Management

of
Valvular
Heart
Disease
I Nyoman Semadi
Thoracic Cardiovascular devision
Surgery Department School of Medicine Udayana
University

The causes of valve diseases

Management of
Valvular Heart
Disease
Asymptomatic

Medical tx

Problem !!

Poor
outcome

Symptomatic

Surgery

Good
outcome

another problem !!

Surgery not too early , not too late

Severity
of the disease
Comorbidity
age
CAD
vitality
etc

When is too late

to operate
the art of medicine

Guidelines..
HELP !

The experience
of
the center

What to consider

Risk
-General condition ?
Benefit

-Cardiac condition ?

-Quality of life ?

-Psychological

-Survival ?

condition ?

Primum
-Symptom relieve ? non nocere.. ! -Comorbidities ?

The Patophysiology
of valvular heart disease
Pressure
overload

Mitral
Stenosis
(to LA)

Volume
overload

Aortic
Regurgitation

Mitral
Regurgitation

Aortic
Stenosis
JACC 1984;3:916-23

Mitral Stenosis
Reduce LV preload
Increase LA pressure

Increase Pulmonary pressure

intervention
Secondary pulmonary vasoconstriction
Severe Pulmonary Hypertension
Intervention ?
Reduce RV function

Intervention ?

Taniguchi, Circulation 1990;82:798-807

Organic Mitral Regurgitation

Pure Volume overload

Compensated by eccentric hypertrophy

LA and LV dilatation

LV dysfunction
Mehta RH
Am J Cardiol 2000;86:1193-7

Increase sympathetic activation

Increase preload
Decrease after-load

Supranormal EF

Carabello BA.
J Heart Valve Dis 2000;9:600-99

Aortic Regurgitation
Volume and pressure overload
Increase preload and afterload

LV dilatation and LVH

AVR/r
Reduce systolic
hypertension
Decreased afterload
Increase EF
(even in severe depression pre EF)
Taniguchi, Circulation 1990;82:798-807

Management Of Valvular Heart

Diseases, Surgical
Approaches
Indication
Limiting Symptomes dyspite optimal medical

therapy
Mild symptoms but progresive haemodynamic
deteoritation

Surgical approach for Valve diseases

Valvotomy (percutaneously ballon valvuloplasty)
Valve commisurotomy (closed cardiac surgery)
Valve repair (opened cardiac surgery)
Valve Replacement (opened cardiac surgery )

Surgery for Valvular

Heart Diseases
Preserving native valve repair

valvotomy, Blind mitral valvotomy:

Cutler & Levine (1925)
Reconstructing of MR with annular ring
Replacement of the valve
Mechanical prosthesis
bioprosthesis

Mitral Valve Surgery

(older concept)

Restoration of mitral competence

Increase afterload
Decrease preload

Significant reduction of post op EF

Sarris GE. J Thorac Cardiovascular Surg 1988;95:969-79

Mitral Valve
Surgery
(newer concept)
Restoration of mitral competence

Destruction of mitral
apparatus

maintaining mitral apparatus

as an Important functional
component of LV

maintaining LV
shape & contractility
Significant reduction of EF
Little / no reduction of EF
Sarris GE. J Thorac Cardiovascular Surg 1988;95:969-79

Mitral valve thickening and

scrooling

Intervention
stenosis

for Mitral

Non surgery :Mitral valvuloplasty (balloon)

Surgery will be performed when:
Symptomatic,
mitral valve area < 1,0 cm2,
mitral valve score>10 with LA thrombus

Surgical intervention
repair (Mitral Valve repair = MVr)
Replacement ( Mitral Valve Replacement = MVR )

Mitral regurgitation

with LA

Mitral regurgitation
Surgery
Indication
MR , asymptomatically: NYHA class 1-

2, LV function getting worse, Seller 3-4

MR, symptomatically: NYHA class 3-4,
LV function moderate, Seller 3-4
Surgical intervention
repair (Mitral Valve repair = MVr )
Replacement (Mitral Valve Replacement =

MVR )

Mitral valve repair with ring

Surgical implantation of
the ring

Mitral valve ring position

Aortic Regurgitation
Surgery
Indication
a/ symptomatically, severe AR with LV

function getting worse

Should be operation :
LVEDD > 70 mm
LVEDVI 200 cc / M 2
ESD 50 mm
ESD 26 mm and ESWI 1,9
Surgical intervention
repair ( Aortic Valve repair = AVr)
Replacement ( Aortic Valve Replacement=
AVR )

Aortic stenosis surgery

Indication
symptomatically, valve area <1,0 cm2

diameter
EF >30%
Surgical intervention

No calcification of leaflet
Comissurotomy
Moderate Calcification
Debridement : Repair (AVr)
Severe Calcification
Replacement (AVR)

Surgical approach : transaortic

Valve replacement technique

Implantation of valve prosthesis

Valve Prostheses
Two Type of Prostheses :
Man made
Boll in cage type( Starr-Edward )
Tilting disc
Bileaflet prostheses
Tissue graft
Homograf (human)
Xenograf (animal) can be expected 8 12
years

Prosthetic Valves

Tissue valve prosthesis

Tissue aortic valve

prosthesis

Mitral valve ring

Aortic Stenosis
Aortic Stenosis patients has a good prognosis as long as they

are asymptomatic even in severe aortic stenosis

Once the symptom occur ( angina, syncope, heart failure)

the prognosis will drastically worsen without AVR

Severe aortic stenosis AVA < 1 cm2 , mean AVG 50 mmHg

LV dysfunction

Ross J,Jr, Braunwald E.

Circulation 1968 ;38 supp
V:V61-7

Mitral Stenosis and PH

Severe PH increase

operative mortality (> 4x)

Operative mortality 12 %
Long-term outcome was

good
(Circulation 1995; 92 suppl 9:II-13742)

(Circulation 1995; 92 suppl 9:II-137-42)

Although PH worsens prognosis in MS,

PA pressure usually returns to or toward normal
following successful intervention.

Valve Replacement is
associated 3,5% operative
mortality over all

Long Term Management of

anticoagulant
After Valve Replacement with

mechanical prosthesis , the

anticoagulant was given long life
Valve replacement with bio prosthesis,
anticoagulant was given for 3 month
Patient with anticoagulant therapy
must be monitor of INR and give
adjusted oral anticoagulant
INR range of 2.5 - 3

The aim of Anticoagulant

therapy
To reduced of systemic

thromboembolism
To prevent valve thrombosis and
dysfunction

Post operative Care of

cardiac surgery Patients

Summary
In most cases, there is never too late to operate

the valve problem

However, some consideration have to be made
The patient condition
The experience of the center
The financial issues
The government policy

..after all, we are treating the patient,

NOT only the valves..

 Consultation as soon as diagnosis was

established
Surgery depend on heart and whole
body condition (indication and
contraindication)
The management of cardiac diseases
by team
General phycision should be referral
cardiac diseases patient to cardiac
centre