ECHO 2013 / Asymptomatic Valvular Disease When to Intervene
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Asymptomatic Valvular Disease:
Can Echocardiography Help with Management Decisions?
Neil J. Weissman, MD
MedStar Health Research Inst at
MedStar Washington Hospital Center
&
Professor of Medicine
Georgetown University
Washington, D.C.
Disclosures
Academic Echo Core Lab with multiple pharmaceutical and device commercial sponsors
No direct COI with this lecture
www.EchoCoreLab.org
Valvular Heart Disease
•General Agreement
–Operate for symptomatic severe valve stenosis or regurgitation
•General Disagreement
–Operate for asymptomatic severe valve stenosis or regurgitation
Chronic Severe MR - When to Operate
What You Need to Know
•Etiology
•Pathphysiology
•Echocardiographic findings
•Natural history
•Surgical morbidity, mortality
•Expertise of surgeon
Aortic vs Mitral Regurgitation
MR AR
Pathophysiology |
Pure volume |
Volume and |
|
overload |
pressure |
|
|
overload |
Preload |
|
|
Afterload |
Normal to |
Aortic vs Mitral Regurgitation
MR AR
Pathophysiology |
Pure volume |
Volume and |
|
overload |
pressure |
|
|
overload |
Preload |
|
|
Afterload |
Normal to |
EF after surgery |
= |
Aortic vs Mitral Regurgitation
AR
MR
EF reflects (closer to) true LV performance
EF is overestimation of true LV performance
Mitral Regurgitation
•Favorable loading conditions
•Ejection phase indices often remain normal
•Masks severity of contractile dysfunction
•Contractile dysfunction develops earlier in MR than with AI
Late Survival of Operative Survivors
Pre-op Echo EF vs Postop Survival
|
100 |
|
|
|
|
|
(%) |
80 |
|
|
|
|
|
60 |
|
|
|
|
72% |
|
Survival |
|
|
|
|
|
|
|
EF 60% |
|
|
|
53% |
|
40 |
|
|
|
|
||
EF 50-60% |
|
|
|
|||
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|
|
|
|||
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|
|
|
|
32% |
|
|
|
EF <50% |
|
|
|
|
|
20 |
|
|
|
|
|
|
|
|
|
|
|
|
|
p = 0.0001 |
|
|
|
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|
|
0 |
|
|
|
|
|
|
0 |
2 |
4 |
6 |
8 |
10 |
|
|
|
Years |
|
|
|
Enriquez-Sarano |
Circulation 90:830(1994) |
|
|
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||
Mitral Regurgitation
Major Challenge
1.Identify contractile LV dysfunction
2.Correct MR before irreversible LV dysfunction develops