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