© 2018 Kurt Pfeifer.

Valvular Disease

ASSESSMENT

Data Gathering

History

Symptoms

  • Previous cardiovascular disease

  • Previous cardiac testing (stress tests, cardiac catheterization, echocardiography, CT coronary angiography)

  • Previous coronary interventions (including vessel, stent/bypass type)

  • Orthopnea/nocturnal dyspnea

  • Chest pain

  • Exertional dyspnea or lightheadedness

  • Palpitations

  • Diaphoresis

  • Fatigue

  • Syncope

Exam

  • Cardiac murmurs

  • S4/S3

  • Pulmonary crackles

  • Edema

  • Elevated JVP

Risk Stratification

No well-validated risk stratification tools​ specific for valvular disease are available. 

Diagnostic Studies

MANAGEMENT

Indications for Surgical Delay

  • New or worsened symptoms of cardiac disease

  • Symptomatic aortic or mitral stenosis

  • Critical aortic stenosis (ACC/AHA guideline)

  • Severe valvular disease without recent cardiology evaluation (though ACC/AHA guideline specifically state that elevated-risk elective surgery is reasonable for severe valvular disease with appropriate intraoperative and postoperative hemodynamic monitoring)

Valve Intervention Criteria

  • MITRAL STENOSIS (ACC valvular disease management guideline):

    • SYMPTOMATIC: surgical repair or replacement of commisurotomy if severe

    • ASYMPTOMATIC: commisurotomy if severe or pulmonary capillary wedge pressure (PCWP) >25 mmHg

  • AORTIC STENOSIS: consider intervention based on the following (ACC aortic stenosis appropriate use criteria) - consult with cardiology:

    • SYMPTOMATIC & undergoing elective or urgent major noncardiac surgery: surgical or transcatheter valve replacement (SAVR/TAVR) is appropriate, and balloon aortic valvotomy (BAV) may be considered

    • ASYMPTOMATIC with LVEF<50%: SAVR or TAVR is appropriate but BAV or no intervention may be considered

    • ASYMPTOMATIC with no evidence of LV decompensation:

      • Elective major noncardiac surgery: SAVR/TAVR is appropriate, and no intervention may be considered

      • Urgent major noncardiac surgery: SAVR/TAVR, no intervention, or BAV may be considered

  • MITRAL REGURGITATION​: surgical repair/replacement if severe + symptomatic, LV dysfunction (LVEF <60% or declining on serial studies) or LV end-systolic diameter (LVESD) ≥40 mm (ACC valvular disease management guideline)

  • AORTIC REGURGITATION: surgical replacement if severe + symptomatic, LVEF <50%, or LVESD >50 mm (ACC valvular disease management guideline)

Medication Management

Endocarditis Prophylaxis Indications (ACC valvular disease management guideline)

Prophylaxis against IE is reasonable before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa in patients with the following:

  • Prosthetic cardiac valves, including transcatheterimplanted prostheses and homografts.

  • Prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords.

  • Previous endocarditis.

  • Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device.

  • Cardiac transplant with valve regurgitation due to a structurally abnormal valve.​

Anticoagulation Management

  1. Determine if anticoagulation interruption is required

  • If no bleeding risk factors plus low bleeding risk surgery & on warfarin, do not interrupt anticoagulation

    • Bleeding Risk Factors:

      • Major bleed or ICH within 3 mo

      • Thrombocytopenia

      • Platelet dysfunction (including antiplatelet use)

      • Supratherapeutic INR

      • Bleeding with previous bridging or similar procedure

    • Low Bleeding Risk Procedures:​

      • Very Low: Cataract, Arthrocentesis

      • Low: Carpal tunnel release, Hysteroscopy, Ureteroscopy, CIED placement

    2. Determine if bridging anticoagulation required if anticoagulation interrupted - indications:

  • Reasonable on an individualized basis, with the risks of bleeding weighed against the benefits of thromboembolism (TE) prevention (ACC valvular disease management guideline):

    • Mechanical aortic valve replacement (AVR) and any thromboembolic risk factor (AFib, previous TE, hypercoagulable condition, older-generation mechanical valves [ball-cage or tilting disc], LV systolic dysfunction, or >1 mechanical valve) (2019 ACC/AHA AFib guideline)

    • Older-generation mechanical AVR

    • Mechanical mitral valve replacement (MVR)

  • PERIOP 2 trial found no benefit from postoperative bridging anticoagulation in mechanical valve patients (with only 1 prosthetic valve and no history of CVA/TIA) but provided preoperative bridging to all patients (2018 ASH Annual Meeting presentation)

    3. If bridging required, follow this protocol (ACC Expert Consensus Pathway):

  • Last dose of warfarin 5 days before surgery​ if INR 2-3 (3-4 days before if INR <2 and ≥5 days if INR >3) 

  • Start LMWH 1 mg/kg or therapeutic IV UFH once INR subtherapeutic (36-48 hours after last warfarin dose)

  • Provide last dose of therapeutic LMWH 24 hours before surgery and neuraxial/regional anesthesia; stop UFH 4-6 hours before surgery and neuraxial/regional anesthesia

  • Resume warfarin 12-24 hours after surgery

  • Resume therapeutic LMWH/UFH no earlier than 24 hours after low bleeding risk surgery and 48-72 hours after non-low bleeding risk surgery (always confirm with surgeon before resumption)

Other Perioperative Management

COUNSELING & COMMUNICATION

  • Collaborate with patients' cardiologists

  • Provide anesthesiology with advance notice of patient's with severe valvular disease so appropriate intraoperative care plans can be made

  • Share with patients that current risk estimation tools do not necessarily accurately account for the risks related to valvular heart disease