Valvular Heart Disease

CV system is driven by

changes in pressure (closed loop)

Semilunar valve

• high pressure valves

• aortic, pulmonary valves

• very tight seal

• between ventricles and rest of body

Atrioventricular valves

• include mitral and tricuspid valve

• open with increased pressure from blood pooling in atira → open into ventricle

• calcification can reduce elasticity of primary cords

• ventricular hypertrphy can pull out papillary muscles

Anomalies in valve function

• stenosis → loss of elasticity, seal is not tightly closed

• regurgitation → blood flows backward

Diagnosis

• ECHO

  • monitor yearly

• Cardiac MRI (less common)

• look at valve function, blood flow, valve abnormalities, changes

• presents like HF, angina

Stage A

at risk

Stage B

progressive

asymptomatic, mild-moderate severity

Stage C

aymptomatic, severe

C1: LV/RV remains compensated

C2: decompensation of LV/RV

Stage D

• symptomatic, severe

• developed symptoms as result of VHD

Aortic Stenosis

• most common form

• often occurs from calcification

• manifest ~60

• progressive, unpredictable

• severity depends onf stenosis

• treat HTN, statin tx indicated for atherosclerosis

Aortic Regurgitation

• caused by abnormal valvae leaflets, dilated root of aorta pulling normal leaflets apart

• gradual and progressive

• sx like left-sided HF (dyspnea, pulmonary congestion, fatigue)

• treat HTN

• GDMT for LF dysfunction (ACEi/ARB/Entresto)

Mitral Stenosis

• usually caused by rheumatic heart disease

• mean onset 50-60

• blood flow relies on transmitral pressure gradient

• sx mimic HF (dyspnea, pulmonary congestion, fatigue, edema)

• worse prognosis → may develop afib, PAH

• causes of death if untreated→ progressive HF, systemic/pulmonary embolism, infection

• treatment with anticoag, HR control

Mitral Regurgitation

• possible causes: mitral valve prolapse, distorted papillary muscles, dilation of left ventricles pulling apart mitral apparatus, rheumatic heart disease+stenosis

• GDMT for systolic dysfunction

• GDMT for HR (in reduced LVEF)

Mechanical valve replacement

• durable

• plastic, metal, or carbon alloys

• very thrombogenic → lifelong antithrombotic tx

• may be pref in younger pts

Bioprosthetic valve replacement

• less durable (10-15 years)

• procine or bovine

• less thrombogenic

• Class 1 rec for pts where anticoag is contraindicated for cannot be managed

Considereations in Valve selection

• less than 50 → Mechanical AVE

• 50-65 → either

• 65+ → bioprosthetic AVR

• class 2a recs

• class 1 rec for shared decision making, bioprosthetics for warfarin contraindication

Complications from Valve Replacements

• valve thrombosis

• embolism

• hemolysis

• structural failure

• endocarditis

Mechanical Valve Antithrombotic Therapy

• Warfarin

• Aortic + No risk factors → INR 2-3

  • no bridging needed

• Aortic + risk factors OR mitral → INR 2.5-3.5

  • bridge if warfarin interrupted for noncardiac procedures

• can add aspirin if antiplatelet indicated

Bioprosthetic valve antithrombotic tx

• initial 3-6 mo: Warfarin, INR 2-3

• lifelong aspirin 81 mg po daily

TAVI antithrombotic tx

• initial 3-6 months → aspirin 81 po daily + clopidogrel 75 mg po daily OR warfarin INR 2-3

• Lifelong aspirin 81 mg po daily

Thromboembolic risk factors for mechanical AVR

• older gen valve

• Afib

• previous thromboembolism

• hypercoagulable state

• LV systolic dysfunction

Thromboembolic event management

• aortic mechanical valve → increase INR goal to 2.5-3.5 or add aspirin

• mitral mechanical valve → increase INR goal to 3.5-4.5 or add aspirin

• bioprosthetic valve → warfarin instead of antiplatelet

• suspected mechanical valve thrombosis → urgent imaging → urgent slow infusion fibrinolytic or surgery

• suspected bioprosthetic valve thrombosis → imaging → warfarin

Bridging during Anticoag interruption

• minor procedures where bleeding can be controlled → continue warfarin

• mechanical AVR and no risk factors undergoing invasive procedure → no bridging

• mechanical valve req immediate invasive surgery → 4 factor prothrombin complex

• bioprosthetic valves and invasive procedures → bleed risk score, consider bridging

• invasive procedures for mechanical avr with risk factors, older gen, or mitral valve → bridge