Aortic Valve Flashcards
Do you need to do AVR if AI with ascending aneurysm?
No, correcting STJ dilation will reduce AI. Unlikely for severe AI, but can normally downgrade AI by 2 grades (4+ to 2+)
Weaning off CPB after AVR and increased CVOP, hypotension, decreased SvO2.
What are potential causes and treatment?
Acute right heart failure
1. Air emboli to RCA - back on CPB and perfuse with higher MAPs
2. Obstruction of RCA with valve - back on pump, XC, bypass RCA with SVG
3. Shearing of ostial plaque, plaque embolization - bypass RCA
4. Coronary artery dissection with handheld cardioplegia catheters - bypass RCA
How do you initiate ACP?
Come down on flows, XC innominate, resume flow at 5 cc/kg, uptitrate to radial MAP 50-70mmHg
How do you do an AVR ascending/hemiarch if you can’t clamp
Cool to EEG silence, clamp innominate and initiate ACP, resect ascending and perform open distal anastomosis. De-air aorta, clamp the graft, rewarm after 5 minutes.
Run retrograde cardioplegia during circ arrest. Complete AVR while rewarming.
Come off bypass and dark blood behind heart in a case with ante/retro plegia. Diagnosis and tx?
Coronary sinus injury (during cannulation or if infusion >40mmHg)
Go back on bypass, empty heart.
Repair (5-0 prolene if can see discrete injury, epicardial bovine pericardial patch if cannot identify laceration, GoreTex baffle from epicardium to RA if complete blowout of sinus)
Criteria for severe AS
Severe:
- Aortic Vmax ≥ 4 m/s or mean ∆P ≥ 40 mmHg
- AVA usually 1.0 cm2 (or AVAi 0.6 cm2/m2) but not required
- Dimensionless index 0.25
Very severe: Aortic Vmax ≥ 5 m/s or mean ∆P ≥ 60 mmHg
What is paradoxical low-flow AS?
AVA ≤1.0 cm2 (indexed AVA ≤0.6 cm2/m2) with an aortic Vmax <4 m/s or mean ∆P <40 mm Hg AND stroke volume index <35 mL/m2 measured when patient is normotensive (systolic blood pressure <140 mm Hg)
If HTN –> increased afterload –> less stroke volume and so less gradient
Stented vs stentless valve mode of failure?
Stented pericardial valves fail by stenosis and last longer than porcine valves
Stentless valves fail due to insufficiency; fallen out of favor because of early deterioration
Porcine vs Bovine valve mode of failure?
Per DRJ: Bovine valves have slow progressive failure over time vs porcine which work well for long time and then quickly fail at end
How does life expectancy affect decisions on AVR?
Life expectancy >20 years (and age <65) –> SAVR
Expectancy <10 years –> TAVR
< 1 year –> palliative care
What are the PPM Cutoffs?
EOAI >0.85 → small aortic root
EOAI 0.65–0.85 → Moderate patient prosthesis mismatch (PPM
EOAI < 0.65 → severe PPM
Describe the Konno Root enlargement
extend vertical aortotomy through R sinus and into RVOT, incise ventricular septum to the L of conduction system (Avoid first septal perforator), diamond shaped patch from septum to annulus to aorta and patch to RVOT
What patients need to stay inpatient for AVR?
Severe AS with if signs of HF (CHF, pulmonary edema), syncope, chest pain
AS Indications for AVR:
Class 1: Symptomatic, LVEF < 50%, or other cardiac surgery
Class 2a:
- Decreased exercise tolerance test or fall in SBP ≥ 10 mmHg from baseline to peak exercise
- Vmax ≥ 5 m/s or velocity increase ≥ 0.3 m/s per year
- BNP > 3x normal
Class 2b: Decreasing EF on 3 serial echocardiograms to < 60%, Moderate AS with other cardiac surgery
