Valvular Heart Disease: Aortic Stenosis and Aortic Insufficiency - PowerPoint PPT Presentation

Valvular Heart Disease: Aortic Stenosis and Aortic Insufficiency Ivan Anderson, MD RIHVH Cardiology

Outline • Structure of the Aortic Valve • Causes of Aortic Stenosis and Insufficiency • Prognosis • Assessment and Follow-up of Aortic Stenosis or Aortic Insufficiency • Therapies

Outline • Structure of the Aortic Valve • Causes of Aortic Stenosis and Insufficiency • Prognosis • Assessment and Follow-up of Aortic Stenosis or Aortic Insufficiency • Therapies

Aortic Valve in Diastole

Aortic Valve in Systole

Outline • Structure of the Aortic Valve • Causes of Aortic Stenosis and Insufficiency • Prognosis • Assessment and Follow-up of Aortic Stenosis or Aortic Insufficiency • Therapies

Outline • Structure of the Aortic Valve • Causes of Aortic Stenosis and Insufficiency • Prognosis • Assessment and Follow-up of Aortic Stenosis or Aortic Insufficiency • Therapies

Stenotic Aortic Valve Bicuspid Normal Rheumatic Calcific

Pathophysiology of Aortic Stenosis

Causes of Aortic Insufficiency • 50% Valve Disease – Bicuspid valve – Infective Endocarditis – Calcific valvular disease – Rheumatic valvular disease • 50% Root disease – Marfan syndrome, aortopathy of various varities

The Aortic Root

Leaflet Failure and Root Dilation as Causes of Aortic Insufficiency

Patterns of Bicuspid Aortopathy, with Representative Findings on Echocardiography and Computed Tomography (CT). Verma S, Siu SC. N Engl J Med 2014;370:1920-1929.

Pathophysiological Features of Bicuspid Aortopathy. Verma S, Siu SC. N Engl J Med 2014;370:1920-1929.

Hemodynamics and Murmur

Aortic Valve Area • Normal: 4 cm 2 • Mild Aortic Stenosis: 1.5-2.0 cm 2 • Moderate Aortic Stenosis: 1.0-1.5 cm 2 • Severe Aortic Stenosis: < 1.0 cm 2 • Typically narrowing progresses at 0.1 cm 2 /yr, but variable

RVOT AoV LV LA Parasternal Long Axis

Parasternal Long

LV AoV LA AP3/AP Long Axis View

Outline • Structure of the Aortic Valve • Causes of Aortic Stenosis and Insufficiency • Prognosis • Assessment and Follow-up of Aortic Stenosis or Aortic Insufficiency • Therapies

Outline • Structure of the Aortic Valve • Causes of Aortic Stenosis and Insufficiency • Prognosis • Assessment and Follow-up of Aortic Stenosis or Aortic Insufficiency • Therapies

Prognosis (Classic Teaching) • If Angina is present, mean life expectancy is 5 years • If Syncope is present, mean life expectancy is 3 years • If CHF is present, mean life expectancy is 2 years

Partner 1 Outcomes Leon MB et al. N Engl J Med 2010;363:1597-1607.

A Closer Look 50% 1-year mortality with no valve replacement 30% 1-year mortality with TAVR

Outline • Structure of the Aortic Valve • Causes of Aortic Stenosis and Insufficiency • Prognosis • Assessment and Follow-up of Aortic Stenosis or Aortic Insufficiency • Therapies

Outline • Structure of the Aortic Valve • Causes of Aortic Stenosis and Insufficiency • Prognosis • Assessment and Follow-up of Aortic Stenosis or Aortic Insufficiency • Therapies

Aortic Valve Left Ventricular Outflow Trace

Errors in Estimating Valve Area • Typically arise in echocardiography from an inaccurate measurement of the left ventricular outflow tract • Hence, typically gradient is used

Velocity Across the Aortic Valve and Area Stage Mean Jet Velocity Aortic Valve Area (cm 2 ) Gradient (m/s) (mmHg) Normal 0-9 1 3-4 Mild 10-20 <3 > 1.5 Moderate 20-40 3-4 1.0-1.5  40  4 Severe < 1.0

Hemodynamics and Murmur of Aortic Insufficiency

Follow-up Interval with Echocardiogram for Aortic Insufficiency • Mild (severity): echo every 3-5 years • Moderate : echo every 1-2 years • Severe: echo every 6-12 months, more often if LV is dilating JACC Vol. 63, No. 22, 2014

Physical Signs with Severe AI • De Musset sign: head bobs with heartbeat • Water hammer pulse • Traube sign: booming systolic and diastolic sounds heart over femoral artery • Muller sign: systolic pulsation of uvula • Duroziez sign: systolic mumur with compression of the femoral arery proximally and diastolic mumur when compressed distally • Quincke sign: capillary pulsations with transmitting light through the fingernails

Follow-up Interval with Echocardiogram for Aortic Stenosis • Mild (severity): echo every 3-5 years • Moderate : echo every 1-2 years • Severe: echo every 6-12 months JACC Vol. 63, No. 22, 2014

Outline • Structure of the Aortic Valve • Causes of Aortic Stenosis and Insufficiency • Prognosis • Assessment and Follow-up of Aortic Stenosis or Aortic Insufficiency • Therapies

Outline • Structure of the Aortic Valve • Causes of Aortic Stenosis and Insufficiency • Prognosis • Assessment and Follow-up of Aortic Stenosis or Aortic Insufficiency • Therapies

Rick A. Nishimura et al. JACC 2014;63:e57-e185

Surgery with Severe Aortic Stenosis • Symptomatic (Ia) • LVEF < 50% (Ia) • Undergoing other cardiac surgery (Ia) • Vmax > 5.0 m/s or mean gradient > 60 mmHg (IIa) • Abnormal Exercise Treadmill Test (IIa) • Vmax increasing > 0.3 m/s per year and low surgical risk

Rick A. Nishimura et al. JACC 2014;63:e57-e185

Surgery with Severe Aortic Insufficiency • Symptomatic (Ia) • LVEF < 50% (Ia) • Undergoing other cardiac surgery (Ia) • LVEF ≥ 50% and LV end systolic dimension > 50 mm (IIa) • LVEF ≥ 50% and LV end diastolic dimension > 65 mm (IIa)

Left Ventricular End Systolic Dimension End Systolic Dimension

Left Ventricular End Diastolic Dimension LV End Diastolic Dimension

Risk Estimation Surgical Versus Percutaneous Aortic Valve Replacment

Surgical Aortic Valve

Transcatheter Aortic-Valve Replacement. Smith CR et al. N Engl J Med 2011;364:2187-2198.

Time-to-Event Curves for the Primary Composite End Point. Leon MB et al. N Engl J Med 2016;374:1609-1620.

Aortic Valve Replacement Leading to Complete Heart Block

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