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C42 Cardiology and Cardiac Surgery
Valvular Heart Disease
Toronto Notes 2019
Mitral Valve Repair vs. Replacement for Severe Ischemic Mitral Regurgitation
NEJM 2014;370:23-32
Purpose: Ischemic mitral regurgitation is associated with significant mortality risk. The purpose of
this study was to compare the effectiveness and safety of repairing versus replacing the mitral valve in patients with severe chronic ischemic mitral regurgitation.
Study Design: RCT with 251 patients with severe ischemic mitral regurgitation were randomly assigned to mitral valve repair or chordal-sparing replacement. The primary endpoint was the left ventricular end-systolic volume index (LVESVI)
at 12 mo.
Results: There were no significant between-group differences in LVESVI, in the rate of major adverse cardiac or cerebrovascular events, in functional status, or in quality of life at 12 mo. The rate of moderate or severe mitral regurgitation recurrence at 12 mo was significantly higher in the repair group than in the replacement group (32.6% vs. 2.3%, respectively).
Conclusions: No significant difference in left ventricular reverse modelling or survival at 12 mo between patients who underwent mitral valve repair or replacement. Replacement provided more durable correction of mitral regurgitation, but there were no significant differences in clinical outcomes.
Investigations
• ECG:lowvoltage,non-specific,diffuseST-Twavechanges±non-ischemicQwaves • CXR:mildcardiacenlargement
• Echo:LAE,RAE;specificDopplerfindingswithnosignificantrespiratoryvariation • cardiaccatheterization:increasedend-diastolicventricularpressures
• endomyocardialbiopsy:todetermineetiology(especiallyforinfiltrativeRCM)
Management
• excludeconstrictivepericarditis
• treatunderlyingdisease:controlHR,anticoagulateifAFib
• supportivecareandtreatmentforCHF,arrhythmias
• cardiactransplant:mightbeconsideredforCHFrefractorytomedicaltherapy
Prognosis
• dependsonetiology
Valvular Heart Disease
• seeGuidelinesontheManagementofValvularHeartDisease.JACCJun10;63(22):2438-88fordetails
Infective Endocarditis
• seeInfectiousDiseases,ID16
• AmericanHeartAssociation(AHA)2007guidelinesrecommendIEprophylaxis
■ only for patients with:
◆ prosthetic valve material
◆ past history of IE
◆ certain types of congenital heart disease
◆ cardiac transplant recipients who develop valvulopathy
■ only for the following procedures: ◆ dental
◆ respiratory tract
◆ procedures on infected skin/skin structures/MSK structures ◆ not GI/GU procedures specifically
Rheumatic Fever
• seePediatrics,P54
Prognosis
• acutecomplications:myocarditis(DCM/CHF),conductionabnormalities(sinustachycardia,AFib), valvulitis (acute MR), acute pericarditis (not constrictive pericarditis)
• chronic complications: rheumatic valvular heart disease – fibrous thickening, adhesion, calcification of valve leaflets resulting in stenosis/regurgitation, increased risk of IE ± thromboembolism
• onsetofsymptomsusuallyafter10-20yrlatencyfromacutecarditisofrheumaticfever • mitralvalvemostcommonlyaffected
Valve Repair and Valve Replacement
• indication for valve repair or replacement depends on the severity of the pathology; typically recommended when medical management has failed to adequately improve the symptoms or reduce the risk of morbidity and mortality
• pathologiesthatmayrequiresurgicalinterventionincludecongenitaldefects,infections,rheumatic heart disease as well as a variety of valve diseases associated with aging
• valverepair:balloonvalvuloplasty,surgicalvalvuloplasty(commissurotomy,annuloplasty),chordae tendineae shortening, tissue patch
• valve replacement: typically for aortic or mitral valves only; mitral valve repair is favoured in younger individuals; percutaneous techniques being established
Choice of Valve Prosthesis
Table 15. Mechanical Valve vs. Bioprosthetic Valve
Mechanical Valve
Good durability
Less preferred in small aortic root sizes
Increased risk of thromboembolism (1-3%/yr): requires long-term anticoagulation with coumadin
Bioprosthetic Valve
Limited long-term durability (mitral<aortic) Good flow in small aortic root sizes
Decreased risk of thromboembolism: long-term anticoagulation not needed for aortic valves
Some recommendation for limited anticoagulation for mitral valves
Decreased risk of hemorrhage
Target INR Aortic valves: 2.0-3.0 (mean 2.5) 2.5-3.5 (mean 3.0)
Increased risk of hemorrhage: 1-2%/yr
Mitral valves: