2009 12 08 Aortic Valve Disease - Dr. Stultzdrstultz.com/Presentations/2009 12 08 Aortic...
Transcript of 2009 12 08 Aortic Valve Disease - Dr. Stultzdrstultz.com/Presentations/2009 12 08 Aortic...
Aortic Valve DiseaseAortic Valve DiseaseIllustrative CasesIllustrative Cases
December 8, 2009December 8, 2009
David Stultz, MD, FACCDavid Stultz, MD, FACC
Southwest Cardiology, IncSouthwest Cardiology, Inc
Handout available at http://www.drstultz.com
© 2009 David Stultz, MD
DisclosuresDisclosures
Nothing to discloseNothing to disclose
© 2009 David Stultz, MD
ObjectivesObjectives
Understand the use of echocardiographyUnderstand the use of echocardiographyto assess aortic valve diseaseto assess aortic valve disease
Apply clinical guidelines to managementApply clinical guidelines to managementof aortic valve diseaseof aortic valve disease
© 2009 David Stultz, MD
Aortic Valve AnatomyAortic Valve Anatomy
Hurst 12th ed.
© 2009 David Stultz, MD
Selected Abnormalities of Aortic ValveSelected Abnormalities of Aortic Valve
Aortic StenosisAortic Stenosis
–– Narrowing of the valve orificeNarrowing of the valve orifice
Aortic RegurgitationAortic Regurgitation
–– Incompetence of the valveIncompetence of the valve
–– BloodBlood ““leaksleaks”” from aorta to left ventricle infrom aorta to left ventricle inventricular diastoleventricular diastole
Bicuspid Aortic ValveBicuspid Aortic Valve
EndocarditisEndocarditis
© 2009 David Stultz, MD
How to Assess the Aortic ValveHow to Assess the Aortic Valve
Clinical HistoryClinical History
Physical ExaminationPhysical Examination
EchocardiographyEchocardiography
–– TransthoracicTransthoracic
–– TransesophagealTransesophageal
AngiographyAngiography
Cardiac CT (not regurgitation, though)Cardiac CT (not regurgitation, though)
MRIMRI
© 2009 David Stultz, MD
Why do aortic valves becomeWhy do aortic valves becomestenoticstenotic??
Valvular StenosisValvular Stenosis–– Bicuspid valve with calcificationBicuspid valve with calcification
–– AgeAge--relatedrelated calcificcalcific aortic stenosisaortic stenosis
–– RheumaticRheumatic
–– Rare causes: Congenital, Rheumatoid, SevereRare causes: Congenital, Rheumatoid, Severeatherosclerosis (Hyperlipidemia),atherosclerosis (Hyperlipidemia), alkaptonuriaalkaptonuria
SupravalvularSupravalvular StenosisStenosis
SubvalvularSubvalvular StenosisStenosis–– DiscreteDiscrete
–– Hypertrophic CardiomyopathyHypertrophic Cardiomyopathy
Braunwald 8th ed.
© 2009 David Stultz, MD
Normal aortic valve Bicuspid aortic stenosis
Rheumatic aortic stenosis Age related aortic stenosis
Braunwald 8th ed.
© 2009 David Stultz, MD
NormalNormal trileaflettrileaflet aortic valve echoaortic valve echo© 2009 David Stultz, MD
© 2009 David Stultz, MD
How to assess aortic stenosis by echoHow to assess aortic stenosis by echo
22--D echoD echo
–– PlanimetryPlanimetry –– measure the valve orificemeasure the valve orifice
Doppler HemodynamicsDoppler Hemodynamics
–– Continuity equationContinuity equation
–– Peak/Mean pressure gradientPeak/Mean pressure gradient
© 2009 David Stultz, MD
PlanimetryPlanimetry
Technically difficult, may overestimate valve areaTechnically difficult, may overestimate valve area
Transthoracic Transesophageal
© 2009 David Stultz, MD
Echo DopplerEcho Doppler
Echo probe generates sound waveEcho probe generates sound wave
Sound wave reflects off tissue/bloodSound wave reflects off tissue/blood
Echo probe has a time window to listenEcho probe has a time window to listenfor these reflectionsfor these reflections
Moving targets (blood) will create aMoving targets (blood) will create afrequency shift in the sound wavefrequency shift in the sound wave
This frequency shift can be translated intoThis frequency shift can be translated intoa velocitya velocity
Can measure the velocity of blood flowCan measure the velocity of blood flow
© 2009 David Stultz, MD
Continuity equationContinuity equation
Without a nozzle, theWithout a nozzle, thewater velocity insidewater velocity insidethe hose (1/2the hose (1/2””) is the) is thesame as after thesame as after thehosehose
© 2009 David Stultz, MD
Continuity equationContinuity equation
With a nozzle, the water velocityWith a nozzle, the water velocityinside the hose (1/2inside the hose (1/2””) is lower) is lowerthan after the nozzlethan after the nozzle
Nozzle reduces the orifice areaNozzle reduces the orifice area
Know diameter of hose (1/2Know diameter of hose (1/2””))
Can measure velocity of water in theCan measure velocity of water in thehosehose
Can measure the velocity of waterCan measure the velocity of waterafter the nozzleafter the nozzle
What is the effective orifice createdWhat is the effective orifice createdby the nozzle?by the nozzle?
© 2009 David Stultz, MD
Conservation of massConservation of mass
Flow before nozzle = Flow after nozzleFlow before nozzle = Flow after nozzle
Area of hose * velocity of water in hose =Area of hose * velocity of water in hose =Orifice area * velocity of water after hoseOrifice area * velocity of water after hose
–– Area = (Area = (½½ * diameter)* diameter)22 * 3.14(* 3.14(ππ))
Can solve equation for orifice areaCan solve equation for orifice area
Continuity equationContinuity equation
© 2009 David Stultz, MD
Continuity equationContinuity equation
Now think of the aortic valveNow think of the aortic valve
Can measure LVOT diameterCan measure LVOT diameter
Can measure LVOT velocity (or TVI)Can measure LVOT velocity (or TVI)
Can measure velocity (or TVI) after aortic valveCan measure velocity (or TVI) after aortic valve
Can solve for aortic valve orificeCan solve for aortic valve orifice
Simplified Bernoulli equationSimplified Bernoulli equation
–– 4v4v22 = mmHg pressure gradient= mmHg pressure gradient
© 2009 David Stultz, MD
© 2009 David Stultz, MD
Case 1Case 1
77 year old African American Male77 year old African American Male
Referred for evaluation of murmurReferred for evaluation of murmur
Medical history: HTNMedical history: HTN
Asymptomatic, able to walk up and downAsymptomatic, able to walk up and downstairs, shovel snowstairs, shovel snow
BP 146/86BP 146/86
Crescendo/Crescendo/DescrescendoDescrescendo 3/6 systolic3/6 systolicmurmur at left lowermurmur at left lower sternalsternal borderborder
© 2009 David Stultz, MD
© 2009 David Stultz, MD
© 2009 David Stultz, MD
© 2009 David Stultz, MD
© 2009 David Stultz, MD
© 2009 David Stultz, MD
© 2009 David Stultz, MD
Severe aortic stenosisSevere aortic stenosis
Aortic valve area <1.0cmAortic valve area <1.0cm22
Peak aortic velocity >4.0mPeak aortic velocity >4.0m22
Mean aortic valve gradient >40 mmHgMean aortic valve gradient >40 mmHg
© 2009 David Stultz, MD
Pathphysiology of Aortic StenosisPathphysiology of Aortic Stenosis
Previously felt to occur as a normalPreviously felt to occur as a normalprocess of aging, related toprocess of aging, related to mechnicalmechnicalstress on normal valvestress on normal valve
Current theory involves inflammatoryCurrent theory involves inflammatoryprocess with T lymphocyte andprocess with T lymphocyte andmacrophage infiltration with lipidmacrophage infiltration with lipidaccumulation, resulting in bone formationaccumulation, resulting in bone formation(calcification)(calcification)
Braunwald 8th ed.
© 2009 David Stultz, MD
Prevalence of Aortic StenosisPrevalence of Aortic Stenosis
At age 65At age 65
–– 29% have aortic sclerosis29% have aortic sclerosis
Irregular thickening of leafletsIrregular thickening of leaflets
Mild/early form of stenosisMild/early form of stenosis
–– 2% have aortic stenosis2% have aortic stenosis
Braunwald 8th ed.
© 2009 David Stultz, MD
Risk factors for ASRisk factors for AS
GeneticGenetic –– familial clustering noted infamilial clustering noted insome casessome cases
Elevated LDLElevated LDL
ElevatedElevated Lp(aLp(a))
DiabetesDiabetes
SmokingSmoking
HypertensionHypertension
Braunwald 8th ed.
© 2009 David Stultz, MD
Pathphysiology of Aortic StenosisPathphysiology of Aortic Stenosis
Valve orifice area slowly declines overValve orifice area slowly declines overtimetime
Symptoms progress graduallySymptoms progress gradually
LV pressure overload results inLV pressure overload results inconcentric hypertrophyconcentric hypertrophy
Increased LV wall mass, diastolicIncreased LV wall mass, diastolicdysfunctiondysfunction
Braunwald 8th ed.
© 2009 David Stultz, MD
Symptoms of AS (Severe)Symptoms of AS (Severe)
Exertional Dyspnea/Heart failureExertional Dyspnea/Heart failure
Chest painChest pain
–– 50% with significant coronary atherosclerosis50% with significant coronary atherosclerosis
SyncopeSyncope
–– Vasodilation with fixed cardiac outputVasodilation with fixed cardiac output
© 2009 David Stultz, MD
Physical Examination of ASPhysical Examination of AS
Palpation of the carotid upstrokePalpation of the carotid upstroke–– ParvusParvus etet tardustardus
Systolic murmurSystolic murmur–– CrescendoCrescendo--decrescendodecrescendo
Heart failureHeart failure–– Crackles in lung fieldsCrackles in lung fields
–– Jugular venous distensionJugular venous distension
–– EdemaEdema
© 2009 David Stultz, MD
© 2009 David Stultz, MD
Management of AsymptomaticManagement of AsymptomaticSevere Aortic StenosisSevere Aortic Stenosis
Up to 33% remain asymptomatic for 5Up to 33% remain asymptomatic for 5yearsyears
Without symptoms, prognosis is generallyWithout symptoms, prognosis is generallygoodgood–– Risk of sudden death 1Risk of sudden death 1--2%/year2%/year
Consider exercise testing under directConsider exercise testing under directcardiologist supervisioncardiologist supervision–– VerifyVerify ““asymptomaticasymptomatic””
–– Assess for fall in blood pressureAssess for fall in blood pressure
Pellikka PA, Sarano ME, Nishimura RA, et al. Outcome of 622 adults with asymptomatic, hemodynamically significant aortic stenosisduring prolonged follow-up. Circulation 2005;111:3290 –5.Rafique AM, Biner S, Ray I, Forrester JS, Tolstrup K, Siegel RJ. Meta-analysis of prognostic value of stress testing in patients withasymptomatic severe aortic stenosis. Am J Cardiol. 2009 Oct 1;104(7):972-7.
© 2009 David Stultz, MD
Does statin treatment affect AS?Does statin treatment affect AS?
Retrospective studies show slowing ofRetrospective studies show slowing ofprogressionprogression
Prospective (Prospective (atorvastatinatorvastatin) study showed no) study showed nobenefit in advancedbenefit in advanced calcificcalcific aortic stenosisaortic stenosis
Prospective (Prospective (rosuvastatinrosuvastatin) study showed) study showedslowing of progression in less severe aorticslowing of progression in less severe aortic
stenosisstenosis
Ongoing prospective trial usingOngoing prospective trial using ezetimideezetimide ((ZetiaZetia))
Cowell SJ, Newby DE, Prescott RJ, et al: A randomized trial of intensive lipid-lowering therapy in calcificaortic stenosis. N Engl J Med 2005; 352:2389.Moura LM, Ramos SF, Zamorano JL, et al: Rosuvastatin Affective Aortic Valve Endothelium to slow theprogression of aortic stenosis. J Am Coll Cardiol 2007; 49:554.
© 2009 David Stultz, MD
Case 1 managementCase 1 management
Exercised for 9 minutes on treadmillExercised for 9 minutes on treadmill
–– Manual modified protocolManual modified protocol
–– 6.8 METS6.8 METS
–– 83% maximum predicted heart rate83% maximum predicted heart rate
–– Good rise in blood pressureGood rise in blood pressure
–– Mild shortness of breath symptomsMild shortness of breath symptoms
Started on Beta blockerStarted on Beta blocker
© 2009 David Stultz, MD
Case 1 PlanCase 1 Plan
Remains asymptomatic 1 year laterRemains asymptomatic 1 year later
Plan for clinical followPlan for clinical follow--up every 6 monthsup every 6 months
If other heart surgery (CABG) indicated,If other heart surgery (CABG) indicated,valve will be replacedvalve will be replaced
© 2009 David Stultz, MD
Case 2Case 2
48 year old male48 year old male
Heart murmur appreciated on physicalHeart murmur appreciated on physicalexaminationexamination
Mild shortness of breath with exertionMild shortness of breath with exertion
–– Climbing 3 flights of stairsClimbing 3 flights of stairs
–– No Chest painNo Chest pain
Overweight, quit smoking recentlyOverweight, quit smoking recently
DM, HTN, HLPDM, HTN, HLP
© 2009 David Stultz, MD
EchocardiogramEchocardiogram© 2009 David Stultz, MD
A closer look at the aortic valveA closer look at the aortic valve© 2009 David Stultz, MD
© 2009 David Stultz, MD
© 2009 David Stultz, MD
© 2009 David Stultz, MD
Bicuspid Aortic ValveBicuspid Aortic Valve
Moderate to severe aortic stenosisModerate to severe aortic stenosis
–– Aortic valve area 1.1 cmAortic valve area 1.1 cm22
–– Mean pressure gradient 44.5 mmHgMean pressure gradient 44.5 mmHg
–– Peak velocity 4.4Peak velocity 4.4 m/sm/s
Mild aortic valve regurgitationMild aortic valve regurgitation
Dilated of aortic root (4.3 cm)Dilated of aortic root (4.3 cm)
© 2009 David Stultz, MD
Bicuspid aortic valveBicuspid aortic valve
11--2% Incidence in live births2% Incidence in live births
Male predominance (up to 80%)Male predominance (up to 80%)
Association with disorders of aortaAssociation with disorders of aorta
–– CoarctationCoarctation
–– DilitationDilitation/aneurysm/aneurysm
–– DissectionDissection
Symptomatic stenosis develops around age 50Symptomatic stenosis develops around age 50
Familial form with autosomal dominantFamilial form with autosomal dominantinheritance (NOTCH1 gene mutation)inheritance (NOTCH1 gene mutation)
Carabello BA, Paulus WJ. Aortic stenosis. Lancet. 2009 Mar 14;373(9667):956-66. Epub 2009 Feb 21.Braunwald 8th ed.
© 2009 David Stultz, MD
Management of ModerateManagement of ModerateBicuspid Aortic StenosisBicuspid Aortic Stenosis
If there is aortic dilatation (>4.0cm)If there is aortic dilatation (>4.0cm)
–– Beta Blockers unless contraindicatedBeta Blockers unless contraindicated
Moderate to severe regurgitationModerate to severe regurgitation
–– Echo every yearEcho every year
–– Surgery if aortic root >5.0cm or >0.5cm/1Surgery if aortic root >5.0cm or >0.5cm/1yearyear
Without aortic dilatationWithout aortic dilatation
–– No specific medical therapyNo specific medical therapy
–– Echo every 1Echo every 1--2 years or if clinical change2 years or if clinical changeBonow RO, Carabello BA, Chatterjee K, de Leon A C Jr, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah
PM, Shanew ise JS; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2008 focused update incorporated into theACC/A HA 2006 guidelines for the management of patients w ith valvular heart disease: a report of the American College of Cardiology/Amer ican HeartAssociation Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients w ith valvular heart disease).Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J
Am Coll Cardiol. 2008 Sep 23;52(13):e1-142
© 2009 David Stultz, MD
Case 2 plan of careCase 2 plan of care
On statin forOn statin for hyperlipidemiahyperlipidemia
Treatment of DM, HTN (ARB)Treatment of DM, HTN (ARB)
Aspirin 81mg dailyAspirin 81mg daily
FollowupFollowup office and echo in 6 monthsoffice and echo in 6 months
© 2009 David Stultz, MD
Another example of Bicuspid Aortic ValveAnother example of Bicuspid Aortic Valve© 2009 David Stultz, MD
Case 3Case 3
44 year old white male44 year old white male
Referred for loud murmurReferred for loud murmur
Spouse started hearing his heart at nightSpouse started hearing his heart at nightabout 1 month agoabout 1 month ago
Asymptomatic, physically active, able toAsymptomatic, physically active, able toclimb stairsclimb stairs
No smoking, DM, HTNNo smoking, DM, HTN
6/6 loud6/6 loud holodiastolicholodiastolic murmurmurmur
© 2009 David Stultz, MD
Transthoracic EchoTransthoracic Echo© 2009 David Stultz, MD
© 2009 David Stultz, MD
© 2009 David Stultz, MD
© 2009 David Stultz, MD
Indications for Valve replacementIndications for Valve replacementin Aortic regurgitationin Aortic regurgitation
Connective tissue disease with aortic rootConnective tissue disease with aortic rootdilitationdilitation (25%)(25%)
Congenital, including bicuspid (13%)Congenital, including bicuspid (13%)
Infective endocarditis (10%)Infective endocarditis (10%)
AgeAge--relatedrelated calcificcalcific degeneration (7%)degeneration (7%)
Other/Unknown/Idiopathic (35%)Other/Unknown/Idiopathic (35%)–– Trauma, rheumatic,Trauma, rheumatic, syphillissyphillis, aortic, aortic
dissection,dissection, fenfluraminefenfluramine ++ phenterminephentermine,,Antiphospholipid syndromeAntiphospholipid syndrome
Crawford & DiMarco, 2nd edBorer JS, Hochreiter C, Herrold EM, Supino P, Aschermann M, Wencker D, Devereux RB, Roman MJ, Szulc M, Kligfield P, IsomOW. Prediction of indications for valve replacement among asymptomatic or minimally symptomatic patients with chronic aorticregurgitation and normal left ventricular performance. Circulation. 1998 Feb 17;97(6):525-34.
© 2009 David Stultz, MD
How to assess aortic regurgitationHow to assess aortic regurgitation
HistoryHistory
PhysicalPhysical
EchocardiogramEchocardiogram
AngiographyAngiography
MRIMRI
© 2009 David Stultz, MD
EchocardiographicEchocardiographic evaluation ofevaluation ofaortic regurgitationaortic regurgitation
Color DopplerColor Doppler–– Jet areaJet area–– Jet heightJet height
–– PISA EROPISA ERO
PressurePressure ½½ timetimeRegurgitantRegurgitant fraction, volumefraction, volumeDescending thoracic aortic flow reversalDescending thoracic aortic flow reversal
Left ventricular EF and dimensionsLeft ventricular EF and dimensionsNo single criteria is perfectNo single criteria is perfectEccentric jets are oftenEccentric jets are often worseworse thanthancalculated/estimatedcalculated/estimated
© 2009 David Stultz, MD
ColorColor dopplerdoppler
Feigenbaum 6th ed
Mild Moderate Severe
Visual inspectionVisual inspection
Also Jet area and jet heightAlso Jet area and jet height
© 2009 David Stultz, MD
PressurePressure ½½ timetime–– Measurement of time it takes for aorticMeasurement of time it takes for aortic
pressure to equalize to (pressure to equalize to (½½) left ventricular) left ventricular
pressurepressure
–– Variable thresholds in literature!Variable thresholds in literature!
<300ms consistent with severe regurgitation<300ms consistent with severe regurgitation
300300--500ms moderate500ms moderate
>500ms mild>500ms mild
© 2009 David Stultz, MD
Flow reversal in descendingFlow reversal in descendingthoracic aortathoracic aorta
© 2009 David Stultz, MD
Transesophageal EchoTransesophageal Echo© 2009 David Stultz, MD
Case 3 managementCase 3 management
SevereSevere posteriorlyposteriorly eccentric aortic regurgitationeccentric aortic regurgitationLV diastolic dimension 6.9cmLV diastolic dimension 6.9cmEF 60EF 60--65%65%
No clear etiologyNo clear etiologyBlood cultures obtainedBlood cultures obtained–– 2 of 2 initially positive gram +2 of 2 initially positive gram + coccicocci
–– 1 of 4 subsequently positive gram +1 of 4 subsequently positive gram + coccicocci–– Initially admitted, treated with IV antibioticsInitially admitted, treated with IV antibiotics–– Blood cultures staph, all different speciesBlood cultures staph, all different species
–– Antibiotics stopped, no symptomsAntibiotics stopped, no symptoms
© 2009 David Stultz, MD
Criteria for Surgery?Criteria for Surgery?
Asymptomatic Severe Aortic regurgitationAsymptomatic Severe Aortic regurgitation
–– EF <50%EF <50%
–– Systolic dimension >5.5cmSystolic dimension >5.5cm
–– Diastolic dimension >7.5cmDiastolic dimension >7.5cm
Guidelines are complicated, but becomeGuidelines are complicated, but becomemore vigilant about surveillance whenmore vigilant about surveillance when
–– Systolic dimension >5.0cmSystolic dimension >5.0cm
–– Diastolic dimension >7.0cmDiastolic dimension >7.0cm
© 2009 David Stultz, MD
Issues not addressed in guidelinesIssues not addressed in guidelines
NoncoronaryNoncoronary cuspcusp prolapseprolapse with severewith severeeccentric jet hitting anterior leaflet of theeccentric jet hitting anterior leaflet of themitral valvemitral valve
–– ? Possibility to distort Mitral valve architecture? Possibility to distort Mitral valve architecture
Unclear etiologyUnclear etiology
LifestyleLifestyle
–– Both patient and spouse hear the murmurBoth patient and spouse hear the murmur
© 2009 David Stultz, MD
Referred for elective surgeryReferred for elective surgery
Mechanical orMechanical or bioprostheticbioprosthetic valve?valve?
IntraoperativelyIntraoperatively, torn, torn noncoronarynoncoronary cuspcuspnotednoted
Overall stable postoperative courseOverall stable postoperative course
© 2009 David Stultz, MD
Case 4Case 4
Male in mid 40Male in mid 40’’ss
History of automobile accident withHistory of automobile accident withorthopedic traumaorthopedic trauma
Several years afterward, noted to haveSeveral years afterward, noted to havemurmurmurmur
Echo showed aortic regurgitationEcho showed aortic regurgitation
Overall asymptomaticOverall asymptomatic
Does not want to take medicationsDoes not want to take medications
© 2009 David Stultz, MD
Echo 8 years laterEcho 8 years later……© 2009 David Stultz, MD
ManagementManagement
LV diastolic dimension 7.6cmLV diastolic dimension 7.6cm
EF 55EF 55--60%60%
Class 2A indication for surgery by guidelinesClass 2A indication for surgery by guidelines
Vasodilator therapy (Vasodilator therapy (NifedipineNifedipine, ACE inhibitors), ACE inhibitors)are a Class 2B indicationare a Class 2B indication
Pt declines surgery and medicationsPt declines surgery and medications
66--12 month clinical and echo12 month clinical and echo followupfollowup
Bonow RO, Carabello BA, Chatterjee K, de Leon A C Jr, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah
PM, Shanew ise JS; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2008 focused update incorporated into theACC/A HA 2006 guidelines for the management of patients w ith valvular heart disease: a report of the American College of Cardiology/Amer ican HeartAssociation Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients w ith valvular heart disease).Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J
Am Coll Cardiol. 2008 Sep 23;52(13):e1-142
© 2009 David Stultz, MD
5 years later after last echo5 years later after last echo© 2009 David Stultz, MD
As time passesAs time passes……
InitialInitial 5 Years Later5 Years Later
LVH decreasesLV diastolic dimension decreases
© 2009 David Stultz, MD
As time passesAs time passes……
InitialInitial 5 Years Later5 Years Later
Pressure ½ Time decreasesCorrelating with worse regurgitation
© 2009 David Stultz, MD
As time passesAs time passes……
InitialInitial 5 Years Later5 Years Later
© 2009 David Stultz, MD
Variable natural historyVariable natural history
Asymptomatic patients with normal LV functionAsymptomatic patients with normal LV function–– <6%/year have symptoms and/or LV dysfunction<6%/year have symptoms and/or LV dysfunction
–– <3.5%/year progress to asymptomatic LV dysfunction<3.5%/year progress to asymptomatic LV dysfunction
–– <0.2%/year have sudden cardiac death<0.2%/year have sudden cardiac death
Asymptomatic patients with LV dysfunctionAsymptomatic patients with LV dysfunction–– >25%/year progress to have symptoms>25%/year progress to have symptoms
Symptomatic Severe Aortic RegurgitationSymptomatic Severe Aortic Regurgitation–– >10%/year mortality rate>10%/year mortality rate
Bonow RO, Carabello BA, Chatterjee K, de Leon A C Jr, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah
PM, Shanew ise JS; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2008 focused update incorporated into theACC/A HA 2006 guidelines for the management of patients w ith valvular heart disease: a report of the American College of Cardiology/Amer ican HeartAssociation Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients w ith valvular heart disease).Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J
Am Coll Cardiol. 2008 Sep 23;52(13):e1-142
© 2009 David Stultz, MD
ConclusionConclusion
Case illustrations of decision making forCase illustrations of decision making for
–– Asymptomatic severe aortic stenosisAsymptomatic severe aortic stenosis
–– Moderate bicuspid aortic stenosis with aortic rootModerate bicuspid aortic stenosis with aortic rootdilatationdilatation
–– Asymptomatic severe aortic regurgitationAsymptomatic severe aortic regurgitation
Symptoms + Severe AS or AR = SurgerySymptoms + Severe AS or AR = Surgery
No clear medical managementNo clear medical management
–– Consider Beta blockers for aortic root dilatationConsider Beta blockers for aortic root dilatation
–– StatinsStatins for mildfor mild--moderate aortic stenosis?moderate aortic stenosis?
© 2009 David Stultz, MD
ReferencesReferences
Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA,O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS; American College of Cardiology/American HeartAssociation Task Force on Practice Guidelines. 2008 focused update incorporated into the ACC/AHA 2006guidelines for the management of patients with valvular heart disease: a report of the American College ofCardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998guidelines for the management of patients with valvular heart disease). Endorsed by the Society of CardiovascularAnesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. JAm Coll Cardiol. 2008 Sep 23;52(13):e1-142.
Borer JS, Hochreiter C, Herrold EM, Supino P, Aschermann M, Wencker D, Devereux RB, Roman MJ, Szulc M, KligfieldP, Isom OW. Prediction of indications for valve replacement among asymptomatic or minimally symptomaticpatients with chronic aortic regurgitation and normal left ventricular performance. Circulation. 1998 Feb17;97(6):525-34.
Cowell SJ, Newby DE, Prescott RJ, et al: A randomized trial of intensive lipid-lowering therapy in calcific aortic stenosis.N Engl J Med 2005; 352:2389.
Moura LM, Ramos SF, Zamorano JL, et al: Rosuvastatin Affective Aortic Valve Endothelium to slow the progression ofaortic stenosis. J Am Coll Cardiol 2007; 49:554.
Pellikka PA, Sarano ME, Nishimura RA, et al. Outcome of 622 adults with asymptomatic, hemodynamically significantaortic stenosis during prolonged follow-up. Circulation 2005;111:3290 –5.
Rafique AM, Biner S, Ray I, Forrester JS, Tolstrup K, Siegel RJ. Meta-analysis of prognostic value of stress testing inpatients with asymptomatic severe aortic stenosis. Am J Cardiol. 2009 Oct 1;104(7):972-7.
© 2009 David Stultz, MD