02.18b Surgical Management for Valvular Heart Disease

Question 1

Etiology of MS

Answer 1

Rheumatic fever

RHD

Question 2

Pathophysiology of MS

Answer 2

Leaflet thickening or calcification
Commissural fusion
Chordal fusion and shortening

Question 3

Exertional dyspnea
Decreased exercise capacity
Orthopnea/paroxysmal nocturnal dyspnea
Hemophysis and pulmonary edema
Pulmonary hypertension
Afib

Answer 3

MS

Question 4

Auscultatory findings in MS

Answer 4

Increased first heart
Opening snap
Apical diastolic rumble

Question 5

Primary cause of mortality for MS

Answer 5

Progressive pulmonary and systemic congestion

Question 6

CXR findings for MS

Answer 6

Straight left border (left atrial enlargement, pulmonary artery enlargement)
Double contouring

Question 7

For ruling out left atrial appendage thrombus and Mr severity for percutaneous mitral balloon valvotomy candidates

Answer 7

Transesophageal echocardiography

Question 8

First choice of treatment for MS

Answer 8

Percutaneous mitral balloon valvotomy

Question 9

lf not amenable for valvotomy

Answer 9

Commissurotomy

Mitral valve repair or replacement

Question 10

Etiology of MR

Answer 10

Mitral valve prolapse
RHD
CAD
Infective endocarditis
Certain drugs
Collagen diseases, carcinoid diseases
Trauma
Previous chest radiation

Question 11

Apical holosystolic murmur and forceful apical impulse

Transmitted to the left axilla or left sternal border

Answer 11

MR

Question 12

Insufficiency occurs secondary to annular dilatation or leaflet perforation with normal leaflet motion

Answer 12

Type I

Question 13

Thickened leaflet prolapsed, or ruptured or elongated chordae tendinae with increased leaflet motion
Myxomatous conditions, MVP

Answer 13

Type II

Question 14

Restricted leaflet motion

RHD, chronic ischemic MR

Answer 14

Type III

Question 15

If you have MR, what to find in ECG

Answer 15

LA and LV enlargement

Question 16

Evaluate LV size and function, RV and LA size, PA, MR severity
To evaluate MR mechanism

Answer 16

Transthoracic echocardiograph

Question 17

Establish anatomic basis of MR to assess feasibility of repair, and guide the repair

Answer 17

TEE

Question 18

Indications of surgical intervention for patients with MR

Answer 18

Any symptomatic patient with MR
Asymptomatic severe MR with LV systolic dysfunctions
*Recent onset of Afib, pulmonary HPN, abnormal response to stress testing

Question 19

Treatment of choice for MR

Answer 19

Mitral valve repair

Question 20

Etiologies of AS

Answer 20

Calcification
Congenital
Rheumatic

Question 21

Pathophysiology of AS

Answer 21

Pressure overload

Question 22

Exertional dyspnea
Angina
Syncope
Decreased exercise capacity
Heart failure

Answer 22

AS

Question 23

Harsh, crescendo-decrescendo
Systolic murmur at right 2nd ICS
Radiating to carotid arteries

Answer 23

AS

Question 24

ECG findings in AS

Answer 24

LV hypertrophy

Conduction abnormalities, Afib

Question 25

Exercise testing of AS

Answer 25

Dobutamine stress echocardiography

Question 26

Procedure for AS with CAD risks, symptomatic but inconclusive results in non invasive tests regarding AS severity

Answer 26

Cardiac catheterization

Question 27

Management of AS

Answer 27

Medical therapy Aortic balloon valvotomy Surgery

Question 28

Etiology of AR

Answer 28

``` Aortic root disease Congenital Calcific degeneration Rheumatic disease Infective endocarditis Myxomatous degeneration ```

Question 29

What will happen if the heart keeps pumping blood to the aorta and blood keeps coming back

Answer 29

Left ventricular dilatation

Question 30

AS is ______ | AR is ______

Answer 30

Pressure overload | Volume overload

Question 31

High pitched decrescendo diastolic murmur in 3rd ICS

Answer 31

AR

Question 32

Bounding pulses quickly collapsing pulses

Answer 32

Corrigan's sign

Question 33

Pistol shot sounds by auscultation

Answer 33

Traube sign

Question 34

ECS findings in AR

Answer 34

Left axis deviation | Intraventricular conduction defects

Question 35

Assess the severity, cause of AR, degree of pulmonary HPN

Answer 35

TTE

Question 36

Considered surgical emergency in AR

Answer 36

With aortic dissections | Infectious endocarditis with severe AR in failure

Question 37

Has traditionally been performed through a median sternotomy incision

Answer 37

Aortic valve replacement

Question 38

Types of surgery

Answer 38

Aortic valve replacement | Aortic valve repair

Question 39

Etiology of TS

Answer 39

Organic (rheumatic fever, endocarditis, rarely trauma)

Question 40

Etiology of TR

Answer 40

Functional (mitral valve disease, pulmonary hpn, RV failure)

Question 41

Pathophysiology of TR/TS

Answer 41

Elevated RA pressure | Right heart failure

Question 42

Signs of severe TS

Answer 42

``` Jugular vein distension Hepatomegaly Splenomegaly Ascites Lower extremity edema ```

Question 43

Diagnosis of TS

Answer 43

``` CXR TTE (size, structure, motion) ```

Question 44

Management of TS

Answer 44

Tricuspid valve repair | Tricuspid valve replacement

Question 45

Pathology of multivalve disease

Answer 45

Rheumatic heart disease Calcific disease Marfan syndrome Secondary to another valve pathology

Question 46

Advantages of mechanical aortic prosthesis

Answer 46

Highly durable | Minimized risk for reoperation

Question 47

Disadvantages of mechanical aortic prosthesis

Answer 47

Require permanent anticoagulation (warfarin) Risk of hemorrhagic complications Lifestyle changes

Question 48

Types of valve of mechanical aortic prosthesis

Answer 48

Ball-cage valve (Starr-Edwards) Single titling disc (Medtronic-Hall, Ominicarbon) Bileaflet prosthesis

Question 49

Advantagaes of biologic valves

Answer 49

Less thrombogenic Less anticoagulant-related complications Good for older population

Question 50

Disadvantages of biologic valves

Answer 50

More prone to structural failure | Higher chance of reoperation

Question 51

Types of biologic valves

Answer 51

Stented and non-stended heterografts Homografts Autografts (pulmonic valve auto-transplantation, Ross operation)

Question 52

Recommendation for warfarin INR 2-3

Answer 52

Increase INR to 2.5-3.5

Question 53

Recommendation for warfarin INR 2.5-3.5

Answer 53

Increase INR to 3.5-4.5

Question 54

Recommendation for no aspirin

Answer 54

Starts ASA 75-100mg

Question 55

Recommendation for warfarin plus ASA

Answer 55

May increase ASA to 325mg

Question 56

Recommendation for ASA alone

Answer 56

Increae ASA to 325mg or add Clopidogrel 75 mg OD and/or warfarin

Question 57

What level of INR is at higher risk for hemorrhage

Answer 57

> 5

Question 58

What to do when INR is 5-10 and not bleeding

Answer 58

Withhold warfarin, serial INR Vit K1 (phytonadione) Restart warfarin

Question 59

What to do in emergency cases of bleeding

Answer 59

Transfuse fresh frozen plasma | Low dose Vit K