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Valvular Heart Disease How to Monitor, How to Manage,
When to Refer
DAVID B. MIN, MD INTERMOUNTAIN HEART INSTITUTE
16th Annual Cardiovascular Update October 8, 2016

Disclosures
David Byung Min, MD None
CV Update 10.09.2016 Min Valvular Heart Disease 2

Outline
Guidelines on Management of Valvular Heart Disease Heart Murmurs Initial Assessment of Heart Murmurs Disease-Specific Pearls
Aortic Stenosis Aortic Regurgitation Mitral Regurgitation Mitral Stenosis
When to Refer Summary

2014 valve guidelines Total: 129 pages!
Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(22):2438-2488. doi:10.1016/j.jacc.2014.02.537.

Normal Heart Sounds S1 S2 S1
Mitral Regurgitation
Heart Sounds
Aortic Stenosis
Aortic Regurgitation Mitral Stenosis

Initial Assessment of Heart Murmur
History & Physical Presence or Absence of Symptoms
ECG CXR Transthoracic Echocardiogram
2-dimensional & Doppler

Stages of Progression of Valvular Heart Disease
Stage A At Risk
Stage B Progressive
(Mild Moderate)
Stage C Severe &
Asymptomatic
Stage D Severe &
Symptomatic
Stage C1 LV/RV
Compensated
Stage C2 LV/RV
Decompensated

Disease Specific Pearls

Aortic Sclerosis vs. Aortic Stenosis
Aortic Sclerosis Thickened, stiff valve with normal cusp motion No significant increase in gradient (velocity < 2.5 m/s) Precursor to stenosis in many patients
Aortic Stenosis
Thickened, stiff, echogenic aortic cusps with Impaired cusp separation Commissural fusion Increased transvalvular pressure gradient

Aortic Stenosis
Roberts WC; Ko JM SO. Circulation 2005 Feb 22;111(7):920-5.

Aortic Stenosis - Pathophysiology
Diastolic Dysfunction
Decreased Coronary Flow
Obstruction
Increased Afterload
Hypertrophy
O2 Mismatch

Symptoms & Survival in Aortic Stenosis
Adapted from Ross J Jr, Braunwald E. Circulation. 1968;38(suppl):6167.
From onset of symptoms mortality is ~ 25% per year. Average survival 2-3 years.

Stages of Valvular AS
Stage A At Risk
Stage B Progressive
Stage C Severe &
Asymptomatic
Stage D Severe &
Symptomatic
Aortic Vmax < 2 m/s
Mild: Vmax 2.0 2.9 m/s or mean P < 20 mmHg
Moderate: Vmax 3.0 3.9 m/s or mean P 20-39 mmHg
Severe: Vmax 4 m/s or mean P 40 mmHg
AVA 1.0 cm2 Very Severe: Vmax 5 m/s or mean P 60 mmHg
Early LV Diastolic Dysfunction Normal LVEF
Diastolic Dysfx LVH
LVEF
Dyspnea, CHF, Angina,
Pre/Syncope

Frequency of Echo for Asymptomatic AS
Stage B Mild
Stage C Severe &
Asymptomatic
Vmax 2.0 2.9 m/s or mean P < 20 mmHg
Vmax 4 m/s or mean P 40 mmHg
AVA 1.0 cm2
Every 3 5 years
Every 6 12 months
Stage B Moderate
Vmax 3.0 3.9 m/s or mean P 20-39 mmHg
Every 1-2 years

Management of Asymptomatic AS
Hypertension: Standard guideline therapy: start at low doses and
titrate Avoid diuretics if LV cavity small
Statin Therapy Conflicting trial results Not indicated for prevention of progression of mild-
moderate AS Concurrent CAD common primary/secondary prevention

Aortic Regurgitation - Etiology
Valve-Related Bicuspid AV Rheumatic Infective Endocarditis Myxomatous Lupus Trauma
Aortic Root-Related Connective Tissue Disorders Dissection Infective Endocarditis Aortitis Hypertension

Chronic Aortic Regurgitation Pathophysiology & Symptoms
Severe AR LV Dilation
Afterload Mismatch Eccentric Hypertrophy
Reversible LV Dysfunction
Irreversible LV Dysfunction
Asymptomatic Dyspnea with
Exertion Palpitations
Syncope Angina
Heart Failure

Stages of Chronic AR
Stage A At Risk
Stage B Progressive
Stage C Severe &
Asymptomatic
Stage D Severe &
Symptomatic
None or Trace
Mild: Jet width < 25% LVOT, VC < 0.3 cm, ERO < 0.1 cm2
Moderate: JW 25-64 %, VC 0.3 0.6 cm, ERO 0.10 0.29 cm2
Severe: Jet width 65% LVOT, VC > 0.6 cm, ERO 0.3 cm2, Holodiastolic flow reversal,
Evidence of LV dilation
Normal LVEF Normal LV volume
or mild dilation
C1: normal LVEF, LVESD 50 mm C2: LVEF < 50%, LVESD > 50 mm
Exertional dyspnea, CHF,
Angina

Frequency of Echo for Asymptomatic Chronic AR
Stage B Mild
Stage C Severe &
Asymptomatic
Every 3 5 years
Every 6 12 months
Stage B Moderate
Every 1-2 years
More frequently if LV dilating!
Other Testing to Consider: CMR if TTE suboptimal Equivocal symptoms
Exercise testing Aortic root-associated AR
CT, CMR, TEE

Management of Asymptomatic Chronic AR
Hypertension (SBP > 140 mmHg): Vasodilators: ACE-I/ARB, dihydrophyridine CCB Avoid beta-blockers
Normotensive: Vasodilators: Controversial

Mitral Valve - Anatomy
Anterior leaflet
P2 P1 P3
LAA Annulus Leaflets Chords Papillary
muscles Ventricular
function & geometry

Mitral Regurgitation - Etiology
Primary (Degenerative) Myxomatous
Fibroelastic Deficiency Infective Endocarditis Rheumatic Other
Secondary (Functional) Ischemic Dilated Cardiomyopathy Hypertrophic Obstructive
Cardiomyopathy

Mitral Regurgitation Mechanism Re
vise
d Ca
rpen
tier C
lass
ifica
tion
Excessive (II) Normal motion (I)
Normal No MR Apical Tethering Functional (IIIB)
Central Jet
Restricted (III)
SECONDARY MR
PRIMARY MR

Chronic MR - Pathophysiology
Chronic MR
LV Volume Overload
Eccentric Hypertrophy
LV & LA Dilation
Systolic Dysfunction
Increased Pulmonary Venous Pressure
Reduced Cardiac Output
Pulmonary Congestion
Pulmonary
Hypertension
Atrial fibrillation
Exertional Dyspnea

Stages of PRIMARY Mitral Regurgitation
Stage A At Risk
Stage B Progressive
Stage C Severe &
Asymptomatic
Stage D Severe &
Symptomatic
None or Trace VC < 0.3 cm
Jet 20-40% LA, VC < 0.7 cm, Regurgitant Vol < 60 mL, Regurgitant Frac < 50%,
ERO < 0.4 cm2
Jet > 40% LA, VC 0.7 cm, Regurgitant Vol 60 mL, Regurgitant Frac 50%,
ERO 0.4 cm2
Mild LAE Normal LV volume Nl Pulm Pressure
Mod-Severe LAE LV Enlargement
Pulm HTN at rest or exercise
Exertional dyspnea,
Decreased exercise
tolerance

Stages of SECONDARY Mitral Regurgitation
Stage A At Risk
Stage B Progressive
Stage C Severe &
Asymptomatic
Stage D Severe &
Symptomatic
None or Trace VC < 0.3 cm
ERO < 0.2 cm2 Regurgitant Vol < 30 mL, Regurgitant Frac < 50%
ERO 0.2 cm2 Regurgitant Vol 30 mL, Regurgitant Frac 50%
Changes secondary to 1
myocardial disease
Changes secondary to 1
myocardial disease
HF Symptoms even after revasc &
optimization

Frequency of Echo for Asymptomatic Chronic MR
Stage B Mild
Stage C Severe &
Asymptomatic
Every 3 5 years
Every 6 12 months
Stage B Moderate
Every 1-2 years
More frequently if LV dilating!
Other Testing to Consider: CMR if TTE suboptimal Unclear Mechanism TEE Equivocal symptoms
Exercise testing

Chronic PRIMARY MR Medical Therapy Recommendations COR LOE
Medical therapy for systolic dysfunction is reasonable in symptomatic patients with chronic primary MR (stage D) and LVEF less than 60% in whom surgery is not contemplated
IIa B
Vasodilator therapy is not indicated for normotensive asymptomatic patients with chronic primary MR (stages B and C1) and normal systolic LV function
III: No Benefit B

Indications for Surgery for MR
PRIMARY MR SECONDARY MR

Chronic SECONDARY MR Medical Therapy
Recommendations COR LOE Patients with

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