Transcript Heart Failure - MCE Conferences

Valvular Heart Disease:
The Mitral Valve
Case
• A 45 year old man presents to establish care.
He was told many years ago that he needed
antibiotics prior to dental work because there
was a problem with a heart valve. He has
occasional palpitations. On exam he has brisk
carotid upstrokes and a holosystolic murmur is
heard best at the apex along with an S3 and a
diastolic rumble.
Case
• What is the next best step?
– Do nothing, this murmur is benign
– Do an exercise stress test because the patient may
have CAD and ischemic heart disease
– Do nothing, exam findings suggest mild disease
– Order an echocardiogram
– Refer the patient to a cardiologist for further
evaluation
Case
• An echocardiogram shows moderately dilated
left atrium, a normal appearing left ventricle
with am EF of 55%, a prolapsing posterior
mitral leaflet and severe MR. Now you should:
– Tell the patient to continue antibiotic prophylaxis
prior to the dental work
– Have the patient follow up with a annual echo
– Refer the patient for valve surgery
– Refer the patient for a defibrilator to prevent
sudden death from MVP
What Makes A Heart Murmur?
• High blood flow through a normal or
abnormal orifice
• Forward flow through a narrowed or irregular
orifice
• Backward flow through an incompetent valve
These Murmurs Are Benign
• Mid systolic murmur at the left sternal border
with grade 2 or less with a normal S1 and S2
and no other abnormal findings in an
otherwise asymptomatic patient
• Associated with normal or increased blood
flow across normal valves
These Murmurs Need Further
Evaluation
• Diastolic Murmurs
• Continuous Murmurs
• Systolic
– Loud
– Early systolic
– Late systolic
– Holosystolic
Strategy For The Evaluation Of Cardiac
Murmurs
Bonow. JACC. 2006.
When To Order An Echo
• Class I
– Diastolic, continuous, holosystolic, late systolic,
clicks, radiation to neck or back
– Symptoms of underlying cardio-pulmonary
disease
– Grade 3 or louder mid systolic murmurs
• Class III
– Mid systolic mumur grade II or less thought to be
innocent
Mitral Valve Disease: From Many Structures
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•
•
Mitral leaflets
Chordae
Papillary muscles
Mitral anulus
Otto. NEJM, 2001.
Etiology of Mitral Regurgitation
• Organic (Primary pathology of the leaflets)
– Degenerative
– Rheumatic
– Endocarditis
– Congenital
• Functional (Secondary to myocardial process)
– Ischemic
– Dilated cardiomyopathy
– Hypertrophic cardiomyopathy
Enriquez-Serano. Contemporary Cardiology, 2009.
Mitral Regurgitation: Epidemiology
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•
•
•
•
Prevalence: >5,000,000
Incidence: >650,000 new cases/year in the US
Most common discharge diagnosis
Most common cause of readmission < 60 days
Cost: > 34.8 billion annualy
Rosamond. Circulation, 2008.
Braunwald. 2007.
Pathophysiology
• Volume overload ->
– LV dilation
– LA dilation
• Acute: Rapidly increasing LA/PV pressures->
pulmonary edema
• Chronic: Slow enlargement of the LA with low
pressures
• Left ventricular dilation and increased EF
followed by LV deterioration
Foster. NEJM, 2002.
Hemodynamic Stages of Mitral Regurgitation
Libby. Braunwald’s Heart Disease. 8th Ed.
Natural History of Severe MR
Libby. Braunwald’s Heart Disease. 8th Ed.
Degenerative Mitral Valve Disease:
Mitral Valve Prolapse
• Most common organic
mitral valve disease
• Incidence about 2-3%
• Usually results in mitral
valve prolapse
• Variable histology
– Increased extracellular
matrix
– Thickened and redundant
– Chordal elongation
Sanders. Forensic Science International, 2007.
Complications
• Chordal rupture and flail leaflet
– 12% of patients
– Most common in older men
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•
•
•
Heart failure
Sudden death
AF
Endocarditis
– Most common compliation, but rare
(100cases/100,000 patient years)
– Higher risk with flail leaflet
Mitral Regurgitation: Mitral Valve Prolapse
Foster. NEJM. 2010.
Echocardiogram: Flail Mitral Leaflet
Foster. NEJM. 2010.
Endocarditis
• Destruction of tissue
by infection
• About 5% of severe
MR
Mitral Regurgitation From Connective
Tissue Disease
Functional Mitral Regurgitation
• Affects 15-20% with HF,
12% 30 days post MI
• Leaflets are normal
• Coaptation is
incomplete
• Can also be associated
with papillary muscle
rupture
Marasco. Heart, Lung and Circulation, 2008.
Prosthetic Valve Failure
Alexander. Circulation, 1995.
Prosthetic Valve Failure
Novarro. JASE, 2000.
St Jude Mitral Valve
Butany. J Clin Path, 2005
Physical Exam Findings
• Brisk carotid upstrokes, laterally displaced
forceful apical impulse
• Murmur: characteristics don’t reliably predict
severity
– Similar to AS, TR and VSD
– Constant intensitiy, holosystolic, loud blowing,
apical with axillary radiation
– Dimimished S1, split S2, possible S3 and loud P2
– Highly variable depending on structures involved
Dynamic Auscultation
Hypertrophic
Obstructive
Intervention
Cardiomyopathy Aortic Stenosis
Valsalva
↑
↓
Standing
↑
↑ or
unchanged
Handgrip or
↓
↓ or
squatting
unchanged
Supine position ↓
↑ or
with legs
unchanged
elevated
Exercise
↑
Amyl nitrite
Isoproterenol
↑↑
↑↑
↑ or
unchanged
↑
↑
Libby. Braunwald’s Heart Disease. 8th Ed.
Mitral
Regurgitation
↓
↓
Mitral Valve
Prolapse
↑ or ↓
↑
↑
↓
Unchanged
↓
↓
↑
↓
↓
↑
↑
XR Findings
• Prominent left atrial
enlargement
• Left ventricular
enlargement
• Pulmonary edema in
acute MR
Enriquez-Serano. Contemporary Cardiology, 2009.
Atrial Fibrillation Affects 50% of
Patients Within 10 Years
Enriquez-Serano. Contemporary Cardiology, 2009.
Acute Mitral Regurgitation Elevated
PAP and Large PCWP V Waves
Libby. Braunwald’s Heart Disease. 8th Ed.
Variable Presentations of Mitral
Regurgitation
Enriquez-Serano. Contemporary Cardiology, 2009.
Mitral Regurgitation Severity By Echo
• Structural
– LA size
– LV size
– Mitral leaflets and apparatus
• Doppler
– Jet area and characterisitics
– Mitral inflow
– Pulmonary vein flow
• Quantitative
– Regurgitant orifice area
– Vena contracta
– Right ventricle
Zoghbi. JASE, 2003.
Medical Management
• Diuretics to maintain euvolemia
• Digoxin and beta blocker for rate control
• Medical therapy directed at underlying
ischemia
• No benefits to vasodilators
• Afterload reduction and inotropic support in
acute mitral regurgitation
Survival: Medical Management of
Organic MV Regurgitation
Mild
Moderate
Severe
Enriquez-Serano. Contemporary Cardiology, 2009.
Mitral Valve Prolapse Repair
Foster. NEJM. 2010.
Prosthetic Mitral Valve
Bloomfield. Heart, 2002.
Survival After Surgical Correction By EF
Libby. Braunwald’s Heart Disease. 8th Ed.
Repair vs Replacement
• Repair can be accomplished in 80-90%
• Advantages
– Possible lower mortality rates
– Possible reduced need for anticoagulation
– Lower risk of endocarditis
Foster. NEJM. 2010.
Possible Survival Benefit With Mitral Valve Repair
Shuhaiber. EJCTS, 2007.
Chronic Severe MR
Bonow. JACC, 2006.
Percutaneous Therapies
• 1/3 of European patients with severe
valve disease are denied surgery
• 1/2 of patients with severe
symptomatic MR
Piazza. JACC, 2009.
Feldman. JACC, 2009
Mitral Stenosis
• Most commonly from
rheumatic fever: 99%
• 2-20 years until symptoms
of MS
• Likely worsened by
recurrent RF
• Also
– Congenital
– CTD, RA
– Mucopolysaccharidoses
• Mimicks
– Tumors
– Infection
– membranes
http://www.yale.edu/imaging/echo_atlas/entities/mitral_stenosis.html
Hemodynamics
• Normal valve orifice 4-6
cm2
• Small valve area
requires higher
pressure gradient
• Symptoms precipitated
by fast heart rate
– Higher LA-LV pressure
gradient
– Lower cardiac output
Libby. Braunwald’s Heart Disease. 8th Ed.
Hemodynamics: Why Symptoms Develop
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Increased left atrial pressure
Increase in left ventricular diastolic pressure
Pulmonary hypertension
Everything is worse with exercise
Chronic atrial changes lead to arrhythmia
Clinical Findings
• Presentation
– Dyspnea, hemoptysis, chest pain, arrhythmia, embolic
events, hoarseness
• Exam findings
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Accentuated S1
Opening snap- at the apex with the diaphragm
A2-OS snap good indicator of severity
Findings of pulmonary hypertension
Low pitched rumbling murmur at the apex
Maneuvers that increase mitral flow increase murmur and
decrease A2-OS time
Echo Determinants Of Mitral Stenosis Severity
Baumgartner. JASE, 2009.
Echo Determinants Of Mitral Stenosis Severity
Mild
Moderate Severe
Valve Area (cm2)
>1.5
1.0-1.5
<1.0
Mean Gradient
(mmHg)
<5
5-10
>10
PAP (mmHg)
<30
30-50
>50
Mitral Valvuloplasty Score
Baumgartner. JASE, 2009.
Natural History of 159 Patients With
Un-Operated Mitral Valve Disease
Expected survival
Mitral stenosis
Mitral regurgitation
Libby. Braunwald’s Heart Disease. 8th Ed.
Management Approach to Mitral Stenosis
Nobuyoshi. Circulation, 2009.
Percutaneous Valvuloplasty
Nobuyoshi. Circulation, 2009.
Long Term Outcome For Percutaneous
Valvuloplasty
Libby. Braunwald’s Heart Disease. 8th Ed.
Endocarditis Prophylaxis
• Prosthetic valve material
• Prior endocarditis
• Congenital heart disease
– Unrepaired cyanotic
– For 6 months following repair with prosthetic
material
– Following incomplete repair with prosthetic
material
• Transplant recipient with abnormal valves