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Chapter3
Aorticstenosisandmitralregurgitation
Guideline:EuropeanSocietyofCardiology(ESC)/EuropeanAssociationfor
Cardio-Thoracic Surgery (EACTS) (2017 ESC/EACTS Guidelines for the management of valvular heart disease):
https://academic.oup.com/eurheartj/article/38/36/2739/4095039
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Aorticstenosis (AS) and mitral regurgitation (MR) are the two most common valvular pathologies in high-income countries. Patients often remain asymptomatic for an extended period before cardiovascular decompensation which leads to the onset of symptoms. In the asymptomatic phase, management involves optimization of cardiovascularriskfactorsandregularsurveillance.Theonsetofsymptomsisassociated withasignificantincreaseinadverseeventsandsuddencardiacdeath.Boxes3.1and3.2 describetheaetiologyofASandMR,respectively.
Box3.1Aetiologyofaorticstenosis
Calcificdegenerationoftheaorticvalve Bicuspidaorticvalve Rheumaticheartdisease Congenital.
Box3.2Aetiologyofmitralregurgitation
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Primary—abnormalityofmitralvalveapparatus:
Degenerative Connectivetissuedisease Rheumaticfever Infectiveendocarditis
Papillarymusclerupture Secondary—functional regurgitation due to distortion of the subvalvular apparatus with a structurallynormalvalveandchordae:
Leftventriculardilatation(ischaemicandnon-ischaemic).
Diagnosis
History
Askabout:
Presenceofsymptomssuchasfatigue,exertionaldyspnoea,angina,syncope,lightheadedness,and palpitations Presenceofcardiovascularriskfactorsandcomorbidities Functionalstatus Historyofrheumaticfever.
Examination
Focusondetectingsignsandcomplications ofvalvularheartdisease(Table3.1andFig.
3.1).
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Table3.1Possibleexaminationfindingsinpatientswithvalvularpathology
Aorticstenosis Mitralregurgitation
B Basalcrepitationsduetopulmonaryoedema
Hypoxia Orthopnoea
C Heavingapexbeat
Slow-risingcentralpulse Crescendo–decrescendomid-systolicmurmurradiatingtothecarotid arteries Softsecondheartsound
Displacedapexbeat Pansystolicmurmurradiatingtothe axilla Thirdheartsound Softfirstheartsound AFiscommon
E Evidenceofinfectiveendocarditis(splinterhaemorrhages,Oslernodes,Janewaylesions)
Ankleoedema
Fig.3.1 Auscultation findings in aortic stenosis and mitral regurgitation. (a) There is a mid-systolic crescendo–decrescendo ejection systolic murmur that radiates to the carotid arteries. There may be reverse splitting or only a single audible second heart sound, due to delayed and softer aortic valve closure(A2).Afourthheartsoundmaybepresentduetoforcefulatrialcontraction.(b)Thereisapan­systolicmurmurthatradiatestotheaxilla.Thereisasoftfirstheartsound(S1)duetoincompletemitral valve closure,andthereis splitting of the second heart sound due toearlyclosureof the aortic valve (A2).Afourthheartsoundmaybepresentduetorapidventricularfilling.A2,aorticsecondheartsound; ESM,ejectionsystolic murmur;PSM,pansystolic murmur;P2,pulmonarysecondheartsound;S1,first heartsound;S3,thirdheartsound;S4,fourthheartsound.
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Investigations
Bedside
ECG:lookforevidenceofleftventricular hypertrophy, leftatrialdilatation,left axisdeviation, LBBB,AF,orQwavesduetoapreviousinfarct.
Bloods
SeeTable3.2.
Table3.2Bloods
U&E Kidneydiseaseisariskfactorforatheroscleroticdisease
Knowledgeofrenalfunctionisrequiredwhenprescribingdiuretics
FBC Anaemiamayexacerbatesymptoms
HbA1c Diabetesisariskfactorforatheroscleroticdisease
Lipidprofile Hyperlipidaemiaisariskfactorforatheroscleroticdisease
BNP ElevatedBNPisapredictorofpooreroutcomes
Imaging
ChestX-ray:lookforevidenceofheartfailureorvalvecalcification.InMR,cardiomegalymay bepresentduetoleftventricularandatrialdilatation.
Other
Transthoracicechocardiography(TTE):confirmsdiagnosis,severity,andaetiology. Transoesophageal echocardiography: sometimes used in MR or AS to further assess for
concomitantvalvepathology. Exercise echocardiography: sometimes used when there is evidence of severe AS or MR on echocardiographybutthepatientisasymptomatic. Thistestprovides prognosticinformationand thepresenceofsymptomsmayjustifyearlysurgicalmanagement.
Cardiacmagneticresonanceimaging(MRI),cardiaccomputedtomography(CT),andcardiac angiography:thesecanprovideadditionalinformationforsurgicalplanningandprognostication.
Diagnosticcriteria
SeeTable3.3.
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2.
3.
4.
Table3.3Criteriaforseverevalvulardisease
Aorticstenosis Mitralregurgitation
Clinical Presenceofsymptoms(angina,dyspnoea,syncope)
Qualitative Leftventricularhypertrophy
Valvemorphology
Quantitative Peaktrans-valvularpressuregradient>40mmHg
Peaktrans-valvularvelocity>4m/s Valvearea<1cm
2
Effectiveregurgitantorificearea>40mm2 Regurgitantvolume>60mL/beat
Leftatrialorleftventricularenlargement
Source:datafrom2017ESC/EACTSGuidelinesforthemanagementofvalvularheartdisease.
Management
Patienteducation
Educatepatientsabouttheimportanceoffollow-upandreportingsymptomsassoonastheyoccur.
Lifestyleandsimpleinterventions
Supportpatientswithweightloss,smokingcessation,dietmodification,andexercise. VigorousoranaerobicexerciseiscontraindicatedinsymptomaticASpatients.
Psychologicalinterventions
Palliativecareinputshouldbeconsideredforsymptomaticpatientsnoteligibleforinterventional management.
Pharmacologicalmanagement
ThereisnoevidencethatmedicaltherapyimprovesthenaturalprogressionofASorMR. Thefocusofmedicalmanagementis:
Totreatanymodifiablecardiovascularriskfactors(hypertension(seeChapter6),Type2diabetes mellitus(seeChapter26),hyperlipidaemia) Tomanageunderlying/concurrentheartfailure(seeChapter5) To reduce preload in acute MR using nitrates and diuretics ± to use inotropes if there is haemodynamicinstability ToattempttomaintainsinusrhythminpatientswithAF(seeChapter4).
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Surgicalmanagement
The strongestindication for intervention is the onsetof symptoms. Intervention can be surgicalor percutaneous depending on the surgical risk of the patient. Decisions about timingandmodeofinterventionneedtobemadebyamultidisciplinaryheartteamafter consideringindividualrisksandbenefitsofintervention.
Mitralregurgitation
PrimaryMR:surgicalrepairisthepreferredmethodofintervention,withpercutaneousedge-to­edgerepairreservedforpatientswithahighsurgicalrisk.Surgeryisindicatedinseveredisease, whichisdeterminedbythe presenceofsymptoms, leftventricularejectionfraction (<60mmHg), pulmonaryarterypressure(>50mmHg),andpresenceofAF AcuteMR:ifthereishaemodynamicinstability,anintra-aorticballoonpumpmaybeusedprior tointervention.
Aorticstenosis
Surgicalaorticvalvereplacement(SAVR): preferredmode ofinterventioninyounger patients withseveresymptomaticASandlowsurgicalrisk Transcatheter aortic valve implantation (TAVI): intervention of choice in patients aged >75 years Balloonvalvuloplasty: canbe considered in haemodynamicallyunstable patientsasabridgeto surgeryorTAVI.
Valvularpathologyandcoronaryheartdisease
InthepresenceofmoderateAS,ifCABGsurgeryisalsorequired,patientsshouldhaveanSAVR Inthepresenceofmoderatesymptomatic MR,ifCABGsurgeryisalsorequired, patientsshould haveamitralvalverepairatthesametime.
Complications
Left ventricular remodelling (hypertrophy and/or dilatation), pulmonary hypertension, heart failure, AF (see Chapter 4), LBBB, and sudden cardiac death may occur as complicationsoftheconditions.Infectiveendocarditismayoccurasacomplicationofan intervention.
Monitoringandfollow-up
In asymptomatic patients with severe MR or AS, 6-monthly follow-up is advised with careful screening for onset of symptoms and progression of echocardiographic parameters.
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Furtherreading
1.EuroSCOREIIsurgicalriskcalculator.Availableat:http://www.euroscore.org/calc.html
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Chapter4
Atrialfibrillation
Guideline: NICE NG196 (Atrial fibrillation: diagnosis and management):
https://www.nice.org.uk/guidance/ng196
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Atrialfibrillation(AF)isacommonarrhythmiathatresultsindyssynchronouscontraction oftheatriarelativetotheventricles.Patientswiththisconditionhaveanincreasedriskof thromboembolismthatmayleadtostroke.
Diagnosis
History
About25–30%ofAFpatientsareasymptomatic(incidentalfinding).Othersmaypresent with:
Shortnessofbreath Palpitations Chestdiscomfort Syncopeorlight-headedness Fatigue Anembolicevent(stroke,transientischaemicattack(TIA);seeChapter56).
Aimtoidentifyanypossiblepredisposingcauses:
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Underlyinginfection Heavyalcoholintake Cocaineormarijuanause Highcaffeineintake Hypertension(seeChapter6) Heartfailure Structuralheartdisease:
Valvular(mitralstenosisorMR;seeChapter3)
Congenital(atrialseptaldefect) Coronaryarterydisease Hyperthyroidism(seeChapter19) Pulmonary conditions, e.g. chronic obstructive pulmonary disease (COPD; see Chapter 81), obstructivesleepapnoea.
Examination
Performafullcardiacexaminationincludingbloodpressure Palpateforanirregularlyirregular±tachycardicpulse Auscultateforirregularlyirregulartachycardia(ifinAFwithrapidventricularrate)±murmurs.
Investigations
Bedside
A12-leadECG(Fig.4.1andBox4.1).
Box4.1Diagnosingatrialfibrillation
AdiagnosisofAFrequiresECGevidenceofthefollowing:
IrregularRRintervals
AND
AbsenceofvisiblePwaves.
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Fig.4.1Electrocardiogramrhythmstripdemonstratingatrialfibrillation.
ReproducedfromWijdicksEFMetal(2016)‘NeurocriticalCare2e’OxfordUniversityPress:Oxford, withpermissionfromOxfordUniversityPress.
Bloods
Usebloodteststoscreenforpossibleunderlyingfactorswhichmightcauseorexacerbate AF:
FBC(anaemia) U&Eandboneprofile(electrolyteabnormalities,e.g.hyperkalaemia) Thyroidscreen(hyperthyroidism) Venousbloodgas(lactateforinfection) Coagulationprofile(anticoagulationmayberequired)
Imaging
Transthoracicechocardiography
Mayrevealstructuralheartdiseaseand/orpresenceof thrombus.Itshouldbeofferedto allpatientswithAF.
Other
AmbulatoryECGmonitoring
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