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BCC > AS/AI > Flashcards

AS/AI Flashcards

1
Q

What are risk factors for aortic stenosis?

A

Increased LDL + DM + HTN + smoking + mediastinal radiation + renal failure + familial hypercholesterolemia + Ca+ metabolism disorders (i.e. hyperPTH) + NOTCH1 mutations

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2
Q

What are the 3 pathophysiological processes that lead to AS?

A

Degenerative calcification, bicuspid aortic valve, and rheumatic AS

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3
Q

What is the prevalence of bicuspid aortic valves?

A

1-2%

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4
Q

When does AS in bicuspid valves normally present?

A

5-6th decade of life

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5
Q

What is LaPlace’s law?

A

Wall stress = wall tension / wall thickness

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6
Q

What is the classic triad of AS?

A

SAD = Syncope, angina, dyspnea

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7
Q

Why do you get angina with AS?

A

Increased O2 delivery is limited due to LVH

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8
Q

What does dyspnea mean with AS?

A

Indicates that the beneficial effects of LVH to maintain LV function has diminished now and is a harbinger of LV failure

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9
Q

When do you need to do a cardiac cath for AS?

A

If noninvasive measures are equivocal in a high risk patient or when there is discrepency between clinical symptoms and echo findings

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10
Q

What is the gold standard for sizing valves in TAVRs?

A

CTA

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11
Q

What is low flow/low gradient AS?

A

EF<50% or stroke volume index < 35 mL/m2 + AVA < 1.0cm2 + mean gradient < 40 mmHg on TTE

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12
Q

What is classic low flow/low gradient AS?

A

AVA < 1.0 cm2 + with dobutamine challenge, the CO and SV index rise and mean AV gradient > 40 mmHg

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13
Q

What is the incidence of classic low flow/low gradient AS?

A

10-15%

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14
Q

What is pseudo low flow/low gradient AS?

A

Not real AS as there isn’t enough flow to move the AV leaflets; with dobutamine challenge, CO and SV index rise but the AVA increases above 1.0 cm2

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15
Q

What is paradoxical low flow/low gradient AS?

A

Normal EF (>50%) + decreased SV index (<35 mL/m2) + AV mean gradient < 40 mmHg + AVA < 1 cm2; indexed AVA < 0.6 cm2/m2 confirms diagnosis

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16
Q

What kind of patient normally has paradoxical low flow/low gradient AS?

A

Elderly patients with LVH + small LV cavity + diastolic dysfunction; seen in 10-25% of AS patients

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17
Q

What are the benefits of a balloon valve angioplasty for AS?

A

Symptom relief (short, weeks to months) but no survival benefits

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18
Q

What are the indications of a BVA for AS?

A

Pediatric patients (bridge to surgery) + bridge to TAVR + improving quality of life for non-surgical/TAVR candidates

19
Q

What are class 1 indications for aortic valve replacement?

A

Symptomatic AS, classic and paradoxical LF/LG AS, and asymptomatic severe AS undergoing cardiac surgery for other indications

20
Q

What are the benefits of using a bioprosthetic valve? Downsides?

A

No anticoagulation; but can undergo structural valve deterioration

21
Q

What are the benefits of a mechanical valve? Downsides?

A

Long durability and easy implantation; but requires anticoagulation and can have thromboembolic complications

22
Q

What are complications seen more commonly with SAVR?

A

Bleeding + renal failure + atrial fibrillation + respiratory complications

23
Q

What are complications seen more commonly with TAVR?

A

Conduction abnormalities + paravalvular leak + stroke + vascular complications + coronary occlusion

24
Q

Which cusps of the AV are in continuity with the aorto-mitral curtain?

A

The noncoronary and left coronary cusps

25
Q

What are the most common causes of aortic insufficiency?

A

Endocarditis and aortic dissection

26
Q

How does the LV compensate with AI?

A

The increased LVEDP due to AI leads to effective decreased stroke volume -> increased HR (decrease regurgitant volume) + increased SVR (increase coronary perfusion pressure)

27
Q

What happens to the LV with long standing AI?

A

Eccentric hypertrophy (due to volume overload)

28
Q

What happens to myocardial work with chronic AI?

A

Increased due to eccentric (and sometimes concentric) hypertrophy -> can be doubled

29
Q

What are the 4 stages of aortic regurgitation?

A

Stage A (at risk), Stage B (progressive -> mild/mod AI), Stage C (asymptomatic severe), Stage D (symptomatic severe)

30
Q

What stage(s) of AI should you start an ACE/ARB?

A

Stage C2 (asymptomatic severe with depressed EF or severely dilated LV) or Stage D (symptomatic severe)

31
Q

What are grade 1 indications for AVR with AI?

A

Stage D AI (severe symptomatic AI) + Stage C2 (severe asymptomatic AI with depressed LVEF) + Stage C with other cardiac surgery

32
Q

What other anomalies are seen commonly with a bicuspid aortic valve?

A

Proximal aortic dilation (40-87%) + aortic dissection (6-9x the risk)

33
Q

What is Siever’s Classification system for bicuspid aortic valves?

A

Sievers 0 = no raphe with two cusps; Sievers 1 (most common) = two smaller, malformed cusps forming the raphe and one larger cusps (normally RCC and LCC fusion); Sievers 2 (least common) = LCC-RCC and RCC-NCC fusions forming 2 raphes

34
Q

Which Siever’s classification for bicuspid AV has the highest risk of aneurysm formation?

A

Sievers 2; due to flow direction and increasing local wall stress

35
Q

What is the effective height of the AV?

A

The ideal height for repair measured from the aortic annulus to free margin of each aortic cusp in diastole (> 8mm)

36
Q

What is the geometric height of the AV?

A

Curved length measured from the aortic annulus to the central part of the free margin (ideally > 20mm)

37
Q

What is the coaptation height of the AV?

A

The amount of leaflet coaptation during diastole (normally 2-5mm)

38
Q

What is the El Khoury Classification?

A

Functional, repair-centered classification of AR

39
Q

What is a Type I El Khoury classification?

A

Normal cusp motion: Ia = dilated distal to STJ (tx = STJ remodeling and ascending aortic graft); Ib = dilation from annulus to proximal ascending dilation (tx = valve sparing root replacement); Ic = aortic annulus dilation (tx = subcommisural annuloplasty); Id = hole in AV (tx = patch repair)

40
Q

What is a Type II El Khoury classification?

A

Cusp prolapse; treatment = prolapse repair

41
Q

What is a Type III El Khoury classification?

A

Cusp restriction; treatment = leaflet repair

42
Q

When do you fix the aorta with asymptomatic bicuspid aortic valve?

A

If aortic root or ascending aorta > 5.5cm OR > 5.0cm with risk factors, low perioperative risk, and access to experienced aortic center

43
Q

When do you fix the aorta with symptomatic bicuspid aortic valve?

A

Aortic root or ascending aorta > 4.5cm

44
Q

Can you do a TAVR for AI?

A

Difficult because the aortic annulus/root might be dilated -> high risk for valve migration and paravalvular leak

BCC (29 decks)

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