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General Principles of Murmur Management

by | 20 May, 2020

Investigations

The main investigations for murmurs include:

  • Chest x-ray: reveal signs of heart failure, such as cardiomegaly
  • ECG: identify arrhythmias and structural changes in the heart
  • Echocardiogram: the definitive investigations for identifying structural lesions

Surgical management

Options for surgical management include:

  1. Valve replacement
  2. Valve repair e.g. balloon valvuloplasty, valvulotomy
  3. (Aortic valve only) Transcatheter aortic valve implantation (TAVI)

Valve replacement is the most common valve surgical procedure. There are 2 options available for replacement valves: bioprosthetic or mechanical. The decision on which to recommend depends on the patient’s age and co-morbidities. The procedure is usually done through a midline sternotomy approach, although left lateral thoracotomy may be used for mitral valve replacement.

Patients should undergo cardiac catheterisation prior to the procedure; stenosed vessels can be treated during the valve replacement surgery.

Chest scars
MIDLINE STERNOTOMY (CENTRE OF IMAGE) AND LEFT LATERAL THORACOTOMY (RIGHT SIDE OF IMAGE) SCARS

Bioprosthetic valves

May be homografts (human) or xenografts (e.g. procine, bovine). They are generally used in elderly patients.

Advantage: No anticoagulation required

Disadvantage: Do not last as long as mechanical valves. Expected durability is 10-20 years

Mechanical valves

Generally used in younger patients. Examples include tilting disc, bileaflet and ball & cage.

Advantage: Very low rate of failure

Disadvantage: Requires anticoagulation with warfarin. It is important to note that novel oral anticoagulants (NOACs) are NOT licensed for use in valve replacement due their high complication rates

Target INR:

Aortic valve replacement: 2-3

Mitral valve replacement: 2.5-3.5

Complications of valve surgery

Medical management

Heart failure and atrial fibrillation should be treated medically. It is important to note that NOACs should not be used in patients with moderate to severe mitral stenosis or prosthetic valves as there is lack of evidence of their efficacy.

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