the lab - Camenae Group

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Most superheroes wear tights and speedos
Sorry, I don’t wear tights nor speedos
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Speed Racer:
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White pants, blue shirt, brown
shoes & yellow gloves?!
… also red socks & scarf?!
Sorry …
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Speed Racer ?!?
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If he wore a real racing suit …
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SR’s Mach 5
His Trixie:
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My Mach 5
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Cheap, All-American
& seriously fast
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My Trixie:
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His Chim Chim:
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a.k.a., Sherrie “My Sweetie”
Vallabhan
My Chim Chim:
a.k.a., Skittles “I am really a
Piranha” Vallabhan
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Group picture:
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My Clan:
Purpose of normal cardiac valves:
› Provide unidirectional flow of blood within
the heart and blood vessels
› No obstruction to flow
› No reversal of flow
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Aortic Valve (AV)
Mitral Valve (MV)
Pulmonic Valve (PV)
Tricuspid Valve (TV)
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Valvular heart disease accounts for approximately
10-20% of all cardiac surgical procedures in the US
Primary causes of valve disease:
› Age-associated calcific valve disease
› Congenital
g
valve disease:
 Bicuspid AV disease
 Myxomatous MV disease
› Rheumatic valve disease (very rare in US)
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Approximately 67% of cardiac valve surgeries are AV
replacement (AVR) usually for AV stenosis (AS)
Most MV surgeries are for MV regurgitation (MR) and
less often for MV stenosis (MS)
Non-invasive assessment:
› History (symptoms):
 Shortness of breath or exercise intolerance
 Angina
 Syncope
S
or near syncope
 Palpitations and arrhythmias
› Physical exam:
 Evaluate for heart failure and murmurs
 AV Stenosis (AS: easiest to auscultate)
 MV Regurgitation (MR)
 AV Regurgitation (AR)
 MV Stenosis (MS: most difficult to auscultate)
› Chest x-ray and ECG are less specific
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Non-invasive assessment:
› Trans-Thoracic Echo (TTE)
 Gold standard initial study and should be
performed
f
d on allll patients
ti t with
ith suspected
t d
valvular heart disease
 Results obtained:
 Chamber sizes & wall thickness
 LV & RV systolic & diastolic function
 Valvular function (visual inspection & doppler
assessment)
 Misc. info: pericardial disease, vegetations, etc.
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Non-invasive assessment:
› Trans-Esophageal Echo (TEE)
 Especially useful for:
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MV disease
di
and
d to
t lesser
l
extent
t t AV disease
di
Prosthetic MV and AV
Assessment of valvular endocarditis
Intra-cardiac thrombus (especially in the atria)
Atrial septal defects (ASD), patent foramen ovale
(PFO), and ventricular septal defects (VSD)
 Not as helpful for TV and PV disease. PV is very
difficult to visualize with both TTE and TEE
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Invasive assessment:
› Performed in the cardiac cath lab
› Purpose:
 Qua
Quantify
y degree
deg ee of
o valvular
a u a abnormalities
ab o a es
 Quantify degree of heart failure and/or pulmonary
hypertension (HTN)
 Assess degree of coronary artery disease (CAD)
› Not indicated unless:
 Patient is symptomatic
 Echo (TTE) is suggestive of LV or RV dysfunction
 Patient is being considered for surgical or
percutaneous repair or replacement
Stenotic lesions
Regurgitant lesions
 Mixed (combined)
(
)
 Can involve any of the four cardiac
valves
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AV stenosis (AS)
AV regurgitation (AR)
 MV stenosis (MS)
( )
 MV regurgitation (MR)
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Right & left heart catheterization is required for
evaluation of AS when:
› The TTE data is not conclusive as to the severity of the
AS
› Evaluation of CAD (for possible concurrent CABG). In
general, coronary
general
coronar angiograph
angiography sho
should
ld be performed
on all patients > 35 years of age.
› Evaluation of severity of CHF if present
› Evaluation of other valvular lesions (e.g., MR, TR, etc.)
if present on TTE
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E.g.: A 25 female w/ congenital bicuspid AV
who has clear, severe AS by TTE and is
symptomatic will not require cardiac
catheterization prior to surgery.
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Right heart catheterization:
› Pressure measurements:
 Pulmonary artery (PA)
 Pulmonary artery wedge pressure (PAWP)
 RVEDP
 Right atrial (RA)
› Cardiac output & index (CO/CI)
› Intra-cardiac shunts
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Requires dual transducer measurements of
the LV and aortic pressures simultaneously
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Severity of AS:
› Mild AS: AV area > 1.5 cm2
› Moderate AS: AV area 1.0 – 1.5 cm2
› Severe AS: AV area < 1.0 cm2
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Be very careful (common sources of error):
› The CO measurements are a common source of
error and can result in an over (or under)
estimation of the true AV area calculation.
› Irregular heart rhythms (e.g.,
(e g atrial fibrillation) or
frequent PACs & PVCs
› Sloppy technique in obtaining and analyzing the
hemodynamic data
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For all forms of valvular disease, you need
to carefully assess ALL of the clinical data
before you decide to send surgery
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Assessment in the cardiac cath lab:
› Right heart cath (same data as for AS)
› Dual transducer measurements:
 Simultaneous LV & LA measurements:
 Direct (via trans-septal approach)
 Indirect (via PCWP measurement)
› Common sources of error:
 Very irregular heart beats (e.g., AFib)
 Inaccurate PCWP measurement
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Calculated MV area:
› > 2.5 cm2 : normal
› 1.5 – 2.5 cm2 : mild MS
› 1.0 – 1.5 cm2 : moderate MS
› < 1.0 cm2 : severe
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Treatment:
› Medical therapy:
 Diuretics
 AV nodal blocking agents:
 Beta-blockers
 Diltiazem or Verapamil
 Coumadin if AFib (high risk of stroke)
› Percutaneous balloon mitral valvuloplasty
(only appropriate in patients with rheumatic
MS with good anatomy {e.g., minimal Ca++)
› Surgical MV replacement
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Overview:
› The valve opens appropriately, i.e., there is
no restriction to forward flow (no stenosis).
› But the valve does not close appropriately
and therefore, there is “backflow” or
regurgitation of blood back into the
chamber that it just exited.
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Examples:
› AV regurgitation (AR)
› MV regurgitation (MR)
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Overview (con’t):
› Results in a decrease in the “net forward
cardiac output (NFCO):
 NFCO = TFCO – RF
 TFCO = Total forward CO
 RF = Regurgitant Fraction
› LV compensates by increasing the TFCO to
maintain NFCO which results in a volume
overload state and eccentric hypertrophy of
the LV for both AR and MR.
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Assessment of AR and MR in the cath lab:
Right heart cath (same data as for AS or MS)
Single transducer system
Full left heart cath
AR: angiography of ascending aorta (visualize
the backflow of contrast into the LV)
› MR: LV angiography (visualize backflow of
contrast into the LA)
› Caution: the quality of the angiography greatly
affects the ability to quantify the degree of AR
or MR accurately (e.g., inadequate volume of
contrast delivered will underestimate the degree
of AR or MR)
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Treatment for AR and MR:
› Medical therapy:
 Afterload reduction agents ( SVR): ACEI, ARB,
CaCh Blks
 Diuretics
› Percutaneous devices:
 AR: none
 MR: MV clip (MitralClip) and others (each device is
designed for a very specific type of MV defect)
› Surgical:
 AR: replacement in vast majority of patients; repair
is very rare
 MR: repair is attempted in as many patients as
possible but dependent on the patient’s anatomy
and skill and expertise of the CT surgeon.
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A good quality H & P (recognition of
potential for valvular heart disease)
A good quality TTE (gold standard initial
test)
Follow the patients based upon presence
or absence of symptoms and with serial
echoes
Once symptomatic or if they develop echo
features which require invasive therapies,
then refer for R & L heart catheterization.
Final recommendation for optimum therapy
should ALWAYS be based on ALL the data.
Do you not know that in a race all the runners run, but only one
receives the prize? Run in such a way as to get the prize.
------- 1st Corinthians 9:24
Special thanks to:
My wife Sherrie
(25 years and counting)
The Cath Lab Crew and
Dr Nancy Vish
(21 years are counting)
My Lord & Savior Jesus Christ