心脏瓣膜病动态监测和手术转诊

Valvular Heart Disease: Ambulatory Monitoring and Surgical Referral Dr. Shane Shapera Previous version: Dr. Wassim Saad for AIMGP October 2006 Valvular Heart Disease nFocus on: nAortic stenosis nChronic mitral regurgitation nMitral Stenosis (extra slides if time permits) nWho should have an Echo? nAt first contact? Follow up? nHow do we interpret the results? nHow should we follow patients? nHow often should they be seen in clinic? nAre there options for medical management? nWhen should we refer to a surgeon? References nNew ACC/AHA Practice Guidelines: nACC/AHA 2006 Practice Guidelines for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Valvular Heart Disease) JACC. 2006;48(3):598-675. Reminder nClass I: There is evidence and/or general agreement that a given procedure or treatment is useful and effective nClass II: There is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment nIIa: Weight of evidence/opinion is in favor of usefulness/efficacy nIIb: Usefulness/efficacy is less well established by evidence/opinion. nClass III: There is evidence and/or general agreement that the procedure/treatment is not useful and in some cases may be harmful. A new referral n62 year old man nRFR: Family MD “heard a murmer” nPMH: HTN and obesity nMeds: ASA and Norvasc nHPI: nTold he has a murmer 2 years ago nNo symptoms of CVS or respiratory nature nLimited physical activity, but no limitations A new referral nO/E: nHR: 88 BP: 150/85 nJVP normal nHarsh midsystolic ejection murmer (3/6) over aortic area radiates to the clavicle nNormal pulses nRemainder of physical exam normal Questions to think about: nIs a 2D-Echo appropriate in this patient? nWhich patients require an echo? nAre there any symptoms that need to be considered when deciding whether to order an echo? Recommendations for Echocardiography in Asymptomatic Patients With Cardiac Murmurs Indication Class Diastolic, Continuous, Holosystolic or late Systolic murmurs I Grade 3 or greater midsystolic murmursI Murmurs with ejection click or radiation to neck or back I Murmurs associated with abnormal physical findings on cardiac palpation or auscultation IIa Murmurs associated with an abnormal ECG or chest x-ray IIa Grade 2 midsystolic murmur (Innocent)III Recommendations for Echocardiography in Asymptomatic Patients With Cardiac Murmurs Indication Class Diastolic, Continuous, Holosystolic or late Systolic murmurs I Grade 3 or greater midsystolic murmursI Murmurs with ejection click or radiation to neck or back I Murmurs associated with abnormal physical findings on cardiac palpation or auscultation IIa Murmurs associated with an abnormal ECG or chest x-ray IIa Grade 2 midsystolic murmur (Innocent)III Recommendations for Echocardiography in Symptomatic Patients With Cardiac Murmurs IndicationClass Signs / symptoms of CHF, MI, ischemia or syncopeI Signs / symptoms of endocarditisI Signs / symptoms of thromboembolismI Signs/ symptoms likely due to noncardiac disease but cardiac disease not excluded by standard cardiovascular evaluation IIa Back to the case nCXR: normal nECG: LVH (aVL 11mm) nECHO: nAVA 1.4cm2 with a mean gradient 30mmHg nMild concentric LVH nGrade I LV nFinal interpretation: moderate AS Aortic Stenosis: Causes nTwo most common causes of AS: nCalcification of the valve nOlder patients nVery similar to an atherosclerotic process nBicuspid aortic valve nYounger patients nMechanical abnormality leading to degeneration Aortic Stenosis: Natural History Prognosis mnemonic: A-S-D Aortic Stenosis: Classification AVAGradientJet Velocity Mild AS 40 mmHg 4 m/s Critical AS 5 m/s Questions to think about for our patient with moderate AS nWhat is his expected prognosis? nHow should he be followed? nWhen should we offer a surgical intervention? nIs there medical therapy we can offer? Aortic Stenosis: Follow-up nExpect prolonged latency period nLow M&M while asymptomatic nProgression of stenosis is highly variable nTreatment based largely on symptoms nAverage survival 2-3 yrs once symptoms nRisk of sudden cardiac death once symptoms Aortic Stenosis: Follow-up nACC Guidelines suggest “frequent monitoring” of asymptomatic patients looking for: nSymptoms of angina, syncope and SOB nSigns of CHF (raised JVP, SOA, crackles) Aortic Stenosis: Follow-up nWhen should you repeat an ECHO? nChanging signs or symptoms nPatient becomes pregnant nRoutine follow-up nMild AS:q 3-5 years nModerate AS:q 1-2 years nSevere AS:q 1 year Aortic Stenosis: When to operate? Indication for Aortic Valve RepairClass Severe AS (AVA 80% n60% have no progression of symptoms nSignificant limiting symptoms n10 yr survival rate of 0-15% nIf severe pulmonary HTN nMean survival 1.5 cm21.0 1.5 cm2 50 mmHg Mean Gradient 10 mmHg Mitral Stenosis: Initial Exam nHx dyspnea, hemoptysis, hoarseness, CHF, thromboembolism, endocarditis nP/E evidence of Afib, pulmonary HTN, CHF nCXR heart size, pulmonary edema nECG rhythm, LAE, RVH due to pulmonary HTN Mitral Stenosis: Initial Echo nBaseline Echocardiogram nDoppler to assess severity nDetermines valve area, RVSP and gradient nVisualize leaflets and commissures nDetermines timing and type of interventions nAssesses for other valvular lesions nChamber size & function nConsider exercise Echo if clinical picture doesnt fit with Echo findings Follow Up - Asymptomatic nMild MS (MVA 1.5cm2) nPatients remain stable for years nShould be seen annually and have CXR, ECG nModearte-Severe MS (MVA 1.5cm2) nInitially, assess valve morphology & look for pulmonary HTN (PAP 50mmHg) nIf intervention is not appropriate, then follow as for mild MS (above) Follow up When to re-Echo? nRepeat any time symptoms change nRoutine follow-up nMild MS repeat Echo q 3-5 years nMod MS repeat Echo q 1-2 years nSevere MS repeat Echo q 1 year Who Should be Referred to a Surgeon? IndicationClass NYHA II with moderate or severe MS (MVA1.5cm2)I Asymptomatic patient with moderate or severe MS (MVA1.5cm2) who have pulmonary HTN (PAP50) I Asymptomatic patient with moderate or severe MS