Clinical Update: Common Valvular Heart Disease

Chowdhury H Ahsan, MRCP, MD, Ph.D. Assistant Professor of Medicine University of California Medical Center

Mitral Stenosis
Etiology
Rheumatic (nearly all adult MS) Degenerative (calcification) Congenital (parachute MV)

Others: post-inflammatory, metabolic syndromes etc.,,

Mitral Stenosis
Clinical Presentations
Asymptomatic
Dyspnea, PND, Orthopnea Hemoptysis Atrial fibrillation Systemic embolization

Mitral Stenosis
Diagnosis
Clinical - Loud S1 and P2 (pulmonary hypertension) - mid diastolic rumble - OS indicating pliable leaflets - short OS-S2 interval indicates severe MS - other auscultatory signs as per co-existing disease ECG - P mitrale: broad, notched P wave in II and biphasic in V1 - RVH and rightward axis if significant PHT

Mitral Stenosis
Diagnosis
CXR - LAA and LA enlargement - increased upper lobe vascularity - Kerley B and A lines - dilated PA - MV calcification

Mitral Stenosis
Asymptomatic - no specific therapy

Management Principles

- endocarditis prophylaxis - if appropriate, rheumatic fever prophylaxis Mild and Mod MS ( MVA > 1.5 sq cm and 1.0 to 1.4 sq cm) - Normal physical activity - No specific therapy, restoration of NSR in case of AFib - restoration of NSR and anticoagulation in case of Afib - intervention if PASP > 60 mm of Hg or exertional symptoms

Mitral Stenosis :
53 yr old female from East Europe presented with increasing SOB and Fatigue Has Rheumatic Mitral stenosis Exercise Echo followed by Cath was done

Mitral Valve: hockey stick appearance indicating Rheumatic Valve Disease Valve area varied between 1.4 to 1.6
Exercise Echo was done

Exercise or DSE for evaluation of MS

Lower MVA at rest showing more pronounced change in mean diastolic gradient with stress
Hecker S et al, AJC 1997 and Cheriex EC et al, Int J Cardiol 1994

Exercise did not change the gradient across MV

Not severe MS to account for patients symptoms

Simultaneous LV and LA pressure tracing

Kaplan-Meier product-moment event rates in patients with mitral stenosis. The cutoff point (18 mm Hg) was derived from the obtained performance of the test according to the presence or absence of clinical events Reis et al, JACC 2004

36 year old male with HIV, HTN, Hepatitis B +C and a history of cocaine and alcohol abuse is found to have a heavily calcified Mitral valve and Mitral annulus with severe Mitral Stenosis

2-D Echo showing heavily calcified Mitral valve leaflets and Mitral stenosis

3-D Echo of Mitral Stenosis

LA view

LV view

3-D measurement of Mitral valve area

LA view

LV view

MVA= 0.914 cm2

Real Time TTE of the Mitral Valve

Real Time TTE of MS

A B C

LA

Real Time TTE of MVA in MS

Bland-Altman graphs displaying differences against average values between traditional and real-time three-dimensional (RT3D)-determined mitral valvular area. The thick line represents mean difference, and the thin lines represent the limits of agreement (all measurements in cm2).
Zamarano et al., JACC 2004; 43: Pages 2091

Real Time TTE of MVA in MS

Zamarano et al., JACC 2004; 43: Pages 2091

3-D TEE
ALL gated acquistion Superior image resolution Temporal artifacts Intra-operative guidance Surgeons want it in the OR

Mitral Stenosis
Severe MS - is usually symptomatic

Management Principles

- Percutaneous mitral commissurotomy (PMC) is the treatment modality of choice in the vast majority - PMC in optimal anatomy has acturial survival rate of 95% after 7 years - PMC in skilled centers has a mortality of < 1%

- Success of PMC depends on the pre-PMC valve anatomy

- Commissural calcification is a predictor of suboptimal outcome - Complications: severe MR, embolization and cardiac perforation

Mitral Stenosis

Management Principles

Surgical treatment - commissurotomy (only occasionally indicated, usually PMC) - valve replacement

Indications for percutaneous valvuloplasty of MS

Class I
Symptomatic patients (NYHA II, III, or IV), moderate or severe MS (MVA 1.5) and valve morphology favorable for percutaneous balloon valvotomy in the absence of left atrial thrombus or moderate to severe MR

 Class IIa Asymptomatic patients with moderate or severe MS and valve morphology favorable for percutaneous balloon valvotomy who have pulmonary hypertension (PAP > 50 at rest or 60 with exercise) in the absence of LA thrombus or moderate to severe MR Patients with NYHA III-IV symptoms, moderate or severe MS and a nonpliable calcified valve who are at high risk for surgery in the absence of LA thrombus or mod/sev MR

 Class IIb
Asymptomatic patients, moderate or severe MS and valve morphology favorable for percutaneous balloon valvotomy who have new onset of AF in the absence of left atrial thrombus or mod/sev MR. Patients in NYHA III-IV, mod or sev MS, and a nonpliable calcified valve who are low-risk candidates for surgery

 Relative contraindications
Left atrial thrombus
TEE frequently performed prior to the procedure to rule out thrombus According to Palacios and Vahanian, no

consensus regarding thrombus localized in L atrial appendage.

Limit to patients with contraindications to surgery or

those with urgent need for intervetion

Significant MR (3+ to 4+)

Determination of echocardiographic score (Wilkins Score)

Braunwald: Heart Disease: A Textbook of Cardiovascular Medicine, 6th ed

Immediate outcomes of percutaneous valvuloplasty of MV

The immediate results of percutaneous mitral valvotomy are similar to those of surgical mitral commissurotomy
Mean MVA doubles (from 1.0 cm2 to 2.0 cm2) 50% to 60% reduction in transmitral gradient. Overall, 80% to 95% procedural success (MVA >1.5 cm2 and a decrease in LA pressure to <18 mm Hg).

Most common acute complications

severe MR 2% to 10% residual ASD
Large ASD (>1.5:1 L->R shunt) in <12% with the double balloon technique and <5% with the Inoue balloon technique. Smaller ASD detected by TEE in larger numbers of patients.

Less frequent complications

Mortality

perforation of LV (0.5% - 4.0%) embolic events (0.5% - 3%) MI (0.3% - 0.5%). 1% to 2% < 1% with increasing experience in selected patients.

Long-term results of percutaneous valvuloplasty of MS

Survival rate 60 % - 90 % over 3-7 yrs Restenosis rate 40% after 7 yrs. Randomized trials comparing percutaneous approach with both closed and open surgical commissurotomy consisted mainly of younger patients with favorable morphology.
No significant difference in acute hemodynamic results or complication rate. No difference in clinical improvement or exercise time in early follow-up More favorable hemodynamics and symptomatic results with percutaneous approach than closed commissurotomy and equivalent results with open commissurotomy.

MR stable or decreaswes slightly. ASD likely to close later in majority of cases.

Vahanian: Circulation, Volume 109(13).April 6, 2004.1572-1579

BONOW ET AL., ACC/AHA TASK FORCE REPORT JACC Vol. 32, No. 5, November 1998:1486-1588

BONOW ET AL., ACC/AHA TASK FORCE REPORT JACC Vol. 32, No. 5, November 1998:1486-1588

Event-free survival after balloon mitral valvuloplasty for 736 patients enrolled in the Balloon Valvuloplasty Registry who were stratified by baseline echocardiographic morphology score:

<8 > 8
8 to 12 P < 0.0001

> 12

Braunwald: Heart Disease: A Textbook of Cardiovascular Medicine, 6th ed

 Percutaneous BMV is the procedure of choice in patients who have symptomatic, hemodynamically severe stenosis with an echocardiographic score of 8 or less and without left atrial thrombus

2-D images of left atrial thrombus

Previous month study (LAA smoke)

Present study

CBC and surgery comparable and good result when Echo score<8 BUT, remember age Patient outcome after CBC for MS

Age NYHA I/II 5 yr Mortality <40 97% o 40-54 63 5 55-69 36 31 >70 19 59 Poor correlation between Echo score and higher age and outcome

Shaw TRD et al, Heart 2003

Aortic Stenosis
Etiology
Most common surgical valve disease in the developed world Degenerative/calcification - most common cause in the industrialized world - under 70 years of age ~ 70 % bicuspid and ~ 15 % tricuspid - over 70 years of age, >50 % tricuspid and ~ 25 % bicuspid

Rheumatic
- most common cause in the developing world - almost always associated with MV disease Other - associated with other congenital cardiac abnormalities (Co-arctation, VSD, Hypoplastic left heart, etc.,,)

Aortic Stenosis
Diagnosis
Clinical - pulsus parvus et tardus (absent in hypertensives and elderly)

- systolic thrill and typical heaving apical impulse

- S4 and late peaking ejection systolic murmur - paradoxical split of 2nd HS in severe AS

- other auscultatory signs modified by co-existing disease

ECG - LVH with strain

CXR
- dilated ascending aorta (post-stenotic dilatation) - Valve calcification

Aortic Stenosis
Diagnosis
Echo (primary diagnostic modality) - AV anatomy (tricuspid, bicuspid, calcification) - Mild Vs. Moderate Vs. Severe AS - AVA and gradients can be calculated - progression of disease can be monitored - assessment of LV function and coexisting lesions Cath - ususally done to assess coronaries prior to valve surgery - helpful to assess severity in complex situations

Aortic Stenosis
Management Principles
Asymptomatic - no specific therapy - endocarditis prophylaxis - if appropriate, rheumatic fever prophylaxis Mild and Mod AS ( AVA > 1.5 sq cm and 1.0 to 1.4 sq cm) - Normal physical activity - No specific therapy, restoration of NSR in case of AFib - approx. progression is a decrease by 0.1 sq cm per year - annual echo follow-up

Aortic Stenosis
Management Principles
Severe AS - usually symptomatic within 2 years - asymptomatic severe AS : no surgery - asymptomatic severe AS: exercise symptoms=?surgery - symptomatic severe AS: surgery - symptomatic severe AS if not operated has an average life expectancy of 2 to 3 years - severe AS with HF has mortality of nearly 100% in 1to 2 years if not operated

Aortic Stenosis
Management Principles

Nonsurgical (Balloon vavuloplasty) - only a palliative treatment

- high risk elderly patients or as an emergent procedure

AS: Case History

66 yr. Male, s/p CABG 10 yrs back
Increasing dyspnea Inferolateral fixed defect, no ischemia Echo: dilated LV, global HK, EF ~20% AV- thickened, markedly restricted

3.2 m/sec

Severe AS with LV Dysfunction

Two Important questions to ask:
a. Is there a non-severe aortic stenosis with a small calculated AVA due to or reflecting a low cardiac output in the presence of LV dysfunction unrelated to valve disorder

b. Is there sufficient contractile reserve to indicate a potential benefit and a reasonable perioperative risk that would justify surgery

AORTIC STENOSIS WITH POOR LV DYDFUNCTION

67 yr. Male no prior H/O of CAD presented with class III/IV symptoms of CHF and had AS with severe LV systolic dysfunction

67 yr. Male, SOB, h/o CAD

No significant change in gradient on dobutamine infusion

No evidence of sufficient contractile reserve

LVOT velocity on rest (left)

LVOT velocity on peak dose dobutamine (right)

DSE in AS with LV systolic dysfunction

DSE directed AVR showed benefit

Schwammenthal E etal, Chest, June, 01

Dobutamine Echo in severe AS

With increase in flow, significant increase in AVA in nonsevere AS and a fall in valve resistance

CRITICAL AS: LOW CARDIAC OUTPUT VELOCITY <2

VELOCITY >4
In-between
Dobutamine
AVA, Resistance
AV Resistance:
Cath: (1.33 X P)/(CO/HR XSEP) Echo: (1.33 X4 Vmax2)/ (LVOT area X Velocity)

Ribichini, Anotorini-Canterin, Heart, 1999

LOW OUTPUT LOW GRADIENT SEVERE AS: DOES CONTRACTILE RESERVE MATTER?

Monin J et al. Circulation 2003

CASE PRESENTATION
46 yrs. Female with SOB, Orthopnea, PND.
Rt Heart Cath: PA 55/25 PCWP 30 with prominent V waves (upto 50 mmHg) Lt Heart Cath: EF 70% with minimal CAD

TEE shows:

Severe Mitral Regurgitation

Repair vs. Replacement:

Better LV function Improved Survival

Survival of patients with severe MR and EF

Survival of patients with severe MR and NYHA class

Mitral Valve Prolapse

Types
Women 20 to 50 years Low BP, orthostatic hypotension, palpitations, chest pain Mid systolic click, maybe mid systolic murmur

Echo:
- thickened, redundant leaflets - leaflet excursion (prolapse) into LA in systole

- redundant chordae tendinae, trivial or mild MR

Little progression of MR, Abx prophylaxis

Mitral Valve Prolapse

Types
Men 40 to 70 years Myxomatous and thickened MV Significant leaflelt prolapse Significant MR, progressive MR Complications: Chordal rupture, Afib

Endocarditis prophylaxis
Surgery for MR often required Classic or non-classic combined MVP equal in male and females. More complications in MEN

Transthoracic echocardiographic image in parasternal long-axis view, showing posterior mitral leaflet bowing backward and prolapsing into left atrium during systole. LV=left ventricle.
LA=left atrium. PML=posterior mitral valve leaflet.

Transgastric short axis view of mitral valve with corresponding scallops.

Hayek, E et al. Lancet, 2005

Chronic MR
Key Points
- Asymptomatic severe MR: ususally no surgery - Asymptomatic severe MR: ? surgery if MV repair possible - Symptomatic severe MR is an indication for surgery - LV contractility is abnormal in severe MR even if EF is normal - EF <60 % in severe MR is an indication to operate - Echo ES dimension > 45 mm is an indication to operate - Afterload reduction provides symptomatic relief but ? prevents progression (except in established LV dysfunction)

Chronic AR
Key Points
- Asymptomatic severe AR: ususally no surgery - Symptomatic severe AR is an indication for surgery - EF < 50 % in severe AR is an indication to operate - Echo ES dimension > 55 mm is an indication to operate - Afterload reduction (ACEI and Nifedipine) slow progression of AR - Valve repair is generally not possible unlike MR

large-volume, 'collapsing' pulse bounding peripheral pulses; also known as Watson's water hammer pulse low diastolic and increased pulse pressure Corrigan's pulse (rapid upstroke and collapse of the carotid artery pulse) de Musset's sign (head nodding in time with the heart beat) Quincke's sign (pulsation of the capillary bed in the nail) Traube's sign (systolic and diastolic murmurs described as 'pistol shots' heard over the femoral artery when it is gradually compressed) Duroziez's sign (a double sound heard over the femoral artery when it is compressed distally)

Example of a Jet of Aortic Regurgitation, as Shown by Color-Flow Imaging

Enriquez-Sarano, M. et al. N Engl J Med 2004;351:1539-1546

Classification of the Severity of Aortic Regurgitation

Enriquez-Sarano, M. et al. N Engl J Med 2004;351:1539-1546

Example of Quantitation of Aortic Regurgitation by the Convergence of the Proximal Flow

Enriquez-Sarano, M. et al. N Engl J Med 2004;351:1539-1546

Guidelines for Indications for Surgery in Patients with Severe Aortic Regurgitation

Enriquez-Sarano, M. et al. N Engl J Med 2004;351:1539-1546

Infective Endocarditis
In Intravenous Drug Abusers the incidence increases severalfold greater than that of patients with rheumatic heart disease or prosthetic valves. The incidence in IVD is believed to be 1.5-20 per 1000 addicts per year 65-80% of cases are men Average age ranges from 27-37 years of age

Steps in the Pathogenesis

Valvular endothelial damage Platelet-fibrin thrombus formation Adherence of bacteria to platelet-thrombus plaque Local bacterial proliferation with hematogenous seeding

Right or Left??

Left sided IE
Well established in the literature that infective endocarditis in the general pop. occurs most frequently on the left side of the heart (MV and Aortic valves) The predilection of Left sided IE is related to 3 factors: higher pressures on the left side that produce more turbulent flow, predisposing the mv and av valves to damage higher oxygen content supporting bacterial growth more congenital and acquired lesions of the left valves than right

Right sided IE
Rights sided (TV) IE accounts for 5-10% of cases of IE Approximately 76% of cases of endocarditis among IDUs occur on the right side. Factors include: IDU-related valvular endothelial injury ie the TV faces the heaviest bombardment and thus most endothelial damage Physiologic effects of injected substances cause vasospasm, intimal damage, and thrombus formation, predisposing the valve to bacterial aggregation Specific organisms associated with IDUs ie S. aureus has more right-sided involvement vs enterococcal which has more leftsided involvement. Levine et al.

Microorganisms
S. aureus and Groups A, B, and G Step most common. S. aureus (coagulase production/clotting cascade) V. Strep (Dextran production) S. aureus/v. strep (platelet aggregation) S. pyogenes (increased adherence) Streptococcus Enterococcus found in older men with GU disease/surgery S. epidermidis common among IVD S. bovis is often associated with a GI malignancy

Clinical Features And Complications

Fever: Most common symptom and sign in pts Heart murmurs: Commonly not audible in pts with TV IE Spleenomegaly: 15-50% of pts with IE Peripheral manifestations: petechiae, splinter hemorrhages (dark red, linear flame-shaped streaks in te nail bed), oslers nodes, Janewayss lesions Musculoskeletal: common complain systemic emboli: splenic, renal, stroke, coronary artery, extremities, mesenteric arteries CHF: secondary to valve destruction or distortion RI: immune complex-mediated glomerulonephritis

Prophylaxis
The recommended ab prophylaxis regimens depends on the degree of risk associate with both the cardiac abnormality and the bacteremia causing procedure Cardiac conditions are classified into high, moderate, and negligible risk Negligible risk does not require ab High and moderate differ only for GI/GU procedures

Risk of Endocarditis
Negligible Risk
MVP without murmur or regurgitation Physiologic murmurs Isolaged secundum ASD Surgically repaired ASD, VSD, or PDA Cardiac pacemakers/defibrillators Hx of rheumatic fever or Kawasaki without valvular dysfunction Previous CABG

High Risk
All Prosthetic heart valve Previous bacterial endocarditis Complex cyanotic congenital heart disease Surgical pulmonary shunts

Moderate Risk
MVP with regurgitation and/or myxomatous leaflets HCM Acquired valvular heart disease (acquired valvular stenosis, regurgiation, and rheumatic heart disease Congenital malformations not mentioned above (Ostium primum ASD, VSD, PDA, Bicuspid aortic valvue, coarctation)

Prophylactic Regimens GU/GI

Situation High-Risk pts Antibiotics Ampicillin + Gentamicin Vancomycin + gentamicin Amoxicillin or ampicillin Vancomycin Regimen
Ampicillin 2.0 gm im or iv plus gent 1.5 mg/kg within 30min of starting procedure; 6 h later, amp 1 gm im/iv or amox 1 g orally Vanc 1 g iv over 1-2 h plus gent 1.5 mg/kg iv/im; complete within 30 min of starting procedure
Amoxicillin 2.0 g orally 1 h before procedure, or amp 2.0 g im/iv within 30 min of starting procedure Van 1 g iv over 1-2 h complete infusion within 30 min of starting procedure

Allergic to amp/amox Moderate-Risk

Allergic to amp/amox

Key Points: Infective Endocarditis

Mortality high (can be 20% in-hospital) 80% Native valve endocarditis Embolic events, large size, abscess, S.Aureus, DM are risk factors for poor outcome ASA Heparin no benefit in embolic situation Left sided IE benefit with surgery especially if associated with CHF BLOOD CULTURES AND TEE ESSENTIAL

2-D images of Mitral valve endocarditis

AV Endocarditis
Transthoracic Echo

MV Endocarditis
TEE

Prosthetic Valve
Prosthetic Valve Thrombosis: Early PHV thrombosis <5mm low complications 3-4% Early PHV thrombosis >5mm higher events Late PHV thrombosis: >50% CHF In-hospital mortality 25% 80% eventually needed Valve surgery Thrombolytics an option

3-D TEE of MV

LA

LA

AV AML

AML

P1
PML

P3

P3

P1

3-D TEE of MV Bioprosthesis

28yr old F with MVR and thrombosis

Prosthetic Heart Valve: VP-PM Valve Prosthesis- Patient Mismatch

30 Day Mortality can be as high as 25% Moderate mismatch 6% vs. mild 3%

CHF, Refractory CHF and HF Deaths high

Prosthesis size <21 mm important factor Early recognition is very important TEE and 3-D Echo helpful

Blais, C et al. and Ruel, M et al. J Thor Cardio Surg. 2004

Significant Tricuspid Regurgitation

97% cases cause identified 85% cases secondary 15% organic TV disease Causes include: PHT, Cardiomyopathy: ischemic, non-ischemic, valvular heart disease Responds to primary problem Annular dilatation is important to note Ring Repair is to be considered

Pathological process of tricuspid annular dilatation. Arrows designate the intercommissural distance that increases with dilatation and that is measured intraoperatively.

Comparison of cardiac-related event free survival rates between the two groups. Group 1 = mitral valve repair (MR) (dashed lines); group 2= MR and tricuspid valve repair (TR).
Dreyfus, G: Annal Thor Surg, Dec 2004

Percutaneous valvuloplasty for pulmonic valve stenosis

Pulmonary Stenosis:
Common congenital defect Mild to moderate PS in children has a generally benign clinical course Usually trileaflet, fused commissures mechanically dilated with balloon. Heavy calcification rare - well suited for balloon valvuloplasty. Not well suited for valvuloplasty - Noonans syndrome, primary fibromuscular subvalvular narrowing. 1982 balloon valvuloplasty of PV introduced

Clinical outcomes
Treatment of choice for PS 98% success rate Procedural mortality < 0.5% Avg PG decrease from 80-90s to 30s Effect sustained on long-term f/u (~ 7 yrs) Complications
Mild transient PI Transient RBBB Bleeding, vascular complications

Percutaneous valvuloplasty of aortic valve

AS
Percutaneous dilatation of stenotic AV is not as successful as that of PS or MS Lack of significant clinical improvement of calcified AS by valvuloplasty led to dominance of surgical AVR for treatment of choice for severe AS. Balloon valvuloplasty is more effective in noncalcified congenital AS

AS: Whats New

Surgical AVR is the treatment of choice in vast majority of patients. However, there is growing elderly population with AS at high risk due to comorbidities, who may be poor surgical candidates. Balloon aortic valvuloplasty provides only transient improvement of valvular function and has unacceptably high restenosis rate. This sets the stage for emergence of percutaneous valve replacement. Percutaneous pulmonic valve implants reported in 2000

Initial studies

Eur Heart J 2002 (23) 1045-1049

First report of left sided percutaneous valve implants by Bonhoeffer Use of bovine jugular vein containing a valve which was dissected and sutured into a stent in lambs Valve initially implanted in descending aorta for acute aortic insufficiency model. Orientation and orthotopic position optimized in further animal models In vitro testing showed a satisfactory durability for up to 2 yrs.

Schematic views of device

Left - 3 parts of device are represented separately (from top: platinum stent, nitinol stent, and valve). Middle - Fully expanded device is shown longitudinally and axially. Righ - diagrams demonstrate where nitinol and platinum stents are attached, which allowed stepwise approach.

From: Boudjemline: Circulation, Volume 105(6).February 12, 2002.775778

Newly designed stent crimped on outer balloon of delivery system before being covered. Notice spontaneous expansion of nitinol stent. Boudjemline: Circulation, Volume 105(6).February 12, 2002.775-778

(1) Whole system advanced in left ventricle. (2) Device then uncovered, deploying nonsutured part of nitinol stent. Free wires of nitinol stent positioned in bottom of native leaflet. (3) Balloons are inflated to expand platinum stent (4) Finally deflated, and retrieved, leaving device in position.

Boudjemline: Circulation, Volume 105(6).February 12, 2002.775-778

First human case of percutaneous AV implant

Cribier et al, Circulation 2002 (106) 30063008

57yo male with severe AS, cardiogenic shock, and contraindications for surgery Percutaneous Heart Valve (PHV): 3 bovine pericardial leaflets mounted within a stent 14 mm in length, 21-23 mm diameter 2.5 yr durability

Patient
57yo male with AVA 0.6 cm2, transvalvular gradient of 30 mm Hg, and EF 14 % previously declined AVR by several CT surgical teams presented with cardiogenic shock. PMH included PVD, silicosis, lung cancer and chronic pancreatitis. No myocardial contractility reserve shown on dobutamine echo. Aortic valvuloplasty performed with initial improvement of hemodynamics, with reduction of gradient to 13, increased AVA to 1.06 Following week, cardiogenic shock recurred with impending death (SBP 70, EF 8 12 %) Implantation of investigational PHV as last resort, potentially life-saving intervention

Percutaneous Heart Valve (PHV) 14 mm in length Trileaflet Tissue valve made of three equal size sections of bovine pericardium

The percutaneous valve crimped over the 30-mm-long balloon before implantation

From: Cribier: Circulation, Volume 106(24).December 10, 2002.3006-3008

Results
Immediately after procedure
MG 6, LVEDP 25, CI 2.5, AVA 1.9 LV angiogram revealed normal flow across AV, no MR, and EF 17% Coronary ostia patent Mild paravalvular AI Procedure time 126 min TEE: complete exclusion of native AV by PHV, MG 9, AVA 1.6 by planimetry, moderate paravalvular AI from nonapposed calcified commisure of bicuspid AV

 Echocardiographic assessment

Follow-up

Permanent anticoagulation with heparin and ASA IV vasopressors at decreasing doses over first 4 wks TEE at 1, 4, 7, and 9wks post implant showed thin leaflets and unchanged paravalvular regurgitation. AVA 1.6 to 1.5 Mean gradient 15 to 14 EF in range of 13 to 20 %

Clinical course
Improved CHF, increased activity Noncardiac complications in subsequetn 4-mo f/u w PE, septicemia, worsening R leg ischemia requiring amputation, infection and unhealing ulcer Pt died 17 weeks after PHV implantation. No acute episode of heart failure during f/u.

Subsequent case series:

Improved device 3 equine pericardial leaflets Valve durability 5 yrs 6 patients Mean age 75, multiple comorbidies, NYHA class IV TEE showing heavily calcified AV, AVA < 0.6 cm2 Results Device successfully delievered in 5 pts. 1 pt who had severe AI after balloon angioplasty died after balloon-PHV assembly ejected in asc aorta at time of inflation AVA = 0.5 1.7 cm2 No significant residual gradient post procedure Mild (3/5 patients) and mod (2/5 patients) AI all paravalvular EF = 24 % 41 % First 3 patients died of non-cardiac cause at 18, 4, and 2 wks. 2 Pts alive at 8 wks with no sign of CHF

Journal of the American College of Cardiology. 2004;43(4):698-703

Pulmonary valve implant

 First percutaneous valve implantation in humans was PV by Bonhoeffer in 2000 12 yr old boy w PV stenosis and PI of a prosthetic conduit from RV to PA Use of bovine jugular valve Subsequent case series 8 patients with either stenosis or insufficiency 10 mo f/u Sustained gradient reduction Mainly in pediatric population ACC 04 - report of 44 patients Median f/u 12.5 mo Procedural success > 90%

JACC (2004) 43:1082-7

JACC (2002) 39:1664-1669

Percutaneous repair of mitral regurgitation

Background 2 emerging techniques

Edge-to-edge repair Journal of Interventional Cardiology (2003) 16:93-96. Annuloplasty 1 1. Annuloplasty Uses close proximity of coronary sinus to MV annulus to cinch or compress posterior portion of annulus 2. Edge-to-edge repair 2 Based on repair technique by Alfieri Suture placed in center of anterior and posterior leaflets creating double orifice.

Effect of annuloplasty device on mitral annular geometry

A: In ischemic mitral regurgitation, the leaflets fail to coapt. The guiding catheter has been positioned in the coronary sinus.

B: The annuloplasty device decreases the distance between the anterior and posterior annulus, increasing leaflet coaptation.

Catheter Cardiovasc Interv (2003) 60:410-416

EVEREST I Endovascular Valve Edge-to-edge REpair STudy Phase I

30 patients, multicenter trial Inclusion Criteria Symptomatic, moderate to severe MR Asymptomatic, moderate to severe MR with LV dysfunction Exclusion criteria EF <30%, endocarditis, rheumatic heart disease, & renal insufficiency. Results: first 10 patients presented at ACC 2004 MR reduced to +2 in 7/10 patients. No intraprocedural complications At 30 day f/u, 2+ MR was stable in 6 patients.

Percutaneous Valvuloplasty MV valvuloplasty efficacious in carefully selected patients AV valvuloplasty Only transient improvement and high restnosis rate in adult population Last resort or bridge to surgery in patients with severe calcified AS PV valvuloplasty mainly in pediatric population Well-accdepted treatment for PS and good f/u results Percutaneous Valve repair Currently investigational devices for MR only Still early stage with no published results (that I know of) in human Percutaneous valve replacement/implantation Early stages with very limited data on human Promising results for PV in pediatric population Limited but promising data in human for AV implant in non-surgical candidates Larger scale clinical trials and long term data needed Unanswered questions regarding ideal material, paravalvular leaks, durability, complications and more. Overall, percutaneous valve intervention is an exciting field in interventional cardiology but still at an infantile stage with potentially immense clinical application!

Summary

Thank You !!!