#83 Valvular heart disease, anticoagulation, TAVR, and primary care

February 19, 2018 | By Matthew Watto, MD

Get the latest on valvular heart disease: TAVR vs SAVR, choice of valve type, rheumatic heart disease, antibiotic prophylaxis for endocarditis, who needs an echocardiogram, and anticoagulation goals with tips from cardiologist, Dr Eli Gelfand, Section Chief of General Cardiology at Beth Israel Deaconess Medical Center in Boston and an Assistant Professor of Medicine at Harvard Medical School. Correspondent Dr Kate Grant joins us for this conversation w/Dr Gelfand about his common sense approach to the evaluation and management of valvular heart disease.

Written by Kate Grate, MD and Matthew Watto, MD.

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Clinical Pearls

1. Symptoms of decompensated VHD include breathlessness, lethargy, fatigue, palpitations, orthopnea, ankle swelling and reduced exercise tolerance. A good history includes asking about what they do all day, and which activities of daily living they avoid.
2. Medical treatment cannot prevent progression of worsening VHD (probably because disease identified too late). Goal is to control symptoms until definitive valve repair or replacement performed. Diuretics, rate control improve symptoms in mitral stenosis.
3. Antibiotic prophylaxis for infective endocarditis is no longer routinely given to all patients with murmurs, but many patients still expect antibiotics before dental procedures. High risk patients = those w/prosthetic valve replacement/repair, previous infective endocarditis, heart transplant w/valve pathology, or certain types of congenital heart disease. Toothbrushing causes bacteremia.
4. Choice of valve: Mechanical heart valves are more durable than bioprosthetic heart valves, but require lifelong anticoagulation. Mechanical aortic valve preferred if patient <55 yo, and mitral valve if <70 yo. Bioprosthetic valves preferred in older, sicker patients, or if long-term anticoagulation not feasible.
5. TAVR (Transcatheter Aortic Valve Replacement) is noninferior to SAVR (Surgical Aortic Valve Replacement) for patients w/intermediate surgical risk. TAVR improves mortality and quality of life for patients at high or unacceptable surgical risk. Success depends on patient selection, NOT patient preference.
6. Risks of TAVR include increased vascular complications (less common with newer low profile technology), higher rates of short-term aortic valve reintervention, pacemaker implantation, and aortic regurgitation compared with SAVR. Longevity of these valves is not known yet (UpToDate TAVR Complications).
7. Direct oral anticoagulants (DOACs): Avoid use in patients with 1) mechanical heart valves, 2) rheumatic heart disease with mitral stenosis 3) significant mitral stenosis and 4) those with decompensated valvular heart disease likely to require surgery in the near future (these groups were generally excluded from trials). DOACs can be used in patients with native valvular heart disease, bioprosthetic heart valves, and atrial fibrillation with VHD excluding mitral stenosis (2017 AHA/ACC VHD Guidelines).

Case from Kashlak Memorial
Miss Sapien is a 25 year old female, diagnosed with a Bicuspid Aortic Valve as a child. She has been well until now participating in regular fitness and a running club. Her training partner notices she can’t complete her typical workout or keep up on her usual distance run. She gets easily winded and lightheaded. She becomes breathless during sexual intercourse. Swollen ankles make her unable to tie her gym shoes. She has been trying to train more thinking she is unfit. She wants to get pregnant.

Evaluation of valvular heart disease (VHD)
Patients usually present with symptoms of fatigue, shortness of breath, and dyspnea on exertion. Younger patients may present with exercise intolerance. Initial workup should include a search for alternative explanations for symptoms e.g. anemia, thyroid disease, etc

Is this symptomatic aortic stenosis? Challenging in patients with multiple comorbidities. Requires careful history and evaluation by a multidisciplinary team. May need to confirm w/functional stress testing, which can induce hypotension, ventricular arrhythmias, angina, dyspnea, etc. Trial of valvuloplasty may be helpful.

An echocardiogram (echo) is not always necessary for new heart murmurs. Older patients often have benign flow murmurs e.g. soft, systolic murmur of aortic sclerosis. Younger patients may have a benign flow murmur (grade 1 systolic murmur at right upper sternal border). Red flags include the presence of carotid delay (parvus et tardus, small amplitude and delayed carotid pulse), continuous murmur (causes: patent ductus, AV fistula for dialysis, aortic coarctation), diastolic murmur, and grade 3 or louder systolic murmur. Patients w/new murmur and angina, syncope, or symptoms of heart failure also warrant an echocardiogram.

Bicuspid aortic valve present in about 1% of the population. Check these patients for concomitant aortopathy (e.g. coarctation, aortic root dilatation). Calcific aortic stenosis may occur by age 40 years old. Also at risk for aortic dissection (Mordi and Tzemos. Review. Card Res Pract. 2012).

Choice of valve type and anticoagulation
Mechanical valves are more durable than bioprosthetic valves, but require lifelong anticoagulation. Bioprosthetic valves won’t last more than 10 years in a younger patient, but may last 20-30 years in older patients (Dr Gelfand). In general, mechanical valves are recommended for aortic valve replacement prior to age 55, or mitral valve replacement prior to age 70. Bioprosthetic valves are recommended if patient’s life expectancy is shorter than the life of a bioprosthetic valve, or if anticoagulation is contraindicated (UpToDate Anticoagulation in Prosthetic Valves ). The Ross procedure, which swaps the pulmonic valve for the damaged/diseased aortic valve, may last longer than other valves but is complex and not widely available (Dr Gelfand). Valvuloplasty is not used much anymore, but may be a reasonable option during pregnancy (Dr Gelfand).

Bioprosthetic valves require at least 3 months (up to 6 mo) of vitamin K antagonist (VKA) with a goal INR 2.5, plus aspirin (ASA) 75-100 mg daily. VKA can be stopped after 3 months, but ASA 75-100 mg daily should be continued lifelong as monotherapy (2017 AHA/ACC VHD Guidelines). Three to six months are required for endothelialization of the bioprosthetic valve. Note: some experts utilize direct oral anticoagulants (DOACs) for bioprosthetic valves since these agents have been studied in patients with chronic atrial fibrillation and a bioprosthetic valve (2017 AHA/ACC VHD Guidelines Section 2.4.3; UpToDate Anticoagulation in Prosthetic Valves ).

Mechanical valves require lifelong anticoagulation with VKA, plus ASA 75-100 mg daily. Goal INR is 2.5 (2-3) for mechanical aortic valve and 3 (2.5-3.5) for mechanical mitral valves, ball-in-cage, or mechanical aortic valve with additional risk factors (e.g. atrial fibrillation, LV dysfunction, or previous thromboembolism) 2017 AHA/ACC VHD section 11.2.2. DOACs are contraindicated in mechanical valves because RE-ALIGN trial NEJM 2013 showed increased thrombosis and bleeding events in this population with dabigatran. The new On-X mechanical aortic valve requires VKA with INR goal 2-3, plus ASA 75-100 mg for first 3 months, but after 3 months an INR goal of 1.5-2, plus ASA daily is adequate. After TAVR, dual antiplatelet therapy with clopidogrel 75 mg and ASA 75-100 mg daily is recommended for the first 6 months, followed by lifelong ASA 75-100 mg daily (IIb-consensus rata). The 2017 AHA/ACC section 11.2.2 also mention that anticoagulation with VKA and INR goal of 2.5 plus ASA is reasonable for the first 3 months after TAVR (IIb-Nonrandomized rating).

Direct oral anticoagulants (DOACs) should be avoided in patients with 1) mechanical heart valves 2) rheumatic heart disease with mitral stenosis 3) significant mitral stenosis and 4) those with decompensated valvular heart disease likely to require surgery in the near future (these groups were generally excluded from trials). DOACs can be used in patients with native valvular heart disease, bioprosthetic heart valves, and atrial fibrillation with VHD excluding mitral stenosis (2017 AHA/ACC VHD Guidelines).

Medical therapy for symptoms
Young patients with valvular heart disease (VHD) have their whole lives ahead of them and may have trouble coming to terms with the need for surgery, and lifelong anticoagulation.

Medications for valvular heart disease often don’t work to delay disease progression because we cannot identify these patients early enough to provide meaningful preventive therapy (Dr Gelfand).

Symptoms in patients with mitral stenosis respond well to diuretics, and rate control of atrial fibrillation. Those w/tricuspid stenosis may also benefit from diuretic therapy. Patients with symptomatic aortic stenosis need a surgical procedure. Don’t mess around with medications (Dr Gelfand).

Antibiotic prophylaxis
Antibiotic prophylaxis is recommended for 1) Prosthetic valve or valve repaired w/prosthetic material 2) history of infective endocarditis 3) certain congenital heart defects and 4) heart transplant with abnormal heart valve function (AHA on IE from 9/2017 ).

Dental risk stratification: high risk procedures are those in which there is manipulation of the gingival or periapical region of the teeth. That said, bacteremia also occurs from toothbrushing, even w/o dental extraction (Lockhart et al. PMC2746717. Circulation 2009.)

Rheumatic heart disease
Rheumatic heart disease is still endemic in Africa, SE Asia and Oceania so be aware when treating immigrant populations (Watkins et al. NEJM 2017). Recurrent episodes of rheumatic fever are required to damage heart valves. Mitral valve lesions are most common with regurgitation more common than stenosis. Aortic valve lesions occur in 20-30% (either regurgitation or stenosis). Tricuspid disease is often subclinical and pulmonic disease is rare (Clinical Manifestations of RHD. UpToDate). Mitral valvuloplasty can be effective and long lasting (Dr Gelfand).

TAVR versus SAVR
Transcatheter aortic valve replacement/implantation (TAVR aka TAVI) is now more common in the United States than surgical aortic valve replacement (SAVR) [Dr Gelfand]. The risks for TAVR include increased vascular complications (less common with newer technology), higher rates of short-term aortic valve reintervention, pacemaker implantation, and aortic regurgitation compared with SAVR (UpToDate TAVR Complications). SAVR associated with increased risk for major bleeding and atrial fibrillation. TAVR may be considered for patients w/intermediate, high, or unacceptable surgical risk. Benefits of TAVR in low risk patients unknown. Longevity of TAVR is unknown. This influences decision making for younger patients who may face repeat surgery.  Here is a brief evidence summary with links:

• PARTNER 2 randomized trial Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients NEJM 2016 showed similar risk for death or disabling stroke at 2 years. TAVR noninferior to SAVR for intermediate risk patients.
• SAPIEN 3 2016 Nonrandomized trial of low profile SAPIEN 3 TAVR in high risk and inoperable patients.
• PARTNER 1 Inoperable Lancet 2015, 5 year outcomes: TAVR improves survival and functional status versus medical therapy in patients who aren’t surgical candidates.
• PARTNER 1 High risk Lancet 2015, 5 year outcomes: RCT of TAVR vs SAVR. No statistical difference in all cause mortality, but TAVR had increased risk moderate-severe aortic regurgitation. Mortality was increased in those with aortic regurgitation following TAVR.

Goal: Listeners will learn to identify and manage the valvular heart disease and recall the basic indications for transcatheter aortic valve replacement.

Learning objectives:

After listening to this episode listeners will…

1. Recognize signs and symptoms valvular heart disease
2. Explain the natural history of valvular heart disease
3. Recall appropriate INR goals and antithrombotic therapy for prosthetic heart valves
4. Identify patients who may benefit from transcatheter aortic valve replacement
5. Counsel patients about the basic options available to treat valvular heart disease
6. Identify patients with valvular heart disease who may benefit from direct oral anticoagulants instead of warfarin
7. Recommend antibiotic prophylaxis to prevent infective endocarditis in certain high risk populations
8. Recall the criteria for echocardiography in patients with heart murmurs
9. Identify resources to learn about valvular heart disease

Disclosures: Dr Gelfand and The Curbsiders report no relevant financial disclosures.

Time Stamps

• 00:00 Disclaimer
• 00:35 Intro
• 02:55 Guest bio
• 04:15 Getting to know our guest
• 12:18 Picks of the week
• 17:07 Clinical case of aortic stenosis
• 18:00 Types of valve procedures available and initial workup for valvular disease
• 26:11 Counseling patients about a heart murmur
• 29:33 Symptoms in valvular heart disease
• 31:07 Who needs an echo?
• 32:36 Who needs a referral?
• 34:40 Frequency of echocardiogram
• 36:25 Medications for valvular heart disease
• 39:12 Diuretics and aortic stenosis
• 40:40 Medication for mitral stenosis and anticoagulants in valvular heart disease
• 43:31 INR goals and use of ASA by valve type and position
• 45:23 Endocarditis prophylaxis
• 48:50 Rheumatic heart disease
• 51:55 Valvulitis and a quick history lesson
• 53:50 Transaortic valve replacement
• 57:58 Multidisciplinary teams and how to determine if valve is causing symptoms
• 62:14 Take home points
• 63:47 Closing thoughts from The Curbsiders
• 66:15 Outro

Links from the show:

1. The Poisoner’s Handbook: Murder and the Birth of Forensic Medicine in Jazz Age New York by Deborah Blum Link: http://a.co/gFyav29
2. Chicken Tonight Country French Sauce – 500g by Chicken Tonight Link: http://a.co/3e0SesN
3. Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted by Gerald Imber MD Link: http://a.co/2I3XJls
4. Eugene Braunwald and the Rise of Modern Medicine by Thomas H. Lee Link: http://a.co/1sMAHHc
5. Where the Wild Things Are by Maurice Sendak Link: http://a.co/cgqIWSz
6. Funky Cardboard Stool by Remember Link: http://a.co/b2naHD7
7. Gangs Of New York Amazon Video ~ Leonardo DiCaprio Link: http://a.co/2eWNg5U
8. https://www.netflix.com/title/80117545 American Vandal. 2017 TV-MA 1 Season.
9. American College of Cardiology Mobile Apps full list of resources
10. DynaMed Plus http://www.dynamed.com/home/about
11. Links to 9 bitesize videos from Khan Academy, which give an overview of valvular heart disease and each valve problem in more detail.
12. The Link to the 3M Littman Stethoscope website training app  listen and diagnose heart sounds https://www.3m.co.uk/3M/en_GB/Littmann-UK/education/studentcampaign/ “3M™ Littmann® Learning Institute App. Get free access to the app and take your auscultation training and reference sounds anywhere.”
13. Driving restrictions (check each state for variations in DMV rules) https://www.dmv.ca.gov/portal/dmv/?1dmy&urile=wcm:path:/dmv_content_en/dmv/dl/driversafety/cdl_guidelines#eight_1
14. Rules about Flying Rules about flying – federal aviation authority https://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/guide/dec_cons/disease_prot/valve
15. Advice for patients re: Valves AHA http://www.heart.org/HEARTORG/Conditions/More/HeartValveProblemsandDisease/Heart-Valve-Problems-and-Disease_UCM_450280_SubHomePage.jsp
16. Heart valve travel advice https://www.sjmglobal.com/en-int/patients/heart-valve-disease/living-with-your-treatment/traveling-after-heart-valve-surgery?alert=DeepLinkSoftAlert&clset=92f57278-460e-4300-b7fe-89e52a04194f%3acadddb93-fcc4-47f2-8ceb-fd88f01ca17f
17. American Heart Association prophylaxis guidelines https://www.heart.org/HEARTORG/Conditions/CongenitalHeartDefects/TheImpactofCongenitalHeartDefects/Infective-Endocarditis_UCM_307108_Article.jsp
18. Research paper Do patients at risk of infective endocarditis need antibiotics before dental procedures?  2017;358:j3942 doi: 10.1136/bmj.j3942
19. NICE clinical guideline 64 – Prophylaxis against infective endocarditis  2016 https://www.nice.org.uk/guidance/cg64