Published on February 25, 2014
Valvular Heart Disease Richard Allenbach, PA-C Director, Heart Valve Clinic Via Christi Hospitals, Wichita
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 2
Anatomy of the Heart 3
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 4
Aortic Stenosis Definition A narrowing of the aortic valve leaflets that restricts the normal flow of blood through this valve. 5
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. 6
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 Aortic stenosis can be caused by various infections Adults who have had rheumatic fever may also be at risk for aortic stenosis In some cases adults may develop aortic stenosis resulting from a congenital abnormality 7
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.” 8
Diagnosis of Aortic Stenosis Detailed Clinical History Echocardiography 9 Physical Exam Heart Catheterization
Treatment of Aortic Stenosis Surgery Medical Management 10
Natural History of Aortic Stenosis 11
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 12
Sobering Perspective 13
Addressing a Serious Unmet Need 14
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 15
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 16 F, Bauman P, et al. Circulation 1982; 66: 1105-10.
Treatment: Surgical Mechanical heart valve – 1960 First PVT animal First Corevalve implantation animal implantation A. Cribier JC. Laborde Homograft – 1962 Porcine valve – 1965 First Edwards/PVT Transapical Beating Heart AVR Webb, Lichtenstein – Nov 29, 2005 Pericardial tissue valve – 1969 1960 2000 200 200 1 2 17 2007 First PVT Transcatheter AVR CE approval of CoreValve by Antegrade Approach 1,200 implants and Edward Alain Cribier - April (Sept2002 2007; 500 implan 16, 5, Surgery 1Schwartz 2004 F, Bauman P, et al. Circulation 1982; 66: 1105-10. First CoreValve Transcatheter AVR by Retrograde Approach Laborde, Lal, Grube – July 12, 2004 Adapted from P. Serruys
Prosthetic Aortic Valves 19
Aortic Valve Replacement Hospital Mortality • 108,791 isolated AVR patients • STS Data Registry 20 Brown et al. JCTVS 2009;137:82-90
Conventional AVR Stroke Rate J Thorac Cardiovasc Surg 2009;137:82-90 21
Surgical Aortic Valve Replacement remains the “Gold Standard to which emerging therapies will be compared”. 22
Transcatheter Aortic Valve Replacement (TAVR)
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 24
Characteristics of a TAVR Patient 17 TAVR patients may present with some of the following: Severe, symptomatic native aortic valve stenosis 25
Commercially Available Transcatheter Valves 26
Risk and Benefits 27
Risks Injury to blood vessels Stroke Heart rhythm problems Unplanned open heart surgery Kidney problems Death – Guaranteed if nothing is done 28
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” 29
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 30
Aortic Valve 31 Mitral Valve
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”. 32
Mitral Regurgitation (MR) MR occurs when the mitral valve fails to close completely, causing blood flow to move backward Symptoms may include: • Shortness of breath • Heart palpitations • Fatigue • Lightheadedness • Cough • Swollen feet or ankles • Excessive urination Mayo Clinic (www.mayoclinic.com) 33
Mitral Regurgitation 34
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 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) 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. 35
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 36
Diagnosis of Mitral Regurgitation Detailed Clinical History Echocardiography 37 Physical Exam Heart Catheterization
Treatment of Mitral Regurgitation 38
Mitral Valve Surgery • • • • 39 Repair Replacement Minimally Invasive Percutaneous
Mitral Valve Repair Mitral Valve Replacement 40
Many patients are not considered appropriate candidates for mitral valve surgery Large portion of mitral regurgitation patients are left untreated— ineligible for surgical treatment or denied surgical intervention1-2 Factors prohibiting Surgery include6: • Impaired LVEF • High operative risk • Multiple comorbidities 2% Surgical Patients (30K) 49% 49% High-Risk Patients*,3-5 (860K) Surgical Candidates (850K) • Advanced age * Note: High-Risk Patients are defined as any patient with an EF<35% or an age of 75+. 1. 2. 3. 4. 5. 6. 41 Lung B, et al. Eur Heart J. 2003;24:1231-1243. Mirabel M, et al. Eur Heart J. 2007;28:1358-1365. U.S. Census Bureau, Statistical Abstract of the U.S. Nkomo et al. Burden of Valvular Heart Diseases: A Population-based Study, Lancet, 2006; 368: 1005-11. Patel, et al. Mitral Regurgitation in Patients with Advanced Systolic Heart Failure, J of Cardiac Failure, 2004. Rankin, et al, J of Thoracic and Cardiovascular Surgery, March 2006 Of surgical candidates, up to 50% of patients are not referred to surgery, even if a surgical indication exists 2
MitraClip Therapy Filling a Treatment Gap 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* Move Invasive Medical Therapy MitraClip Increased MR Reduction * Source: MitraClip Clip Delivery System Instructions for Use. 42 MV Surgery
MitraClip System Overview 43
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 45
Via Christi Heart Valve Clinic Team 46
Hybrid Operating Room Blends components of: Traditional operating room Cardiac catheterization lab Radiology suite 47
Via Christi Hybrid Operating Room 48
How to Contact Us Heart Valve Clinic at Via Christi 316-268-8650 929 N St Francis 49
Calcification Inhibitors in CKD and Dialysis Patients
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