Anaesthesia For Valvular Heart Diseases Made by: Dr. Meenal Aggarwal Moderator: Dr. Aparna.
Valvular Diseases - Students
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Valvular Disease
Cindy Chan, MD
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Normal heart
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Disease of Aortic Valve
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Aortic Stenosis (AS)
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Etiology of ASEtiology of AS• Congenital (bicuspid)Congenital (bicuspid)
• RheumaticRheumatic
• “ “Senile” calcificSenile” calcific
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Aortic StenosisAortic Stenosis
DiastoleDiastole SystoleSystole
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RheumaticRheumatic SenileSenileCalcificCalcific
CongenitalCongenitalBicuspidBicuspid
Aortic StenosisAortic Stenosis
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Rheumatic
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BicuspidBicuspid
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FishFishmouthmouth
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““Senile” calcificationSenile” calcification
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• < < age 65 = age 65 = congenitalcongenital
• >age 65 = >age 65 = “senile” calcific“senile” calcific
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AortaAorta
LVLV120 mmHg120 mmHg
120 mmHg120 mmHg
NORMALNORMAL
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AortaAorta
LVLV220 mmHg220 mmHg
120 mmHg120 mmHg
STENOSISSTENOSIS
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AortaAorta
PressurePressure
What is the effect of increased pressure What is the effect of increased pressure on the LV?on the LV?
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220 mmHg220 mmHg
AortaAorta
LVLV
LeftLeftventricular ventricular hypertrophyhypertrophy
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LVHLVH( increased stiffness)( increased stiffness)
LV end-diastolicLV end-diastolic pressurepressure
CHFCHF
DemandsDemands
AnginaAngina
SystolicSystolicPressure loadPressure load
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Clinical TriadClinical Triad of Aortic Stenosisof Aortic Stenosis
Heart FailureHeart Failure
AnginaAngina
SyncopeSyncope
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SyncopeSyncopeInability to increase cardiacInability to increase cardiac output with exerciseoutput with exercise
Ventricular arrhythmiasVentricular arrhythmias
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Aortic StenosisAortic StenosisNatural HistoryNatural History
Per
cen
t su
rviv
alP
erce
nt
surv
ival
Age
100
90
80
70
60
5050
Latent PeriodLatent Period
OnsetOnsetSevere SymptomsSevere Symptoms
40 50 60 7040 50 60 70
AverageAverageDeathDeath3-4 Years3-4 Years
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Aortic StenosisNatural History
00 11 2 2 3 3 4 4 55
AnginaAngina
FailureFailureSyncopeSyncope
Per
cen
t su
rviv
alP
erce
nt
surv
ival
100100
9090
8080
7070
6060
5050
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Physical findings of ASPhysical findings of AS• MurmurMurmur• SoundsSounds• CarotidCarotid• ApexApex
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S1 S2
LV = Ao NormalNormalAoAo
LALA
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S1 S2
Aortic Aortic StenosisStenosis
LV
Ao
LALA
Stenosis is a pressure gradient across a valve
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LV
Ao
AorticAorticStenosisStenosis
S2S1
Crescendo-Crescendo-decrescendodecrescendo
Murmur mustMurmur mustbe crescendo-decrescendobe crescendo-decrescendoin timingin timing
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Aortic Stenosis
• Timing =Timing = SystoleSystole
• Frequency = HighFrequency = High
• Location = R or L SBLocation = R or L SB
• Position = Leaning forwardPosition = Leaning forward
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Ejection clickEjection clickEarly systolic soundEarly systolic sound
suggests bicuspid valvesuggests bicuspid valve
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LV
Ao
AorticAorticStenosisStenosis
Crescendo-Crescendo-decrescendodecrescendo
S2
S1
EjectionEjectionClickClick
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Carotid artery pulsationCarotid artery pulsation
NormalNormal AbnormalAbnormal “Pulsus parvus et tardus”Pulsus parvus et tardus”
This is a clue to help determine AORTIC STENOSISThis is a clue to help determine AORTIC STENOSIS
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Summary of Physical FindingsSummary of Physical Findings
• Harsh crescendo - decrescendo murmur Harsh crescendo - decrescendo murmur
(often radiating into the neck)(often radiating into the neck)
• Ejection click (if pliable)Ejection click (if pliable)
• Carotid - pulsus parvus et tardusCarotid - pulsus parvus et tardus• Apical impulse - S4Apical impulse - S4
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Opening snap, early ejection systolic
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S4 (atrial gallop)S4 (atrial gallop) Forceful left atrial contractionForceful left atrial contraction
May feel at apexMay feel at apex
DI ASTOLIC ABNORMALITY OF LVDI ASTOLIC ABNORMALITY OF LV
( LV compliance)( LV compliance)
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S4 (atrial gallop)
DIASTOLIC ABNORMALITY OF LVDIASTOLIC ABNORMALITY OF LV Apical impulseApical impulse
NORMALNORMAL
S1S1 S2S2 S1S1 S2S2S4S4
ABNORMALABNORMAL
S4S4
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S4
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Laboratory testsLaboratory testsin Aortic Stenosisin Aortic Stenosis
• Chest x-rayChest x-ray - - LV prominenceLV prominence
• EKG - LVHEKG - LVH• Echocardiogram -Echocardiogram -EtiologyEtiology
SeveritySeverity
LV size & functionLV size & function
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EchocardiogramEchocardiogram
Major diagnostic testMajor diagnostic test
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Echocardiogram in ASEchocardiogram in AS AnatomyAnatomy• Detect calcificationDetect calcification
• Evaluate opening of valveEvaluate opening of valve
PhysiologyPhysiology• Quantitative obstructive gradientQuantitative obstructive gradient
• Allow calculation of valve areaAllow calculation of valve area
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The use ofThe use ofDoppler EchoDoppler Echo
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VelocityVelocity
5 M /sec5 M /sec
AortaAorta
LVLV220 mmHg220 mmHg
120 mmHg120 mmHg
GradientGradient
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Doppler Echo in Aortic Stenosis
Pressure Gradient:Pressure Gradient:
Pressure = 4 x VelocityPressure = 4 x Velocity
Example:Example: Velocity = 5 Meters/ secVelocity = 5 Meters/ sec
Pressure Gradient= 4 x 5 x 5 = 100 mmHgPressure Gradient= 4 x 5 x 5 = 100 mmHg
2
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Continuity Equation
Velocity X Area = Velocity X AreaLVOT Aortic Valve
= = 5 M/sec5 M/sec1.0 M/sec x 5 cm1.0 M/sec x 5 cm22
? Aortic valve area = 1.0 cm 22x x ??
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Aortic ValveAortic Valve AreaArea
Normal 3 .0 cm2Normal 3 .0 cm2Mild AS 1.5 - 2.0Mild AS 1.5 - 2.0Moderate AS 1.0 - 1.5Moderate AS 1.0 - 1.5Severe AS <1.0Severe AS <1.0
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Catheterizationifif
Non-invasive tests are equivocalNon-invasive tests are equivocal
Age > 50 (to detect CAD)Age > 50 (to detect CAD)
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Catheterization in A.S.
S1 S2 S1
Left Ventricle to Aorta Left Ventricle to Aorta Pressure GradientPressure Gradient
LV
Ao
220 m220 mmHg
120 120 mm Hg
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Antibiotic prophylaxisAntibiotic prophylaxis• Dental, GI or GU proceduresDental, GI or GU procedures
• AmoxicillinAmoxicillin
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Indications for SurgeryIndications for Surgery
=
SymptomsSymptoms+
Critical stenosisCritical stenosisGradient > 50mmHgGradient > 50mmHg
AorticAortic valve area < 0.8 cm2valve area < 0.8 cm2oror
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Prosthetic valvesProsthetic valves MechanicalMechanical Ball valve Ball valve
Tilting diskTilting disk
Bileaflet (St.Jude)Bileaflet (St.Jude)
TissueTissue PorcinePorcine
HomograftHomograft
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Tissue valveTissue valve
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Starr- EdwardsStarr- Edwards
““Ball inBall in a cage”a cage”
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MechanicalMechanical
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Tissue
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AdvantagesAdvantages DisadvantagesDisadvantages
MechanicalMechanical Long lastingLong lasting Need anticoagulationNeed anticoagulation
TissueTissue No anticoagulation DegeneratesNo anticoagulation Degenerates
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Ross procedureRoss procedure
Aortic position = Aortic position = Pulmonic autograftPulmonic autograftPulmonic position = Pulmonic position = Pulmonic homograftPulmonic homograft
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Complications of Prosthetic heart valves
• ThromboembolismThromboembolism• Bleeding Bleeding 22 to anticoagulation to anticoagulation• Prosthetic valve dysfunctionProsthetic valve dysfunction• Periprosthetic regurgitationPeriprosthetic regurgitation• EndocarditisEndocarditis Serious - 5%/yr Death - 1-2%/yrSerious - 5%/yr Death - 1-2%/yr
oo
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Aortic Aortic RegurgitationRegurgitation
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Abnormalities of valve leafletsAbnormalities of valve leaflets CongenitalCongenital RheumaticRheumatic EndocarditisEndocarditisAbnormalities of aortic rootAbnormalities of aortic root Aortic dissectionAortic dissection Marfan’s syndromeMarfan’s syndrome SyphilisSyphilis
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AortaAorta
In diastole, aortic valve is not In diastole, aortic valve is not competent to hold up pressurecompetent to hold up pressure or volumeor volume
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DiastolicDiastolic Volume load Volume load
LV dilatationLV dilatationLV end-diastolicLV end-diastolic pressurepressure
CHFCHF
DemandsDemands
Rarely,anginaRarely,angina
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ASAS = = Pressure overloadPressure overload = =
LV HLV Hypertrophyypertrophy
ARAR = = Volume overloadVolume overload = = LV DilatationLV Dilatation
SystolicSystolic
DiastolicDiastolic
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AortaAorta
In diastole, aortic valve is not In diastole, aortic valve is not competent to hold up pressurecompetent to hold up pressure or volumeor volume
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Low diastolic pressure = incompetent valveLow diastolic pressure = incompetent valve
High systolic pressure = large stroke volumeHigh systolic pressure = large stroke volume
Therefore, wide pulse pressureTherefore, wide pulse pressure
i.e. 200 / 40 mmHgi.e. 200 / 40 mmHg
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Physical findings of ARPhysical findings of AR• Wide pulse pressure 200/40Wide pulse pressure 200/40
• CardiomegalyCardiomegaly
• MurmurMurmur
• Peripheral findings ofPeripheral findings of
wide pulse pressurewide pulse pressure
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Aortic Regurgitation
Early diastolicEarly diastolic high-pitchedhigh-pitched blowing murmurblowing murmur
LVLV
AoAo
LALA
S1S1 S2S2
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Aortic Regurgitation
• Timing =Timing = Early DiastoleEarly Diastole
• Frequency = HighFrequency = High• Location = R or L SBLocation = R or L SB• Position = Position = Leaning forwardLeaning forward
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“Wide pulse pressure” Wide pulse pressure” signssigns
• Head bob (deMusset’s)Head bob (deMusset’s)
• Uvula (Muller’s)Uvula (Muller’s)
• Finger capillaries (Quincke’s)Finger capillaries (Quincke’s)
• Brachial (Waterhammer)Brachial (Waterhammer)
• Femoral to & fro (Duroziez’s)Femoral to & fro (Duroziez’s)• Carotid double beating Carotid double beating (pulsus bisferiens)(pulsus bisferiens)
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Aortic Regurgitation
• Treatment– Acute – surgery– Chronic – afterload reduction with ACE-I– Surgery if:
• Symptomatic• LV dysfunction (EF <55% or LV end-systolic dimension >5.0
cm)• Aortic root diameter >4.5cm in Marfan or >5.0 in non-Marfan
pt (avoid rapid expansion)– Often requires aortic root repair– No percutaneous approaches (unlike AS)
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Acute Acute Aortic RegurgitationAortic Regurgitation
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Severe acuteSevere acute ARAR
Surgical emergencySurgical emergency
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Infective endocarditisInfective endocarditis
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AcuteAcute versusversusChronicChronic
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CHRONIC
AortaAortaAortaAorta
ACUTE
LVLVLVLV
LALA
Massivepulmonary edema
Small stiff LVSmall stiff LV
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Acute vs ChronicAcute vs Chronic
Cardiomegaly No YesCardiomegaly No Yes
Wide pulse No YesWide pulse No Yes pressurepressure
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Natural HistoryNatural HistoryAR AR 10 year survival10 year survival
Mild >90%Mild >90% Severe ~50%Severe ~50%
Heart failure 90% Heart failure 90% <2 yrs<2 yrs
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Follow-upFollow-up• Regular clinical evaluationRegular clinical evaluation
• Periodic assessment of Periodic assessment of
LV functionLV function
• Antibiotic prophylaxisAntibiotic prophylaxis
• Medical rx - diureticsMedical rx - diuretics
afterload-lowering afterload-lowering
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BREAK
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Disease of Mitral Valve
Cindy Chan, MD
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Mitral Stenosis
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Normal Anatomy
Mitral Stenosis
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Atrial fibrillation Atrial fibrillation 50-80%50-80%
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Mitral Stenosis
If mild-mod MS (valve area 1.8 cm2 – 1.3 cm2), asymptomatic or DOE
If severe MS (valve area < 1.0 cm2), pulm HTN, low CO, right HF
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Mitral Stenosis
S1 S2
LV
LA
OSOS
Mid-diastolic Rumble
Pre-systolic accentuation
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Mitral Stenosis
Timing = Mid DiastoleFrequency = LowLocation = ApexPosition = Left lateral decubitus
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Mid diastolic murmur
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Blood Stasis in the Left AtriumTransesophageal Echo
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Left Atrial Appendage ClotTransesophageal Echo
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Mitral Stenosis
• Treatment– If total valve score 8 or less, ballon
valvuloplasty– If >8 or with combined stenosis & regurg,
valve replacement
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Valve score
• 1-4 points for– Mitral leaflet thickening– Mitral leafley mobility– Submitral scarring– Commissural calcium
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Mitral Regurgitation
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Mitral Valve Regurgitation
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If acute, pulm edemaIf acute, pulm edema
Atrial fibrillationAtrial fibrillation
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Mitral Regurgitation
LALA
LV
S1S1 S2Systole S1Murmur should beholosystolic
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Mitral Regurgitation
Timing = Pan SystolicFrequency = HighLocation = ApexPosition = L lateral decubitusRadiation = Axilla
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Holosystolic murmur
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S3 (Ventricular gallopS3 (Ventricular gallop sound)sound)
• Timing- Early diastolicTiming- Early diastolic
• Frequency- LowFrequency- Low
• Rarely palpableRarely palpable
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S3
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Diagnosis
• EKG: there may be left atrial enlargement with chronic MR, atrial fibrillation or normal sinus rhythm
• Echo: accurate, non-invasive technique to assess cardiac chamber and valve anatomy and function. The etiology of MR may be diagnosed (i.e., ruptured chordae, valve prolapse, ischemia inducing a wall motion abnormality to name a few). Doppler echo detects the regurgitant flow and allows estimates of its severity.
• Cardiac catheterization: this allows for hemodynamic evaluation of the cardiac chambers and valves as well as determine the presence of coronary disease. Cardiac catheterization is done particularly when surgery is contemplated.
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Mitral Regurgitation
• Treatment– Acute – emergent surgery– Chronic – surgery if symptomatic, EF <60%, or
LV end-systolic diameter >4.5 cm
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Mitral Valve Prolapse
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Mitral Valve Prolapse
• Epi– Found in up to 10% healthy young women (most
commonly female)– Associated with collagen diseases (Marfan’s, Ehlers-
Danlos)– Associated with skeletal deformities (pectus excavatum
or scoliosis)• S/S
– Usually asymptomatic– Mid-systolic clicks (with late systolic murmur if
leaflets fail to come together)– CP, dyspnea, fatigue, palpitations
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Myxomatous Mitral Valve with Mitral Valve Prolapse
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Diagnosis
• EKG: usually normal• Echo: There are specific echo criteria that define
mitral valve prolapse. The echo demonstrates the myxomatous nature and redundancy of the valve structure. It reveals the prolapsing motion of the valve in real-time. Doppler echo demonstrates associated mitral regurgitation. This along with clinical features makes the diagnosis of this disorder
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Mitral Valve Prolapse
• Treatment– BB to tx hyperadrenergic state– Valve repair favored over replacement– Include shortening of chordae, chordae trasfers,
wedge resection of redundant valve tissue, mitral annular ring
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Other valvular diseases…
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Tricuspid Stenosis
• Etiology– Rheumatic– Carcinoid syndrome
• S/S– Diastolic rumble at lower left sternal border,
opening snap, large a wave– R heart failure (hepatomegaly, ascites,
dependent edema)
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Tricuspid Stenosis
• Dx– Echo
• Tx– Valvuloplasty ineffective (often with residual
TR)– Replacement (severe when mean diatolic
pressure gradient >5 mmHg
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Tricuspid Regurgitation
• Etiology– RV dilatation from any cause (pulm HTN, severe
PR, cardiomypathy, MI, L heart failure, Ebstein anomaly)
• S/S– Holosystolic murmur at LSB, increases with
inspiration, c-v wave in jugular venous pulsations, S3
– RV failure
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Tricuspid Regurgitation
• Dx– Echo
• Tx– Diuretics– Tx L HF, pulm HTN– If surgery for other reasons, tripcuspid
annuloplasty
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Pulmonic Stenosis
• Etiology– Often assoc with other cardiac lesions– Often with domed or dysplastic valve (eg Noonan syndrome)– Increased resistance to RV outflow, then elevated RV pressure, the
limited pulm blood flow
• S/S– Asympotmatic if mild (PV-PA peak gradient < 30 mmHg)– Moderate (30-50) to severe (>50) experience DOE, CP, syncope,
and RV failure– Loud, harsh systolic murmur, radiates to L shoulder, increases
with inspiration, ejection click (which decreases with inspiration), parasternal lift (from RVH), thrill, S4, prominent a wave
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Pulmonic Stenosis
• Dx– Echo
• Tx– Percutaneous balloon valvuloplasty if
symptomatic or resting peak gradient >50 mmHg
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Pulmonic Regurgitation
• Classification– High-pressure causes (pulm HTN)– Low-pressure causes (dilated pulm annulus,
carcinoid plaque, post-surgical repair)
• S/S– Diastolic murmur, widely split S2, S3
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Pulmonic Regurgitation
• Dx– Echo
• Tx– Primary cause
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One more thing about valve replacement…
• Bioprosthetic valves – life expectancy 10-15 years (less for younger pts & pts on HD)– No anticoagulation
• Mechanical valves – longer life expectancy– Mitral: INR 2.5-3.5 (greater risk of
thrombosis)– Aortic: INR 2.0-2.5
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Some physical exam skills….
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Description of Murmur
a. Loudness
b. Pitch
c. Timing
d. Location - Radiation
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Description of MurmurDescription of Murmur
Loudness: GRADELoudness: GRADE
II IIIIIIIIIIIVIV VVVIVI
Soft - not heard initiallySoft - not heard initiallySoft- heard initiallySoft- heard initiallyLoudLoudLoud with thrill - feltLoud with thrill - feltLoud with one edge Loud with one edge Loud- without stethLoud- without steth
Ph
ysio
logi
cP
hys
iolo
gic
Ab
nor
mal
Ab
nor
mal
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LocationLocationPulmonicPulmonic
MitralTricuspidTricuspid
AorticAortic
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How do you tell
systole from diastole?
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Wiggers DiagramWiggers Diagram
S1S1 S2S2SystoleSystole S1S1DiastoleDiastole
LubbLubb DupDup
AoAo
LVLV
LALA
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S2SystoleSystoleS1S1 S1S1 DiastoleDiastole
NormalNormal
SystoleSystoleS1S1 S2 S1S1DiastoleDiastole
TachycardiaTachycardia
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QRS of EKGQRS of EKG
Carotid upstrokeCarotid upstroke
Apical impulseApical impulse
Heart soundsHeart soundsS1S1 S2S2SystoleSystole
Must first tell systole from diastoleMust first tell systole from diastole
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TIMING OFTIMING OF MURMURSMURMURS
• SYSTOLICSYSTOLICMitral RegurgitationMitral RegurgitationTricuspid RegurgTricuspid Regurg Aortic StenosisAortic StenosisPulmonic StenosisPulmonic StenosisASDASDVSDVSDHOCM (IHSS)HOCM (IHSS)Flow (innocentFlow (innocent))
• DIASTOLIC
Mitral StenosisMitral Stenosis
Tricuspid StenosisTricuspid Stenosis
Aortic RegurgitationAortic Regurgitation
Pulmonic Regurg Pulmonic Regurg
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S2S2
LVLV
AoAo
LALA
OS S3S3S1S1 S4S4 S1S1
Diastolic soundsDiastolic sounds
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LOW FREQUENCYLOW FREQUENCY
S3S3
S4S4 The murmur of Mitral StenosisThe murmur of Mitral Stenosis
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BellBell
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S1S1 S2S2SystoleSystole S1S1DiastoleDiastole
LubbLubb DupDup
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S1S1 S2S2SystoleSystole S1S1DiastoleDiastole
LubbLubb DupDup
S4S4 S3S3
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LOW FREQUENCYLOW FREQUENCY
S3S3
S4S4
TimingTiming LocationLocation
EARLYEARLY DIASTOLEDIASTOLE
LATELATE DIASTOLEDIASTOLE
APEXAPEX
APEXAPEX
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S4S4
S4S4,S1... S2,S1... S2
““aa Stiff….Wall” Stiff….Wall”
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S3S3
S1…S2,S1…S2,S3S3
““Slurp…..ing Slurp…..ing inin
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S4S4 S3S3
S4S4,S1... S2 S1…S2,,S1... S2 S1…S2,S3S3
““aa Stiff Wall” Stiff Wall” ““Slurp ing Slurp ing inin
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ManeuversIntervention Hypertrophic
Obstructive
Cardiomyopathy
Aortic Stenosis Mitral Prolapse
Valsalva Up Down Up
Standing Up Down Up (and earlier onset)
Handgrip or squatting
Down Up Down
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Thanks!