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oral boards > AHA: MS > Flashcards

AHA: MS Flashcards

1
Q

bp v mech

class 1 recommendation(s) for mitral valve choice

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

“For patients who require heart valve replacement, 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 valve replacement for whom anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired, a bioprosthetic valve is recommended.”

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2
Q

bp v mech

class 1 recommendation(s) for mitral valve choice

(2)

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

“For patients who require heart valve replacement, 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 valve replacement for whom anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired, a bioprosthetic valve is recommended.”

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3
Q

bp v mech

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

A
  • <65yo = mech (2a)
  • ≥65yo = bp (2a)

assuming no contraindication to warfarin

“For patients <65 years of age who have an indication for MVR, do not have a contraindication to anticoagulation, and are unable to undergo MVRx, it is reasonable to choose a mechanical prosthesis over a bioprosthetic valve.”
“For patients ≥65 years of age who require MVR and are unable to undergo MVRx, it is reasonable to choose a bioprosthesis over a mechanical valve.”

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4
Q

bp v mech

mitral valve choice if warfarin contraindicated

A

bp (1)

“For patients who require heart valve replacement, 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 valve replacement for whom anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired, a bioprosthetic valve is recommended.”

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5
Q

bp v mech

mitral valve choice in <65yo

assuming no contraindication to warfarin

A

mech
(2a)

“For patients <65 years of age who have an indication for MVR, do not have a contraindication to anticoagulation, and are unable to undergo MVRx, it is reasonable to choose a mechanical prosthesis over a bioprosthetic valve.”
“For patients ≥65 years of age who require MVR and are unable to undergo MVRx, it is reasonable to choose a bioprosthesis over a mechanical valve.”

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6
Q

bp v mech

mitral valve choice in ≥65yo

assuming no contraindication to warfarin

A

bp
(2a)

“For patients <65 years of age who have an indication for MVR, do not have a contraindication to anticoagulation, and are unable to undergo MVRx, it is reasonable to choose a mechanical prosthesis over a bioprosthetic valve.”
“For patients ≥65 years of age who require MVR and are unable to undergo MVRx, it is reasonable to choose a bioprosthesis over a mechanical valve.”

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7
Q

bp v mech

mitral valve choice in 50-65yo

assuming no contraindication to warfarin

A

mech
(2a)

“For patients <65 years of age who have an indication for MVR, do not have a contraindication to anticoagulation, and are unable to undergo MVRx, it is reasonable to choose a mechanical prosthesis over a bioprosthetic valve.”
“For patients ≥65 years of age who require MVR and are unable to undergo MVRx, it is reasonable to choose a bioprosthesis over a mechanical valve.”

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8
Q

vmax in mild MS

A

<5†

m/s

†AHA classifies >5-10 as severe & ≤5 as not

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9
Q

vmax in mod MS

A

5-10†

m/s

†AHA classifies >5-10 as severe & ≤5 as not

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10
Q

vmax in sev MS

A

>10†

m/s

†AHA classifies >5-10 as severe & ≤5 as not

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11
Q

AVA in mild MS

A

> 1.5†

cm2

†AHA classifies ≤1.5 as severe & <1.5 as not

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12
Q

AVA in mod MS

A

1.0-1.5†

cm2

†AHA classifies ≤1.5 as severe & <1.5 as not

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13
Q

AVA in sev MS

A

<1.0†

cm2

†AHA classifies ≤1.5 as severe & <1.5 as not

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14
Q

mean gradient in mild MS

A

<5†

mmHg

†AHA classifies >5-10 as severe & ≤5 as not

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15
Q

mean gradient in mod MS

A

5-10†

mmHg

†AHA classifies >5-10 as severe & ≤5 as not

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16
Q

mean gradient in sev MS

A

> 10†

mmHg

†AHA classifies >5-10 as severe & ≤5 as not

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17
Q

mitral valve

vmax <5 m/s

A

mild MS†

†not included in AHA

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18
Q

mitral valve

vmax = 5-10 m/s

A

mod MS†

†not included in AHA

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19
Q

mitral valve

vmax >10 m/s

A

sev MS†

†not included in AHA

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20
Q

MVA >1.5 cm2

<3.0

A

mild MS†

†AHA classifies ≤1.5 as severe & <1.5 as not

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21
Q

MVA = 1.0-1.5 cm2

A

mod MS†

†AHA classifies ≤1.5 as severe & <1.5 as not

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22
Q

MVA = <1.0 cm2

A

sev MS†

†AHA classifies ≤1.5 as severe & <1.5 as not

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23
Q

mitral valve

mean gradient <5 mmHg

A

mild MS†

†AHA classifies >5-10 as severe & ≤5 as not

24
Q

mitral valve

mean gradient = 5-10 mmHg

A

mod MS†

†AHA classifies >5-10 as severe & ≤5 as not

25
Q

mitral valve

mean gradient >10 mmHg

A

sev MS†

†AHA classifies >5-10 as severe & ≤5 as not

26
Q

Is degenerative or rheumatic MS more common?

27
Q

PLA ⇒ pulm edema

28
Q

PASP in mild MS

PA systolic pressure

A

<30†

mmHg

†AHA classifies “WNL @ rest” as up to mild - mod & does not specify values for sev

29
Q

PASP in mod MS

PA systolic pressure

A

30-50†

mmHg

†AHA classifies “WNL @ rest” as up to mild - mod & does not specify values for sev

30
Q

PASP in sev MS

PA systolic pressure

A

>50†

mmHg

†AHA classifies “WNL @ rest” as up to mild - mod & does not specify values for sev

31
Q

mitral valve

dPt1/2 <150 ms

diastolic PHT (pressure half-time)

A

mild MS†

†AHA classifies ≥150 as severe & <150 as not

32
Q

mitral valve

dPt1/2 = 150-200 ms

diastolic PHT (pressure half-time)

A

mod MS†

†AHA classifies ≥150 as severe & <150 as not

33
Q

mitral valve

dPt1/2 > 200 ms

diastolic PHT (pressure half-time)

A

sev MS†

†AHA classifies ≥150 as severe & <150 as not

34
Q

PASP <30 mmHg

PA systolic pressure

A

mild MS†

†AHA classifies “WNL @ rest” as up to mild - mod & does not specify values for sev

35
Q

PASP = 30-50 mmHg

PA systolic pressure

A

mod MS†

†AHA classifies “WNL @ rest” as up to mild - mod & does not specify values for sev

36
Q

PASP >50 mmHg

PA systolic pressure

A

sev MS†

†AHA classifies “WNL @ rest” as up to mild - mod & does not specify values for sev

37
Q

dPt1/2 in mild MS

diastolic PHT (pressure half-time)

A

mitral valve

<150†

ms

†AHA classifies ≥150 as severe & <150 as not

38
Q

dPt1/2 in mod MS†

diastolic PHT (pressure half-time)

A

mitral valve

150-200†

ms

†AHA classifies ≥150 as severe & <150 as not

39
Q

dPt1/2 in sev MS

diastolic PHT (pressure half-time)

A

mitral valve

> 200†

ms

†AHA classifies ≥150 as severe & <150 as not

40
Q

indication(s) for intervention in severely sx, severe non-rheumatic calcific MS

A

MVI “may be considered only after” discussing high procedural risks (2b)

MVI = mitral valve intervention (NOS)

“In severely symptomatic patients (NYHA class III or IV) with severe MS (MVA≤1.5cm2, Stage D) attributable to extnesive mitral annual calcification, valve intervention may be considered only after discussion of the high procedural risk and the individual patient’s preferences and values.” (2b)

41
Q

indication(s) for intervention in non-rheumatic calcific MS

A

basically none, only:
severely sx (NYHA III-IV), severe MS ⇒ MVI “may be considered only after” discussing high procedural risks (2b)

MVI = mitral valve intervention (NOS)

“In severely symptomatic patients (NYHA class III or IV) with severe MS (MVA≤1.5cm2, Stage D) attributable to extnesive mitral annual calcification, valve intervention may be considered only after discussion of the high procedural risk and the individual patient’s preferences and values.” (2b)

42
Q

Wilkins score indicating favorable mitral valve morphology

A

≤8

https://drive.google.com/file/d/1-UrIQilWndc3quVWMxYzq96wsuuprNXQ/view

43
Q

Wilkins score components

A

leaflet: mobility, thickening, calcification + subvalvular thickening
(graded 1-4 x4 = range 4-16)

https://drive.google.com/file/d/1-UrIQilWndc3quVWMxYzq96wsuuprNXQ/view

44
Q

indication(s) for intervention in asx moderate rheumatic MS

45
Q

indication(s) for intervention in asx severe rheumatic MS

A
  • PASP>50 ⇒ PMBC (2a)
  • new afib ⇒ PMBC (2b)

at a CVC

46
Q

indication(s) for intervention in sx moderate rheumatic MS

A

MVA>1.5 (i.e. mod MS) + NYHA ≥II + “hemodynamically significant” during exercise, i.e. PAWP>25 OR mean grad>15 ⇒ PMBC (2b)

at a CVC

“In symptomatic patients (NYHA class II, III, or IV) with rheumatic MS and an mitral valve area >1.5 cm2, if there is evidence of hemodynamically significant rheumatic MS on the basis of a pulmonary artery wedge pressure >25 mmHg or a mean mitral valve gradient >15 mmHg during exercise, PMBC may be considered if it can be performed at a Comprehensive Valve Center.”

47
Q

indication(s) for intervention in sx severe rheumatic MS

A
  • NYHA ≥II + <mod(2+) MR + no LA thrombus + good anatomy ⇒ PMBC at a CVC (1)
  • NYHA ≥III + concomitant <3 surg OR PMBC not an option (d/t already failed, not an anatomic candidate, or not available) ⇒ MVR/x (1)
  • NYHA ≥III + not candidates or high-risk for surgery ⇒ PMBC at a CVC (2b)

“1. In symptomatic patients (NYHA class II, III, or IV) with severe rheumatic MS (mitral valve area ≤1.5 cm2, Stage D) and favorable valve morphology with less than moderate (2+) MR in the absence of LA thrombus, PMBC is recommended if it can be performed at a Comprehensive Valve Center.” (1)
“2. In severely symptomatic patients (NYHA class III or IV) with severe rheumatic MS (mitral valve area ≤1.5 cm2, Stage D) who 1) are not candidates for PMBC, 2) have failed a previous PMBC, 3) require other cardiac procedures, or 4) do not have access to PMBC, mitral valve surgery (repair, commissurotomy, or valve replacement) is indicated.” (1)
“6. In severely symptomatic patients (NYHA class III or IV) with severe rheumatic MS (mitral valve area ≤1.5 cm2, Stage D) who have a suboptimal valve anatomy and who are not candidates for surgery or are at high risk for surgery, PMBC may be considered if it can be performed at a Comprehensive Valve Center.”

48
Q

mgmt of asx severe rheumatic MS with PASP>50

+ <mod(2+) MR + no LA thrombus + good anatomy

A

PMBC
(2a)

at a CVC

49
Q

mgmt of asx severe rheumatic MS with new afib

+ <mod(2+) MR + no LA thrombus + good anatomy

A

PMBC
(2b)

at a CVC

50
Q

mgmt of moderate rheumatic MS (MVA>1.5) + NYHA ≥II + “hemodynamically significant” during exercise, i.e. PAWP>25 OR mean grad>15

A

PMBC
(2b)

at a CVC

“In symptomatic patients (NYHA class II, III, or IV) with rheumatic MS and an mitral valve area >1.5 cm2, if there is evidence of hemodynamically significant rheumatic MS on the basis of a pulmonary artery wedge pressure >25 mmHg or a mean mitral valve gradient >15 mmHg during exercise, PMBC may be considered if it can be performed at a Comprehensive Valve Center.”

51
Q

mgmt of severe rheumatic MS + NYHA ≥II + <mod(2+) MR + no LA thrombus + good anatomy

A

PMBC
(1)

at a CVC

“1. In symptomatic patients (NYHA class II, III, or IV) with severe rheumatic MS (mitral valve area ≤1.5 cm2, Stage D) and favorable valve morphology with less than moderate (2+) MR in the absence of LA thrombus, PMBC is recommended if it can be performed at a Comprehensive Valve Center.” (1)

52
Q

mgmt of severe rheumatic MS + NYHA ≥III + concomitant <3 surg OR PMBC not an option (d/t already failed, not an anatomic candidate, or not available)

A

MVR/x
(1)

“2. In severely symptomatic patients (NYHA class III or IV) with severe rheumatic MS (mitral valve area ≤1.5 cm2, Stage D) who 1) are not candidates for PMBC, 2) have failed a previous PMBC, 3) require other cardiac procedures, or 4) do not have access to PMBC, mitral valve surgery (repair, commissurotomy, or valve replacement) is indicated.” (1)

53
Q

mgmt of severe rheumatic MS + NYHA ≥III + not candidates or high-risk for surgery

A

PMBC
(2b)

at a CVC

“6. In severely symptomatic patients (NYHA class III or IV) with severe rheumatic MS (mitral valve area ≤1.5 cm2, Stage D) who have a suboptimal valve anatomy and who are not candidates for surgery or are at high risk for surgery, PMBC may be considered if it can be performed at a Comprehensive Valve Center.”

54
Q

What does PMBC mean?

A

percutaneous mitral balloon commissurotomy

55
Q

further testing/evaluation of moderate MS with exertional sxs

A

exercise testing
(1)

to measure MV gradient and/or PAWP

“1. In patients with rheumatic MS and a discrepancy between resting echocardiographic findings and clinical symptoms, exercise testing with Doppler or invasive hemodynamic assessment is recommended to evaluate symptomatic response, exercise capacity, and the response of the mean mitral gradient and pulmonary artery pressure.”

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