Heart Failure in Valvular Heart

Disease
Abdul Hakim Alkatiri, MD, SpJP, FIHA
Mitral Stenosis

Restriction and
narrowing of
mitral valve
Impairment of left
ventricular filling
 Etiology of Mitral Stenosis
Rheumatic Fever (>90% cases)
50% patients will have known history
Average 20 years prior to clinical symptoms
Congenital stenosis of MV
Extensive calcification
endocarditis
 Mitral Stenosis:
Pathophysiology
Right Heart Failure: Pulmonary HTN
Hepatic Congestion Pulmonary Congestion
JVD Atrial Fib
Tricuspid Regurgitation LA Thrombi
RA Enlargement LA Enlargement
LA Pressure

RV Pressure Overload
RVH
RV Failure LV Filling
 Clinical Presentation of MS
Natural history variable
10 year survival (symptoms)
50-60%
Early onset
Dyspnea and reduced exercise capacity
Advanced
SOB at rest
Pulmonary congestion (orthopnea, PND etc)
Pulmonary HTN (RHF)
Hoarseness from laryngeal nerve compression
 Continuing Medical Implementation ...bridging the care gap
Tachycardia shortens diastole
Decreases the overall time for transmitral flow,
In order to maintain CO, the flow rate per unit time must increase
Pressure gradient increase proportionate to square of flow rate
LAP Pulmonary venous congestion and symptoms

So, patients with MS do not tolerate

tachycardia
 MITRAL
REGURGITATION
 Mitral Apparatus
Mitral Valve leaflets
Chordae tendinae
Papillary muscles
MV annulus
LV myocardium and
LA wall
Etiology of Mitral Regurgitation
MITRAL ANNULUS
Annular calcification (MAC)

LEAFLETS
Rheumatic disease
Endocarditis
Myxomatous disease
(MVP)
CHORDAE TENDINAE
Rupture
endocarditis

PAPILLARY MUSCLE
Dysfunction (MI or ischemia)

LEFT VENTRICLE
Cavity dilatation
 Mitral Regurgitation

Acute Primary
(degenerative)
Secondary
- ischemic
- functional
Chronic (nonischemic)
 Stages of Primary Mitral Regurgitation
Stage Definition Valve Anatomy Valve Hemodynamics Hemodynamic Symptoms
Consequences
A At risk of MR Mild mitral valve No MR jet or small central None None
prolapse with jet area <20% LA on Doppler
normal coaptation Small vena contracta
Mild valve <0.3 cm
thickening and
leaflet restriction
B Progressive Severe mitral valve Central jet MR 20%40% LA Mild LA None
MR prolapse with or late systolic eccentric jet enlargement
normal coaptation MR No LV
Rheumatic valve Vena contracta <0.7 cm enlargement
changes with leaflet Regurgitant volume Normal
restriction and loss <60 cc pulmonary
of central coaptation Regurgitant fraction <50% pressure
Prior IE ERO <0.40 cm2
Angiographic grade 12+
 Stages of Primary Mitral Regurgitation (cont.)
Stage Definition Valve Anatomy Valve Hemodynamic Symptoms
Hemodynamics Consequences
C Asymptomatic Severe mitral valve Central jet MR Moderate or None
severe MR prolapse with loss >40% LA or severe LA
of coaptation or holosystolic enlargement
flail leaflet eccentric jet MR LV enlargement
Rheumatic valve Vena contracta Pulmonary
changes with 0.7 cm hypertension may
leaflet restriction Regurgitant volume be present at rest
and loss of central 60 cc or with exercise
coaptation Regurgitant fraction C1: LVEF >60%
Prior IE 50% and LVESD
Thickening of ERO 0.40 cm2 <40 mm
leaflets with Angiographic grade C2: LVEF 60%
radiation heart 34+ and LVESD
disease 40 mm
 Stages of Primary Mitral Regurgitation (cont.)
Stage Definition Valve Anatomy Valve Hemodynamic Symptoms
Hemodynamics Consequences
D Symptomatic Severe mitral valve Central jet MR Moderate or Decreased
severe MR prolapse with loss >40% LA or severe LA exercise
of coaptation or flail holosystolic enlargement tolerance
leaflet eccentric jet MR LV enlargement Exertional
Rheumatic valve Vena contracta Pulmonary dyspnea
changes with leaflet 0.7 cm hypertension
restriction and loss Regurgitant volume present
of central 60 cc
coaptation Regurgitant fraction
Prior IE 50%
Thickening of ERO 0.40 cm2
leaflets with Angiographic grade
radiation heart 34+
disease
 Stages of Secondary Mitral Regurgitation (cont.)

Grade Definition Valve Anatomy Valve Associated Cardiac Symptoms

Hemodynamics Findings

A At risk of MR Normal valve No MR jet or Normal or mildly Symptoms due to

leaflets, chords, small central jet dilated LV size with coronary ischemia
and annulus in a area <20% LA on fixed (infarction) or or HF may be
patient with Doppler inducible (ischemia) present that
coronary disease Small vena regional wall motion respond to
or a contracta <0.30 abnormalities revascularization
cardiomyopathy cm Primary myocardial and appropriate
disease with LV medical therapy
dilation and systolic
dysfunction
 Stages of Secondary Mitral Regurgitation (cont.)

Grade Definition Valve Anatomy Valve Associated Cardiac Symptoms

Hemodynamics Findings
B Progressive Regional wall ERO <0.20 cm2 Regional wall motion Symptoms due to
MR motion Regurgitant abnormalities with coronary ischemia
abnormalities with volume <30 cc reduced LV systolic or HF may be
mild tethering of function present that
mitral leaflet LV dilation and respond to
Annular dilation systolic dysfunction revascularization
with mild loss of due to primary and appropriate
central coaptation myocardial disease medical therapy
of the mitral
leaflets
 Stages of Secondary Mitral Regurgitation (cont.)
Grade Definition Valve Anatomy Valve Associated Symptoms
Hemodynamics Cardiac Findings
C Asymptomatic Regional wall ERO 0.20 Regional wall Symptoms due
severe MR motion cm2 motion to coronary
abnormalities Regurgitant abnormalities ischemia or HF
and/or LV volume 30 cc with reduced LV may be present
dilation with systolic function that respond to
severe tethering LV dilation and revascularization
of mitral leaflet systolic and appropriate
Annular dilation dysfunction due medical therapy
with severe loss to primary
of central myocardial
coaptation of disease
the mitral
leaflets
 Stages of Secondary Mitral Regurgitation (cont.)
Grade Definition Valve Anatomy Valve Associated Symptoms
Hemodynamics Cardiac Findings
D Symptomatic Regional wall ERO 0.20 cm2 Regional wall HF symptoms
severe MR motion Regurgitant motion due to MR
abnormalities volume 30 cc abnormalities persist even after
and/or LV with reduced LV revascularization
dilation with systolic function and optimization
severe LV dilation and of medical
tethering of systolic therapy
mitral leaflet dysfunction due Decreased
Annular to primary exercise
dilation with myocardial tolerance
severe loss of disease. Exertional
central dyspnea
coaptation of
the mitral
leaflets
 Physical Examination
S1 reflecting failure of leaflets to close
properly
S3
In most case pansystolic murmur heard best at
apex and radiates to axilla or back, usually
blowing and high pitched in quality ( acute
MR decresendo murmur)
Acute Mitral Regurgitation:
Pulmonary Edema
High LA Pressure

Chronic Mitral Regurgitation:

Dilated LA with less elevated
pressure
Mechanism of
Heart Failure in
Acute MR
Mechanism
of HF in
Chronic MR
 Management of MR
Acute MR Chronic
Reduce the resistance to Operative repair once
forward flow symptoms develop or LV
(Vasodilators) starts to dilate
Relieve pulmonary
edema (Diuretics)
AORTIC STENOSIS
 Aortic Stenosis

Thickened and
restricted
opening of aortic
valve
Obstruction to LV
outflow

Normal Tricuspid Aortic Valve

 Etiology of Aortic Stenosis
Valvular
Congenital, acquired calcific, rheumatic
Subvalvular
Hypertrophic cardiomyopathy
Supravalvular
Coarctation, congenital
What Causes Aortic Stenosis in
More
Adults?
Common
Age-Related Aortic stenosis in patients over the age
Calcific Aortic of 65 is usually caused by calcific
Stenosis (calcium) deposits associated with
aging

Adults who have had rheumatic fever

Rheumatic Fever
may also be at risk for aortic stenosis

Congenital In some cases adults may develop

Abnormality aortic stenosis resulting from a
congenital abnormality
Less Common

31
 Clinical Presentation of AS

Angina
Imbalance myocardial oxygen
supply and demand
Symptom Median survival
Syncope
Peripheral vasodilation with Angina 5 yrs
inability to augment CO with Syncope 3 years
exercise
HF HF 2 years
Increased LAP from high LVEDP
Contractile dysfunction if
longstanding pressure overload
 Aortic Stenosis Is Life Threatening
and Progresses Rapidly

Survival after onset of symptoms is 50% at 2 years and 20% at

5 years1
Surgical intervention for severe aortic stenosis should be
performed promptly once even minor symptoms occur 1
 AS - Pathophysiology

Blood flow across the AV is impeded

Once AVA 50%:
Significant LV pressure needed to drive blood into
aorta
Results in LV hypertrophy
LV compliance (Stiffer LV) =>
Increased end diastolic pressure
 AS -Exam
1. Carotid pulse
Weakend (parvus) and delayed (tardus) due to LV
obstruction

2. Murmur
Late peaking systolic ejection murmur

3. S4
Atrial contraction into stiff LV
 CLINICAL OUTCOMES

Asimptomatic Patients
The severity of outflow tract obstruction
gradually increases over 10 to 15 years

84 % with velocity <

Survival free of 3 m/sec
symptoms at 2
years 21 % with velocity >
4 m/sec
Aortic Regurgitation
 Etiology of Aortic Regurgitation
Abnormalities of valve leaflets Dilatation of aortic root

Congenitally bicuspid Degenerative

valve Marfan syndrome
Calcific AS in older Aortic dissection
patient Syphilitic aortitis
Infective endocarditis Ankylosing spondylitis
Rheumatic Bechet syndrome
Pathophysiology of acute & chronic AR
 AR Clinical Manifestations
SOB on exertion
Fatigue
Decreased exercise tolerance
 AR - Examination

Murmur
Blowing diastolic along LSB
Widened pulse pressure
Name Description
Bisferins Double impulse
Corrigans Marked distention and collapse
deMusset Head bobbing
Duroziez To and fro murmur
Hill Greater popliteal SBP
Muller Uvula pulsations
Quincke Nail bed pulsation
Traube Pistol shot femoral art
Management of Heart Failure in
Valvular Heart Disease
Abdul Hakim Alkatiri, MD, SpJP, FIHA
Mitral Stenosis
Management of mitral stenosis

Medical therapy Intervention

Diuretics for LHF/RHF

Anticoagulation in AF
Endocarditis PBMV
prophylaxis
Digitalis/Beta Mitral Valve Surgery
blockers/CCB: Rate
control in AF (Repair or Replacement)
 Mitral Stenosis: Medical Therapy
Recommendations COR LOE
Anticoagulation (vitamin K antagonist [VKA] or
heparin) is indicated in patients with 1) MS and AF
(paroxysmal, persistent, or permanent), or 2) MS and I B
a prior embolic event, or 3) MS and a left atrial
thrombus
Heart rate control can be beneficial in patients with
IIa C
MS and AF and fast ventricular response
Heart rate control may be considered for patients
with MS in normal sinus rhythm and symptoms IIb B
associated with exercise
 Mitral Stenosis: Intervention
Recommendations COR LOE
PMBC is recommended for symptomatic patients
with severe MS (MVA <1.5 cm2, stage D) and
I A
favorable valve morphology in the absence of
contraindications
Mitral valve surgery is indicated in severely
symptomatic patients (NYHA class III/IV) with severe
MS (MVA <1.5 cm2, stage D) who are not high risk I B
for surgery and who are not candidates for or failed
previous PMBC
Concomitant mitral valve surgery is indicated for
patients with severe MS (MVA 1.5 cm2, stages C or I C
D) undergoing other cardiac surgery
Balloon Mitral Commissurotomy
 Mitral Stenosis: Intervention (cont.)

Recommendations COR LOE

PMBC is reasonable for asymptomatic patients
with very severe MS (MVA 1 cm2, stage C) and
IIa C
favorable valve morphology in the absence of
contraindications
Mitral valve surgery is reasonable for severely
symptomatic patients (NYHA class III/IV) with
IIa C
severe MS (MVA 1.5 cm2, stage D) provided there
are other operative indications
Indications for Intervention for Rheumatic Mitral Stenosis
Mitral Regurgitation
 Management of MR
Acute MR Chronic
Reduce the resistance to Operative repair once
forward flow symptoms develop or LV
(Vasodilators) starts to dilate
Relieve pulmonary
edema (Diuretics)
 Medical therapy

Acute MR Acute MR with HF

Diuretics ACE inhibitor advanced

Nitrate MR and severe symptoms,
Sodium nitroprusside not suitable for surgery,
inotropics + IABP residual symptoms
hypotension following surgery
 Chronic Primary Mitral Regurgitation:
Medical Therapy

Recommendations COR LOE

Medical therapy for systolic dysfunction is reasonable
in symptomatic patients with chronic primary MR
IIa B
(stage D) and LVEF less than 60% in whom surgery is
not contemplated
Vasodilator therapy is not indicated for normotensive
asymptomatic patients with chronic primary MR III: No
B
(stages B and C1) and normal systolic LV function Benefit
Chronic Primary Mitral Regurgitation: Intervention
Recommendations COR LOE
MV surgery is recommended for symptomatic
patients with chronic severe primary MR (stage D) I B
and LVEF >30%
MV surgery is recommended for asymptomatic
patients with chronic severe primary MR and LV
I B
dysfunction (LVEF 30%60% and/or LVESD 40
mm, stage C2)
MV repair is recommended in preference to MVR
when surgical treatment is indicated for patients
I B
with chronic severe primary MR limited to the
posterior leaflet
Chronic Primary Mitral Regurgitation: Intervention
(cont.)

Recommendations COR LOE

MV repair is recommended in preference to MVR
when surgical treatment is indicated for patients with
chronic severe primary MR involving the anterior I B
leaflet or both leaflets when a successful and durable
repair can be accomplished
Concomitant MV repair or replacement is indicated in
patients with chronic severe primary MR undergoing I B
other cardiac surgery
 Surgical th/ of secondary MR
Dilated LV anular dilatation annuloplasty
MR ec. ischemic heart
diseasetrevascularization ( moderate/
severe MR MVR)
tranchateter th/ of secondary MR mitral
clips
Mitral
Annuloplasty
 Follow up echo
Asymptomatic moderate MR and preserved LV
func-tion can be followed up every 2 years
Asymptomatic severe MR and preserved LV
function should be seen every 6 months and
echocardiography performed annually
Aortic Stenosis
 AS - Treatment
Only effective treatment for severe
symptomatic disease is surgical correction
What if asymptomatic?
20% of patients will progress over 20 years if mild
disease only
 Medical Therapy
unsuitable
candidates for surgery or TAVI

awaiting a Diuretics
surgical or TAVI procedure
 Aortic Stenosis: Medical Therapy
Recommendations COR LOE
Hypertension in patients at risk for developing AS
(stage A) and in patients with asymptomatic AS
(stages B and C) should be treated according to
I B
standard GDMT, started at a low dose, and
gradually titrated upward as needed with frequent
clinical monitoring
Vasodilator therapy may be reasonable if used with
invasive hemodynamic monitoring in the acute
management of patients with severe
IIb C
decompensated AS (stage D) with New York Heart
Association (NYHA) class IV heart failure (HF)
symptoms
 Aortic Stenosis: Timing of Intervention

Recommendations COR LOE

AVR is recommended with severe high-gradient AS who
have symptoms by history or on exercise testing (stage I B
D1)
AVR is recommended for asymptomatic patients with
I B
severe AS (stage C2) and LVEF <50%
AVR is indicated for patients with severe AS (stage C or
I B
D) when undergoing other cardiac surgery
 Aortic Stenosis: Choice of Surgical or
Transcatheter Intervention
Recommendations COR LOE
Surgical AVR is recommended in patients who meet
an indication for AVR with low or intermediate I A
surgical risk
For patients in whom TAVR or high-risk surgical AVR is
being considered, members of a Heart Valve Team
I C
should collaborate closely to provide optimal patient
care
TAVR is recommended in patients who meet an
indication for AVR for AS who have a prohibitive
I B
surgical risk and a predicted post-TAVR survival >12
months
TAVI
 Follow up
Asymptomatic severe AS every 6 months
for the occurrence of symptoms, change in
exercise tolerance, change in echo parameters
Significant calcification, mild and moderate AS
reevaluated yearly
Aortic Regurgitation
 AR - Treatment
Asymptomatic disease progresses very slowly
Surgery if:
Symptoms
Impaired LV function
Death occurs within 4 years after angina or 2
years after HF
 Medical Therapy

Hypertension
Chronic severe AR
and HF w/ Surgery is
contraindicated

LV dysfunction persists
postoperatively

vasodilators (angiotensin-converting
enzyme (ACE) inhibitors or angiotensin
receptor blockers (ARBs)
 Medical Therapy

Marfan Syndrome
slow aortic root dilatation

Beta reduce the risk of aortic

Blocker complications

should be considered before and

after surgery
 Aortic Regurgitation: Medical Therapy
Recommendations COR LOE
Treatment of hypertension (systolic BP >140 mm Hg) is
recommended in patients with chronic AR (stages B
and C), preferably with dihydropyridine calcium
I B
channel blockers or angiotensin-converting enzyme
(ACE) inhibitors/angiotensin-receptor blockers (ARBs)

Medical therapy with ACE inhibitors/ARBs and beta

blockers is reasonable in patients with severe AR who
have symptoms and/or LV dysfunction (stages C2 and IIa B
D) when surgery is not performed because of
comorbidities
 Aortic Regurgitation: Intervention
Recommendations COR LOE
AVR is indicated for symptomatic patients with severe
AR regardless of LV systolic function I B
(stage D)
AVR is indicated for asymptomatic patients with chronic
severe AR and LV systolic dysfunction (LVEF <50%) I B
(stage C2)
AVR is indicated for patients with severe AR (stage C or
D) who are undergoing other cardiac surgery I C
 Follow up
Mild-moderate AR reviewed on a yearly
(echo performed every 2 years)
Severe AR, Normal LV function 6 months
after their initial examination
AR with stable parameters should be
followed annually
 Summary
Valve Disease
Identify the most common causes of 4 common
valve lesions
Remember clinical presentations
Surgery treatment of choice any time symptoms
present or LV dysfunction
THANK YOU