Further information: Infective Endocarditis (see p443) from Cardiovascular Medicine, 3rd Edn*

ESC Clinical Practice Guidelines on Prevention, Diagnosis and Treatment of Infective Endocarditis (2009) (ESC website accessed 08/28/09)   Full text

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Further information: Aortic Valve Disease (see p381), Mitral Valve Diseases (see p397), and Echocardiographic Assessment of Valvular Heart Disease (see p487) from Cardiovascular Medicine, 3rd Edn*

Acute valvular regurgitation is sometimes difficult to diagnose and information on the medical management of patients is limited because there are no randomized, clinical trials to provide guidance. Although acute regurgitation can occur in any valve – i.e. aortic, mitral, pulmonic, or tricuspid – it has greater clinical impact and is more common in valves of the left side of the heart. The mitral and aortic valves are the subject of a recent article by Stout and Verrier [1].

When the acute aortic regurgitation is severe, medical therapy is often insufficient, and therefore, a patient presenting with severe acute valvular regurgitation often has a surgical emergency. It is critical that an immediate and correct diagnosis be made, although it is not uncommon for acute valvular regurgitation to be misdiagnosed as chronic. The majority of patients with severe acute aortic or mitral valve regurgitation present with symptoms of shock, such as weakness, dizziness, an altered mental state, dyspnea and hemodynamic instability. However, there are differences in acute aortic and mitral valve regurgitation that must be detected, and patients with chronic aortic or mitral valve regurgitation may present with symptoms similar to acute regurgitation. Therefore, physical examination needs to be enhanced by other diagnostic testing, especially emergent echocardiography with Doppler, in order to reach a correct diagnosis.

[1] Stout DK, Verrier ED. Acute valvular regurgitation. Circulation 2009;119:3232-3241

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Further information: Aortic Valve Disease (see p381) from Cardiovascular Medicine, 3rd Edn*

In the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) trial [1], the clinical effects of long-term, intensive lipid-lowering therapy with daily use of simvastatin and ezetimibe were evaluated in patients with asymptomatic, mild-to-moderate aortic-valve (AV) stenosis, and no other indication for lipid-lowering treatment.

A patient total of 1873 underwent randomization at 173 study sites in seven European countries, with 944 patients assigned to 40 mg of simvastatin and 10 mg of ezetimibe daily and 929 patients assigned to placebo. The primary outcome was a composite of major cardiovascular events, including death from cardiovascular causes, AV replacement, nonfatal myocardial infarction (MI), hospitalization for unstable angina pectoris, heart failure, coronary-artery bypass grafting (CABG), percutaneous coronary intervention (PCI), and nonhemorrhagic stroke. Secondary outcomes were events related to AV stenosis and ischemic cardiovascular events.

At median follow-up of 52.2 weeks, the simvastatin-ezetimibe group recorded a primary composite outcome in 333 patients (35.3%) and a primary outcome was recorded in 355 patients (38.2%) in the placebo group (hazard ratio [HR] in the simvastatin-ezetimibe group, 0.96; 95% confidence interval [CI], 0.83–1.12; P=0.59). In 267 patients (28.3%) in the simvastatin-ezetimibe group, AV replacement was performed, and 278 patients (29.9%) had AV replacement in the placebo group (HR, 1.00; 95% CI, 0.84–1.18; P=0.97). Fewer patients had ischemic cardiovascular events in the simvastatin-ezetimibe group (148 patients) than in the placebo group (187 patients) (HR, 0.78; 95% CI, 0.63–97%; P=0.02), mainly because of the smaller number of patients who underwent CABG. Cancer occurred more frequently in the simvastatin-ezetimibe group (105 vs. 70, P=0.01).

The investigators concluded that simvastatin-ezetimibe did not reduce combined AV events and ischemic events in patients with aortic stenosis. Although the therapy reduced the incidence of ischemic cardiovascular events, they were not related to AV stenosis, and concern over the numbers of patients with new and fatal cancers indicates that the therapy requires further investigation.

[1] Rossebo AB, Pedersen TR, Boman K et al. Intensive lipid lowering with simvastatin and ezetimibe in aortic stenosis (SEAS). N Engl J Med 2008;359:1343-56

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Improved outcomes after aortic valve surgery for chronic aortic regurgitation with severe left ventricular dysfunction

This study [1] examined patients undergoing aortic valve surgery for chronic aortic regurgitation (AR) in order to compare survival among those with and without severe left ventricular dysfunction (LVD), identify risk factors for death, including LVD and date of operation, and estimate contemporary risk for cardiomyopathic patients. A total of 724 patients underwent primary isolated valve surgery for chronic AR at the Cleveland Clinic from January 1972 to January 1999. Of this total, 88 (12%) had a LV ejection fraction of 30% or less on preoperative left ventriculogram or echocardiograms. These patients constituted the severe LVD group. The other 636 (88%) patients with LV ejection fractions of greater than 30% comprised the nonsevere LVD group. Routine follow up was conducted every 2 years after surgery and cross-sectionally in 2001 to determine functional status, vital status, and whether they had undergone cardiac re-operation.  The median follow-up for survivors was 6 years (mean 8.3±6.5 years). Propensity matching was used to address the diversity of differences between the two groups in order to make a fair survival comparison.

After aortic valve surgery across the entire study time (follow up extended reliably to 25 years), survival was worse among propensity-matched patients with severe LVS as compared to otherwise similar patients with nonsevere LVD (91% vs 96% at 30 days; 81% vs 92% at 1 year; 68% vs 81% at 5 years; 46% vs 62% at 10 years; 26% vs 41% at 15 years; 12% vs 24% at 20 years; and 5% vs 12% at 25 years, (p [log rank] = 0.04); however, the survival of patients with severe LVD improved significantly across the study time frame (P=0.0004). The hospital mortality among propensity-matched patients who underwent surgery prior to 1985 was 17% in the severe LVD group (7 of 41; CL 11–15%) and 3% in the nonsevere LVD group (1 of 40; CL 0.3–8%; P = 0.03), but from 1985 onward, the hospital mortality was 0% for both groups.

The authors concluded that “long-term survival of patients with severe LVD improved progressively and by about 1985 was comparable with that of patients with nonsevere LVD; hospital mortality decreased to a comparable value” and “early and late survival was also good and did not change appreciably over the experience in patients with LV function.” The authors point out that their study demonstrates that “aortic valve surgery in patients with chronic AR and cardiomyopathy is no longer a high-risk procedure for which transplantation is a better option.”  They speculate that this may be due to better medical managements with the use of angiotensin-converting enzyme inhibitors and beta blocks as routine therapy, more sophisticated myocardial protection intraoperatively, reduced complications as a result of intraoperative transesophageal echocardiography, improved replacement heart valves, use of new inotropes and availability of postoperative optimal medical therapy and device options, e.g. biventricular synchronous pacing and implantable cardioverter-defibrillators. They note that the study has limitations, such as referral biases, patient selection bias, nonrandomization of LV dysfunction; duration of preoperative AR could not be determined and could have differed between groups, and the results may not be generalizable to other populations since it was a single-institution study. Based on their findings, they conclude that “for the patient who presents late with AR and severe LVD, surgery is the preferred treatment and can be performed with acceptable risk and late survival.”

1. Bhudia SK, McCarthy PM, Kumpati GS, et al. Improved outcomes after aortic valve surgery for chronic aortic regurgitation with severe left ventricular dysfunction. J Am Coll Cardiol 2007;49(13):1465-1471

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ESC 2007 Guidelines on the management of valvular heart disease (Eur Heart J 2007;28:230-268)   Full text

ACC/AHA 2006 Guidelines for the Management of Patients with Valvular Heart Disease (Circulation 2006;114 450-527)   Executive summary   Full text

ACCF/AHA 2005 Clinical Competence Statement on Cardiac Imaging with Computed Tomography and Magnetic Resonance. (Circulation 2005;112:598-617)   Full text

ESC 2004 Guidelines on prevention, diagnosis and treatment of infective endocarditis (Eur Heart J 2004;25:267-276)   Executive summary   Full text

ACC/AHA/ASE 2003 Guidelines for the Update for the Clinical Application of Echocardiography (Circulation 2003;108:1146)   Summary article   Full text