AHA 2020 Valve Guidelines Flashcards
What is 4 grade system for scoring valve disease?
A: At risk
B: Progressive
C: Severe asymptomatic
D: Severe symptomatic
Echo follow up for surgical tissue valve? mechanical? TAVR?
Baseline, 5 years, 10 years then annually
Baseline
Baseline and annually
Echo surveillance for MV repair? transcatheter?
Baseline, 1 year then 2-3y?
Baseline and annually
Rheumatic fever secondary prevention? 3 antibiotic regimens?
- 10 years until over 40 years (What ever longer)
- Pen G every 4 weeks, Sulfadiazine 1g orally once daily, Pen V 200mg bid
Secondary prevention for rheumatic fever if no residual valve disease? without carditis at all?
- 10 year until age 21
- 5 year until age 21
Describe the three kinds of severe AS
D1: Severe and high gradient
D2: Symptomatic LFLG with reduced EF (AVA < 1, Vmax < 4m/s), LVEF < 50%
D3: Symptomatic/Paradoxical: as above but normal EF and SVI < 35
What medication may reduce mortality in patients post TAVI?
ACEi/ARB (Class 2a)
All indications for AVR in asymptomatic AS? (7)
- Other OR (Class 1 Severe, IIb Moderate)
- LVEF < 50% (Class 1)
- Decreased BP or exercise capacity on EST (Class 2a)
- BNP 3x normal (Class 2a)
- Vmax > 5 m/s (Class 2a)
- Decreased LVEF to < 60% in 3 serial studies (Class 2a)
- Progression > 0.3 m/s/yr (Class 2a)
7 reasons to pick tissue valve over mechanical?
- Age > 65
- Patient Preference
- Inabililty to anticoagulate
- Avoid PPM (TAVI ERO > SAVR for given valve size)
- Access to surgical center for reintervention
- Access to center for VIV
- Limited access to medical center for VKA monitoring
When to choose SAVR instead of TAVR? (4)
< 65y with LE > 20y
> 80 or LE < 10y -> TAVR
TAVR > SAVR for high surgical risk
What Life Expectancy do you need for TAVI?
12 months
4 measures of high surgical risk for TAVI?
- STS > 8%
- 2 or more frailty measures
- 1-2 or more organ systems with
- Possible Procedure specific impediment
What blood pressure target for severe AR?
- 140mmhg
3 class 2 indications for AR?
- LVESD > 50
- 3 serial echo that show LV dilation up to LVEDD > 65, or LVEF decrease to low normal range (55-60%)
- Moderate for CVSx
What % of patients with BAV will have an affected FDR?
20-30%
4 indications for intervention in BAV Aortopathy?
- > 5.5
- > 5 with following:
- fam hx dessection
- Growth > 0.5cm/year
- Coarctation
- 4.5 underoing OHS
What is MVA cut off for severe MS? PHT?
MVA < 1.5 cm2
> 150ms
what is rate of progression for MS?
0.1 cm/yr
3 indications for OAC in MS?
Recurrent emboli
AF
LA thrombus
Class 1 indication for MVR/Balloon valvuloplasty?
-MVA < 1.5cm with symptoms and <2+ MR and LA thrombus
Class II indications for MS intervention?
- Asymptomatic with MVA < 1.5 with elevated pulmonary pressures or new Afib
- Symptomatic non severe MS that is hemodynamically significant (PCWP > 25, MV MG > 15mmg during exercise)
3 class one indications for MVR in patients with severe MR?
- Symptomatic
- LVEF < 60%
- LVESD > 40mm
Name 2 class 2 indications for MVR in MR?
- > 95% chance of repair <1% mortality
- Progressive increase in LV size or decrease EF
LVESD and PASP cut off for TEER for MR? LVEF range?
< 70 mmhg
< 70 LVESD
20-50%
6 echo features of Severe TR?
- Central jet > 50% RA
- VC > 7mm
- ERO > 0.40
- Residual Volume > 45 ml
- Dense continuous doppler signal with triangular shape
- Hepatic ven systolic flow reversal
What is the only class one indication for TVR?
-Severe Tr undergoing left sided valve surgery
5 indications for TVR for TR?
- Severe TR at time of left sided surgery (Class 1)
- Progressive TR at time of left sided surgery (Previous RHF, Annular dilation > 4.0cm) (Class 2)
- Severe Primary TR with RHF
- Severe Secondary TR with RHF with annual dilation without increased PAP
- Primary TR severe TR with progressive RV dilation or systolic dysfunction
INR target for AVR, MVR?
- AVR no RFs: 2-3
- AVR with RFs: 2.5-3.5
- MVR: 2.5-3.5
What to do with anticoagulation after TE on aortic mechanical valve, mitral mechanical valve, tissue valve
- Mechanical AVR: Increase INR goal to 3 or add ASA
- Mechanical MVR: Increase INR goal to 4 or add ASA
- Tissue: Start on VKA
How to manage mechanical valve thrombosis?
-If left sided and symptoms -> slow infusion lytic or emergency surgery (Class 1)
4 imaging modalities to evaluate suspected mechanical valve thrombosis?
- TTE
- TEE
- Fluoroscopy
- CT imaging
How to manage thrombosis of tissue valve?
VKA
Three types of mechanical valves to bridge for?
- Mitral
- AVR with RFs
- AVR old generation
NOT for AVR with no RF’s
Valve in valve increases risk of the 3 following
- PPM
- Paravalvular leak
- Coronary artery obstruction
3 causes of valvular PV regurg? Paravalvular?
- Valvular: Pannus, Thombus, Vegetation
- PVL: Suture line dysfunction, annular disruption, endocarditis
3 ways to make ‘Definite IE’ diagnoses based on DUKE criteria?
- 2 major
- 1 major, 3 minor
- 5 minor
What is blood culture criteria for IE?
-Causative agent from 2 separate blood cultures (12h apart or 3/4 separate cultures of blood)
OR 1 single Coxiella burnetti IgG > 1:800
IE evidence on Echo? (4)
- Oscillating intracardiac mass on valve or supporting structures
- Abscess
- Partial dehiscence of a PV
- New valvular regurgitation
What are the 5 minor criteria?
- Predisposition (Heart condition, IVDU)
- Fever > 38
- Vascular phenomena: Major arterial emboli, septic pulmonary infarct , hemorrhages, Janeway lesions
- Immunological phenomena: Oslers, GN, Roth spot
- Micro evidence: Blood culture that does not meet major criteria
8 indications for surgery in IE ? Name the Class 1 and Class 2
- HF symptoms in patients with valve dysfunction
- S. Aureus/fungal organism
- Heart block, aortic abscess
- Persistent infection (fever/bacteremia) lasting > 5 days after appropriate antimicrobial therapy
- All IE with CIEDs (Complete removal of system needed)
- PVE with relapsing infection
- Recurrent emboli (2a)
- Vegetation > 10mm (left sided) (2a)
Symptomatic women with VHD should get what prior to preganncy ideally?
Valve intervention
What to do with patient with MVA < 1.5 pre pregnancy?
PMBC
Fetal and maternal mortality with severe AS?
- Maternal: 10%
- Fetal: 30-40%
Maternal mortality on OAC with pregnancy? Valve thrombosis?
1% mortality, 5% thrombosis
When to switch to UFH in pregnancy/labor?
Switch to UFH 36h before, stop 6h before
3 candidates for lysis of thrombosis in preganncy?
- Obstructive left sided valve lesion
- Thrombosis with embolic complications
- Thrombus > 10mm
What are wait times for Emergent, Urgent and Elective TAVI?
Emergent < 48h
Urgent < 2 weeks
Elective < 12 weeks
To maintain high volume status how many TAVIs do centers need to perform?
50
6 things in TAVI work up?
ECG
Echo
Cath
CT
History and Physical
Frailty score
Name 5 conditions that favor TAVI?
STS 3 or greater (intermediate or > )
Advanced age > 75, frailty, limited mobility
Small annulus (< 21 mm )
Longevity unlikely (need 2 year LR though)
Mediastinal anatomy unfavourable for Surgery
Name 8 conditions that favor SAVR?
Aortic root anatomy infavorable for TAVI
High grade AV block, RBBB
Non femoral access required
Congenital BAV
Risk of Coronary obstruction
Pure Aortic Insufficiency
Concomitant conditions requiring surgery
Aortic aneurysm or dissection
Endocarditis
How often for echo post TAVI? ECG?
ECG: 30 days and annually
Echo: 30 days, 1 year and as indicated
What are the 4 parameters of Risk assessment for deciding for procedures (open vs. transcatheter)
- STS predicted risk of death
- Frailty
- Cardiac or other major organ system compromise
- Procedure specific impediment
What is low STS predicted risk for SAVR? MVR?
< 3%
< 1%
What are 4 reasons someone would be high for surgical procedures?
- STS > 8%
- 2 or more frailty indices
- 1 or 2 organ system compromise
- Possible procedure specific inmpediment
What are 4 reasons someone would have prohibitive surgical risk?
Risk of death or major comorbidity > 50% at 1 year
2 or more frailty markers
3 or more organs involved
severe procedure specific impediment
What are two technical/anatomic RFs for SAVR?
- Prior mediastinal radiation
- Ascending aortic calcification
What are 7 technical/anatomic RFs for TAVR?
- Occlusive iliac disease
- Aortic arch ahterosclerosis
- Severe MR or TR
- Low lying coronary arteries
- Basal septal hypertrophy
- Bicuspid/Unicuspid
- Extensive LVOT calcification
What are three markers of futility?
STS > 15
LE < 1y
Poor candidate for rehabilitation
What is mortality rate for AVR? AVR + MVR?
2%
9%
When is SAVR recommended instead of TAVR?
- Age < 65 with > 20 years LE (if no other CI to SAVR)
When is TAVR recommended above SAVR?
> 80y with LE < 10 years
What is grey zone for TAVR vs SAVR?
65-80 age
If patients turned down for SAVR, how long does LE need to be to have TAVR?
> 1 year
Age cut off above which should have prosthetic aortic valve?
> 65 years
Review Mechanical Valve vs. Prosthetic Valve factors
What is indicated for reversal of VKA for emergent reasons?
- PCC complex,
- adjunctive use of VKA reasonable if does not need OAC for 7 days
What to do for INR > 5 if no bleeding?
Just hold VKA, no INR
What to do with INR for mechanical AVR if TE event? MVR?
- increase to 3
- Increase to 4
How to decide between Fibrinolytic vs Surgery for PV thrombus?
Surgery:
- Available surgical expertise
- Low surgical risk
- CI to lytic
- Recurrent valve thrombosis
- NYHA IV
- Large Clot > 0.8cm2
- LA thrombus
- Concomitant CAD need for revascularization
- Other valvular disease
- Possible pannus
- Patient choice
6 indications for early surgery in IE?
- HF
- Resistant Organism
- > 5 days Rx
- Abscess
- Recurrent TE (2a)
- Large Emboli > 10 mm (2b)
5 indications for cath prior to SAVR?
- Concomitant MR
- Angina
- LV dysfunction
- History of CAD
- RFs for CAD (Including Men > 40 and Post menopausal Women)
When to get echo for VHD prior to non cardiac surgery?
When valvular disease is moderate or greater
When to replace aortic valve prior to non cardiac surgery>
When indications otherwise to replace
What do you need in mod-severe MS to be able to have non cardiac surgery?
- PASP < 50mmhg
- Asymptomatic
Why should all patients with CIED have TEE?
To evaluate extension to the left sided heart valves
How to treat Generator/Lead erosion?
7-10 days abx
How to treat pocket infection?
10-14 dyas antibiotics
How long to treat lead vegetation?
4-6 weeks
When to implant new device if pocket infection/lead erosion?
Negative blood cultures for 72 hours -> implant new CIED following adequate debridement of the generator pocket
When to implant new CIED if blood culture + but TEE negative?
Implant if repeat blood cultures are negative for at least 72 hours
When to implant a new CIED if blood culture and TEE positive?
Repeat blood cultures after CIED removal -> If lead vegetatino only implant new CIED if repeat blood cultures are negative for 72 hours
If valve vegetation, implant new CIED after 14 days from first negative blood cultures
What site should be implanted repeat CIED?
a Non ipsilateral site
When should Ancef be given prior to CIED implant? Vancomycin?
1 hour
2 hour
Review CCS TAVI guideline table on SAVR vs TAVR Patient selection
What is low risk for AVR by STS? MVR?
AVR: 3%
MVR: 1%
One of these 4 things makes an intervention Prohibitive risk:
STS predicting 50% risk at 1 year
2 or more Frailty indices
3 or more organ systems dysfunctional with are not expected to improve post operatively
Severe Procedure specific impediment
Median mortality of AVR? MVR? Combined with CABG
AVR: 2%
MVR: 5%
If combined with CABG -> double the above
What is the decreased exercise criteria for severe asymptomatic AS?
- Low surgical risk
- SBP drop by more than 10mmhg from rest to peak exercise
- Decreased exercise capacity compared to age/gender norms
When to consider a Ross procedure?
Patients under 50 who prefer a bioprosthetic AVR and have appropriate anatomy
Is SAVR or TAVR recommended for patients with class 2a recommendations for AS?
SAVR (many of the class 2a recommendations qualify that patient must be low surgical risk)
What are 4 causes of secondary TR?
Pulm HTn
RV annular dilation without PHtn (AF)
DCM
RV volume overload (Shunt, High output state)
What is 15y risk of structural deterioration if age 20, 40, >70
20’s: 50%
40’s: 30%
> 70: 10%
What to do if TE with aortic mechanical valve? mitral mechanical valve?
Aortic: Increase INR target to 3, or add ASA
Mitral: Increase INR target to 4, or add ASA
What is class 1 indication for Lytic/Surgery for Mechanical Valve thrombosis?
Left sided and symptomatic
When to consider ViV for Prosthetic valve dysfunction? Percutaneous repair
ViV: Stenosis or Valvular regurg with symptoms and not candidate for surgery
Percutaneous Repair: Paravalvular regurgitation
What need to be done before changing a patient from IV to PO therapy early?
Baseline TEE before switching oral therapy and a repeat TEE 1-3 days before completing the antibiotic therapy
3 ways to make a diagnosis of definite Endocarditis?
Clinical criteria by Duke
Pathologic criteria: Biopsy of valve confirming vegetation/abscess
Microorganisms on vegetation/intracardiac abscess
how to decide on timing of IE surgery post stroke?
If no neurologic deficit -> No delay
If large neurologic deficit and hemodynamically stable -> 4 weeks reasonable
When to switch from Warfarin -> LMWH/UFH in pregnancy?
1 week prior to planned pregnancy (other resources say at 36 weeks)
When to perform CABG/AVR instead of TAVR/PCI when TAVR initially planned?
LMCA stenosis or multivessel CAD SYNTAX > 22
When to get echo pre op based on valve disease?
moderate or greater regurg or stenosis
When is it OK to go through with elective non cardiac surgery with severe rheumatic MS?
Asymptomatic and PASP < 50mmhg
Review factors that favor SAVR vs. TAVR based on AHA 2020 guidelines
What are the only class 1 indications for bioprosthetic valve over mechanical?
Patient preference
Anticoagulation contraindicated/unable to comply
5 indications for INR 3.0 target in BioProsthetic AVR
- AF
- LV dysfunction
- Hypercoagulable state
- TE events
- Older generation (Ball in cage) valve
What class of indication is Aspirin in Mechanical valves?
2b if they have an indication for antiplatelet
What are 4 indications for TEE in IE?
- Diagnosis unclear
- Rule out complication (Abscess)
- Rule out device lead involvement
- Intra-op
What is class 1 indication for lytic/surgery for mechanical valve? And another class 1 indication for surgery only
- Left sided mechanical obstruction with symptoms
- Intractable hemolysis
4 indications for BAV Aortopathy repair if 5 - 5.5 cm
- Family history dissection
- More than 5mm/yr growth
- Coarctation
- Going for OHS
Review AVR decision making algorithm
Review SAVR vs. TAVR favorable characteristics
Review anatomic issues relating to SAVR and TAVR
How to decide in Severe Secondary MR to pursue TEER vs. MV surgery?
LVEF > 50% OR undergoing CABG -> MV surgery (2b)
LVEF < 50% -> TEER (2a)
What are three reasons in BAV Aortopathy (5-5.5cm) to operate?
- Aortic Coarctation
- Family history of dissection
- Rapid growth (>5mm/year)
What are 5 class 1 indications for Rheumatic MS intervention?
Severe symptomatic (NYHA II-IV) MS with no LA thrombus, Less than moderate MR and favorable valve morphology for PBMV
Severe symptomatic NYHA III-IV MVR if
- PMBV failed
- Not candidate for PMBV
- Going for OHS
- No access for PMBV
4 reasons to pursue pre-pregnancy valvular intervention for?
- Symptomatic Severe VHD
- Asymptomatic Severe MS
- Asymptomatic Severe AS (Can use EST or BNP to risk stratify)
- Asymptomatic Severe MR with valve suitable for repair
What are three indications for intervention for VHD during pregnancy?
- Severe AS with NYHA III/IV symptoms or hemodynamic deterioration
- Severe MS with NYHA III/IV symptoms or hemodynamic deterioiration
Severe MR with NYHA IV symptoms refractory to medical therapy
Name 5 complications of PMBV?
- Severe MR
- Stroke (Calcium dislodgement)
- Tamponade
- Residual ASD
- Access site bleeding or infection
