Cases in Valvular Heart Disease Casos clinicos de cardiopatia valvular

Howard Weitz, M.D. February 2012

Case 1
A 60 year old man underwent an aortic valve replacement as treatment of symptomatic aortic stenosis five years ago. A mechanical bileaflet aortic valve was implanted. He has normal left ventricular function and no history of atrial fibrillation. He has been maintained on warfarin anticoagulation with his INR apprx 2.5. You have been notified that as treatment of chronic cholecystitis he is scheduled to undergo laparoscopic cholecystectomy in 10 days.

Case 1
The surgeon requests your recommendations regarding the management 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 before surgery. 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 procedure warfarin is therapeutic

Case 1
The surgeon requests your recommendations regarding the management 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 before surgery. 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 procedure warfarin is therapeutic.

Antithrombotic Therapy in Patients with Mechanical Valves who Require Interruption of Warfarin Therapy for Noncardiac Surgery
Continue antithrombotic therapy for procedures where bleeding inconsequential:
Skin Eye surgery Dental
Cleaning Caries

Journal of the American Dental Association, November 2003

Review of clinical studies: anticoagulants and dental procedures Warfarin and Low dose aspirin (100 mg/d)

Journal of the American Dental Association, November 2003

Review of clinical studies: anticoagulants and dental procedures Warfarin Low dose aspirin (100 mg/d)
The weight of evidence in the dental literature does not support the long-held belief that an oral anticoagulant regimen 1 must 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, provided that local hemostatic measures are used. Articles that document oral surgery experiences of patients taking aspirin alone or in combination with clopidogrel have not reported any cases of unusual intraoperative or postoperative bleeding problems. This experience is anecdotal.

Low risk of valve thrombosis

Bileaflet aortic valve Normal LV function Sinus rhythm Stop warfarin 48-72 hours before procedure Restart warfarin within 24 hours after

High risk of valve thrombosis: mitral valve tricuspid valve

Aortic valve AND

atrial fibrillation prior thromboembolism hypercoagulable older generation valve LVEF < 30% a second mechanical valve

therapeutic unfractionated heparin when INR < 2.0 Restart as soon as possible

Usefulness / efficacy less well established by evidence / opinion LMWH

How about LMWH for prosthetic valve?

ACCP 2008 Guideline

ACCP 2008 Guideline Bridging anticoagulation and mechanical valve

High Risk for thromboembolism

Mitral prosthesis Older aortic prosthesis Recent TIA, stroke

Moderate Risk for thromboembolism Bileaflet aortic valve AND

atrial fibrillation prior stroke, TIA CHADS2 pts

Low Risk for thromboembolism Bileaflet aortic valve

Case 1: Prosthetic valve perioperative anticoag

In patients at Low Risk of valve thrombosis (eg bileaflet aortic valve and no risk factors ((atrial fibrillation,
previous thromboembolism, left ventricular dysfunction, hypercoagulable conditions, older generation prosthetic valves, mechanical mitral valve,

it is recommended that warfarin be stopped 48-72 hours before surgery and resumed within 24 hours following surgery.
or more than one mechanical valve)),

Case 2
A 40 year old man has recently moved to your city and you are seeing him for initial internal medicine evaluation. Hx: Heart murmur since childhood. He was told that it was due to an abnormal 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 area peaking in mid-systole. Radiates to carotid arteries II/VI diastolic descrescendo diastolic blowing murmur heard in aortic area radiating to left sternal border

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)

Case 2
Upon review of the echocardiogram you 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

Case 2
Upon review of the echocardiogram you 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

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)

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

Our patient
Bicuspid aortic valve
Moderate aortic stenosis Mild aortic regurgitation

Dilated aortic root Normal left ventricle No symptoms Healthy

Case 2

Case 2

From: Tadros T., et l.: Circulation 2009;119;880-890

Bicuspid aortic valve Ascending Aorta

From: Fedak P, Verma S, David T., et al.: Circulation 2002;106;900-904

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

When is BAV Surgery Indicated ?

Ascending aorta replacement

Aortic valve replacement

Approach to the patient with BAV severe AS or AR who is undergoing valve replacement

Approach to the patient with BAV severe AS or AR who is undergoing valve replacement

Case 2 Bicuspid aortic valve

Surgery to repair or replace the ascending aorta in a patient with bicuspid aortic valve is indicated when the ascending aortic 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

Case 2: Bicuspid Aortic Valve Disease

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

Aortic dilatation may result in aortic dissection

Case 3
You recommend
Answer D. Refer for mitral valve repair.

He has symptomatic severe MR. Valve repair is the desired approach.

From: Otto, C.: New England Journal of Medicine 345:740-746. 2001

Chronic Severe Mitral Regurgitation

From Otto, C. New England Journal of Medicine, 345:740-746, 2001

Chronic Severe Mitral Regurgitation

From Otto, C. New England Journal of Medicine, 345:740-746, 2001

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, preserve chordal apparatus.

Better post op LV function.

Mitral valve repair (from Otto, C., Heart 83:2003)

Case 3 Mitral regurgitation

In the patient with severe mitral regurgitation and normal left ventricular function, ejection fraction should be higher than normal. The treatment of symptomatic severe mitral regurgitation is surgery even if left ventricular function is normal and as long as the left ventricular ejection fraction is > 30%. Mitral valve repair is preferred over mitral valve replacement.

Case 4
Answer A. AVR

He has severe aortic insufficiency and impaired left ventricular function (LVEF < 50%)

Chronic Aortic Regurgitation

Chronic AI Increased stroke volume is ejected into aorta - systemic hypertension and increased afterload.

Chronic Aortic Regurgitation - Medical Rx

Vasodilator therapy (improve stroke vol., reduce regurgitant volume, does NOT decrease mortality) Three uses of vasodilators in chronic severe AR
Rx when patient inoperable Short term improvement in hemodynamics while awaiting AVR Prolongation of the asymptomatic phasein pts with normal systolic fxn.
Only 2 studies (nifedipine; ACEI) Mixed results 2006 Guideline witholds recommendation

No data to support empiric use of diuretic, verapamil, ACE-I.

Chronic Severe Aortic Regurgitation Indications 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

Indications for Valve Replacement Severe AR (June 2006)

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 aortic stenosis heard in aortic area and radiating to carotids and precordium Stool heme positive

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

Colonoscopy

Case 5
Which of the following, in addition to the finding noted at colonoscopy, 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

Case 5
Which of the following, in addition to the finding noted at colonoscopy 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

N Engl J Med 1958;259:196

Von Willebrand Factor

Gigantic multimeric protein Mediates adhesion of platelets to sites of vascular damage Large multimers cleaved by plasma metalloprotease under conditions of high shear stress Absence of large multimers of vWF cause bleeding from gastrointestinal angiodysplasia

From Warkentin TE, Moore JC, Anand SS, et al.: Gastrointestinal bleeding, anngiodysplasia, cardiovascular disease and acquired von Willebrand syndrome. Transfus Med Rev 2003; 17:272-86.

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.

Case 5: Aortic stenosis and GI bleed

Gastrointestinal bleeding in the setting of critical aortic stenosis is often a result of gastrointestinal angiodysplasia and a relative decrease in functioning von Willebrands factor (vWF) caused by shear dependant vWF proteolysis. Aortic valve replacement often results in recovery of active high molecular weight multimers of vWF and cessation of bleeding.