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Cases in Valvular Heart Disease
Casos clinicos de cardiopatia valvular
Howard Weitz, M.D.
February 2012
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Case 1
A 60 year old man underwent an aortic valve replacementas treatment of symptomatic aortic stenosis five years ago.A mechanical bileaflet aortic valve was implanted. He hasnormal left ventricular function and no history of atrial
fibrillation. He has been maintained on warfarinanticoagulation with his INR apprx 2.5. You have beennotified that as treatment of chronic cholecystitis he isscheduled to undergo laparoscopic cholecystectomy in 10days.
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Case 1
The surgeon requests your recommendations regarding themanagement of his anticoagulation prior to surgery. You suggest:
A. Perform the surgery while INR therapeutic.B. Discontinue warfarin 5 days prior to surgery and admit to hospital for
continuous heparin infusion. Discontinue heparin 8-12 hours beforesurgery.C. Discontinue warfarin 5 days prior to surgery and begin low molecular
weight heparin during the period of subtherapeutic INR.D. Discontinue warfarin 72 hours prior to procedure and restart warfarin
within 24 hours after the procedure.E. Discontinue warfarin 72 hours prior to procedure and start heparin
infusion12 hours after the procedure continuing until post procedurewarfarin is therapeutic
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Case 1
The surgeon requests your recommendations regarding themanagement of his anticoagulation prior to surgery. You suggest:
A. Perform the surgery while INR therapeutic.B. Discontinue warfarin 5 days prior to surgery and admit to hospital for
continuous heparin infusion. Discontinue heparin 8-12 hours beforesurgery.C. Discontinue warfarin 5 days prior to surgery and begin low molecular
weight heparin during the period of subtherapeutic INR.D. Discontinue warfarin 72 hours prior to procedure and restart warfarin
within 24 hours after the procedure.E. Discontinue warfarin 72 hours prior to procedure and start heparin
infusion 12 hours after the procedure continuing until post procedurewarfarin is therapeutic.
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Antithrombotic Therapy in Patients with MechanicalValves who Require Interruption of Warfarin Therapy
for Noncardiac Surgery
Continue antithrombotic therapy for procedures wherebleeding inconsequential:
Skin
Eye surgery
Dental
Cleaning
Caries
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Journal of the American Dental Association, November 2003
Review of clinical studies: anticoagulants and dental proceduresWarfarin and Low dose aspirin (100 mg/d)
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Journal of the American Dental Association, November 2003
Review of clinical studies: anticoagulants and dental proceduresWarfarin
Low dose aspirin (100 mg/d)
1
The weight of evidence in the dental literature does not
support the long-held belief that an oral anticoagulant regimenmust be altered or discontinued before most dental procedures,including oral surgery.
Currently the INR does not require alteration of the therapy
regimen unless the INR value is greater than 4.0, providedthat local hemostatic measures are used.
Articles that document oral surgery experiences of patientstaking aspirin alone or in combination with clopidogrel have notreported any cases of unusual intraoperative or postoperativebleeding problems. This experience is anecdotal.
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Low risk of valve thrombosis
Bileaflet aortic valveNormal LV functionSinus rhythm
Stop warfarin 48-72 hours before proceRestart warfarin within 24 hours after
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High risk of valve thrombosis:mitral valvetricuspid valve
Aortic valve ANDatrial fibrillationprior thromboembolismhypercoagulableolder generation valveLVEF < 30%a second mechanical valve
therapeutic unfractionated hepawhen INR < 2.0Restart as soon as possible
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LMWH
Usefulness / efficacy less well established by evidence / opinion
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How about LMWH for prosthetic valve?
ACCP 2008 Guideline
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ACCP 2008 GuidelineBridging anticoagulation and mechanical valve
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High Risk for thromboembolism
Mitral prosthesis
Older aortic prosthesisRecent TIA, stroke
Moderate Risk for thromboembol
Bileaflet aortic valve ANDatrial fibrillation
prior stroke, TIACHADS2 pts
Low Risk for thromboembolism
Bileaflet aortic valve
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Case 1: Prosthetic valve perioperative anticoag
In patients at Low Risk of valve thrombosis (egbileaflet aortic valve and no risk factors ((atrial fibrillation,
previous thromboembolism, left ventricular dysfunction, hypercoagulableconditions, older generation prosthetic valves, mechanical mitral valve,
or more than one mechanical valve)), it is recommended thatwarfarin be stopped 48-72 hours before surgery
and resumed within 24 hours following surgery.
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Case 2
A 40 year old man has recently moved to your city and you are seeinghim for initial internal medicine evaluation.
Hx: Heart murmur since childhood. He was told that it was due to anabnormal heart valve.
Hx: Leads active life, exercises. No symptoms
No medications.
Pe: BP 130/55. HR 60
II/VI crescendo - decrescendo systolic murmur heard in aortic areapeaking in mid-systole. Radiates to carotid arteries
II/VI diastolic descrescendo diastolic blowing murmur heard in aortic arearadiating to left sternal border
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Case 2
Echocardiogram
Normal left ventricular systolic function
Bicuspid aortic valve
valve area 1.2 cm2, mean aortic valve gradient 28 mm Hg
Mild aortic regurgitation Normal mitral and tricuspid valves
Aortic root dilated 5.1 cm (normal < 4.0 cm)
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Case 2
Upon review of the echocardiogramyou recommend:
A. Repeat echo in 6 months
B. Repeat echo in 1 year
C. Initiate beta blocker therapy
D. Aortic root replacement
E. Aortic root replacement and aortic valve replacement
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Case 2
Upon review of the echocardiogramyou recommend:A. Repeat echo in 6 months
B. Repeat echo in 1 year
C. Initiate beta blocker therapyD. Aortic root replacement
E. Aortic root replacement and aortic valve replacement
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Case 2
Echocardiogram
Normal left ventricular systolic function
Bicuspid aortic valve
valve area 1.2 cm2, mean aortic valve gradient 28 mm Hg
Mild aortic regurgitation Normal mitral and tricuspid valves
Aortic root dilated 5.1 cm (normal up to 4.0 cm)
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Classification of Aortic Stenosis
Mild Valve area > 1.5 cm2
Mean aortic valve gradient < 25 mm Hg
or Jet velocity < 3.0 m/s
Moderate Valve area 1.0 1.5 cm2
Mean aortic valve gradient 25-40 mm Hg
Or Jet velocity 3.0 4.0 m/s
Severe Valve area < 1.0 cm2
Mean aortic valve gradient > 40 mm Hg Jet velocity > 4.0 m/s
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Our patient
Bicuspid aortic valve
Moderate aortic stenosis
Mild aortic regurgitation
Dilated aortic root
Normal left ventricle
No symptoms
Healthy
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Case 2
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Case 2
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From: Tadros T., et l.: Circulation 2009;119;880-890
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Bicuspid aortic valve Ascending Aorta
From: Fedak P, Verma S, David T., et al.: Circulation 2002;106;900-904
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Bicuspid Aortic Valve
Most common congenital heart lesion 1-2% of population Males 4:1 Family clusters. Echo screening of first degree relatives
Majority will require intervention (surgery)
Consequences Aortic stenosis Aortic regurgitation Disease of the aorta (dilatation, dissection)
More rapid than in idiopathic aortic dilatation
No evidence that Beta blocker prevents progression of aortic
dilatation
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When is BAV Surgery Indicated ?
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Ascending aorta replacement
Aortic valve replacement
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Aortic valve replacement
Approach to the patient with BAV severe AS or AR
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Approach to the patient with BAV severe AS or ARwho is undergoing valve replacement
Approach to the patient with BAV severe AS or AR
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Approach to the patient with BAV severe AS or ARwho is undergoing valve replacement
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Case 2 Bicuspid aortic valve
Surgery to repair or replace the ascending aorta in a patientwith bicuspid aortic valve is indicated when the ascendingaortic diameter is > 5.0 cm Bicuspid aortic valve disease is often accompanied by disruption of
aortic media (elastin, collagen, smooth muscle) and may involve:
Aortic valve Aortic annulus
Sinus of valsalva
Ascending aorta
Pulminary trunk
Coronary ostia
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Case 2: Bicuspid Aortic Valve Disease
Bicuspid aortic valve disease is often accompanied bydisruption of aortic media (elastin, collagen, smooth muscle)and may involve:
Aortic valve
Aortic annulus Sinus of valsalva
Ascending aorta
Pulminary trunk
Coronary ostia
Aortic dilatation may result in aortic dissection
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Case 3
You recommend
Answer D. Refer for mitral valve
repair.
He has symptomatic severe MR. Valve
repair is the desired approach.
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From: Otto, C.: New England Journal of Medicine 345:740-746. 2001
Ch i S Mi l R i i
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Chronic Severe Mitral Regurgitation
From Otto, C. New England Journal of Medicine, 345:740-746, 2001
Ch i S Mit l R it ti
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Chronic Severe Mitral Regurgitation
From Otto, C. New England Journal of Medicine, 345:740-746, 2001
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Mitral Regurgitation - Surgical Rx.
Valve repair when possible. Lower operative mortality
Better late outcomes
Better preservation of LV function.
Lower likelihood of long term anticoagulation 7-10% reoperation at 10 years (similar reop rate
following MV Replacement)
If valve replacement necessary, preservechordal apparatus. Better post op LV function.
Mitral valve repair (from Otto, C., Heart 83:2003)
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Case 3 Mitral regurgitation
In the patient with severe mitral regurgitation andnormal left ventricular function, ejection fraction
should be higher than normal.
The treatment of symptomatic severe mitralregurgitation is surgery even if left ventricularfunction is normal and as long as the left ventricularejection fraction is > 30%.
Mitral valve repair is preferred over mitral valvereplacement.
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Case 4
Answer A. AVR
He has severe aortic insufficiency and impairedleft ventricular function (LVEF < 50%)
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Chronic Aortic Regurgitation
Chronic AI Increased stroke volume isejected into aorta - systemic hypertensionand increased afterload.
Chronic Aortic Regurgitation - Medical Rx
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Chronic Aortic Regurgitation Medical Rx
Vasodilator therapy (improve stroke vol., reduceregurgitant volume, does NOT decrease mortality)
Three uses of vasodilators in chronic severe AR Rx when patient inoperable
Short term improvement in hemodynamics while awaitingAVR
Prolongation of the asymptomatic phasein pts with normalsystolic fxn.
Only 2 studies (nifedipine; ACEI)
Mixed results
2006 Guideline witholds recommendation
No data to support empiric use of diuretic,verapamil,ACE-I.
Ch i S A i R i i
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Chronic Severe Aortic RegurgitationIndications for Valve Replacement
Symptomatic
Unoperated mortality > 10%/yr
Asymptomatic with:
Decreasing LV function (LVEF < 50%) Unoperated progression to symptoms > 25%/yr
Increasing LV size (LV end systolic dimension > 55mm)
Note: normal LV end systolic dimension < 45mm
Case 4: Aortic regurgitation
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Case 4: Aortic regurgitationIndications for Valve Replacement Severe AR (June 2006)
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Case 5
An 80 year old man presents for evaluation of fatigue.
Known severe aortic stenosis (no angina, syncope, chf)
No prior history of abnormal bleeding, or clotting disorder.
Bp 120/70 HR 90 sinus
III/VI mid peaking crescendo-decrescendo murmur of aorticstenosis heard in aortic area and radiating to carotids andprecordium
Stool heme positive
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Case 5
Echo: Severe aortic stenosis, normal left ventricular function
No change from echo of one year ago
Hbg 7.5 (was 14.0 six months ago), microcytic hypochromic
Colonoscopy
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Colonoscopy
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Case 5
Which of the following, in addition to the finding noted atcolonoscopy, best explains the cause of his anemia?
A. Acquired disorder impairing platelet adhesion
B. Inherited disorder impairing platelet adhesion
C. Acquired disorder of thrombin generation
D. Inherited disorder of thrombin generation
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Case 5
Which of the following, in addition to the finding noted atcolonoscopy best explains the cause of his anemia?
A. Acquired disorder impairing platelet adhesion
B. Inherited disorder impairing platelet adhesionC. Acquired disorder of thrombin generation
D. Inherited disorder of thrombin generation
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N Engl J Med 1958;259:196
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Von Willebrand Factor
Gigantic multimeric protein
Mediates adhesion of platelets to sites of vascular damage
Large multimers cleaved by plasma metalloprotease underconditions of high shear stress
Absence of large multimers of vWF cause bleeding fromgastrointestinal angiodysplasia
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From Warkentin TE, Moore JC, Anand SS, et al.: Gastrointestinal bleeding, anngiodysplasia, cardiovasculardisease and acquired von Willebrand syndrome. Transfus Med Rev 2003; 17:272-86.
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From Vincentilli A, Susen S, Le Tourneau T, et al.: Acquired von Willebrand syndrome in aortic stenosis.N Engl j Med 2003;349:343-9.
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Case 5: Aortic stenosis and GI bleed
Gastrointestinal bleeding in the setting of criticalaortic stenosis is often a result of gastrointestinalangiodysplasia and a relative decrease in
functioning von Willebrands factor (vWF) caused by
shear dependant vWF proteolysis. Aortic valvereplacement often results in recovery of active highmolecular weight multimers of vWF and cessationof bleeding.