Medical management of valvular heart disease

1. DR BISWA RANJAN PATRA
RESIDENTOF MEDICINE
P.G.I.M.E.R & DR. R.M.L HOSPITAL, NEW DELHI

3.  1. MITRAL STENOSIS
 2. MITRAL REGURGITATION

4.  CAUSES
 1. RHEUMATIC FEVER (99% OF CASES)
 PATTERN OFVALVE INVOLVEMENT
▪ Isolated MS-25%
▪ Combined MS with MR- 40%
▪ AorticValve -35%
▪ TricuspidValve-6%
 2. AS A COMPLICATION OF
 Malignant carcinoid disease
 SLE
 RA
 Mucopolysaccharidoses
 3. METHYSERGIDE THERAPY

5.  DIRECTEDTOWARDS-
 1. Prevention of recurrent rheumatic fever
 2. Prevention and treatment of complications of MS
 3. Monitoring disease progression to allow
intervention at optimal time point

6.  1. PRIMORDIAL PREVENTION
 2. PRIMARY PREVENTION
 3. SECONDARY PREVENTION

10.  INFECTIVE ENDOCARDITIS-
risk 0.17/1000 patients. prophylaxis not recommended.
 SYSTEMIC EMBOLISM- anticoagulant therapy
indicated in
 MS and AF (persistent or paroxysmal)
 any previous embolic events (even in sinus rhythm)
 documented left atrial thrombus.
 also may be considered in severe MS and sinus rhythm when
there is left atrial enlargement (dia>55 mm) or spontaneous
contrast on echocardiography.
 TARGET INR – 2-3

11.  Management of AF with AF is similar to the
management for AF of any cause.
 However, it is more difficult to restore and maintain
sinus rhythm due to
 pressure overload of the left atrium
 effects of rheumatic process on atrial tissue and
conducting system.

12. (With persistant symptoms after intervention/ when intervention is not
possible )
 Oral Diuretics
 Restriction of salt intake
 Digitalis- not benificial in sinus rhythm, useful in
slowing FVR in AF & in pt with Right sided HF
 For Hemoptysis- measures designed to reduce
pulmonary pressure
 Sedation
 assumption of upright posture
 aggressive diuresis

13.  PROCEDURE OF CHOICE .
 RECOMENDATIONS-
 1. Symptomatic patients with moderate to severe MS (MVA
<1cm2/m2 or <1.5 cm2 in normal sized adults, with favorable
valve morphology, no or mild MR and no evidence of LA
thrombus.
 2. Asymptomatic patients with very severe MS (<1cm2) with
favorable valve anatomy.
 3. Symptomatic patients in whom surgery carries a high risk of
adverse outcomes, even when valve morphology not ideal

16.  Patient education, avoid vigorous physical activity.
 AVR- Severe AS pt with symptoms, EF<50%, asyptomatic pt
undergoing any heart surgery.
also when symptoms/ fall in BP with exercise.
 Medical therapy- (class IIb)
DIURETICS,ACEI- used with caution
B BLOCKERS- should be avoided
 AF/Flutter- treated promptly with cardioversion
 Appropriate t/t for concurrent cardiac condition- HTN / CAD
(class I)
 No benefits with lipid lowering drugs (class III)

17.  Transcatheter AorticValve Replacement
 Percutaneous/ transapical approach
 Alternative in patients with prohibitive surgical risk and
high surgical risk.
 TAVI resulted in substantial reduction in death,
hospitalisation & lead to significant relief of symptom

18.  Pt education, avoid vigorous sports
 AVR-Symptomatic pt with severe AR, asymptomatic pt with
EF<50% or severe LV dilation ESD>50mm.
 Asymptomatic patients- t/t for systemic arterial diastolic
hypertension (class I)
 AF & bradyarrthymias poorly tolerated- promptly treated
 Vasodilators for chronic AR with significant volume overload-
(class IIa)

22. THANK YOU