thank you it's a pleasure to be here um and a pleasure to start off this talk
i don't know if the heavy mayo faculty is referring to the excess
adipose tissue so we've broken up these talks into
we're going to talk about valve stenosis in the first talk
and then dr prendergrass is going to talk about the specific interventions
for valve disease and later on i'll talk about regurgitated valve lesions so
we're going to start off this morning this is actually a
table in the european society of cardiology valuable heart disease
guidelines these are all the questions you need to
know in order to properly manage the other heart disease we're not going
to discuss each of those symptoms or questions during the talk today and
break it down to be very practical about what you need to know to move a patient
forward in their care and the critical decisions that you need
to make with them let's start off with a couple of
questions just to gauge where we're at this is a 50 year old man who's active
and asymptomatic murmur was appreciated on a routine
physical examination late peaking three over six systolic
ejection murmur single s2 three plus carotid delays on his
echocardiogram you can see some of this data there his ejection fraction is 48
percent he's got a bicuspid valve that's
calcified he's got a mean gradient of 42 and a calculated valve area of 1.0
so the question that's going to come up is how do you want to manage this
patient
are we going to do a surgical AVR a TAVR take him to the cafe for hemodynamic
assessment put him on a treadmill or just observe
okay i'm going to give you the answer during the talk not right now
the next question is a seven-year-old man with class two dyspnea for two years
with the same type of physical examination
and his echo numbers are here his ef is 62
bicuspid valve mean gradient of 22 and a valve area of 1.3
same question how should we treat this
individual
more diversity in answers okay we have work to do
all right so obviously we're talking about aortic stenosis to begin with
i said i wasn't going to spend a lot of time on etiology but one of the
important things here first of all we know that degenerative aortic stenosis
is the most common cause that we're seeing today
and it's going to continue to increase as our society lives longer and ages
longer but it's also important to know that for
patients who are not in the over 60 category if you have
severe aortic stenosis in younger people you need to be thinking more about these
congenital lesions that require more investigation rather than just treating
the aortic stenosis so the bicuspid valve and we'll talk about that later on
requires uh evaluation of the aorta and evaluation of the family for instance so
a 40 to 60 year old with severe AS think
bicuspid aortic valve because sometimes ECHO images aren't
always obvious at the beginning now the pathophysiology of aortic
stenosis is that this obstruction dramatically increases the afterload in
the ventricle the response of the ventricle to try to normalize that wall
stress is to get thicker decrease it try to minimize the wall
stress but it also causes a mismatch in coronary flow so you get
diastolic dysfunction from the thickened heart muscle and from the
afterload mismatch the patients have and you get ischemia at the sub-endocardial
level obviously those can cause shortness of
breath they can cause anginal symptoms with aortic stenosis they are typically
predictable the patient gets the symptoms at the same
level of effort on a predictable basis they can also
get syncope typically due to the obstruction
and causing a vasodepressor response so syncope is a particularly bad sign
if you have an AS patient with syncope that's probably someone who's going to
require an intervention sooner rather than later
now this is the natural history that we understand for unoperated aortic
stenosis and you can tell that with an average age of death in the mid
50s this is a historic cohort i think we're doing much better
now and your TAVR practices will tell you
that most patients are living well beyond their 50s with severe aortic
stenosis now but the point of this curve is
that aortic stenosis has a long period where the pathophysiology and
hypertrophy are occurring and the onset of symptoms is really the
harbinger of things that are going to be bad happening to this patient so once
symptoms start the natural history becomes much worse
for aortic stenosis patients and that is an indication to move on to more
aggressive therapy and an intervention
so the hallmarker that we're trying to find in our investigations is
identifying a patient who has severe AS and echocardiography
really is the baseline evaluation technique
the 2d features give you the anatomy the doppler gives you
the physiology so you obviously want to look at the LV size and function those
have critical impact on the way we manage patients the
location of the stenosis valvular maybe there's a sub-valvular
rigid of some kind the rare supra-valvular stenosis
typically seen in patients with familial hypercholesterolemia
we want to make sure that there isn't other concomitant structural heart disease
that would impact the way you would manage a patient the 2d does not really
tell you about the severity of the AS historically people said well there's
only one leaflet moving and there's two leaflets moving a little bit
it doesn't really tell us the pathophysiology very well the doppler is
where the money is so really don't use the 2d for that
evaluation we do know that doppler echocardiography
and catheter-derived gradients track very well so you can rely on the
doppler in most cases to be the assessment of your severity of aortic
valve stenosis now doppler echocardiography
cannot overestimate the gradient unless they are severely anemic
and then if you have decreased blood velocity uh blood viscosity
the doppler signal the 4v squared doesn't apply
but it can us underestimate the gradient if you do not have the adequate angle to
evaluate the AS in in the echo lab that means they're having to evaluate
the aortic stenosis from multiple imaging windows
so remember in most cases the gradient you get from
doppler is going to be underestimating or equivalent to the gradient the
patient is actually seeing
aortic valve area in the echo lab however is a calculated
feature which means it's prone to errors particularly the LVOT
diameter which is squared in the formula so if you make any measurements in
measuring your LVOT diameter you're going to grossly
overestimate or alter the aortic valve area
the definition of severe has changed over my career
it used to be 50 millimeters and 0.8 centimeters square we're now down to 40
millimeters of mercury for a mean gradient
uh and one centimeter square for severity of aortic valve stenosis
very severe is divine by this greater than five meter per second
peak velocity across the aortic valve
so how we approach patients is obviously you're always going to want to take a
history and do a physical examination and have
an assessment of where you think this patient is at
and you get the echocardiogram as the first clue
if your clinical impression and your echocardiographic impression match
you do not need further hemodynamic testing you know how to manage that
patient based on those numbers but if your clinical impression and your
echocardiogram are at odds with one another
you need to do more evaluation now we've got on this slide here that
usually or historically has meant proceeding to invasive evaluation
it's never wrong to necessarily send the patient back for a repeat doppler study
particularly if you look at the echocardiogram and
you see that they didn't do an adequate job of assessing the aortic valve they
didn't do gradients from multiple windows those
types of things repeating the doppler can always be helpful
TEE can be helpful in some patients although the angles to assess the
gradient are often not as readily obtained by transesophageal echo
and ct scanning does have a role the higher the calcium score
calcif higher the calcification of the aortic valve the more likely it is
severe aortic stenosis but the point here is if your echo
impression and your clinical impression match you don't need
to do a additional testing so
we're looking for the severe AS occasionally we get these patients that
have low gradient but also have a severe
valve area that could be to that doppler angle
phenomenon you couldn't get the right doppler angle on it
so that might be a case that you would want to consider hemodynamic cath
but there is an algorithm in the guidelines to talk about how you assess
these patients that have so-called low-flow
low-gradient aortic valve stenosis they break it down based on whether the
ejection fraction is normal or abnormal so for patients
who have a normal ejection fraction there's this this table which is really
nice in the guidelines document all of these features on this table
would favor someone who has severe aortic valve stenosis despite that
gradient in the echocardiogram being low again likely indicating that we are
underestimating the severity of the gradient by
by echocardiogram
so i'm going to move that over there for the patient who has low injection
fraction we generally like to do a dobutamine
echocardiogram but you could do a dobutamine hemodynamic cath if that was
what you do better in your institution if on
the dobutamine the aortic valve area increases to greater than one centimeter
per second under dobutamine provocation that is probably
someone who does not have severe aortic stenosis and really has myocardial
disease and needs to be managed for their left
ventricular cardiomyopathy but if the dobutamine induced gradient
goes to greater than 40 millimeters of mercury
or there is no increase in cardiac output at all
then you're going to use the same table that's here on the right hand side of
the screen to help judge whether the patient is likely to have severe aortic
stenosis
so now that we've got someone with severe aortic stenosis
we want to figure out how we're going to manage patients with symptoms in
patients without symptoms i already indicated on the natural
history curve that when symptoms start the natural history really turns bad
so that really is the first indication for operation AS
if a patient has symptoms that are attributable to the aortic stenosis
aortic valve intervention is indicated also if they have a need for other
cardiac intervention and they have at least moderate a s
if they need bypass grafting if they need mitral valve operation or something
like that then replacing the aortic valve is also
reasonable
the other indication is if the ejection fraction has falled if that left
ventricle is starting to decompensate because it can't keep up with the
afterload insult then that's another indication for aoric
valve intervention the bigger conundrum comes for patients
who are completely asymptomatic and who have a normal ejection fraction
the historic teaching has been the number one cause for death in an
asymptomatic patient with severe s is going to the operating room
but as operative interventions or our non-operative interventions have gotten
better we might be able to change a person's
natural history if we figure out the right cues to serve as
indicators for operation so again if this algorithm plays out if
they have symptoms we recommend intervention if they're
asymptomatic we look at their ejection fraction
if the ejection fraction has dropped that's also an indication for
intervention historically we've otherwise observed
patients we do have data though that maybe
sometimes patients can't detect their symptoms they are
under reporting their symptoms and using treadmill exercise testing
historically thought to be contraindicated in aortic stenosis
might actually give you a clue to patients who are having
compromised under effort that we can detect otherwise and here
you can look at the dramatic difference in patients who had a positive treadmill
exercise test defined as either very poor
performance compared to age predicted exercise capacity
or their blood pressure drops or they had ventricular arrhythmias
much worse survival than patients who had a truly normal treadmill exercise
test so if we put that into this algorithm
you can consider operating on people who have poor
exercise capacity the other thing we know is that severe
isn't just severe there are gradations of severe and the more severe the eric
stenosis the worse the long-term outcome so
this is this concept of very severe erect stenosis and maybe we should
consider operating earlier because operation is almost
inevitable in these individuals anyway so and particularly as our procedures
get lower and lower procedural mortality rates why not
intervene on someone if the 30-day mortality is only one percent if
we know that this is going to be the survival curve if we watch them
so back to this algorithm
for those patients with very severe is that you can offer them an intervention
with a very low procedural mortality rate and a very
high procedural success rate that's another patient who could
consider earlier operation even if they're asymptomatic
so if we line all these up these end up being indications for intervention in
patients with severe aortic valve stenosis
symptoms low ef poor exercise capacity or very severe aortic valve stenosis
so what about this patient that we talked about how should we have managed
this individual he's active and asymptomatic
most of you voted to do a treadmill exercise test for him
not altogether unreasonable but his ef is already low
so this is a patient that we would probably say let's go ahead and do
offer him an intervention if he was not sure about that then offering that
treadmill exercise test might be the clinical tiebreaker for him
as he's making his decision with you about whether to proceed or not
we'll come back to the fact that he has a bicuspid aortic valve here in a couple
of slides for this 70 year old man there was a
mixture of responses here so he's symptomatic
he has a physical examination consistent with severe ass
but he has an echocardiogram that suggests not severe ais so this is the
case where the clinical impression and the echocardiographic
impression don't match one another so we needed more information in this case so
um likely a hemodynamic catheterization would be a reasonable way to go in this
individual to figure out what's going on down here
or if he truly does have non-severe AS what are the other causes for his
dyspnea
now let's go back to the bicuspid aortic valve another important
issue to realize in bicuspid valve is the fact that the aorta is often
abnormal in patients with bicuspid aortic valve
and so you must address that bicuspid aortic valve can also be familial
so it's important that you screen the first-degree relatives for bicuspid
aortic valve and it's important that you look at the
aorta at least at the initial evaluation you
should do one methodology that scans the entire aorta
to make sure you're seeing both the ascending and descending
aorta remember that bicuspidoric valve is also associated with coarctation of
the aorta which is important why you want to do that
if your echocardiographic images show you the aortic root and ascending aorta
sufficient and you see that it tracks with the ct
or mra then you can use echocardiography to
follow the aortic root in the future if they are discrepant you're going to
have to repeat these other imaging modalities in the future
you also need to know indications for re for operating
for aortic root replacement so if you're going to do avr because the
patient meets one of the other criteria for intervention
and their aorta is at least 45 millimeters you can also replace the
root if the patient has a familial history of
aortic dissection or rapidly growing a sin aorta you're
going to want to intervene on that route regardless and otherwise if it gets to
5.5 centimeters
so these are the pearls for aortic valve stenosis remember the doppler gradient
cannot overestimate it the valve area can be problematic by
echo those are the intervention indications
as discussed during this talk now let's move over to the mitral valve
and another question here here's a 30 year old woman who's active and
asymptomatic she has the examination listed there her
ejection fraction is normal her la's big she's got a pliable valve with a mean
gradient of five a calculated valve vary of 1.9
normal tricuspid valve velocities so how are we going to manage her
mitral valve replacement left and right heart cath
balloon valvottomy or follow up in one
year
excellent okay so mitral valve stenosis a little bit different than aortic valve
stenosis obviously it's usually rheumatic although that is
disappearing in the united states for sure but mitral
annual calcification is becoming an increasing
etiology for mitral valve stenosis the hallmark obviously has increased
left atrial pressures and pulmonary congestion because the
stenotic lesion is before the left ventricle the left ventricle
rarely is impacted by mitral valve stenosis
it is the left atrium and the pulmonary vasculature which are involved
so pulmonary congestion the effect on dilatation can cause atrial arrhythmias
and you can get right-sided failure as a consequence of those
shortness of breath is the most common thing hemoptysis is a bad sign in
someone with mitral stenosis it is a disease that has a slowly
progressive course
10-year plateaus from rheumatic fever to any symptoms etc so this is one that
progresses more slowly and because it progresses so slowly
patients may not perceive that they are having effort
impact because they get used to their current level of activities and don't
understand that they perhaps could expect more from themselves
same echocardiogram to assess the sonatic lesion
doppler again is the gold standard in fact it's better than cath in most case
in most cases because we're usually using
wedge pressures as a surrogate for left atrial pressure and that causes some
inherent inaccuracies in the true transmitral
gradient so unless you're going to do transseptal and direct left atrial
measurements you're not getting a true transmitral gradient but you are getting
that with doppler echocardiography and you can almost always align that
doppler angle well so again the doppler is not going to
overestimate the trans-mitral gradient the valve area slightly more reliable to
calculate here severe mitral stenosis has a great
valve vary of less than 1.5 i generally think of 5
milligrams and low less as being mild 10 milligrams and more as being
severe in terms of a gradient remember that this gradient is highly dependent
on heart rate the faster the heart rate the higher the gradient's going to be
so at a kind of normal heart rate severe ms is going to be patients who have
gradients of eight to ten millimeters of mercury
for patient who has severe class iii symptoms with a mean gradient of six
so this is the case where the clinical impression and the doppler
impression don't look the same so severe symptoms
but a pretty mild looking mitral valve on doppler
that's when you want to want to do exercise hemodynamics
so get that patient's heart rate up on the left hand side are the resting
studies resting gradient of 6 but with exercise
the gradient went up to almost 30 millimeters of mercury
and you can see that the pulmonary pressure is also dramatically increased
in this patient so a patient who has effort related
symptoms but pretty mild-looking stenosis at rest
exercised them to match when they get their symptoms and see if the valve is
in fact functionally severe so symptoms out of proportion to the
echo get exercise hemodynamics and remember if you have a high gradient
but the mitral valve area looks mild often that can be due to
mitral regurgitation issues so that's that's an indication where you're
probably going to want to get a transesophageal study
to make sure that there isn't severe mr if you haven't seen it on the
transthoracic imaging we obviously anticoagulate patients with
mitral stenosis in af this is where warfarin is going to be
the indicated agent because this does count as valvular af
um and you're going to treat patients who have advanced symptoms
with mild symptoms simply slowing the heart rate down can be the most
effective therapy so giving someone who has mild symptoms in
mitral stenosis a beta blocker can make them quite content with their
symptom status um the first line of therapy and
hopefully dr prendergrass will be talking about
this is to consider whether a valvotomy is indicated in these patients
you're going to want to look for patients who have very pliable valves
and uh early indications for operation might be
pulmonary artery pressures greater than 60 even if the patient doesn't have
symptoms and now even more so a new onset of
atrial fibrillation if they have mild symptoms we're going
to observe these individuals and because the ventricle is unaffected
you can follow them approximately annually so this woman
what should we do for her so she's active and asymptomatic
she only has mild stenosis there wouldn't there's not a mismatch between
her symptoms and her echo the other thing is her physical examination with
an s 2 to opening snap interval of 100
milliseconds also indicates mild ms on physical examination if the
s2 opening snap interval is closer together 60 to 80
milliseconds that's a patient who has more severia so
this person acts like mild ms measures like mild ms
so this is an individual that we can observe over time
and 68 of you selected that as part of the question
so with that i will conclude and thank you for your attention this morning
thank you very much steve for