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RCE Guidelines Studying > AHA 2020 Valve Guidelines > Flashcards

AHA 2020 Valve Guidelines Flashcards

1
Q

What is 4 grade system for scoring valve disease?

A

A: At risk

B: Progressive

C: Severe asymptomatic

D: Severe symptomatic

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2
Q

Echo follow up for surgical tissue valve? mechanical? TAVR?

A

Baseline, 5 years, 10 years then annually

Baseline

Baseline and annually

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3
Q

Echo surveillance for MV repair? transcatheter?

A

Baseline, 1 year then 2-3y?

Baseline and annually

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4
Q

Rheumatic fever secondary prevention? 3 antibiotic regimens?

A
  • 10 years until over 40 years (What ever longer)

- Pen G every 4 weeks, Sulfadiazine 1g orally once daily, Pen V 200mg bid

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5
Q

Secondary prevention for rheumatic fever if no residual valve disease? without carditis at all?

A
  • 10 year until age 21

- 5 year until age 21

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6
Q

Describe the three kinds of severe AS

A

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

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7
Q

What medication may reduce mortality in patients post TAVI?

A

ACEi/ARB (Class 2a)

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8
Q

All indications for AVR in asymptomatic AS? (7)

A
  • 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)
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9
Q

7 reasons to pick tissue valve over mechanical?

A
  • 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
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10
Q

When to choose SAVR instead of TAVR? (4)

A

< 65y with LE > 20y

> 80 or LE < 10y -> TAVR

TAVR > SAVR for high surgical risk

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11
Q

What Life Expectancy do you need for TAVI?

A

12 months

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12
Q

4 measures of high surgical risk for TAVI?

A
  • STS > 8%
  • 2 or more frailty measures
  • 1-2 or more organ systems with
  • Possible Procedure specific impediment
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13
Q

What blood pressure target for severe AR?

A
  • 140mmhg
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14
Q

3 class 2 indications for AR?

A
  • 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
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15
Q

What % of patients with BAV will have an affected FDR?

A

20-30%

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16
Q

4 indications for intervention in BAV Aortopathy?

A
  • > 5.5
  • > 5 with following:
  • fam hx dessection
  • Growth > 0.5cm/year
  • Coarctation
  • 4.5 underoing OHS
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17
Q

What is MVA cut off for severe MS? PHT?

A

MVA < 1.5 cm2

> 150ms

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18
Q

what is rate of progression for MS?

A

0.1 cm/yr

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19
Q

3 indications for OAC in MS?

A

Recurrent emboli

AF

LA thrombus

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20
Q

Class 1 indication for MVR/Balloon valvuloplasty?

A

-MVA < 1.5cm with symptoms and <2+ MR and LA thrombus

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21
Q

Class II indications for MS intervention?

A
  • 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)
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22
Q

3 class one indications for MVR in patients with severe MR?

A
  • Symptomatic
  • LVEF < 60%
  • LVESD > 40mm
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23
Q

Name 2 class 2 indications for MVR in MR?

A
  • > 95% chance of repair <1% mortality

- Progressive increase in LV size or decrease EF

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24
Q

LVESD and PASP cut off for TEER for MR? LVEF range?

A

< 70 mmhg

< 70 LVESD

20-50%

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25
Q

6 echo features of Severe TR?

A
  • 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
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26
Q

What is the only class one indication for TVR?

A

-Severe Tr undergoing left sided valve surgery

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27
Q

5 indications for TVR for TR?

A
  • 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
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28
Q

INR target for AVR, MVR?

A
  • AVR no RFs: 2-3
  • AVR with RFs: 2.5-3.5
  • MVR: 2.5-3.5
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29
Q

What to do with anticoagulation after TE on aortic mechanical valve, mitral mechanical valve, tissue valve

A
  • Mechanical AVR: Increase INR goal to 3 or add ASA
  • Mechanical MVR: Increase INR goal to 4 or add ASA
  • Tissue: Start on VKA
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30
Q

How to manage mechanical valve thrombosis?

A

-If left sided and symptoms -> slow infusion lytic or emergency surgery (Class 1)

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31
Q

4 imaging modalities to evaluate suspected mechanical valve thrombosis?

A
  • TTE
  • TEE
  • Fluoroscopy
  • CT imaging
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32
Q

How to manage thrombosis of tissue valve?

A

VKA

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33
Q

Three types of mechanical valves to bridge for?

A
  • Mitral
  • AVR with RFs
  • AVR old generation

NOT for AVR with no RF’s

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34
Q

Valve in valve increases risk of the 3 following

A
  • PPM
  • Paravalvular leak
  • Coronary artery obstruction
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35
Q

3 causes of valvular PV regurg? Paravalvular?

A
  • Valvular: Pannus, Thombus, Vegetation

- PVL: Suture line dysfunction, annular disruption, endocarditis

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36
Q

3 ways to make ‘Definite IE’ diagnoses based on DUKE criteria?

A
  • 2 major
  • 1 major, 3 minor
  • 5 minor
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37
Q

What is blood culture criteria for IE?

A

-Causative agent from 2 separate blood cultures (12h apart or 3/4 separate cultures of blood)

OR 1 single Coxiella burnetti IgG > 1:800

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38
Q

IE evidence on Echo? (4)

A
  • Oscillating intracardiac mass on valve or supporting structures
  • Abscess
  • Partial dehiscence of a PV
  • New valvular regurgitation
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39
Q

What are the 5 minor criteria?

A
  • 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
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40
Q

8 indications for surgery in IE ? Name the Class 1 and Class 2

A
  • 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)
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41
Q

Symptomatic women with VHD should get what prior to preganncy ideally?

A

Valve intervention

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42
Q

What to do with patient with MVA < 1.5 pre pregnancy?

A

PMBC

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43
Q

Fetal and maternal mortality with severe AS?

A
  • Maternal: 10%

- Fetal: 30-40%

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44
Q

Maternal mortality on OAC with pregnancy? Valve thrombosis?

A

1% mortality, 5% thrombosis

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45
Q

When to switch to UFH in pregnancy/labor?

A

Switch to UFH 36h before, stop 6h before

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46
Q

3 candidates for lysis of thrombosis in preganncy?

A
  • Obstructive left sided valve lesion
  • Thrombosis with embolic complications
  • Thrombus > 10mm
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47
Q

What are wait times for Emergent, Urgent and Elective TAVI?

A

Emergent < 48h

Urgent < 2 weeks

Elective < 12 weeks

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48
Q

To maintain high volume status how many TAVIs do centers need to perform?

49
Q

6 things in TAVI work up?

A

ECG

Echo

Cath

CT

History and Physical

Frailty score

50
Q

Name 5 conditions that favor TAVI?

A

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

51
Q

Name 8 conditions that favor SAVR?

A

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

52
Q

How often for echo post TAVI? ECG?

A

ECG: 30 days and annually

Echo: 30 days, 1 year and as indicated

53
Q

What are the 4 parameters of Risk assessment for deciding for procedures (open vs. transcatheter)

A
  • STS predicted risk of death
  • Frailty
  • Cardiac or other major organ system compromise
  • Procedure specific impediment
54
Q

What is low STS predicted risk for SAVR? MVR?

55
Q

What are 4 reasons someone would be high for surgical procedures?

A
  • STS > 8%
  • 2 or more frailty indices
  • 1 or 2 organ system compromise
  • Possible procedure specific inmpediment
56
Q

What are 4 reasons someone would have prohibitive surgical risk?

A

Risk of death or major comorbidity > 50% at 1 year

2 or more frailty markers

3 or more organs involved

severe procedure specific impediment

57
Q

What are two technical/anatomic RFs for SAVR?

A
  • Prior mediastinal radiation

- Ascending aortic calcification

58
Q

What are 7 technical/anatomic RFs for TAVR?

A
  • Occlusive iliac disease
  • Aortic arch ahterosclerosis
  • Severe MR or TR
  • Low lying coronary arteries
  • Basal septal hypertrophy
  • Bicuspid/Unicuspid
  • Extensive LVOT calcification
59
Q

What are three markers of futility?

A

STS > 15

LE < 1y

Poor candidate for rehabilitation

60
Q

What is mortality rate for AVR? AVR + MVR?

61
Q

When is SAVR recommended instead of TAVR?

A
  • Age < 65 with > 20 years LE (if no other CI to SAVR)
62
Q

When is TAVR recommended above SAVR?

A

> 80y with LE < 10 years

63
Q

What is grey zone for TAVR vs SAVR?

64
Q

If patients turned down for SAVR, how long does LE need to be to have TAVR?

65
Q

Age cut off above which should have prosthetic aortic valve?

A

> 65 years

66
Q

Review Mechanical Valve vs. Prosthetic Valve factors

67
Q

What is indicated for reversal of VKA for emergent reasons?

A
  • PCC complex,

- adjunctive use of VKA reasonable if does not need OAC for 7 days

68
Q

What to do for INR > 5 if no bleeding?

A

Just hold VKA, no INR

69
Q

What to do with INR for mechanical AVR if TE event? MVR?

A
  • increase to 3

- Increase to 4

70
Q

How to decide between Fibrinolytic vs Surgery for PV thrombus?

A

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
71
Q

6 indications for early surgery in IE?

A
  • HF
  • Resistant Organism
  • > 5 days Rx
  • Abscess
  • Recurrent TE (2a)
  • Large Emboli > 10 mm (2b)
72
Q

5 indications for cath prior to SAVR?

A
  • Concomitant MR
  • Angina
  • LV dysfunction
  • History of CAD
  • RFs for CAD (Including Men > 40 and Post menopausal Women)
73
Q

When to get echo for VHD prior to non cardiac surgery?

A

When valvular disease is moderate or greater

74
Q

When to replace aortic valve prior to non cardiac surgery>

A

When indications otherwise to replace

75
Q

What do you need in mod-severe MS to be able to have non cardiac surgery?

A
  • PASP < 50mmhg

- Asymptomatic

76
Q

Why should all patients with CIED have TEE?

A

To evaluate extension to the left sided heart valves

77
Q

How to treat Generator/Lead erosion?

A

7-10 days abx

78
Q

How to treat pocket infection?

A

10-14 dyas antibiotics

79
Q

How long to treat lead vegetation?

80
Q

When to implant new device if pocket infection/lead erosion?

A

Negative blood cultures for 72 hours -> implant new CIED following adequate debridement of the generator pocket

81
Q

When to implant new CIED if blood culture + but TEE negative?

A

Implant if repeat blood cultures are negative for at least 72 hours

82
Q

When to implant a new CIED if blood culture and TEE positive?

A

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

83
Q

What site should be implanted repeat CIED?

A

a Non ipsilateral site

84
Q

When should Ancef be given prior to CIED implant? Vancomycin?

A

1 hour

2 hour

85
Q

Review CCS TAVI guideline table on SAVR vs TAVR Patient selection

86
Q

What is low risk for AVR by STS? MVR?

A

AVR: 3%

MVR: 1%

87
Q

One of these 4 things makes an intervention Prohibitive risk:

A

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

88
Q

Median mortality of AVR? MVR? Combined with CABG

A

AVR: 2%

MVR: 5%

If combined with CABG -> double the above

89
Q

What is the decreased exercise criteria for severe asymptomatic AS?

A
  • Low surgical risk
  • SBP drop by more than 10mmhg from rest to peak exercise
  • Decreased exercise capacity compared to age/gender norms
90
Q

When to consider a Ross procedure?

A

Patients under 50 who prefer a bioprosthetic AVR and have appropriate anatomy

91
Q

Is SAVR or TAVR recommended for patients with class 2a recommendations for AS?

A

SAVR (many of the class 2a recommendations qualify that patient must be low surgical risk)

92
Q

What are 4 causes of secondary TR?

A

Pulm HTn

RV annular dilation without PHtn (AF)

DCM

RV volume overload (Shunt, High output state)

93
Q

What is 15y risk of structural deterioration if age 20, 40, >70

A

20’s: 50%

40’s: 30%

> 70: 10%

94
Q

What to do if TE with aortic mechanical valve? mitral mechanical valve?

A

Aortic: Increase INR target to 3, or add ASA

Mitral: Increase INR target to 4, or add ASA

95
Q

What is class 1 indication for Lytic/Surgery for Mechanical Valve thrombosis?

A

Left sided and symptomatic

96
Q

When to consider ViV for Prosthetic valve dysfunction? Percutaneous repair

A

ViV: Stenosis or Valvular regurg with symptoms and not candidate for surgery

Percutaneous Repair: Paravalvular regurgitation

97
Q

What need to be done before changing a patient from IV to PO therapy early?

A

Baseline TEE before switching oral therapy and a repeat TEE 1-3 days before completing the antibiotic therapy

98
Q

3 ways to make a diagnosis of definite Endocarditis?

A

Clinical criteria by Duke

Pathologic criteria: Biopsy of valve confirming vegetation/abscess

Microorganisms on vegetation/intracardiac abscess

99
Q

how to decide on timing of IE surgery post stroke?

A

If no neurologic deficit -> No delay

If large neurologic deficit and hemodynamically stable -> 4 weeks reasonable

100
Q

When to switch from Warfarin -> LMWH/UFH in pregnancy?

A

1 week prior to planned pregnancy (other resources say at 36 weeks)

101
Q

When to perform CABG/AVR instead of TAVR/PCI when TAVR initially planned?

A

LMCA stenosis or multivessel CAD SYNTAX > 22

102
Q

When to get echo pre op based on valve disease?

A

moderate or greater regurg or stenosis

103
Q

When is it OK to go through with elective non cardiac surgery with severe rheumatic MS?

A

Asymptomatic and PASP < 50mmhg

104
Q

Review factors that favor SAVR vs. TAVR based on AHA 2020 guidelines

105
Q

What are the only class 1 indications for bioprosthetic valve over mechanical?

A

Patient preference

Anticoagulation contraindicated/unable to comply

106
Q

5 indications for INR 3.0 target in BioProsthetic AVR

A
  • AF
  • LV dysfunction
  • Hypercoagulable state
  • TE events
  • Older generation (Ball in cage) valve
107
Q

What class of indication is Aspirin in Mechanical valves?

A

2b if they have an indication for antiplatelet

108
Q

What are 4 indications for TEE in IE?

A
  • Diagnosis unclear
  • Rule out complication (Abscess)
  • Rule out device lead involvement
  • Intra-op
109
Q

What is class 1 indication for lytic/surgery for mechanical valve? And another class 1 indication for surgery only

A
  • Left sided mechanical obstruction with symptoms

- Intractable hemolysis

110
Q

4 indications for BAV Aortopathy repair if 5 - 5.5 cm

A
  • Family history dissection
  • More than 5mm/yr growth
  • Coarctation
  • Going for OHS
111
Q

Review AVR decision making algorithm

112
Q

Review SAVR vs. TAVR favorable characteristics

113
Q

Review anatomic issues relating to SAVR and TAVR

114
Q

How to decide in Severe Secondary MR to pursue TEER vs. MV surgery?

A

LVEF > 50% OR undergoing CABG -> MV surgery (2b)

LVEF < 50% -> TEER (2a)

115
Q

What are three reasons in BAV Aortopathy (5-5.5cm) to operate?

A
  • Aortic Coarctation
  • Family history of dissection
  • Rapid growth (>5mm/year)
116
Q

What are 5 class 1 indications for Rheumatic MS intervention?

A

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
117
Q

4 reasons to pursue pre-pregnancy valvular intervention for?

A
  • 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
118
Q

What are three indications for intervention for VHD during pregnancy?

A
  • 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

119
Q

Name 5 complications of PMBV?

A
  • Severe MR
  • Stroke (Calcium dislodgement)
  • Tamponade
  • Residual ASD
  • Access site bleeding or infection

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