Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

oral boards > AHA: AS > Flashcards

AHA: AS Flashcards

1
Q

dx testing: initial dx

pre-imaging optimization for suspected low-flow, low-gradient AS with normal EF

A

BP control
(1)

“In patients with suspected low-flow, lowgradient severe AS with normal LVEF (Stage D3), optimization of blood pressure control is recommended before measurement of AS severity by TTE, TEE, cardiac catheterization, or CMR.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

dx testing: initial dx

preferred imaging/testing for suspected low-flow, low-gradient AS with reduced EF

A

low-dose dobutamine stress ECHO OR invasive hemodynamic testing (i.e. LHC?)
(2a)

“In patients with suspected low-flow, lowgradient severe AS with reduced LVEF (Stage D2), low-dose dobutamine stress testing with echocardiographic or invasive hemodynamic measurements is reasonable to further define severity and assess contractile reserve.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

dx testing: initial dx

additional TTE calculation/measurement for suspected low-flow, low-gradient severe AS (with normal or reduced EF)

(not the most preferred/1st-line)

A

voutflow tract : vAo
(2a)

ratio of outflow tract to aortic velocities

“In patients with suspected low-flow, lowgradient severe AS with normal or reduced LVEF (Stages D2 and D3), calculation of the ratio of the outflow tract to aortic velocity is reasonable to further define severity.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

dx testing: initial dx

additional imaging for suspected low-flow, low-gradient severe AS (with normal or reduced EF)

(not the most preferred/1st-line)

A

cardiac CT for AV calcium score
(2a)

aortic valve calcium score by CT

♀>1400 / ♂>2000
“In patients with suspected low-flow, lowgradient severe AS with normal or reduced LVEF (Stages D2 and D3), measurement of aortic valve calcium score by CT imaging is reasonable to further define severity.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

dx testing: initial dx

additional testing for asx severe AS

A

exercise testing
(2a)

￬ tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise

“In asymptomatic patients with severe AS (Stage C1), exercise testing is reasonable to assess physiological changes with exercise and to confirm the absence of symptoms.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

dx testing: exercise testing

exercise testing in sx severe AS

A

NO
(3: harm)

“In symptomatic patients with severe AS (Stage D1, aortic velocity ≥4.0 m/s or mean pressure gradient ≥40 mmHg), exercise testing should not be performed because of the risk of severe hemodynamic compromise.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

med tx

med tx for asx AS

A

HTN GDMT
(1)

AND statin if calcific AS (1) AND RAS blocker if s/p TAVI (2b)

“In patients at risk of developing AS (Stage A) and in patients with asymptomatic AS (Stages B and C), hypertension should be treated according to standard GDMT, started at a low dose, and gradually titrated upward as needed, with appropriate clinical monitoring.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

med tx

med tx for calcific AS

sx or asx, i.e. all calcific AS

A

statin
for 1° & 2° ppx of atherosclerosis
(1)

AND HTN GDMT in asx AS (1) AND RAS blocker if s/p TAVI (2b)

“In all patients with calcific AS, statin therapy is indicated for primary and secondary prevention of atherosclerosis on the basis of standard risk scores.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

med tx

med tx for AS s/p TAVI

A

RAS blocker (ACE-I or ARB)
to reduce all-cause mortality
(2b)

AND HTN GDMT in asx AS (1) AND statin if calcific AS (1)

“In patients who have undergone TAVI, renin–angiotensin system blocker therapy (ACE inhibitor or ARB) may be considered to reduce the long-term risk of all-cause mortality.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

3 classic sxs of AS

A
  1. angina
  2. syncope
  3. dyspnea/CHF

in order of increasing mortality

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

3 classic symptoms of AS in order of increasing mortality

A
  1. angina
  2. syncope
  3. dyspnea/CHF
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

mean OS for AS after onset of angina

A

5y

ASD = angina/syncope/dyspnea = 5/3/2y

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

mean OS for AS after onset of syncope

A

3y

ASD = angina/syncope/dyspnea = 5/3/2y

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

mean OS for AS after onset of dyspnea/CHF

A

2y

ASD = angina/syncope/dyspnea = 5/3/2y

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

indication(s) for intervention in sx severe AS

A

YES
severe + sx = indicated
(1)
incl low-flow, low-gradient (1)

“1. In adults with severe high-gradient AS (Stage D1) and symptoms of exertional dyspnea, HF, angina, syncope, or presyncope by history or on exercise testing, AVR is indicated.” (1)
“4. In symptomatic patients with low-flow, low gradient severe AS with reduced LVEF (Stage D2), AVR is recommended.” (1)
“5. In symptomatic patients with low-flow, low gradient severe AS with normal LVEF (Stage D3), AVR is recommended if AS is the most likely cause of symptoms.” (1)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

indication(s) for intervention in sx high-gradient (usual) severe AS

A

YES
severe + sx = indicated
(1)

“1. In adults with severe high-gradient AS (Stage D1) and symptoms of exertional dyspnea, HF, angina, syncope, or presyncope by history or on exercise testing, AVR is indicated.” (1)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

indication(s) for intervention in sx low-flow, low-gradient severe AS

A

YES
severe + sx = indicated
incl low-flow, low-gradient with:
- reduced EF (1)
- normal EF but AS is the most likely cause of sxs (1)

“4. In symptomatic patients with low-flow, low gradient severe AS with reduced LVEF (Stage D2), AVR is recommended.” (1)
“5. In symptomatic patients with low-flow, low gradient severe AS with normal LVEF (Stage D3), AVR is recommended if AS is the most likely cause of symptoms.” (1)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

indication(s) for intervention in asx severe AS

A
  • EF<50% (1)
  • concomitant <3 surg (1)
  • progressive ￬ EF on 3 studies to <60% (2b)

OR if low-risk AND:
- critical AS (i.e. AVA/<0.6cm2, MG≥60mmHg, vmax≥5) (2a)
- high-risk progression (i.e. vmax ￪ ≥0.3m/s/y) (2a)
- (+)exercise test (i.e. ￬exercise tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise) (2a)
- BNP > 3x nl (2a)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

indication(s) for intervention in asx severe AS

(7)

A
  • EF<50% (1)
  • concomitant <3 surg (1)
  • progressive ￬ EF on 3 studies to <60% (2b)

OR if low-risk AND:
- critical AS (i.e. AVA/<0.6cm2, MG≥60mmHg, vmax≥5) (2a)
- high-risk progression (i.e. vmax ￪ ≥0.3m/s/y) (2a)
- (+)exercise test (i.e. ￬exercise tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise) (2a)
- BNP > 3x nl (2a)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

class 2 indication(s) for intervention in asx severe AS

A
  • progressive ￬ EF on 3 studies to <60% (2b)

OR if low-risk AND:
- critical AS (i.e. AVA/<0.6cm2, MG≥60mmHg, vmax≥5) (2a)
- high-risk progression (i.e. vmax ￪ ≥0.3m/s/y) (2a)
- (+)exercise test (i.e. ￬exercise tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise) (2a)
- BNP > 3x nl (2a)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

class 2 indication(s) for intervention in asx severe AS

(5)

A
  • progressive ￬ EF on 3 studies to <60% (2b)

OR if low-risk AND:
- critical AS (i.e. AVA/<0.6cm2, MG≥60mmHg, vmax≥5) (2a)
- high-risk progression (i.e. vmax ￪ ≥0.3m/s/y) (2a)
- (+)exercise test (i.e. ￬exercise tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise) (2a)
- BNP > 3x nl (2a)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

class 2b indication(s) for intervention in asx severe AS

A
  • progressive ￬ EF on 3 studies to <60% (2b)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

class 2b indication(s) for intervention in asx severe AS

(1)

A
  • progressive ￬ EF on 3 studies to <60% (2b)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

class 2a indication(s) for intervention in asx severe AS

A

low-risk AND:
- critical AS (i.e. AVA/<0.6cm2, MG≥60mmHg, vmax≥5) (2a)
- high-risk progression (i.e. vmax ￪ ≥0.3m/s/y) (2a)
- (+)exercise test (i.e. ￬exercise tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise) (2a)
- BNP > 3x nl (2a)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

class 2a indication(s) for intervention in asx severe AS

(4)

A

low-risk AND:
- critical AS (i.e. AVA/<0.6cm2, MG≥60mmHg, vmax≥5) (2a)
- high-risk progression (i.e. vmax ￪ ≥0.3m/s/y) (2a)
- (+)exercise test (i.e. ￬exercise tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise) (2a)
- BNP > 3x nl (2a)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

class 1 indication(s) for intervention in asx severe AS

A
  • EF<50% (1)
  • concomitant <3 surg (1)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

class 1 indication(s) for intervention in asx severe AS

(2)

A
  • EF<50% (1)
  • concomitant <3 surg (1)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

indication(s) for intervention in moderate AS

A
  • concomitant <3 surg (2b)
    regardless of sx status

“In patients with moderate AS (Stage B) who are undergoing cardiac surgery for other indications, AVR may be considered.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

indication(s) for intervention in moderate AS

(1)

A
  • concomitant <3 surg (2b)
    regardless of sx status

“In patients with moderate AS (Stage B) who are undergoing cardiac surgery for other indications, AVR may be considered.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

indication(s) for intervention in asx moderate AS

A
  • concomitant <3 surg (2b)
    (regardless of sx status)

“In patients with moderate AS (Stage B) who are undergoing cardiac surgery for other indications, AVR may be considered.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

indication(s) for intervention in sx moderate AS

A
  • concomitant <3 surg (2b)
    (regardless of sx status)
    In reality, I think we should offer SAVR for these pts.

“In patients with moderate AS (Stage B) who are undergoing cardiac surgery for other indications, AVR may be considered.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

bp v mech

class 1 recommendation(s) for aortic valve choice

A
  • shared decision-making (1)
  • bp if warfarin contraindicated (1)

“In patients with an indication for AVR, the choice of prosthetic valve should be based on a shared decision-making process that accounts for the patient’s values and preferences and includes discussion of the indications for and risks of anticoagulant therapy and the potential need for and risks associated with valve reintervention.”
“For patients of any age requiring AVR for whom VKA anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired, a bioprosthetic AVR is recommended.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

bp v mech

class 1 recommendation(s) for aortic valve choice

(2)

A
  • shared decision-making (1)
  • bp if warfarin contraindicated (1)

“In patients with an indication for AVR, the choice of prosthetic valve should be based on a shared decision-making process that accounts for the patient’s values and preferences and includes discussion of the indications for and risks of anticoagulant therapy and the potential need for and risks associated with valve reintervention.”
“For patients of any age requiring AVR for whom VKA anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired, a bioprosthetic AVR is recommended.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

bp v mech

age-based guideline recommendation(s) for aortic valve choice

A
  • <50yo = mech (2a)
  • OR Ross in <50yo who prefer bp & have approp anatomy (2b)
  • 50-65yo = SDM/individualized (2a)
  • > 65yo = bp (2a)

assuming no contraindication to warfarin

“For patients <50 years of age who do not have a contraindication to anticoagulation and require AVR, it is reasonable to choose a mechanical aortic prosthesis over a bioprosthetic valve.”
“For patients 50 to 65 years of age who require AVR and who do not have a contraindication to anticoagulation, it is reasonable to individualize the choice of either a mechanical or bioprosthetic AVR with consideration of individual patient factors and after informed shared decision-making.”
“In patients >65 years of age who require AVR, it is reasonable to choose a bioprosthesis over a mechanical valve.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

bp v mech

guideline recommendation for aortic valve choice in <50yo

A
  • <50yo = mech (2a)
  • OR Ross in <50yo who prefer bp & have approp anatomy (2b)
  • 50-65yo = SDM/individualized (2a)
  • > 65yo = bp (2a)

assuming no contraindication to warfarin

“For patients <50 years of age who do not have a contraindication to anticoagulation and require AVR, it is reasonable to choose a mechanical aortic prosthesis over a bioprosthetic valve.”
“For patients 50 to 65 years of age who require AVR and who do not have a contraindication to anticoagulation, it is reasonable to individualize the choice of either a mechanical or bioprosthetic AVR with consideration of individual patient factors and after informed shared decision-making.”
“In patients >65 years of age who require AVR, it is reasonable to choose a bioprosthesis over a mechanical valve.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

bp v mech

guideline recommendation for aortic valve choice in 50-65yo

A
  • <50yo = mech (2a)
  • OR Ross in <50yo who prefer bp & have approp anatomy (2b)
  • 50-65yo = SDM/individualized (2a)
  • > 65yo = bp (2a)

assuming no contraindication to warfarin

“For patients <50 years of age who do not have a contraindication to anticoagulation and require AVR, it is reasonable to choose a mechanical aortic prosthesis over a bioprosthetic valve.”
“For patients 50 to 65 years of age who require AVR and who do not have a contraindication to anticoagulation, it is reasonable to individualize the choice of either a mechanical or bioprosthetic AVR with consideration of individual patient factors and after informed shared decision-making.”
“In patients >65 years of age who require AVR, it is reasonable to choose a bioprosthesis over a mechanical valve.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

bp v mech

guideline recommendation for aortic valve choice in >65yo

A
  • <50yo = mech (2a)
  • OR Ross in <50yo who prefer bp & have approp anatomy (2b)
  • 50-65yo = SDM/individualized (2a)
  • >65yo = bp (2a)

assuming no contraindication to warfarin

“For patients <50 years of age who do not have a contraindication to anticoagulation and require AVR, it is reasonable to choose a mechanical aortic prosthesis over a bioprosthetic valve.”
“For patients 50 to 65 years of age who require AVR and who do not have a contraindication to anticoagulation, it is reasonable to individualize the choice of either a mechanical or bioprosthetic AVR with consideration of individual patient factors and after informed shared decision-making.”
“In patients >65 years of age who require AVR, it is reasonable to choose a bioprosthesis over a mechanical valve.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

bp v mech

class 2b recommendation(s) for aortic valve choice

A
  • Ross procedure for <50yo who prefer bp & have approp anatomy (2b)

at a CVC

“In patients <50 years of age who prefer a bioprosthetic AVR and have appropriate anatomy, replacement of the aortic valve by a pulmonic autograft (the Ross procedure) may be considered at a Comprehensive Valve Center.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

bp v mech

class 2b recommendation(s) for aortic valve choice

(1)

A
  • Ross procedure for <50yo who prefer bp & have approp anatomy (2b)

at a CVC

“In patients <50 years of age who prefer a bioprosthetic AVR and have appropriate anatomy, replacement of the aortic valve by a pulmonic autograft (the Ross procedure) may be considered at a Comprehensive Valve Center.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)

recommendation(s) for AVI choice (TAVI v SAVR)

A
  • severe AS <65yo or life expectancy >20y with any indication for AVR: SAVR (1)
  • sx severe AS 65-80yo: SDM for either TAVI or SAVR (1)
  • sx severe AS >80yo or life expectancy <10y: TAVI (1)
  • asx severe AS ≤80yo with EF<50%: same as above for sx pts (1)
  • asx severe AS with (+)exercise test, critical, rapid/high-risk progression, elevated BNP (i.e. who meet asx 2a recommendations): SAVR (1)
  • AVR indicated & bp preferred but anatomy unsuitable for transfemoral TAVI: SAVR (1)
  • sx severe with high/prohibitive surgical risk: TAVI (1) – if predicted post-TAVI survival is >12mo with acceptable quality of life
  • sx severe AS with <12mo predicted survival after AVR OR for whome minimal improvement in quality of life is expected: SDM for palliative care (1)
  • critically ill severe: perc balloon valvuloplasty as bridge to AVR (2b)
  • BAV with non-calcified valve & ≤mild AR: balloon valvuloplasty reasonable (2b)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)

recommendation(s) for AVI choice (TAVI v SAVR)

(8)

A
  • severe AS <65yo or life expectancy >20y with any indication for AVR: SAVR (1)
  • sx severe AS 65-80yo: SDM for either TAVI or SAVR (1)
  • sx severe AS >80yo or life expectancy <10y: TAVI (1)
  • asx severe AS ≤80yo with EF<50%: same as above for sx pts (1)
  • asx severe AS with (+)exercise test, critical, rapid/high-risk progression, elevated BNP (i.e. who meet asx 2a recommendations): SAVR (1)
  • AVR indicated & bp preferred but anatomy unsuitable for transfemoral TAVI: SAVR (1)
  • sx severe with high/prohibitive surgical risk: TAVI (1) – if predicted post-TAVI survival is >12mo with acceptable quality of life
  • sx severe AS with <12mo predicted survival after AVR OR for whome minimal improvement in quality of life is expected: SDM for palliative care (1)
  • critically ill severe: perc balloon valvuloplasty as bridge to AVR (2b)
  • BAV with non-calcified valve & ≤mild AR: balloon valvuloplasty reasonable (2b)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)

age-based guideline recommendation(s) for AVI choice (TAVI v SAVR)

A
  • severe AS <65yo OR life expectancy >20y with any indication for AVR: SAVR (1)
  • sx severe AS 65-80yo: SDM (1) either TAVI or SAVR
  • sx severe AS >80yo OR life expectancy <10y: TAVI (1)

[asx severe AS ≤80yo with EF<50%: same as above for sx pts (1)]

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)

guideline recommendation(s) for AVI choice (TAVI v SAVR) in <65yo

A
  • severe AS <65yo or life expectancy >20y with any indication for AVR: SAVR (1)
  • sx severe AS 65-80yo: SDM for either TAVI or SAVR (1)
  • sx severe AS >80yo or life expectancy <10y: TAVI (1)

[asx severe AS ≤80yo with EF<50%: same as above for sx pts (1)]

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)

age-based guideline recommendation(s) for AVI choice (TAVI v SAVR) in <65yo

assuming intervention indicated

A

SAVR
(1)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)

age-based guideline recommendation(s) for AVI choice (TAVI v SAVR) in 65-80yo

assuming intervention indicated

A

SDM for either TAVI or SAVR
(1)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)

age-based guideline recommendation(s) for AVI choice (TAVI v SAVR) in >80yo

assuming intervention indicated

A

TAVI
(1)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)

guideline recommendation(s) for AVI choice (TAVI v SAVR) in 65-80yo

A
  • severe AS <65yo or life expectancy >20y with any indication for AVR: SAVR (1)
  • sx severe AS 65-80yo: SDM for either TAVI or SAVR (1)
  • sx severe AS >80yo or life expectancy <10y: TAVI (1)

[asx severe AS ≤80yo with EF<50%: same as above for sx pts (1)]

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)

guideline recommendation(s) for AVI choice (TAVI v SAVR) in >80

A
  • severe AS <65yo or life expectancy >20y with any indication for AVR: SAVR (1)
  • sx severe AS 65-80yo: SDM for either TAVI or SAVR (1)
  • sx severe AS >80yo or life expectancy <10y: TAVI (1)

[asx severe AS ≤80yo with EF<50%: same as above for sx pts (1)]

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)

guideline recommendation(s) for AVI choice (TAVI v SAVR) in any age with life expectancy <10y

A
  • severe AS <65yo or life expectancy >20y with any indication for AVR: SAVR (1)
  • sx severe AS 65-80yo: SDM for either TAVI or SAVR (1)
  • sx severe AS >80yo or life expectancy <10y: TAVI (1)

[asx severe AS ≤80yo with EF<50%: same as above for sx pts (1)]

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)

class 2b recommendation(s) for aortic valve intervention in critically ill severe AS

A
  • critically ill severe: perc balloon valvuloplasty as bridge to AVR (2b)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)

class 2b recommendation(s) for aortic valve intervention in non-calcified BAV AS

A
  • BAV with non-calcified valve & ≤mild AR: balloon valvuloplasty reasonable (2b)

AHA ACHD guideline

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)

class 2b recommendation(s) for aortic valve intervention in non-calcified BAV AS

(1)

A
  • BAV with non-calcified valve & ≤mild AR: balloon valvuloplasty reasonable (2b)

AHA ACHD guideline

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)

class 2b recommendation(s) for aortic valve intervention in critically ill severe AS

(1)

A
  • critically ill severe: perc balloon valvuloplasty as bridge to AVR (2b)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

indication(s) for AVR in mixed/combined AS & AR

A
  • +sx + peak transvalvular jet v≥4.0m/s OR mean grad≥40mmHg: AVR (1)
  • asx + peak transvalvular jet v≥4.0m/s AND LVEF<50%: SAVR (1)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

bp v mech

aortic valve choice if warfarin contraindicated

A

bp
(1)

“In patients with an indication for AVR, the choice of prosthetic valve should be based on a shared decision-making process that accounts for the patient’s values and preferences and includes discussion of the indications for and risks of anticoagulant therapy and the potential need for and risks associated with valve reintervention.”
“For patients of any age requiring AVR for whom VKA anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired, a bioprosthetic AVR is recommended.”

56
Q

bp v mech

aortic valve choice in <50yo

assuming no contraindication to warfarin

A

mech
(2a)
OR Ross in <50yo who prefer bp & have approp anatomy (2b)

“For patients <50 years of age who do not have a contraindication to anticoagulation and require AVR, it is reasonable to choose a mechanical aortic prosthesis over a bioprosthetic valve.”
“For patients 50 to 65 years of age who require AVR and who do not have a contraindication to anticoagulation, it is reasonable to individualize the choice of either a mechanical or bioprosthetic AVR with consideration of individual patient factors and after informed shared decision-making.”
“In patients >65 years of age who require AVR, it is reasonable to choose a bioprosthesis over a mechanical valve.”

57
Q

bp v mech

aortic valve choice in 50-65yo

assuming no contraindication to warfarin

A

SDM/individualized
(2a)

for either bp or mech

“For patients <50 years of age who do not have a contraindication to anticoagulation and require AVR, it is reasonable to choose a mechanical aortic prosthesis over a bioprosthetic valve.”
“For patients 50 to 65 years of age who require AVR and who do not have a contraindication to anticoagulation, it is reasonable to individualize the choice of either a mechanical or bioprosthetic AVR with consideration of individual patient factors and after informed shared decision-making.”
“In patients >65 years of age who require AVR, it is reasonable to choose a bioprosthesis over a mechanical valve.”

58
Q

bp v mech

aortic valve choice in >65yo

assuming no contraindication to warfarin

A

bp
(2a)

“For patients <50 years of age who do not have a contraindication to anticoagulation and require AVR, it is reasonable to choose a mechanical aortic prosthesis over a bioprosthetic valve.”
“For patients 50 to 65 years of age who require AVR and who do not have a contraindication to anticoagulation, it is reasonable to individualize the choice of either a mechanical or bioprosthetic AVR with consideration of individual patient factors and after informed shared decision-making.”
“In patients >65 years of age who require AVR, it is reasonable to choose a bioprosthesis over a mechanical valve.”

59
Q

bp v mech

aortic valve choice in <50yo who prefer bp & have approp anatomy

at a CVC

A

Ross
(2b)

“In patients <50 years of age who prefer a bioprosthetic AVR and have appropriate anatomy, replacement of the aortic valve by a pulmonic autograft (the Ross procedure) may be considered at a Comprehensive Valve Center.”

60
Q

SAVR v TAVI

AVI choice in: severe AS <65yo or life expectancy >20y with any indication for AVR

A

in pts for whom bp is approp

SAVR
(1)

61
Q

SAVR v TAVI

AVI choice in: sx severe AS 65-80yo

A

in pts for whom bp is approp

SDM/individualized
(1)

SDM for either TAVI or SAVR

62
Q

SAVR v TAVI

AVI choice in: sx severe AS >80yo or life expectancy <10y

A

in pts for whom bp is approp

TAVI
(1)

63
Q

SAVR v TAVI

AVI choice in: asx severe AS ≤80yo with EF<50%

A

in pts for whom bp is approp

same as above for sx pts (1):
- severe <65yo or life expectancy >20y with any indication for AVR: SAVR (1)
- sx severe 65-80yo: SDM for either TAVI or SAVR (1)
- sx severe >80yo or life expectancy <10y: TAVI (1)

64
Q

SAVR v TAVI

AVI choice in: asx severe AS with (+)exercise test, critical, rapid/high-risk progression, elevated BNP (i.e. who meet asx 2a AVR recommendations)

A

in pts for whom bp is approp

SAVR
(1)

65
Q

SAVR v TAVI

AVI choice in: AVR indicated & bp preferred but anatomy unsuitable for transfemoral TAVI

A

in pts for whom bp is approp

SAVR
(1)

66
Q

SAVR v TAVI

AVI choice in: sx severe AS with high/prohibitive surgical risk
if predicted post-TAVI survival is >12mo with acceptable quality of life

A

in pts for whom bp is approp

TAVI
(1)

67
Q

AVI choice in: sx severe AS with <12mo predicted survival after AVR OR for whom minimal improvement in quality of life is expected

A

in pts for whom bp is approp

SDM for palliative care
(1)

68
Q

AVI choice in: critically ill severe AS

A

in pts for whom bp is approp

perc balloon valvuloplasty as bridge to AVR
(2b)

69
Q

SAVR v TAVI

AVI choice in: severe AS <65yo or life expectancy >20y with any indication for AVR

A

in pts for whom bp is approp

SAVR
(1)

70
Q

SAVR v TAVI

AVI choice in: sx severe AS 65-80yo

A

in pts for whom bp is approp

SDM/individualized
(1)

SDM for either TAVI or SAVR

71
Q

SAVR v TAVI

AVI choice in: sx severe AS >80yo or life expectancy <10y

A

in pts for whom bp is approp

TAVI
(1)

72
Q

SAVR v TAVI

AVI choice in: sx severe AS >80yo

A

in pts for whom bp is approp

TAVI
(1)

73
Q

SAVR v TAVI

AVI choice in: sx severe AS life expectancy <10y

A

in pts for whom bp is approp

TAVI
(1)

74
Q

SAVR v TAVI

AVI choice in: asx severe AS ≤80yo with EF<50%

A

in pts for whom bp is approp

same as above for sx pts (1):
- severe <65yo or life expectancy >20y with any indication for AVR: SAVR (1)
- sx severe 65-80yo: SDM for either TAVI or SAVR (1)
- sx severe >80yo or life expectancy <10y: TAVI (1)

75
Q

SAVR v TAVI

AVI choice in: asx mixed/combined AS & AR with peak transvalvular jet v≥4.0m/s AND LVEF<50%

A

SAVR
(1)

76
Q

vmax in mild AS

A

2-3

m/s

77
Q

vmax in mod AS

A

3-4

m/s

78
Q

vmax in sev AS

A

≥4

m/s

79
Q

vmax in crit AS

A

≥5

m/s

80
Q

AVA in mild AS

A

≥1.5

cm2

81
Q

AVA in mod AS

A

<1.5
(1.0-1.5)

cm2

82
Q

AVA in sev AS

A

<1.0

cm2

83
Q

AVA in crit AS

A

<0.6

cm2

84
Q

mean gradient in mild AS

A

<20

mmHg

85
Q

mean gradient in mod AS

A

20-40

mmHg

86
Q

mean gradient in sev AS

A

≥40

mmHg

87
Q

mean gradient in crit AS

A

≥60

mmHg

88
Q

aortic valve

vmax = 2-3 m/s

A

mild AS

89
Q

aortic valve

vmax = 3-4 m/s

A

mod AS

90
Q

aortic valve

vmax ≥4 m/s

A

sev AS

91
Q

aortic valve

vmax ≥5 m/s

A

crit AS

92
Q

AVA ≥1.5 cm2

<2.5

A

mild AS

93
Q

AVA = 1.0-1.5 cm2

A

mod AS

94
Q

AVA = <1.0 cm2

A

sev AS

95
Q

AVA = <0.6 cm2

A

crit AS

96
Q

aortic valve

mean gradient <20 mmHg

A

mild AS

97
Q

aortic valve

mean gradient = 20-40 mmHg

A

mod AS

98
Q

aortic valve

mean gradient ≥40 mmHg

A

sev AS

99
Q

aortic valve

mean gradient ≥60 mmHg

A

crit AS

100
Q

Is degenerative or rheumatic AS more common?

A

degenerative

101
Q

pattern of dz/pathology underlying degenerative AS

A

leaflet sclerosis (not fusion)

102
Q

pattern of dz/pathology underlying rheumatic AS

A

commissural fusion
(a/w △ or “fish-mouth”-shaped orifice)

103
Q

What constitutes a positive exercise test (for AS)?

A
  • ￬exercise tolerance
  • ￬SBP≥10mmHg from baseline -> peak exercise
104
Q

YES
severe + sx = indicated
(1)
incl low-flow, low-gradient (1)

“1. In adults with severe high-gradient AS (Stage D1) and symptoms of exertional dyspnea, HF, angina, syncope, or presyncope by history or on exercise testing, AVR is indicated.” (1)
“4. In symptomatic patients with low-flow, low gradient severe AS with reduced LVEF (Stage D2), AVR is recommended.” (1)
“5. In symptomatic patients with low-flow, low gradient severe AS with normal LVEF (Stage D3), AVR is recommended if AS is the most likely cause of symptoms.” (1)

A

indication(s) for intervention in sx severe AS

105
Q

mgmt of severe + sx AS = indicated
(1)

“1. In adults with severe high-gradient AS (Stage D1) and symptoms of exertional dyspnea, HF, angina, syncope, or presyncope by history or on exercise testing, AVR is indicated.” (1)

A

indication(s) for intervention in sx high-gradient (usual) severe AS

106
Q

YES
severe + sx = indicated
incl low-flow, low-gradient with:
- reduced EF (1)
- normal EF but AS is the most likely cause of sxs (1)

“4. In symptomatic patients with low-flow, low gradient severe AS with reduced LVEF (Stage D2), AVR is recommended.” (1)
“5. In symptomatic patients with low-flow, low gradient severe AS with normal LVEF (Stage D3), AVR is recommended if AS is the most likely cause of symptoms.” (1)

A

indication(s) for intervention in sx low-flow, low-gradient severe AS

107
Q
  • EF<50% (1)
  • concomitant <3 surg (1)
  • progressive ￬ EF on 3 studies to <60% (2b)

OR if low-risk AND:
- critical AS (i.e. AVA/<0.6cm2, MG≥60mmHg, vmax≥5) (2a)
- (+)exercise test (i.e. ￬exercise tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise) (2a)
- vmax incr ≥0.3m/s/y (i.e. high-risk progression) (2a)
- BNP > 3x nl (2a)

A

indication(s) for intervention in asx severe AS

108
Q
  • EF<50% (1)
  • concomitant <3 surg (1)
  • progressive ￬ EF on 3 studies to <60% (2b)

OR if low-risk AND:
- critical AS (i.e. AVA/<0.6cm2, MG≥60mmHg, vmax≥5) (2a)
- (+)exercise test (i.e. ￬exercise tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise) (2a)
- vmax incr ≥0.3m/s/y (i.e. high-risk progression) (2a)
- BNP > 3x nl (2a)

A

indication(s) for intervention in asx severe AS

(7)

109
Q
  • progressive ￬ EF on 3 studies to <60% (2b)

OR if low-risk AND:
- critical AS (i.e. AVA<0.6cm2, MG≥60mmHg, vmax≥5) (2a)
- (+)exercise test (i.e. ￬exercise tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise) (2a)
- vmax incr ≥0.3m/s/y (i.e. high-risk progression) (2a)
- BNP > 3x nl (2a)

A

class 2 indication(s) for intervention in asx severe AS

110
Q
  • progressive ￬ EF on 3 studies to <60% (2b)

OR if low-risk AND:
- critical AS (i.e. AVA<0.6cm2, MG≥60mmHg, vmax≥5) (2a)
- (+)exercise test (i.e. ￬exercise tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise) (2a)
- vmax incr ≥0.3m/s/y (i.e. high-risk progression) (2a)
- BNP > 3x nl (2a)

A

class 2 indication(s) for intervention in asx severe AS

(5)

111
Q
  • progressive ￬ EF on 3 studies to <60% (2b)
A

class 2b indication(s) for intervention in asx severe AS

112
Q
  • progressive ￬ EF on 3 studies to <60% (2b)
A

class 2b indication(s) for intervention in asx severe AS

(1)

113
Q

low-risk AND:
- (+)exercise test (i.e. ￬exercise tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise) (2a)
- critical AS (i.e. AVA<0.6cm2, MG≥60mmHg, vmax≥5) (2a)
- BNP > 3x nl (2a)
- vmax incr ≥0.3m/s/y (i.e. high-risk progression) (2a)

A

class 2a indication(s) for intervention in asx severe AS

114
Q

low-risk AND:
- (+)exercise test (i.e. ￬exercise tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise) (2a)
- critical AS (i.e. AVA<0.6cm2, MG≥60mmHg, vmax≥5) (2a)
- BNP > 3x nl (2a)
- vmax incr ≥0.3m/s/y (i.e. high-risk progression) (2a)

A

class 2a indication(s) for intervention in asx severe AS

(4)

115
Q
  • EF<50% (1)
  • concomitant <3 surg (1)
A

class 1 indication(s) for intervention in asx severe AS

116
Q
  • EF<50% (1)
  • concomitant <3 surg (1)
A

class 1 indication(s) for intervention in asx severe AS

(2)

117
Q

in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)

recommendation(s) for AVI choice (TAVI v SAVR) for sx severe AS in BAV

A

TAVI can be considered @ CVC
(2b)

“2. In patients with BAV and symptomatic, severe AS, TAVI may be considered as an alternative to SAVR after consideration of patient-specific procedural risks, values, trade-offs, and preferences, and when the surgery is performed at a Comprehensive Valve Center.”

118
Q

cardiac CT aortic valve calcium score indicative of low-flow, low-gradient AS (regardless of EF)

A

♀>1400 / ♂>2000

119
Q

low-risk TAVI trials

A

Evolut Low-Risk:
<3% STS risk & μ=74yo
- TAVI non-inferior for 1° endpoint = 2y composite of death or disabling stroke
- superior for 2° endpoints = 30d disabling stroke,bleeding cx,AKI,afib
- (but ￪ mod+ AR,PPM 17% v 6%)
- ￬ AV gradient @ 1y (8.6 v 11.2 mmHg)

PARTNER 3:
<4% STS risk & μ=73yo
TAVI non-inferior AND superior for:
- 1° endpoint = 1y composite of death,stroke, rehosp
- 2° endpoints = 30d stroke,death,LOS,”poor tx outcome”
- (no ∆ in major vasc cxs, PPM, mod+ PVR)
- ￪ PVL: mod+ @ 30d = 0.8% v 0%; mild @ 1y = 30% v 2%

120
Q

Evolut Low-Risk

A

<3% STS risk & μ=74yo
- TAVI non-inferior for 1° endpoint = 2y composite of death or disabling stroke
- superior for 2° endpoints = 30d disabling stroke,bleeding cx,AKI,afib
- (but ￪ mod+ AR,PPM 17% v 6%)
- ￬ AV gradient @ 1y (8.6 v 11.2 mmHg)

121
Q

PARTNER 3

A

<4% STS risk & μ=73yo
TAVI non-inferior AND superior for:
- 1° endpoint = 1y composite of death,stroke, rehosp
- 2° endpoints = 30d stroke,death,LOS,”poor tx outcome”
- (no ∆ in 30d major vasc cxs, PPM, mod+ PVR)
- ￪ PVL: mod+ @ 30d = 0.8% v 0%; mild @ 1y = 30% v 2%

122
Q

TAVI v SAVR in low-risk

A
  • non-inferior for composite outcomes in both trials (PARTNER 3 & Evolut Low-Risk)
  • ￬ 30d stroke/disabling stroke
  • ￪ / ∅∆ PPM, mod+ AR
123
Q

differences/pros&cons between balloon-expandable v self-expanding TAVI valves

A

balloon-expandable = SAPIEN3
- bovine
- intra-annular
- annulus size 16-28mm (valves 20-29mm)
- 14Fr sheath (except 16Fr for 29mm)
- NOT re-capturable
- lower profile (better for coronary height/access)
- ￪annular rupture (slightly) with heavily/circumferentially calcified valves
- slightly easier to implant

self-expanding = Evolut PRO
- porcine - supra-annular (so can fit a larger fxnal size in a smaller annulus or valve-in-valve)
- annulus size 18-30mm (valves 23-34mm)
- 18Fr sheath
- re-capturable
- higher profile (worse for coronary height/access)
- ￪PPM rate
- slightly better flow dynamics (preferred for small annulus OR valve-in-valve with borderline size for pt-prosth mismatch)

(per Kim & interwebs)

124
Q

anatomic criteria for TAVI candidacy

A
  • access vessels (CFAs) ≥6mm
  • coronary height ≥10mm (with lg/non-effaced sinuses)
  • sinus diameter ≥30mm
    ± annulus size 18-29mm ?
125
Q

TAVI procedure steps

A
  1. bilat CFA access (6Fr R, 10Fr L), + R CFV access
  2. transvenous pacing wire to RV (& test it)
  3. heparin (ACT≥250)
  4. 5Fr marker pigtail up the R CFA to aortic root (basal portion of NCC)
  5. aortogram (achieve linear alignment of the three cusps i.e. coplanar image projection)
  6. get to root with J-wire ￫ 6Fr exchange catheter ￫ cross native valve with straight wire ￫ J-wire & angled pigtail stay sin ventricle
  7. upsize the L CFA & insert the TAVI sheath
  8. cross the native valve with the TAVI delivery system (may use LAO view to get into the arch) & then position with coplanar view to target implant depth of 3mm
  9. rapid pacing + deploy the valve (can stop at 2/3 deployed to check, can still recapture)
  10. stop pacing
  11. aortogram + TTE to check valve

  • Edwards SAPIEN IFU: “Perform a supra-aortic angiogram with fluoroscopic view perpendicular to the aortic valve.”
  • Houston Methodist step-by-step guide: “A series of aortograms, often with rapid right ventricular pacing to allow adequate visualization using dilute contrast, is performed at an implant angle determined from the CTA to verify linear alignment of the three cusps (coplanar image projection).”
  • _Edwards Commander TAVR demo: _
  • “If we want to achieve that 80/20 result which is 80% of this valve sits in the aorta & 20% in the ventricle – because all the shortening comes from the ventricle end – we want to sit this 3mm marker somewhere on the bottom of this pigtail, which is buried down here in the annulus here.”
  • “For Edwards, they want us to teach 80 20. Yeah, most places that I go to, I’ll be honest, shoot for 90/10.”
  • “Pace at 180, okay, looking for 1:1, our SBP≤50 & pulse pressure<10.”
126
Q

size of micropuncture kit sheath

A

5Fr

127
Q

minimum ACT for TAVI

A

250

128
Q

aortogram/fluoro view needed to correctly position TAVI

A

linear alignment of the three cusps i.e. coplanar image projection

  • Edwards SAPIEN IFU: “Perform a supra-aortic angiogram with fluoroscopic view perpendicular to the aortic valve.”
  • Houston Methodist step-by-step guide: “A series of aortograms, often with rapid right ventricular pacing to allow adequate visualization using dilute contrast, is performed at an implant angle determined from the CTA to verify linear alignment of the three cusps (coplanar image projection).”
129
Q

aortogram/fluoro view needed to cross the arch

A

LAO (“opens up the arch”)

  • Edwards SAPIEN IFU: “Perform a supra-aortic angiogram with fluoroscopic view perpendicular to the aortic valve.”
  • Houston Methodist step-by-step guide: “A series of aortograms, often with rapid right ventricular pacing to allow adequate visualization using dilute contrast, is performed at an implant angle determined from the CTA to verify linear alignment of the three cusps (coplanar image projection).”
130
Q

goal rapid pacing for deployment

A

HR=180
1:1 capture
SBP≤50
PP<10

131
Q

Where & what structures are at risk around the aortic annulus?

A
  • bundle of His @ membranous septum @ R-non commissure triangle
  • ant leaflet MV @ NCC>LCC (AMC)
132
Q

Where is the R trigone with respect to the aortic valve?

A

NCC nadir

133
Q

What is another name for the R trigone?

A

posteromedial
(under NCC)

134
Q

characteristics of the R trigone

A
  • R trigone (under NCC) + membranous septum (R-non interleaflet triangle) = central fibrous body between AV/MV/TV
  • R trigone + L trigone + in between = aortomitral curtain (AMC)
  • aka posteromedial trigone
  • larger, firmer (v L trigone)
135
Q

characteristics of the L trigone

A
  • R trigone + L trigone + in between = aortomitral curtain (AMC)
  • aka anterolateral trigone
  • smaller, less firm (v R trigone) “L = lesser”

oral boards (15 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions