Valvular Disease

Atul Jaidka

Case

You are seeing a 78 year old female in your outpatient General Internal Medicine clinic for 1 year of progressive shortness of breath. History and physical are otherwise unremarkable but you hear a 2/6 systolic murmur heard throughout the precordium. How do you workup this patient?

Workup

Case

Transthoracic Echo: 

• Severe valvular aortic stenosis
• Left atrium is moderately dilated
• Ejection Fraction >70%
• Left ventricular size is normal.
• Mild concentric hypertrophy

How would you stage this patient?

Stages

What is severe AS?

Severe AS

• Aortic Vmax ≥4 m/s or mean ∆P ≥40 mm Hg
• AVA typically is ≤1.0 cm2 (or AVAi 0.6 cm2 /m2 ) but not required to define severe AS
• Very severe AS is an aortic Vmax ≥5 m/s or mean P ≥60 mm Hg

Case

Given the recent echocardiographic findings, how will you manage this patient?

Ace Inhibitor?

Ace Inhibitor

• Potential benefit before and after AVR
• Start low and go slow

Review article: https://www.ahajournals.org/doi/pdf/10.1161/JAHA.120.016911

Case

How will you decide if she is a candidate for intervention and what intervention should she get?

Assess Risk/Frailty

Text

TAVI/SAVR

• GIM goal should be to refer patients to a multi-disciplinary Valve team
• TAVI if high risk or frail
• SAVR if not high risk and <65
• In between --> discussion

Low Flow Low Gradient Aortic Stenosis

Low flow low gradient AS

• Know it exists and the theory
• Determine by dobutamine stress echo
• Don't need to know cutoffs etc

Aortic Stenosis

https://www.jacc.org/doi/10.1016/j.jaccas.2021.11.009

Case

You are seeing her in clinic for new onset of palpitations while waiting for TAVI and Holter monitor shows atrial fibrillation. How will you manage her new diagnosis?

Anticoag and AF

Guideline Standoff

Case

You are seeing her in clinic 1 year after her TAVI and he remembers the TAVI coordinator saying something about antibiotics before certain procedures. How will you counsel her?

IE Prophylaxis

Aortic Regurgitation

Acute AR

• Generally not managed by IM
• Surgical emergency and should not be delayed by medical therapy

Chronic AR

• Bicuspid and aortopathy most common causes
• Medical therapy: treat hypertension
  • ACE/ARB/ARNI recommended
• Surgery (Class 1):
  • severe + symptomatic
  • Asymptomatic + EF<55% or other cardiac surgery
  • Lower grade for asymp + dilated LV

Mitral Regurgitation

Acute MR

• Caused by ischemia, IE
• Surgical emergency
• Medical temporizing
  • IABP
  • Afterload reducing agents

Chronic MR

• Primary
  • problem with valve
  • Ie. myxomatous
• Secondary (functional)
  • due to LV dilation
• Primary MR: no class 1 medical therapy
  • don't delay surgery
  • treat LV dysfunction with GDMT
• Secondary MR:
  • treat with GDM and HF specialist

Primary MR

• Severe + symptomatic
  • regardless of LV function
• Severe + asymptomatic + LV dysfunction (LVEF <60 or LVESD > 40mm)

Secondary MR

• No Class 1 intervention
• Focus on GDMT including CRT and revasc
• Despite max GDMT consider PMVR (mitra-clip) if still symptomatic

Mitral Stenosis

Mitral Stenosis

• Rheumatmic and Degenerative most common
• Anticoag if afib, prior embolic event, LA thrombus
• Control heart rate
• Surgery (Class I)
  • Severe + symptomatic
  • PMBC or MV surgery (multi-disciplinary team decision)

Tricuspid Regurgitation

• Class 1 Indication for surgery: severe TR and left sided surgery, tricuspid surgery recommended

Summary

Summary

1. What to know
   • Know physical exam for oral component
   • Know Class 1 indications
   • Severity criteria (except severe AS) not needed
2. Treatment
   • Medical: temporizing
   • Surgery: effective but risk
   • Catheter based: for select patients
3. Symptoms
   • Classic angina, HF (SOB), and syncope
   • Symptom equivalent: LV dysfunction