Valvular Heart Disease

Richard Allenbach, PA-C

Director, Heart Valve Clinic

Via Christi Hospitals, Wichita

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Definition of Valvular Heart Disease

Any condition that affects the proper function of the heart valves. Congenital causes Infectious causes

Rheumatic fever Endocarditis

Degenerative (age-related) causes

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Anatomy of the Heart

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Aortic Stenosis

Gross specimen of minimally diseased aortic valve (left) and severely stenotic aortic valve (right)

Images courtesy of Renu Virmani, MD at the CVPath Institute

Aortic Stenosis Definition

A narrowing of the aortic valve leaflets that restricts the normal flow of blood through this valve.

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Prevalence of Aortic Stenosis

Aortic stenosis is estimated to be prevalent in up to 7% of the population over the age of 651

It is more likely to affect men than women; 80% of adults with symptomatic aortic stenosis are male3.

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What Causes Aortic Stenosis in Adults?

Aortic stenosis in patients over the age of 65 is usually caused by calcific (calcium) deposits associated with aging

In some cases adults may develop aortic stenosis resulting from a congenital abnormality

Adults who have had rheumatic fever may also be at risk for aortic stenosis

Aortic stenosis can be caused by various infections

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Aortic Stenosis Symptoms

The SAD Triad Syncope (passing out) Angina (chest pain, pressure, squeezing,

tightness, heaviness) Dyspnea (shortness of air)

Fatigue Decrease in activity tolerance – “I just can’t do

what I used to be able to.”

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Diagnosis of Aortic Stenosis

Echocardiography Heart Catheterization

Physical ExamDetailed Clinical History

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Treatment of Aortic Stenosis

Surgery Medical Management

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Natural History of Aortic Stenosis

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Dismal Prognosis for Aortic Stenosis

50% one year survival 15% two year survival 5% 5 year survival Uniformly lethal disease Notable not only for

shortened life span, but poor quality of life

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Sobering Perspective

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Addressing a Serious Unmet Need

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Cardiology Views on Severe Symptomatic Aortic Stenosis

Common, undertreated disease state Increasingly common in elderly There is no medical management Dismal short and long term prognosis There is no such thing as truly asymptomatic

severe aortic stenosis Fortunately, there are options

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Treatment: Surgical

Mortality difference for people with symptomatic AS treated with Aortic Valve Replacement (AVR) versus those not undergoing this procedure is one of the most striking in medicine1

AVR can be withheld in such patients only when compelling contraindications exist

1Schwartz F, Bauman P, et al. Circulation 1982; 66: 1105-10.

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Treatment: Surgical

1Schwartz F, Bauman P, et al. Circulation 1982; 66: 1105-10.

Surgery

Porcine valve – 1965

Homograft – 1962

Mechanical heart valve – 1960

Pericardial tissue valve – 1969

First CoreValve Transcatheter AVR by Retrograde ApproachLaborde, Lal, Grube – July 12, 2004

First Edwards/PVT Transapical Beating Heart AVRWebb, Lichtenstein – Nov 29, 2005

First PVT Transcatheter AVRby Antegrade ApproachAlain Cribier - April 16, 2002

CE approval of CoreValve (May 16, 2007; 1,200 implants and Edwards Sapien (Sept 5, 2007; 500 implants)

First Corevalve animal implantation JC. Laborde

First PVT animalimplantationA. Cribier

Adapted from P. Serruys

1960 2002

2004200720012000

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Prosthetic Aortic Valves

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Aortic Valve Replacement Hospital Mortality

• 108,791 isolated AVR patients

• STS Data Registry

Brown et al. JCTVS 2009;137:82-90

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Conventional AVR Stroke Rate

J Thorac Cardiovasc Surg 2009;137:82-90

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Surgical Aortic Valve Replacement remains the “Gold Standard to which emerging therapies will be compared”.

Transcatheter Aortic Valve Replacement (TAVR)

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What is TAVR?

For patients who are either at high risk or too sick for open-heart surgery, TAVR may be an alternative

This less invasive procedure allows the aortic valve to be replaced with a new valve while the heart is still beating

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Characteristics of a TAVR Patient 17

Severe, symptomatic native aortic valve stenosis

TAVR patients may present with some of the following:

Commercially Available Transcatheter Valves

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Risk and Benefits

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Risks

Injury to blood vessels Stroke Heart rhythm problems Unplanned open heart surgery Kidney problems Death – Guaranteed if nothing is done

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Benefits

Return of functional status Less heart failure Improvement in activities of daily living

Walking Showering/bathing Sleeping Social Sense of well-being

“I have my mother back”

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For Appropriate Patients

TAVR is an excellent alternative to open heart surgery.

TAVR is durable

Risk of stroke is elevated slightly

TAVR is cost effective

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Aortic Valve Mitral Valve

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Mitral Regurgitation

“Mitral regurgitation is a disorder in which the heart valve that separates the upper and lower chambers on the left side of the heart does not close properly. Regurgitation means leaking from a valve that does not close all the way”.

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Mitral Regurgitation (MR)

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MR occurs when the mitral valve fails to close completely, causing blood flow to move backward

Mayo Clinic (www.mayoclinic.com)

Symptoms may include: • Shortness of breath• Heart palpitations • Fatigue• Lightheadedness• Cough • Swollen feet or ankles• Excessive urination

Mitral Regurgitation

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Moderate or Severe Valvular Disease Is Common and Increases With Age

Mitral regurgitation is the most common type of heart valve insufficiency in the US1,2

1. Heart Disease and Stroke Statistics 2010 Update: A Report From the American Heart Association. Circulation. 2010;121:e46-e215.2. Nkomo VT et al. Lancet. 2006; 368:1005-1011.

Prevalence of Valvular Heart Disease by Age

Prevalence increases from 0.5% for 18-44

year olds to 9.3% for ≥75

year olds (p<.0001)

Mitral Regurgitation Causes

Mitral Valve Prolapse Infection of the heart valve (endocarditis) Rheumatic Fever – Rare in developed

countries After a heart attack Enlarged Heart Abnormal valve anatomy

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Diagnosis of Mitral Regurgitation

Echocardiography Heart Catheterization

Physical ExamDetailed Clinical History

Treatment of Mitral Regurgitation

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Mitral Valve Surgery

• Repair• Replacement• Minimally Invasive• Percutaneous

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Mitral Valve Repair

Mitral Valve Replacement

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Many patients are not considered appropriate candidates for mitral valve surgery

1. Lung B, et al. Eur Heart J. 2003;24:1231-1243.2. Mirabel M, et al. Eur Heart J. 2007;28:1358-1365.3. U.S. Census Bureau, Statistical Abstract of the U.S. 4. Nkomo et al. Burden of Valvular Heart Diseases: A Population-based Study, Lancet, 2006; 368: 1005-11.5. Patel, et al. Mitral Regurgitation in Patients with Advanced Systolic Heart Failure, J of Cardiac Failure, 2004.6. Rankin, et al, J of Thoracic and Cardiovascular Surgery, March 2006

* Note: High-Risk Patients are defined as any patient with an EF<35% or an age of 75+.

49% High-Risk Patients*,3-5

(860K)

49% Surgical

Candidates (850K)

2%Surgical Patients (30K)

Of surgical candidates, up to 50% of patients are not referred to surgery, even if a surgical indicationexists 2

Factors prohibiting Surgery include6:

• Impaired LVEF

• High operative risk

• Multiple comorbidities

• Advanced age

Large portion of mitral regurgitation patients are left untreated—ineligible for surgical treatment or denied surgical intervention1-2

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MitraClip TherapyFilling a Treatment Gap

Medical Therapy

Medical therapy is limited to symptom management

MV surgery has been the only option that reliably reduces MR

A significant gap exists between medical and surgical options

MitraClip therapy is a percutaneous option to reduce MR in select patients*

MV SurgeryMitraClip

Move Invasive

Increased MR Reduction

* Source: MitraClip Clip Delivery System Instructions for Use.

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MitraClip System Overview

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Valve Clinic

Multidisciplinary, one portal Cardiologist, CT Surgeon Input from multiple specialties

Echo, CTA available Research personnel participate Efficient for patients Not the most efficient for physicians

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Via Christi Heart Valve Clinic Team

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Hybrid Operating Room

Blends components of: Traditional operating room Cardiac catheterization lab Radiology suite

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Via Christi Hybrid Operating Room

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How to Contact Us

Heart Valve Clinic at Via Christi 316-268-8650 929 N St Francis

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