1、Valvular Heart Disease,Aortic StenosisAortic RegurgitationMitral StenosisMitral Regurgitation WK Ng,Aortic Stenosis,Bicuspid aortic valve4th and 5th decadesTricuspid aortic valve6th to 8th decades,Bicuspid aortic valve with leaflet calcification and aortic stenosis,Rheumatic tricuspid aortic valve s
2、tenosis with commissural fusion and nodular calcification of the cusps,Aortic Stenosis Degree of Stenosis,Mild Valve area 1.5cm2 Mean gradient 30mmHgValve area decrease by 0.1 to 0.3cm2 per year Serial echo every 5 years,Aortic Stenosis Timing for Surgery,Moderate aortic stenosis Valve area 1.0 to 1
3、.5cm2 Mean gradient 30 to 49mmHg 6 monthly review Clinical symptom Echocardiographic progression serial studies every 2 years Valve area 1.0cm2 or mean gradient 30 mmHg and symptomatic,Aortic Stenosis Timing for Surgery,Severe aortic stenosis Valve area 50mmHgSymptomaticAsymptomatic,Aortic Stenosis
4、Timing for Surgery,Aortic Stenosis Timing for Surgery,SymptomaticMortality rateAngina: 50% at 5 yearsSyncope: 50% at 3years Cardiac failure: 50% at 2 years,Aortic Stenosis Timing for Surgery,Asymptomatic or vague symptoms Exercise treadmill testing Linderholm et al 1985 Otto et al 1997 cardiac sympt
5、oms6th monthly review,Aortic Stenosis Timing for Surgery,Exercise treadmill testing 104 subjects (m=38, p=4.0) Fall in BP 10mmHg (9%) Dyspnoea (60%) Angina (3%) Lightheadedness (1%) ST depression (69%),Aortic Stenosis Timing for Surgery,Otto et al 8 deaths (4 non-cardiac) 48 AVRJet velocity 4.0m/s A
6、t 2 year: 21% event free survival Jet velocity 3.0-4.0m/s At 2 year: 66% event free survival,Aortic Stenosis Timing for Surgery,Impaired left ventricular function Low transvalvular gradient Inotropic stress echoElderly patients Good prognosis,Aortic Regurgitation,Mild and moderate aortic regurgitati
7、on Annual follow-up Cardiac Symptoms LVF, angina Echocardiogram (echo every 2 to 3 years) LVESD LV function,Aortic Regurgitation Timing for Surgery,Predictors of Survival after AVRHaemodynamic:End systolic volume index 60ml/m2Elevated LVEDP and pulmonary artery and wedge pressureEjection fraction 65
8、 yearsMaleNYHA class III/IV,Aortic Regurgitation Timing for Surgery,Symptomatic/ Left ventricular impairment Aortic valve replacement symptomatic patients have poor outcome with medical therapy Mortality rate angina: 10% per year heart failure: 20% per year,Aortic Regurgitation Timing for Surgery,As
9、ymptomatic patients Echocardiogram 4 to 6 monthly “Rule 55” LVESD 55mm Ejection fraction 55% Fractional shortening 27% Left ventricular function Vasodilator: nifedipine,Aortic Regurgitation Timing for Surgery,Scognamiglio et al (1994) 143 patients 6 years follow-up AVR 34.6% on digoxin 15.3% on nife
10、dipine ? other vasodilators,Severe rheumatic mitral stenosis,High initial peak inflow velocity and prolonged decay,Mitral Stenosis,Increased pulmonary venous pressure: redistribution of blood flow to the apices, with prominent vascularity and interstitial edema. Prominent pulmonary artery and a doub
11、le density at the lower border of the right heart (arrows), which represents the lower border of a dilated left atrium. The straight left heart border also reflects the dilated left atrium,Mitral stenosis,Mitral Stenosis,Left ventricle no volume or pressure overload normal left ventricular function
12、Elevated left atrial pressure LA enlargement Atrial fibrillation Pulmonary hypertension,Mitral Stenosis Timing for Surgery,Severe MS with mild symptoms Prophylaxis against Endocarditis Diuretic reduce left atrial pressure and symptoms Atrial fibrillation rate control anticoagulation,Mitral Stenosis
13、Timing for Surgery,Haemoptysis/Pulmonary hypertension NYHA Class III/IV symptoms Recurrent systemic embolisation ? Recent onset atrial fibrillation,Chest radiograph of a patient with long-standing severe rheumatic mitral regurgitation. Despite a markedly dilated left atrium and left ventricle, the l
14、ung fields are remarkably clear, with few signs of pulmonary vascular congestion. (B) Acute mitral regurgitation caused by ruptured chordae tendineae. Despite normal heart size, radiographic signs of pulmonary edema are present.,Mitral Regurgitation,Timing for Surgery Cardiac symptoms Impaired LV fu
15、nction Ejection fraction 45mm,Echocardiographic Predictors of Good Outcome in Aortic and Mitral Regurgitation,Mitral Valve Prolapse,prevalence of 5 to 10 percent in the general population higher prevalence among young women,Mitral Valve Prolapse,Complications ascribed to mitral-valve prolapse includ
16、e: cerebral embolic events, infective endocarditis, severe valvular regurgitation requiring operation, and sudden death,Transesophageal echocardiogram showing the posterior mitral leaflet prolapsing well into the left atrium (black arrow), with a cystic mass of myxomatous valve tissue on the left ve
17、ntricular side of the mitral valve (white arrow).,Mitral valve prolapse,Mitral Valve Prolapse,Freed et al. and Gilon et al Low prevalence (2.4%) No increased risk of complication except for: primary form of mitral-valve prolapse (redundant and thickened leaflets),Primary Mitral Valve Prolapse,Prophy
18、laxis against infective endocarditis especially if have systolic murmurNo murmur: prophylaxis optional and probably not necessary,Endocarditis prophylaxis recommended High-risk category Prosthetic cardiac valves, including bioprosthetic and homograft valves Previous bacterial endocarditis Complex cy
19、anotic congenital heart disease (eg, single ventricle states, transposition of the great arteries, tetralogy of Fallot) Surgically constructed systemic pulmonary shunts or conduits Moderate-risk category Most other congenital cardiac malformations (other than above and below) Acquired valvar dysfunc
20、tion (eg, rheumatic heart disease) Hypertrophic cardiomyopathy Mitral valve prolapse with valvar regurgitation and/or thickened leaflets1,Endocarditis prophylaxis not recommended Negligible-risk category (no greater risk than the general population) Isolated secundum atrial septal defect Surgical re
21、pair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus (without residua beyond 6 mo) Previous coronary artery bypass graft surgery Mitral valve prolapse without valvar regurgitation1 Physiologic, functional, or innocent heart murmurs1 Previous Kawasaki disease without v
22、alvar dysfunction Previous rheumatic fever without valvar dysfunction Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators,Dental Procedures and Endocarditis Prophylaxis,Endocarditis prophylaxis recommended* Dental extractions Periodontal procedures including surgery, scali
23、ng and root planing, probing, and recall maintenance Dental implant placement and reimplantation of avulsed teeth Endodontic (root canal) instrumentation or surgery only beyond the apex Subgingival placement of antibiotic fibers or strips Initial placement of orthodontic bands but not brackets Intra
24、ligamentary local anesthetic injections Prophylactic cleaning of teeth or implants where bleeding is anticipated,Endocarditis prophylaxis not recommended Restorative dentistry (operative and prosthodontic) with or without retraction cord Local anesthetic injections (nonintraligamentary) Intracanal e
25、ndodontic treatment; post placement and buildup Placement of rubber dams Postoperative suture removal Placement of removable prosthodontic or orthodontic appliances Taking of oral impressions Fluoride treatments Taking of oral radiographs Orthodontic appliance adjustment Shedding of primary teeth,En
26、docarditis prophylaxis recommended Respiratory tract Tonsillectomy and/or adenoidectomy Surgical operations that involve respiratory mucosa Bronchoscopy with a rigid bronchoscope Gastrointestinal tract* Sclerotherapy for esophageal varices Esophageal stricture dilation Endoscopic retrograde cholangi
27、ography with biliary obstruction Biliary tract surgery Surgical operations that involve intestinal mucosa Genitourinary tract Prostatic surgery Cystoscopy Urethral dilation,Endocarditis prophylaxis not recommended Respiratory tract Endotracheal intubation Bronchoscopy with a flexible bronchoscope, w
28、ith or without biopsy Tympanostomy tube insertion Gastrointestinal tract Transesophageal echocardiography Endoscopy with or without gastrointestinal biopsy Genitourinary tract Vaginal hysterectomy Vaginal delivery Cesarean section In uninfected tissue: Urethral catheterization Uterine dilatation and
29、 curettage Therapeutic abortion Sterilization procedures Insertion or removal of intrauterine devices,Other Cardiac catheterization, including balloon angioplasty Implanted cardiac pacemakers,implanted defibrillators, and coronary stents Incision or biopsy of surgically scrubbed skin Circumcision,Pr
30、ophylactic Regimens for Dental, Oral, Respiratory Tract, or Esophageal Procedures Situation Agent Regimen Standard general Amoxicillin Adults: 2.0 g; children: 50 mg/kg orally prophylaxis 1 h before procedure Unable to take oral Ampicillin Adults: 2.0 g IM or IV; children: medications 50 mg/kg IM or
31、 IV within 30 min before procedure Allergic to penicillin Clindamycin Adults: 600 mg; children: 20 mg/kg orally 1 h before procedure or Cephalexin Adults: 2.0 g; children; 50 mg/kg orally or cefadroxil 1 h before procedure or Azithromycin Adults: 500 mg; children: 15 mg/kg or clarithromycin orally 1 h before procedure Allergic to penicillin Clindamycin Adults: 600 mg; children: 20 mg/kg and unable to take oral IV within 30 min before procedure medications or Cefazolin Adults: 1.0 g; children: 25 mg/kg IM or IV within 30 min before procedure,
