Valvular Heart Disease:

Ambulatory Monitoring and Surgical Referral

Dr. Shane Shapera
Previous version: Dr. Wassim Saad
for AIMGP October 2006

Valvular Heart Disease
Focus on:
Aortic stenosis
Chronic mitral regurgitation
Mitral Stenosis (extra slides if time permits)
Who should have an Echo?
At first contact? Follow up?
How do we interpret the results?
How should we follow patients?
How often should they be seen in clinic?
Are there options for medical management?
When should we refer to a surgeon?

References
New ACC/AHA Practice Guidelines:
ACC/AHA 2006 Practice Guidelines for the
Management of Patients With Valvular
Heart Disease: Executive Summary: A
Report of the American College of
Cardiology/American Heart Association
Task Force on Practice Guidelines
(Committee on Management of Patients
With Valvular Heart Disease) JACC.
2006;48(3):598-675.

Reminder
Class I: There is evidence and/or general agreement that
a given procedure or treatment is useful and effective
Class II: There is conflicting evidence and/or a
divergence of opinion about the usefulness/efficacy of a
procedure or treatment
IIa: Weight of evidence/opinion is in favor of
usefulness/efficacy
IIb: Usefulness/efficacy is less well established by
evidence/opinion.
Class III: There is evidence and/or general agreement
that the procedure/treatment is not useful and in some
cases may be harmful.
A new referral
62 year old man
RFR: Family MD heard a murmer
PMH: HTN and obesity
Meds: ASA and Norvasc
HPI:
Told he has a murmer 2 years ago
No symptoms of CVS or respiratory nature
Limited physical activity, but no limitations


A new referral
O/E:
HR: 88 BP: 150/85
JVP normal
Harsh midsystolic ejection murmer (3/6)
over aortic area radiates to the clavicle
Normal pulses
Remainder of physical exam normal
Questions to think about:
Is a 2D-Echo appropriate in this patient?
Which patients require an echo?
Are there any symptoms that need to be
considered when deciding whether to
order an echo?
Recommendations for Echocardiography
in Asymptomatic Patients With Cardiac
Murmurs
Indication
Class
Diastolic, Continuous, Holosystolic or late
Systolic murmurs
I
Grade 3 or greater midsystolic murmurs I
Murmurs with ejection click or radiation to
neck or back
I
Murmurs associated with abnormal physical
findings on cardiac palpation or auscultation
IIa
Murmurs associated with an abnormal ECG or
chest x-ray
IIa
Grade 2 midsystolic murmur (Innocent) III
Recommendations for Echocardiography
in Asymptomatic Patients With Cardiac
Murmurs
Indication
Class
Diastolic, Continuous, Holosystolic or late
Systolic murmurs
I
Grade 3 or greater midsystolic murmurs I
Murmurs with ejection click or radiation
to neck or back
I
Murmurs associated with abnormal physical
findings on cardiac palpation or auscultation
IIa
Murmurs associated with an abnormal ECG or
chest x-ray
IIa
Grade 2 midsystolic murmur (Innocent) III
Recommendations for Echocardiography
in Symptomatic Patients With Cardiac
Murmurs
Indication Class
Signs / symptoms of CHF, MI, ischemia or syncope I
Signs / symptoms of endocarditis I
Signs / symptoms of thromboembolism I
Signs/ symptoms likely due to noncardiac disease
but cardiac disease not excluded by standard
cardiovascular evaluation
IIa
Back to the case
CXR: normal
ECG: LVH (aVL > 11mm)
ECHO:
AVA 1.4cm
2
with a mean gradient 30mmHg
Mild concentric LVH
Grade I LV
Final interpretation: moderate AS
Aortic Stenosis: Causes
Two most common causes of AS:
Calcification of the valve
Older patients
Very similar to an atherosclerotic process
Bicuspid aortic valve
Younger patients
Mechanical abnormality leading to degeneration
Aortic Stenosis: Natural History
Prognosis mnemonic: A-S-D
Aortic Stenosis: Classification
AVA Gradient Jet Velocity
Mild AS < 1.5 cm
2
< 25 mmHg < 3 m/s
Moderate AS 1.0 1.5 cm
2
25 40 mmHg 3 4 m/s
Severe AS < 1.0 cm
2
> 40 mmHg > 4 m/s
Critical AS < 0.75 cm
2
variable Variable, but
often > 5 m/s
Questions to think about for our
patient with moderate AS
What is his expected prognosis?
How should he be followed?
When should we offer a surgical
intervention?
Is there medical therapy we can offer?


Aortic Stenosis: Follow-up
Expect prolonged latency period
Low M&M while asymptomatic
Progression of stenosis is highly variable
Treatment based largely on symptoms
Average survival 2-3 yrs once symptoms
Risk of sudden cardiac death once symptoms

Aortic Stenosis: Follow-up
ACC Guidelines suggest frequent
monitoring of asymptomatic patients
looking for:
Symptoms of angina, syncope and SOB
Signs of CHF (raised JVP, SOA, crackles)

Aortic Stenosis: Follow-up

When should you repeat an ECHO?
Changing signs or symptoms
Patient becomes pregnant
Routine follow-up
Mild AS: q 3-5 years
Moderate AS: q 1-2 years
Severe AS: q 1 year

Aortic Stenosis: When to operate?
Indication for Aortic Valve Repair Class
Severe AS (AVA <1.0cm
2
) with symptoms I
Severe AS undergoing CABG or CVS surgery I
Severe AS and impaired LV function (LVEF < 50%) I
Moderate AS undergoing CABG or CVS surgery IIa
Asymptomatic patients:
- critical AS if operative mortality very low (<1%)
- severe AS with exercise induced hemodynamic changes
- severe AS and risk of rapid progression (age, calcified, CAD)

IIb
IIb
IIb
Aortic Stenosis: Medical Therapy
Baloon Valvotomy
Not an alternative to valve replacement
Many complications (10%)
Most get restenosis in 6 12 months
Can be used as a bridge to OR
Can be used for palliation in non-operative pts
Aortic Stenosis: Medical Therapy
No medical therapy prolongs life
Theoretical benefit of statins, but trials ve so far
Treatment of CHF can reduce symptoms
Diuretics, ACEi, Digoxin have all been used
Atrial fibrillation worsens symptoms
Needs aggressive rate control or cardioversion
All patients should be considered for OR
Age is NOT a contraindication to surgery, but
increases risk of complications

Back to the case
62M with asymptomatic moderate AS
Annual history and physical exam
Repeat Echo q 1-2 years or if symptoms
Discuss prognosis and possibility of valve
replacement in future if symptoms develop
Cover with endocarditis prophylaxis for
dental and surgical procedures
Next referral
68 year old woman
RFR: Murmur heard on routine physical exam
PMH: previous smoker x 20 pk yrs
Meds: Vitamin D and Calcium
HPI:
Very poor physical fitness
Occasional SOB while running for the bus
No chest pain or pre-syncope
Mild SOA and a couple of episodes of PND
Next referral
O/E:
HR: 92 BP: 138/78
JVP normal
Soft S1 with holosystolic murmer at the apex (2/6)
that radiates to the axilla
Mild SOA
Remainder of physical exam normal
Is a 2D-Echo appropriate in this patient?

Recommendations for Echocardiography
in Asymptomatic Patients With Cardiac
Murmurs
Indication
Class
Diastolic, Continuous, Holosystolic or late
Systolic murmurs
I
Grade 3 or greater midsystolic murmurs I
Murmurs with ejection click or radiation to
neck or back
I
Murmurs associated with abnormal physical
findings on cardiac palpation or auscultation
IIa
Murmurs associated with an abnormal ECG or
chest x-ray
IIa
Grade 2 midsystolic murmur (Innocent) III
Recommendations for Echocardiography
in Symptomatic Patients With Cardiac
Murmurs
Indication Class
Signs/symptoms of CHF, MI, ischemia or syncope I
Signs / symptoms of endocarditis I
Signs / symptoms of thromboembolism I
Signs/ symptoms likely due to noncardiac disease but
cardiac disease not excluded by standard cardiovascular
evaluation
IIa
Back to the case
CXR normal
ECG normal
PFTs normal
ECHO
Grade II LV with regional variability
Severe MR
Slightly dilated LA (42mm)
LV end systolic dimension ~42mm
RVSP 65mm Hg
Mitral Regugitation: Natural History
May be asymptomatic for many years
Chronic severe MR tends to increase over time
Usually leads to symptoms within 6 10 years
Eventually develop overload with LV dysfunction
Chronic volume overload state
LV dysfunction
Increased LV end-systolic volume
LV dilatation and higher LV pressures
Pulmonary congestion
Symptoms of CHF
Mitral Regurgitation: Classification
No specific numbers to memorize

Multiple components go into
determining severity (chamber sizes,
LVEF, RVSP, visual assessment, etc)

Final report: Mild, Moderate or Severe

Questions to think about for our
patient with moderate MR
What baseline tests should we do?

How should we follow her up?
When should we reassess her symptoms?
When should we repeat the Echo?

How can we treat her medically?

When should we refer her for surgery?

Mitral Regurgitation: Baseline
Establish clear exercise tolerance
Be sensitive to subtle changes suggesting CHF
Baseline ECG and CXR
Chamber enlargement and complications (Afib)
ECHO
Assess severity and look for possible anatomical
causes of MR (Ischemic vs. functional)
Exercise testing
Consider exercise measurements of PAP and MR if
exercise capacity cant be established on history

Mitral Regurgitation: Follow-up
Asymptomatic mild MR
(normal LVEF, chamber sizes & RVSP)
Annual history and physical
No repeat Echo unless symptoms develop (Class III)

Asymptomatic moderate MR
Annual history and physical
Repeat Echo annually (Class I)
Mitral Regurgitation: Follow-up
Asymptomatic severe MR
History and physical q6months
Watch carefully for development of symptoms
Repeat Echo q6months (Class I)
Watch for Echo evidence of asymptomatic LV
dysfunction which would be an indication for OR
Mitral Regurgitation: When to operate?
General Principles (Class I evidence)*
MV repair is preferred over MV replacement
Acute severe symptomatic MR needs surgical repair
Chronic severe MR should be referred to CVSx if:
Symptomatic (NYHAII) and LV function preserved (LV Gr3)
Symptomatic (NYHAII) and LV end-systolic dimension enlarged
Asymptomatic with any of the following: LV dysfunction,
LV dilatation, pulmonary HTN or new-onset atrial fibrillation
Isolated MV surgery is not indicated for patients with mild
to moderate MR (Class III)

*please see guidelines for complete list of recommendations
Mitral Regurgitation: Medical Therapy
Asymptomatic chronic MR
No specific therapy recommended
No evidence for vasodilators (despite the logical appeal)

Chronic MR secondary to ischemic or dilated CM
Preload reduction is beneficial (Lasix)

LV dysfunction present
Usual therapies for LV failure (BB, ACEi, Biventricular Pacing)

Atrial Fibrillation
Usual therapy with rate control and anticoagulation
Back to the case
68 year old woman

Minimal physical activity, but
occasionally SOB on exertion

Severe MR with Grade 2 LV, regional
wall motion abnormalities and
pulmonary hypertension
Back to the case
History, physical, ECG and CXR done
Dont add much to the picture

Further workup?

Possible ischemic etiology?
Exercise tolerance unclear
Regional wall motion abnormalities on Echo
Stress echo
MR worse with exercise with reversible inferior
wall motion abnormality
Back to the case
Management
Pt is a surgical candidate
NYHA II with preserved LV function (Class I)
Refer for CVSx opinion, TEE & Cath
Treat medically while waiting for OR
Rx for symptoms, underlying CAD and LV
dysfunction with ASA, BB, ACEi, Statin & Lasix
Hold ASA 5 days pre-op
Summary
History and physical exam guide decision to
do an Echo during first visit
Many patients have valvular lesions for years
before they develop symptoms
Patients should be followed clinically and
radiologically at intervals that vary according
to the specific valve pathology and severity
Symptomatic or severe asymptomatic valvular
lesions requires an early surgical opinion
Extras
If time permits, continue with slides on
mitral stenosis otherwise they can serve
as a reference for residents
Last referral
57 year old man
RFR: Murmur heard on routine physical exam
PMH: No cardiac risk factors
Meds: None
HPI: Asymptomatic
O/E:
Loud S1, Low pitched rumbling diastolic murmur with pre-
systolic accentuation at the apex. No opening snap.
Does this patient need an Echo?
Indication
Class
Diastolic, Continuous, Holosystolic or late
Systolic murmurs
I
Grade 3 or greater midsystolic murmurs I
Murmurs with ejection click or radiation to neck
or back
I
Murmurs associated with abnormal physical
findings on cardiac palpation or auscultation
IIa
Murmurs associated with an abnormal ECG or
chest x-ray
IIa
Grade 2 midsystolic murmur (Innocent) III
Back to the case
The echo shows an MVA of 1.3cm
2
.
Chamber size and function are normal
RVSP and gradient across valve normal
CXR and ECG normal
Pt is asymptomatic
Questions about MS?
What should you do at your initial
assessment?
How should you follow up this patient?
When would you refer to a surgeon?
When would you repeat the Echo?
How can you manage these patients
medically?

Mitral Stenosis: Natural History
Asymptomatic patient with MS
10 yr survival >80%
60% have no progression of symptoms
Significant limiting symptoms
10 yr survival rate of 0-15%
If severe pulmonary HTN
Mean survival <3 yr
Mitral Stenosis: Classification
Mild Moderate Severe
Valve area

> 1.5 cm
2
1.0 1.5 cm
2
< 1.0 cm
2

PAP < 30 mmHg 30 50 mmHg > 50 mmHg
Mean
Gradient
< 5 mmHg 5 10 mmHg > 10 mmHg
Mitral Stenosis: Initial Exam

Hx dyspnea, hemoptysis, hoarseness, CHF,
thromboembolism, endocarditis

P/E evidence of Afib, pulmonary HTN, CHF

CXR heart size, pulmonary edema

ECG rhythm, LAE, RVH due to pulmonary HTN

Mitral Stenosis: Initial Echo
Baseline Echocardiogram
Doppler to assess severity
Determines valve area, RVSP and gradient
Visualize leaflets and commissures
Determines timing and type of interventions
Assesses for other valvular lesions
Chamber size & function
Consider exercise Echo if clinical picture
doesnt fit with Echo findings
Follow Up - Asymptomatic
Mild MS (MVA > 1.5cm
2)

Patients remain stable for years
Should be seen annually and have CXR, ECG

Modearte-Severe MS (MVA 1.5cm
2
)
Initially, assess valve morphology & look for
pulmonary HTN (PAP > 50mmHg)
If intervention is not appropriate, then follow
as for mild MS (above)
Follow up When to re-Echo?

Repeat any time symptoms change
Routine follow-up
Mild MS repeat Echo q 3-5 years
Mod MS repeat Echo q 1-2 years
Severe MS repeat Echo q 1 year
Who Should be Referred to a
Surgeon?
Indication Class
NYHA II with moderate or severe MS
(MVA1.5cm
2
)
I
Asymptomatic patient with moderate or severe MS
(MVA1.5cm
2
) who have pulmonary HTN (PAP>50)
I
Asymptomatic patient with moderate or severe MS
(MVA1.5cm
2
) who have new onset atrial fibrillation
IIb
Interventions: balloon valvotomy, repair, replacement
Medical Management - MS
CHF
Salt restriction and intermittent diuretics
See MD immediately if sudden onset SOB
May have A-fib with flash pulmonary edema
Exertional symtpoms
Consider ve chonotropic agents (BB,CCB)
Atrial fibrillation
Rate control and anticoagulation
May consider anticoagulation if stroke w/o Afib

Back to the case
57 year old man
Asymptomatic with mild MS (MVA 1.3cm
2
)
Annual history and physical
Repeat Echo q3-5yrs or sooner if symptoms
Call EMS immediately if acute onset SOB
Endocarditis prophylaxis for dental and surgical
procedures

Questions?