysis

#Hemolysis

#Prostheses

#Investigation

#Treatment

#Valve

#Transfusion

#FolicAcid

A low level of background hemolysis is common in patients with mechanical prostheses (even when functioning normally). Severe hemolysis is uncommon and is usually secondary to valve dysfunction (paravalvular leak, dehiscence, infection). Hemolysis is uncommon in tissue prostheses.

• Investigation: anemia, elevated LDH, low serum haptoglobin level, reticulocytosis, schistocytes on peripheral smear.

• Treatment: treat underlying problem (including further valve surgery if needed); give blood transfusion, folic acid, and iron supplementation

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Echocardiography

Echocardiography

#Echocardiography

#Sensitivity

#Diognosis

#Imaging

#Clinical

#Suspicion

TTE has a low sensitivity of <50% but a high specificity of 98% for the diagnosis of infective endocarditis. TEE has a sensitivity of 75%–95% and a specificity of 85%–98% and is the recommended diagnostic imaging test in patients with prosthetic valves, cases rated at least possible IE by clinical criteria, and patients with complications. TEE is also recommended when the clinical suspicion for IE is high despite a negative TTE.

https://drbhishmacardiologist.com/advanced-coronary-physiology

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Systemic Embolization

Systemic Embolization

#Systemic

#Embolization

#Common

#Complication

#Endocarditis

#Stroke

#Hemorrhagic

This is a common complication, occurring in one-third of patients. Left-sided endocarditis, especially mitral valve, is the most common predisposing lesion.

Other factors associated with increased risk include vegetation size >10 mm; highly mobile vegetations; S. bovis, S. aureus, and Candida infection; and antiphospholipid antibodies. Anticoagulation is not indicated and may increase the risk of hemorrhagic stroke and death.

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Cardiac Complications

Cardiac Complications

#Cardiac

#Complications

#Patients

#Aortic

#Mitral

#Morality

These occur in up to 50% of patients and include the following:

• CHF: due to acute valvular insufficiency, aortic > mitral. This is the leading cause of death in patients with IE.

• Perivalvular abscess: S. aureus is most common. Abscess is associated with increased mortality. Aortic valve involvement and IV drug use are risk factors.

It may extend into the septum and cause conduction abnormalities, including AV block.

• Myocardial infarction: rare complication of IE due to coronary emboli

• Pericarditis: associated with myocardial abscess.

• Hemopericardium/fistulas: due to rupture of mycotic aneurysm on sinus of Valsalva. These have a high mortality of >40%.

https://drbhishmacardiologist.com/heart-failure

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Infective Endocarditis

Infective Endocarditis

#Infective

#Endocarditis

#Epidemology

#MitralValveProlapse

#Pacemakers

#Heart

#Disease

#Nosocominal

#Iatrogenic

Epidemiology

There are approximately 15,000 new cases diagnosed in the United States annually with a male predominance (M:F 2.5:1). Mitral valve prolapse with MR and degenerative aortic valve disease are the leading predisposing conditions.

The incidence of nosocomial and iatrogenic infections is rising due to the increased use of dialysis catheters, permanent pacemakers, and other indwelling central venous catheters .

The mitral valve is most commonly involved, followed by the aortic valve. Right-sided endocarditis, usually tricuspid valve, generally occurs in IV drug users. The majority of patients (75%) with infective endocarditis (IE) have underlying structural heart disease.

https://drbhishmacardiologist.com/mitral-valve-prolapse

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Prosthetic Heart Valves : Complications

Prosthetic Heart Valves : Complications

#Prosthetic

#Heart

#Valves

#Thrombosis

#Complications

#Incidence

#Risk

#Clinical

#Treatment

#Prognosis

Valve Thrombosis

• Incidence: 0.1%–5.7% per patient-year.

• Risks: inadequate anticoagulation and mitral prostheses. There are similar rates for bioprosthetic valves and mechanical valves receiving adequate anticoagulation. There is no difference in rates between different types of mechanical valves receiving adequate anticoagulation.

• Clinical presentation: pulmonary edema, systemic embolism, sudden death • Investigation: decreased intensity of valve sounds, decreased leaflet motion on TTE or fluoroscopy, and increased valve gradient on TTE

• Treatment: anticoagulation with heparin. If thrombus is <5 mm on TTE then anticoagulation may suffice. If >5 mm, then will need further treatment (thrombolysis, thrombectomy or valve replacement).

• Prognosis: valve replacement for valve thrombus has a mortality rate of <15%, thrombolysis has a mortality rate of <10% (with embolization in <20%). Thrombolysis is more effective for aortic valve thrombosis and in recent (<2 week) onset.

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Pulmonary Regurgitation

Pulmonary Regurgitation

#Pulmonary

#Regurgitation

#Causes

#Symptoms

#Examination

#Valves

Causes

These include pulmonary hypertension (causes dilatation of valve ring), infective endocarditis (rarely involves pulmonic valve), connective tissue disease (e.g. Marfan’s), and iatrogenic (following valvotomy, valvuloplasty or PA catheter placement) carcinoid causes.

Symptoms

Patients are often asymptomatic. Symptoms develop when pulmonary hypertension or RV failure occurs and include dyspnea on exertion, lethargy, peripheral edema, and abdominal pain.

Examination

Look for RV heave, occasionally a thrill in pulmonary area. On auscultation P2 may be delayed (large stroke volume), loud (if pulmonary hypertension), or soft (if PV stenosis). Murmur of pulmonary regurgitation (PR) is heard best in the third to fourth intercostal space along the LSB and increases with inspiration

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Pulmonic Stenosis

Pulmonic Stenosis

#Pulmonary

#Stenosis

#Causes

#Symptoms

#Examination

#Compression

#Valvular

Causes include congenital, carcinoid, and rheumatic causes and extrinsic compression. Stenosis may be valvular or supravalvular.

Symptoms

Usually there are none. With severe stenosis there is exertional dyspnea and light-headedness. Eventually symptoms of RV failure may develop.

Examination

Look for prominent a-wave in JVP, RV heave, and occasional thrill in second left intercostal space. On auscultation there is a widely split S2 (as pulmonary valve [PV] closure becomes delayed), P2 becomes softer (unless stenosis is supravalvular), and systolic ejection murmur at left upper sternal border (LUSB), heard best in inspiration.

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Tricuspid Regurgitation (TR)

Tricuspid regurgitation (TR)

#Tricuspid

#Regurgitation

#MarfansSyndrome

#Endocarditis

#Symptoms

#Causes

#Pulmonary

#Hypertension

Causes

These include any cause of RV dilatation (MV disease, congenital heart disease, RV infarction, pulmonary embolism, pulmonary hypertension), infective endocarditis (particularly IV drug abuse), Marfan’s syndrome, Ebstein anomaly, rheumatic fever, and carcinoid causes.

Symptoms

Symptoms are usually mild. As right heart failure develops, patients complain of edema, ascites, nausea, anorexia, and abdominal pain (tender, congested liver). Examination Look for cachexia/wasting, jaundice, and edema. AF is common, along with elevated JVP with systolic V waves and tender pulsatile hepatomegaly. On auscultation RV S3 is often heard, and systolic murmur is audible at LSB (increases with inspiration). Murmur is loudest in TR secondary to pulmonary hypertension

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Tricuspid Stenosis (TS)

Tricuspid stenosis (TS)

#Tricuspid

#Stenosis

#Causes

#Rheumatic

#Fever

#Anorexia

#Mitral

Causes include rheumatic fever (almost always associated with MS), congenital, carcinoid, and pacemaker lead. Symptoms are fatigue, anorexia, and peripheral edema.

Examination

Look for wasting, edema, hepatomegaly, and elevated JVP with prominent a-waves. Rumbling mid-diastolic murmur is heard best at lower left sternal border (LLSB) in inspiration.

Investigation

• ECG: sinus rhythm, RA enlargement (tall peaked p-waves in II, V1 often coincides with signs of LA enlargement because of MS) but no RVH.

• CXR: enlarged RA but normal PA size.

• TTE: 2D image can show thickened restricted leaflets. CW Doppler is diagnostic of increased transvalvular gradient. If diagnosis of TS is made, always look for coexistent MS.

Treatment

Salt restriction and diuretics may markedly improve symptoms. If coexistent MS is being operated on, then surgical valvuloplasty may help. Tricuspid valve (TV) replacement is occasionally performed. Bioprosthetic valves give better results than mechanical valves. TV balloon valvuloplasty is an alternative to surgery.

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Congenital : Bicuspid Aortic Valve

Congenital : Bicuspid Aortic Valve

#Congenital

#Biscuspid

#Aortic

#Valve

#Stenosis

#Fibrosis

#Infants

This is seen in 2% of the population. There is often familial clustering and autosomal dominant inheritance with incomplete penetrance. This condition results in chronic turbulent fl ow, which leads to accelerated leaflet calcification and fibrosis. It usually presents clinically with significant stenosis at ages 45–65 years.

It is often associated with aortic pathology (aneurysm, dissection, or coarctation), so all patients should be screened for aortic involvement at time of diagnosis. Unicuspid aortic valve This presents in infancy.

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