Professional Documents
Culture Documents
Valvular Heart Disease and The Cardiac Exam
Valvular Heart Disease and The Cardiac Exam
Atrial fibrillation
– Prevalence >30% in symptomatic patients and
associated with poorer long term outcome
– Warfarin indicated:
In patients with AF and MS
Patients without history of AF but with MS and embolic CVA
– In patients with prior history of AF who have mitral
valve surgery, decreased postoperative AF observed if
MAZE performed concominantly
Mitral Valve Repair
Percutaneous valvotomy
– Therapeutic intervention of choice if:
LAA thrombus excluded
MR less than moderate
Valvular characteristics favorable
– Pliable leaflets, minimal commisural fusion, minimal valvular or
subvalvular calcification
– Pulmonary HTN not contraindication to valvotomy
– Major complications include: severe MR (1-8%),
systemic embolization (1-3%), and tamponade (1-
2%)
Periprocedural mortality- 1%
Surgical commissurotomy or MVR can be
performed in unfavorable anatomy
Bonow et al. J Am Coll Cardiol 2006; 47: 2141-51
Rheumatic Fever Prophylaxis
Primary prophylaxis
– If living in an endemic area, with pharyngitis and a
+test for group A strep or positive throat culture
– Given once, may be repeated as needed:
PCN G 1.2 million U IM or PCN V 500 mg TID x 10d
Azithromycin 500 mg on day 1, 250 mg daily for 4d
Secondary prophylaxis
– PCN G 1.2 million units IM every 4 weeks or PCN V
250 mg PO BID or erythromycin 250 mg BID
RHD without carditis- At least 5 years or until >21 y of
age
RHD with carditis, no valvular HD- At least 10 y or well
into adulthood
RHD with carditis and valvular HD- At least 10 years
from last episode or until patient is older than 40 years
Acute Aortic Regurgitation
Causes of acute aortic regurgitation:
– Aortic dissection
– Valve distruction from endocarditis
– Traumatic rupture
Classic physical exam findings may be absent in the
acute presentation
– Diastolic murmur may not be present due to sudden increase of
LVEDP
TTE, along with TEE, cath, CT or MRI may be used for
diagnosis
Surgical AV repair or replacement should be performed
emergently
Afterload reducing medications and inotropes may help
to acutely stabilize the patient
IABP contraindicated
Acute Mitral Regurgitation
Most often occurs in:
– Chordae tendineae rupture due to myxomatous valve
disease or endocarditis
– Myocardial infarction with papillary muscle
dysfunction or rupture
Symptoms almost always occur
– Dyspnea and pulmonary edema
Systolic function may occur normal or
hyperdynamic
IABP or afterload reducing drugs to temporize
Surgical intervention for treatment
Chronic Valvular Regurgitation
Cardiac chamber size and function have time to
compensate for dysfunction
– May allow patients to remain asymptomatic for a long time
Both preload and afterload increases
Once increase in cardiac output insufficient→ systolic
function declines → pulmonary HTN may develop and
symptoms develop
LV enlargement and progressive systolic dysfunction are
associated with significant morbidity and mortality
Serial echocardiography and evaluation by a cardiologist
is indicated
Chronic Aortic Regurgitation
Occurs most often in bicuspid AV
Other causes include ascending aortic aneurysm and Marfan’s
Disease
Risk factors for poorer outcome:
– Age
– Cardiac symptoms
– Atrial fibrillation
– LV enlargement
– Lower LVEF
Asymptomatic patients with normal LV size and function do not
require prophylatic surgery
Surgery should be considered if:
– LVESD > 55 mm
– Ejection fraction <60%
– Symptoms develop
Oral afterload reduction (nifedipine or ACE-I) may slow rate of LV
dilation
Bonow et al. J Am Coll Cardiol 2006; 47: 2141-51
Chronic Mitral Regurgitation
Bileaflet valve
Prosthetic Valves- Biological
Biological Valves
– Composed of autologous or xenograft biological
material mounted on stents and a sewing ring
– Warfarin therapy not required due to lower
thromboembolic potential
– Valve durability less when compared to mechanical
valves
– Newer stentless valves with increased longevity
Anticoagulation Guidelines for
Mechanical Valves