ALU201_Ch11.pdf

ADULT VALVULAR HEART DISEASE closures, murmurs, and other sounds can be heard. A heart murmur is a swishy noise produced by An experienced cardiologist can usually distinguish between a benign and a pathological in this chapter.) thought to require surgical intervention. the echocardiogram do not ne...

ADULT VALVULAR HEART DISEASE closures, murmurs, and other sounds can be heard. A heart murmur is a swishy noise produced by An experienced cardiologist can usually distinguish between a benign and a pathological in this chapter.) thought to require surgical intervention. the echocardiogram do not necessarily explain a murmur heard on auscultation. For example, mild mitral valve prolapse (MVP) with very mild mitral regurgitation is commonly reported but can be the individual been given a diagnosis. Proposed insureds still answer “yes” to the murmur question Page 327 ALU 201: Intermediate Medical Life Insurance Writing the valve. Murmurs are graded on a one (I) to six (VI) scale. The starting point is a grade II murmur, one and murmurs heard with the naked ear are grade VI. systolic murmur can be normal (i.e., innocent) or abnormal (i.e., organic). A grade III systolic murmur in adults is usually organic, but normal murmurs in childhood can be this loud. A grade IV systolic murmur is always organic and can be accompanied by a palpable vibration called a thrill. Page 328 short grade II systolic murmur that can be called normal. Typically, this murmur is louder when murmur, but the individual can need aortic valve replacement by age 50. A systolic ejection click is usually present with this disorder and is the clinical clue to the diagnosis. stenosis may not produce an easily heard murmur. Aortic regurgitation cases can have no murmur, Lesion Aortic Stenosis Systolic – upper sternum radiating to carotid Mitral Stenosis Diastolic – rumbling, apex, with opening snap Systolic – blowing, apex, radiating to axilla Systolic – 3rd and 4th intercostal space next to sternum Mitral Valve Prolapse Location Grade I or II, can be III in children but seldom in adults Duration in heart cycle May increase the same as organic murmurs Association Echocardiography in Valvular Heart Disease any valvular, myocardial, pericardial, or congenital heart diseases. Page 329 ALU 201: Intermediate Medical Life Insurance Writing echocardiography in valvular heart disease assessment. Transthoracic Echocardiography (TTE) TTE, or the standard echocardiogram, uses a transducer on the chest to direct ultrasound beams to TTE with Doppler is the routine tool to assess valve stenosis, valve regurgitation, cardiac availability has eliminated most uncertainty regarding borderline murmurs. aortic root disease. For underwriting, aortic regurgitation requires TTE to assess aortic root anatomy Transesophageal Echocardiography (TEE) 1. transthoracic “window”. 2. 3. when there is aortic root disease – better visualization to assess the aortic root and possible mild dissection. Page 330 Echocardiographic Measurements Aortic root 40 millimeters (mm) 56 mm 35 mm 33 mm 10 mm 11 mm 3 mm 36 mm 109 20 grams/m2 89 15 g/m2 Left Ventricular Ejection Fraction Mathematical models can be used to obtain systolic and diastolic volumes to calculate ejection angiography, contrast angiography, and echocardiography by 20%. Thus, underwriting based on a direction. Valve Regurgitation on Echocardiogram Valves do not slam shut. Doppler is highly sensitive, and normal valves will show a trivial Page 331 ALU 201: Intermediate Medical Life Insurance Writing tricuspid valve in 85%, and at the pulmonary valve in 70%. Trivial regurgitation at the aortic valve Quality and Accuracy of Echocardiograms examination. estimated and not measured. Underwriting Assessment of Echocardiogram Reports Ideally, underwriting assessment should include a recent echocardiogram report. Serial disease progression. interpretation summary or conclusion can also be included in the report. thickness and size. conditions, and serial evaluations. Page 332 1. 2. small VSD, which is a clinical diagnosis 3. symptoms 4. 5. at base 6. 7. arrhythmias, such as symptomatic extrasystoles or paroxysmal supraventricular tachycardia Echocardiograms need not be repeated in individuals with mild structural disease unless clinical change is suspected. increase in reported heart murmurs and valvular heart disease despite the decrease in rheumatic 1. 2. 3. Because surgery is available past age 90, detailed diagnostic studies are carried out on Page 333 ALU 201: Intermediate Medical Life Insurance Writing 4. longevity. Aortic Sclerosis valve patients requiring surgery, sclerosis is the underlying cause. Aortic sclerosis is associated bicuspid aortic valve. Aortic Stenosis caused by lesions below (subvalvular) or above (supravalvular) the aortic valve are less common and will not be discussed here. Causes 1. 2. 3. rheumatic valve disease. Diagnosis of Aortic Stenosis Symptoms can include dyspnea, decreased exercise tolerance, syncope or dizziness, and angina. there is an abnormal systolic murmur heard best in the aortic area (second intercostal space on the changes. Echocardiogram 1. systole 2. abnormal valve, either bicuspid or unicuspid 3. > 15) Page 334 4. aortic regurgitation and mitral regurgitation 5. echocardiogram. valve, which is the pressure gradient. The gradient is dependent on the valve area and the velocity according to severity. Valve Area State Peak Gradient Mean Gradient Doppler Echo Gradient 2 > 3.0 Mild stenosis 2.0 Moderate stenosis 1.5 0 0 10 2.5 40 10 3.5 Severe stenosis 50 30 > 4.0 > 50 Critical > 50 > 35 > 4.5 > 70 Other Investigations with symptomatic individuals. Page 335 ALU 201: Intermediate Medical Life Insurance Writing Course valve lesions is not well studied. The natural history, once symptoms have developed, is ominous, until age 60. Congenital aortic stenosis, with or without prior surgical intervention, can cause sudden death is less than 1.0% per year. some individuals by over 0.3 cm2 yearly and in others more slowly. Progression is more rapid disease. 1. 2. elevated blood pressure 3. 4. 5. Surgical Treatment 1. Page 336 2. 3. 4. 5. 6. in a good case is 2%. pulmonary valve. 1. 2. hemodynamics were better with very low gradients at rest or exercise 3. 4. bioprosthetic valves) have limited its use. Presently, its use is controversial and has been decreasing. Transcatheter Aortic Valve Implantation (TAVI) Page 337 ALU 201: Intermediate Medical Life Insurance Writing Course after Valve Replacement Underwriting Without Surgery are listed in Table 5. Mild and moderate cases are associated with no symptoms, no decrease in With Surgery operative, and postoperative reports. A postoperative echocardiogram is essential. For accurate Causes Page 338 ankylosing spondylitis, rheumatoid arthritis, systemic lupus erythematosus, and diet pill disease. syphilis, and occasionally trauma. Diagnosis of Aortic Regurgitation Echocardiogram 1. 2. Abnormal bicuspid or unicuspid valve can be present. 3. 4. 5. mm can require surgical intervention. 6. > 55 mm or > 25 mm/m2. Other Investigations greater than 40 mm. Page 339 ALU 201: Intermediate Medical Life Insurance Writing Course Mild Moderate Severe intolerance Pulse pressure EKG diastolic 70 56 mm > 65 mm 36 mm > 55 mm Enlarged Mildly enlarged Doppler Aortic root Course Dilatation with limited progression, valve surgery is done. Page 340 > 70 arrhythmias, sudden death unless valve replaced 1. 2. 3. 4. 5. Course after Valve Replacement 1. 2. 3. 4. comorbid coronary artery disease 5. 6. valve leaks. Underwriting Without Surgery 1. increased regurgitation on Doppler report 2. rupture. 3. is required, and higher late mortality 4. 5. With Surgery operative, and postoperative reports. A postoperative echocardiogram is essential. Page 341 ALU 201: Intermediate Medical Life Insurance Writing Mitral Stenosis Causes myxoma, congenital stenosis, carcinoid syndrome, systemic lupus erythematosus, rheumatoid Symptoms can include dyspnea, decreased exercise tolerance, palpitations, cough, and chest regurgitation or aortic valve disease, other murmurs can be present. The electrocardiogram can Echocardiogram 1. 2. 3. measured. 4. 5. Doppler echo measures the gradient across the valve and pressures, including an estimate 6. rheumatic damage to the tricuspid valve. State 2 4.0 – 5.0 1.5 – 2.0 1.0 – 1.5 Page 342 Other Investigations Course individual may not recall the clinical acute episode. MS is a progressive disease, with progressive is the most common course. Individuals can gradually decrease their activities to avoid dyspnea and can deny symptoms, but an exercise test quickly reveals their limitation. Complications can 1. 2. 3. 4. death include stroke, endocarditis, and pulmonary embolism. prevent thromboembolic events. Invasive Treatment 1. moderate to severe MS with symptoms 2. moderate to severe MS without symptoms but with pulmonary hypertension. Page 343 ALU 201: Intermediate Medical Life Insurance Writing Surgical procedures include open valvotomy with valve repair, closed valvotomy (now rarely 40 years ago. Since 1985, closed valvotomy has been largely replaced by PMBV, thus avoiding regurgitation. Conversely, open valvotomy or mitral valve replacement surgery can be indicated Course after Invasive Treatment 2 2 2 Underwriting Without Invasive Treatment Individuals with mild cases at older ages who are otherwise healthy and have valve areas over 1.5 cm2 Page 344 With Invasive Treatment Individuals over age 50 with valve areas close to 2.0 cm2, with no pulmonary hypertension, no Causes also be caused by other cardiac diseases including ischemic heart disease with papillary muscle cardiomyopathy. 1. 2. 3. 0.40 cm2 4. Page 345 ALU 201: Intermediate Medical Life Insurance Writing 5. > 45 mm. 6. 7. Other Investigations coronary artery disease. Course 0.1 cm with preserved mitral valve anatomy. It can be > 0.4 cm symptomatic cases. Which approach to take in an asymptomatic individual is controversial. Page 346 2 diameter are thought to indicate progression. associated with a high acute mortality rate. Surgical Treatment 1. 2. 3. >40 mm Page 347 ALU 201: Intermediate Medical Life Insurance Writing 4. Mitral regurgitation cases coming to surgery in the last 10 years have had myxomatous disease 20%, rheumatic heart disease in 20%, endocarditis in 10%, and other causes in 10%. term anticoagulation therapy. Valve replacement is usually indicated with extensive prolapse rupture. anticoagulation or a bioprosthetic valve that does not require anticoagulation but has limited rhythm. A bioprosthetic valve is likely to need replacement in this age group. More than 30% can Course after Valve Surgery times normal. Survival with bioprosthetic valves is slightly better than with mechanical valves at the older age groups. Page 348 Underwriting 1. times normal. 2. 3. Mitral Valve Prolapse mitral valve syndrome, and Barlow’s syndrome. Causes with myocardial ischemia, dilated cardiomyopathy, and hypertrophic cardiomyopathy. Page 349 ALU 201: Intermediate Medical Life Insurance Writing monitor. Echocardiogram 1. 2. MVP 3. 4. 5. 6. Course mostly male, will need mitral valve repair by age 58, and 5% percent by age 70. 1. 2. apical click, no murmur 3. 4. 5. echocardiogram 6. 7. normal body build and habitus. 1. >0.3cm2 2. 3. 4. 5. any symptoms 6. 7. 8. Page 350 2 on Treatment The reader is directed to the treatment section under mitral valve regurgitation. Underwriting important to recognize any associated impairments and consider their mortality risk. Page 351 ALU 201: Intermediate Medical Life Insurance Writing 1. 2. MVP, and mild prolapse reported on echocardiogram. Prolapse may or may not be present has been excluded. 3. MVP and arrhythmias is unproven. The MVP is unlikely to be associated with increased mortality, and the arrhythmias should be underwritten. 4. a. b. c. d. 5. 6. Mitral valve replacement is very likely to be needed in this situation. This is more likely 7. ventricular tachycardia, and arrhythmias controlled with a beta blocker such as propranolol. death, but whether this risk is one in 100 or one in 50 or even higher is impossible to predict. Page 352 Pulmonary stenosis and pulmonary regurgitation are primarily congenital heart anomalies and will not be discussed in this chapter. Function Valve Type and Valve Type and Valve Type Bioprosthesis Associated Coronary Disease higher risk. Functional Capacity Multiple Valve Disease surgical strategy can be to only correct the most severe lesion. Associated tricuspid valve disease is an adverse sign. Page 353 ALU 201: Intermediate Medical Life Insurance Writing Aortic Dilatation Pulmonary Comorbidity Factors ) therapy in individuals with prior gastrointestinal ulceration poses an obvious risk, as does hepatic disease. ® Blood clots on valve Paravalvular leaks Valve/patient size mismatch Endocarditis on valve sudden death appreciated and corrected Blood Clotting Disorders Page 354 previously mild Clots on valves Embolism primarily to brain ) ® anticoagulant complications with other surgeries disease associated with older ages. Expert auscultation skills have been replaced by modern echocardiography, and diagnostic imaging continues to improve steadily. Advances have been Page 355