B P8 C75 Mitral Stenosis Flashcards by Shadow Fox

RMS is now largely concentrated among the LMICs that are endemic for _____.

Group A Streptococcus (GAS) pharyngitis and ARF

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The mechanism for valve damage in RMS is not clear but is thought to be ______ and involves both humoral and cellular immune mechanisms

Autoimmune response to GAS moieties that mimic valve antigens

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_____ is most common in the Western world and is mainly mitral annular calcification (MAC) related, although MS after mitral valve interventions is increasingly seen in tertiary care centers

Degenerative MS (DMS)

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The normal mitral valve area (MVA) is ≥_____ cm2

≥ 4.0 cm2

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A gradient across the mitral valve starts to form with reduction in MVA to _____ cm2, considered mild MS, and symptoms begin to appear, initially with exercise.

Symptoms, more consistently develop at ≤ ____ cm2 and are associated with a 5 to 10 mm Hg gradient

2.0 cm2 - mild - gradient starts to form, symptoms begin to appear

≤1.5 cm2 - associated with 5-10 mm Hg gradient

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Significant hemodynamic changes (gradients in excess of _____ mm Hg) and resting symptoms are common at MVA ≤_____ cm

> 10 mm Hg
< 1.0 cm2

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Guidelines consider “severe” MS based on when symptoms occur and where intervention can improve them, and ≤_____ cm2 is the recommended threshold for this

1.5 cm2

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MS due to a prosthetic valve is generally defined as resting mean valve gradient ≥ _____ mm Hg, peak mitral inflow velocity ≥ _____ msec, or effective orifice area ≤____ cm2.

MVG ≥ 5 mm Hg
Peak Mitral Inflow velocity ≥ 1.9 msec
EOA ≤ 2.0 cm2

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Cardiac valve involvement in ARF starts with inflammation at the valve _____

Edges

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The main abnormality in RMS is _____.

Fusion of the mitral leaflets in critical areas
* at their medial and lateral edges (commissural fusion), and the valve opening
* Narrowest at the valve tips
* Becomes a rigid structure that is oval or fish mouth shaped

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RMS is characterized by _____ rather than just stiff valve leaflets and hence a relatively fixed orifice, and unlike AS, changes very little with varying hemodynamic conditions.

An increased LA pressure is then needed to maintain left ventricular (LV) filling and preserve cardiac output.

Commissural fusion

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While MVA defines anatomic severity, it is the _____ that determines clinical symptoms and improvement after definitive therapies like percutaneous balloon mitral valvuloplasty or surgery

LA pressure

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_____ is one of the most important factors in increasing LA pressures since it significantly reduces diastolic filling time and compromises forward flow, which is immediately seen as high mitral valve gradients and worsening symptoms.

Tachycardia

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Atrial contraction helps overcome the resistance at the mitral valve level and preserve forward flow in MS—not surprisingly, the loss of atrial contraction and tachycardia during _____ can precipitate clinical worsening even in patients previously asymptomatic

Since the gradient across the mitral valve increases as a square of the flow, small increases in the latter can have large effects on the gradient and its resulting symptoms, as seen in pregnancy, severe anemia, thyrotoxicosis, systemic infection, and other hyperdynamic states.

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Chamber compliance (LA and to some extent, LV) also plays a role in development of symptoms, abnormal exercise hemodynamics, pulmonary hypertension (PAH), and degree of relief after relief of stenosis.

A newly recognized subset termed low gradient MS (MVA <____cm2, mean gradient <___ mm Hg, and _____) is now being recognized in the developed world and may account for a significant proportion of patients coming to BMV in some centers

MVA < 1.5 cm2
MVG < 10 mm Hg
Significant symptoms

Some patients with these hemodynamic findings—constituting 11% of BMV patients in one series12—appear to have a physiology akin to heart failure with preserved ejection fraction superimposed on MS and is characterized by older individuals with normal intrinsic LV contractility, decreased LV compliance, and high arterial afterload.

They respond suboptimally to BMV, highlighting that reduced LV compliance may explain symptoms that do not respond to treatment of MS alone.12

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Backward transmission of high LA pressures results in ______ and ______; lung congestion explains exercise intolerance and dyspnea (and pulmonary edema in the most severe cases), and its relief, with diuretics or definitive MS treatment, is associated with immediate clinical benefit through reversing these changes

Pulmonary venous hypertension and increased lung water

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Chronically elevated LA pressure results in ______ . This can improve symptoms for a short period before progressive MS overcomes these mechanisms

The development of ______ also ameliorates these symptoms but at the expense of right heart overload and possibly low cardiac output.

Prolonged elevation of LA pressure and LA remodeling can result in _____ that affects LA compliance. This may not be reversible after BMV, and low net AV compliance, which reflects the LA-LV as a unit, predicts both need for intervention and worse prognosis after BMV.

(1) Alveolar/interstitial thickening that limits alveolar edema
(2) Increased lymphatic drainage helps redistribute alveolar fluid

PAH

LA fibrosis

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_____ are an early marker for LA dysfunction, can be seen in asymptomatic subjects with moderate MS, and are common in both RMS and DMS.

LA strain abnormalities

LA volume is increased and LA emptying fraction is reduced.

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_______ is affected particularly in RMS and both reservoir strain (reflecting LA filling) and conduit strain (a marker for early diastolic emptying) are reduced, especially in patients with _____.

Abnormal _____ is associated with reduced functional capacity, predicts future AF, and identifies adverse prognosis in asymptomatic subjects with moderate MS.

Conduit strain - RMS

Reservoir + Conduit strain - MAC

Peak atrial longitudinal strain (PALS)

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______, a more sensitive parameter for LV function, however, is commonly abnormal in RMS and improves rapidly after BMV.

LV deformation

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Overt RV dysfunction occurs late in the course of MS and is often a consequence of _____.

PAH

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Valve area in RMS decreases approximately _____ cm2 per year.

0.09 cm2/yr

Age, hemodynamic severity at diagnosis, and degree of valve deformity seem to predict progression.About a third show higher rate of progression, but this is not easily predictable from traditional clinical variables.

Recurrent episodes of ARF mediate faster progression in LMICs but this evolution can occur even without repeated episodes suggesting some role for other factors like hemodynamic damage and scarring.

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_____ are an important trigger for definitive therapy and have strong prognostic value

Symptoms

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Patients can first present with AF; almost _____% presented with an embolic episode in the past but early detection of AF in MS and aggressive use of oral anticoagulants (OACs) has markedly reduced this complication.

20%

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_____, initially on exertion and then at rest, is the usual presentation in MS

Dyspnea

Transition to the symptomatic phase is often precipitated by _____ or conditions generating increased flow across the valve—AF and pregnancy commonly bring asymptomatic patients to attention in LMICs

Tachycardia

Stage A MS

* At risk for MS * Mild valve doming during diastole * Normal transmitral flow velocity * No hemodynamic consequences * No symptoms

Stage B MS

* Progressive MS * Valve anatomy: Rheumatic valve changes with commissural fusion and diastolic doming of mitral valve leaflets Planimetered MVA >1.5 cm2 * Valve hemodynamics Increased transmitral flow velocities MVA >1.5 cm2 Diastolic pressure half-time <150msec *Hemodynamic consequences: Mild to moderate LA enlargement Normal pulmonary pressure at rest * No symptoms

Stage C MS

* Asymptomatic severe MS * Valve anatomy: Rheumatic valve changes with commissural fusion and diastolic doming of mitral valve leaflets Planimetered MVA ≤ 1.5 cm2 * Valve hemodynamics: MVA ≤ 1.5cm2 Diastolic pressure half-time ≥150 msec * Hemodynamic consequences: Severe LA enlargement Elevated PASP >50 mm Hg * No symptoms

Stage D MS

* Symptomatic severe MS * Rheumatic valve changes with commissural fusion and diastolic doming of mitral valve leaflets Planimetered MVA ≤ 1.5 cm2 * Valve hemodynamics: MVA ≤ 1.5cm2 Diastolic pressure half-time ≥150 msec * Hemodynamic consequences: Severe LA enlargement Elevated PASP >50 mm Hg * Symptoms Decreased exercise tolerance Exertional dyspnea

The dilated LA (______ syndrome—hoarseness due to compression of the recurrent laryngeal nerve) or pulmonary artery can cause pressure effects.

Ortner syndrome

PE findings due to the pathologic MV

* Loud S1 (and a tapping apex) * Opening snap (OS) * Mid-diastolic murmur with presystolic accentuation

PE findings due to the consequences of MS

* AF * Pulmonary venous and arterial hypertension * Tricuspid regurgitation (TR) * Right heart failure * In late stages, systemic hypoperfusion

The _____ is a classic feature of RMS and arises at the peak of a rapid and forced opening of the restricted mitral leaflet by high LA pressure. It denotes two important things

Opening snap (1) its presence along with a loud S1 implies a pliable mitral valve that is likely to be a good candidate for BMV (2) its timing helps in assessing severity of MS—a **higher LA pressure opens the mitral valve earlier**, and, therefore, time between aortic closure sound and mitral OS **(A2- OS interval) is inversely proportional to the severity of MS**

The S1 is often loud with a _____ mitral valve, but significant leaflet restriction (with fibrosis, calcification or subvalvular pathology) can decrease its intensity

Pliable

As with a loud S1, increasing calcification and rigidity of the body of the leaflets **diminishes OS** and might indicate ______ anatomy for percutaneous intervention.

Unfavorable anatomy

The murmur in MS is difficult to hear and needs practice and a quiet room for best detection; _____ can bring out the findings.

Tachycardia with mild exercise

It is a **low pitched diastolic rumble**, best heard at the **apex** with the _____ of the stethoscope while the patient is in the **left lateral position**. Its onset follows the OS, but may be heard just during **presystolic accentuation** in mild MS and gradually increases in _____ with increasing severity of stenosis.

Bell Length

The _____ of the murmur correlates with severity of MS but the intensity does not.

Length

A presystolic accentuation (coinciding with atrial contraction) is prominent unless the patient is in _____.

Some murmurs may mimic MS—those from high flow across the mitral valve (severe MR, some shunts like ventricular septal defect, or patent ductus arteriosus with high Qp/Qs or other high flow conditions) can be differentiated from MS by their ______.

Clinical context Short murmurs Lack of an OS Presence of an S3 S3 (which occurs later in diastole, is softer and not generally confused with OS) and S4 are not usually audible and their presence **excludes severe MS**

The Austin Flint murmur of aortic regurgitation (AR) usually does not have a ______ and there are clear signs of significant AR

Loud S1, OS, or presystolic accentuation

A _____ A2-OS interval followed by a ____ murmur starting earlier in _____ with prominent presystolic accentuation and signs of PAH or RV overload in a patient with limiting symptoms suggests severe MS.

Short A2-OS interval Long murmur starting early in diastole with prominent presystolic accentuation

______ indicates a pliable valve that could be suitable for BMV.

Loud S1 and prominent OS

MVA is best assessed with _____ in all patients with RMS since it is the most accurate method if done correctly (tracing the **inner edge at valve tips in mid-diastole** of a completely seen, enface orifice of good image quality) and less subject to effect of changing loading conditions

Planimetry

Planimetry is not a good option for MVA in DMS and the _____ may work better.

Continuity equation

_____ is useful to assess valve area in RMS but is **not accurate in valves with prior intervention or in DMS since it is influenced by chamber compliance** and multiple other factors

PHT

The proximal isovelocity surface area (PISA) method and continuity equation can provide good measurements but are more complex and the latter is not useful if there is either _____.

AR or MR

Transesophageal echocardiography (TEE), both 2D and 3D, provides greater details of valve anatomy and is very useful for excluding _____, although computed tomography (CT) can substitute for this.TEE is often used during BMV to guide the procedure as well as assess immediate results and complications.

LA Clot

The most often used score is the _____ sscore that combines leaflet mobility and calcification along with leaflet and subvalvular thickening into a numerical score

Wilkins score

Both EKG and chest x-ray can show consequences of MS in the form of _____. In the later stages, the EKG can show AF and x-ray can show the presence and degree of pulmonary congestion. Exercise testing can be performed safely in most patients with MS and plays an important role in evaluating patients with severe MS who are ______ and those who are symptomatic with _____ Stress echo can document exercise limitation and resolve discordance between symptoms and clinical or echocardiographic severity, and finding ______ can indicate need for BMV

LA enlargement (P mitrale) and RV pressure overload Asymptomatic or have equivocal symptoms Moderate MS Exercise-induced PAH

_____ is a dreaded complication of MS—it is common, increases with age and severity of MS, worsens hemodynamic as well as clinical status, is an important determinant of the high risk of stroke, and can limit survival in patients with RMS.

AF seems to be driven by both _____, which together can cause structural and electrical remodeling

LA stretch Inflammation

_____ were good predictors for new-onset AF

Larger LA dimension and MVA of 1.5 cm2 or less

Worldwide, _____ is one of the most common valve conditions in pregnant women with structural heart disease.

Cardiac output peaks in the second trimester, and patients with MS are often first detected at this time or present with worsening symptoms around ____ weeks of gestation.

24-30 weeks AOG

Delivery is the other dangerous time period; a third of pregnant patients developing heart failure due to MS become symptomatic around the time of delivery and in the first week postpartum, often in the first _____ hours, due to high LA pressures caused by increased venous return following relief of inferior vena cava (IVC) compres- sion and autotransfusion of blood from the utero-placental circuit after delivery.

72 hours post partum

The modified WHO risk stratification algorithm appropriately classifies untreated severe MS as a Class _____ risk (pregnancy is contraindicated)

Class IV

Vaginal delivery is the best option for patients with _____.

* Mild MS and mild symptoms (NYHA I-II) * Asymptomatic moderate MS Beta blockers can cause fetal bradycardia, hypoglycemia, and a mild increase in premature births, but no major congenital abnormalities have been conclusively identified. Intrauterine growth restriction has been described especially for **atenolol** used in the second trimester. Calcium channel blockers can be used for rate control (FDA Category D) but **amiodarone is contraindicated**. Diuretics can affect uteroplacental perfusion and amniotic volume but have been used with few major adverse effects. Direct current cardioversion can be performed, if needed urgently. Anticoagulation needs thoughtful planning and use per guidelines.

Caesarean delivery is indicated in those with _____.

* Severe symptoms (NYHA III-IV) * Moderate symptoms with significant PAH, and when BMV could not be undertaken previously

BMV is the treatment of choice for managing pregnant patients but the success depends on the time of intervention. BMV before ____ weeks of gestation has poorer fetal outcomes and should be delayed as much as reasonable, optimally to after _____ weeks.

< 20 weeks AOG: poorer fetal outcomes **>24 weeks AOG: Optimal**

_____ RMS is clearly a mechanical obstruction that needs structural intervention (either BMV or surgery).

Severe symptomatic RMS -------- It mainly involves rate control, management of secondary conditions that could worsen MS (including AF, anemia, thyrotoxicosis, or infection), and judicious diuresis in patients who still continue to have exercise intolerance. At the same time, secondary prophylaxis for ARF and OACs to prevent embolic events should be meticulously offered per guideline recommendations. Patients with RMS with any **incidence of AF** and those in **sinus rhythm with history of prior thromboembolism or LA thrombus** should receive OACs. It is reasonable to consider OACs in patients with **severely dilated LA or those with severe spontaneous contrast in the LA** per European guidelines (no U.S. recommendation). **Direct-acting OACs are not recommended.** Rate control with any suitable drug is indicated in patients with AF and a rapid ventricular response and may help in patients in sinus rhythm who develop significant symptoms during exercise. **Beta blockers** decrease heart rates, thus creating longer diastolic filling time and reduced gradients but have not been consistently shown to improve exercise capacity. **Ivabradine** might better control tachycardia during exercise than beta blockers. **Digoxin** is helpful only in patients with AF.

Standard criteria for intrapregnancy BMV for MS include _____.

Severe MS, NYHA Class III or IV symptoms while on optimal medical treatment + Suitable valve anatomy

Asymptomatic patients are not currently recommended intervention unless they have _____.

Severe PAH (>50 mm Hg) or new-onset AF and have favorable anatomy

BMV is a very efficacious as well as cost effective treatment and is the preferred modality in most patients with ______.

Valve area <1.5 cm2 and suitable anatomy ---------- * It might be considered in those with valve area >1.5 cm2 if symptoms can be clearly attributed to MS, especially if they develop high PAP. * BMV might also be considered rather than offering surgery in patients with somewhat unfavorable anatomy, particularly those at high surgical risk

An LA thrombus is a contraindication for the procedure even though some experienced centers have safely performed BMV after ____ months of OAC

2-3 months

Predictors of procedural success include:

Extent of valve thickening Mobility and subvalvular involvement Uneven leaflet thickening Commissural asymmetry Calcification

Although none of the scores based on echocardiography are very good at predicting outcomes, a Wilkins score <_____in general predicts good outcomes, while those with a score >11 are best treated with surgery.

<8: Good outcomes >11: Best treated with surgery

Patients with intermediate scores (between 9 and 11) can still have reasonable results and should be considered for BMV in ____.

Experienced centers

An MVA ≥_____ cm2 and MR ≤_____ (without in-hospital major adverse cardiac and cerebrovascular events) are considered to be a good result after BMV

MVA ≥1.5 cm2 MR ≤2/4 (without in-hospital major adverse cardiac and cerebrovascular events)

A post- procedure area of >_____cm2 seems to predict good long-term outcomes.

> 1.8 cm2

Class I recommendations for intervention for RMS

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 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. (IB)

Some degree of _____ MR has been reported in 20% of patients in recent series. It generally is tolerated well and remains stable or improves

Mild MR or worsening MR

MR arising from _____ actually predicts a good outcome.

Commissural splitting

Acute severe MR is one of the most feared complication of BMV but is rare (<1% to 2%). Severe MR due to tear of the _____ or damage to the _____ usually requires early surgery. Most other patients tolerate severe MR initially with only a minority needing emergency intervention.

Anterior leaflet central scallop Subvalvular apparatus

Post-BMV _____, which is strongly related to suboptimal immediate results, affects long-term outcome

Restenosis

_____ were factors associated with BMV outcome.

Greater age Higher NYHA class Suboptimal relief of MS during the initial procedure

Post-BMV restenosis, which is strongly related to suboptimal immedi- ate results, affects long-term outcomes. It develops over many years and can be treated with _____ with reasonable success if the mechanism is once again fusion of commissures

Repeat BMV ---------- In patients with restenosis,results of repeat BMV are comparable to surgery but may be less successful if MS is due to valve leaflet rigidity and degeneration

Surgery is indicated in patients with _____.

(1) Contraindication for BMV (2) Those in whom BMV was unsuccessful (3) Those with other conditions that would warrant surgery (TR, AS, or CAD)

A ______ can be performed concomitantly with surgery to reduce AF burden and related morbidity

Maze procedure and LA ligation

Three types of surgery are offered for MS:

Closed mitral valvotomy (CMV) Open mitral valvotomy (OMV) Mitral valve replacement (MVR) ---------- There is good long-term experience with all the three methods, and the results are durable with low rates of MR and reoperation

_____ is the surgical procedure of choice, especially in the young. It has excellent results that are comparable to MVR but avoids many of the long-term issues with prosthetic valves.

OMV ---------- OMV is associated with mortality rates under 2%, excellent relief of symptoms, excellent long-term survival (96% at 10 years), and freedom from reoperation (98% at 9 years)

____ is a chronic process that causes extensive calcification of the mitral valve annulus with extension into the base of both leaflets

MAC ---------- It is now becoming an important cause of MS in the developed world The exact mechanism for MS is not clear but a number of factors including reduced diastolic annular expansion and stiff leaf- lets have been postulated

Unless there are distinct indications for its use, ____ is the least preferred option due to higher risk, need for anticoagulation with mechanical valves, and high bioprosthesis failure rate in young patients.

MVR ---------- MVR has higher operative mortality (3% to 10%) and lower 10-year survival than OMV, but these statistics might reflect a more suboptimal patient substrate.

_____ seem to predict development and severity of MS due to DMS

MAC in the anterior annulus Involvement of the anterior leaflet and in particular the A2 scallop, Extension into more than half of the leaflet length

The _____ leaflet is often very restricted due to significant calcification but the tips of both leaflets remain mobile in DMS

Posterior

The mitral gradient due to MAC increases variably, roughly 0.8 ± 2.4 mmHg/year and MVA decreases _____ cm2/year, which is slower than in RMS

0.05 cm2

In DMS, here may occasionally be a _____ diastolic rumble, but not the classical signs of RMS such as a loud S1 or OS. Symptomatic patients with severe DMS have modest gradients and higher MVA (e.g., 8.0 ± 3.8 mm Hg and 1.26 ± 0.19 cm2, respectively in the Mayo series) than RMS

Short diastolic rumble

The main abnormality in DMS involves the _____ of the valve leaflets rather than the **tips as in RMS** and is unevenly distributed around the valve inflow.

Base of the valve leaflets ----------- Early mitral filling is often preserved and late diastolic gradients can become minimal in beats with long RR intervals, unlike in RMS In addition, comorbidities reduce LA compliance and increase LV stiffness, both of which can lead to elevated LA pressure despite smaller Doppler gradients across the mitral valve; it is sometimes difficult to be certain that MAC related mitral inflow obstruction rather than comorbidities is the dominant cause of symptoms.

Planimetry, the reference standard for RMS, may not work well since MS due to _____ is not a fixed obstruction at one level (e.g., at the leaflet tip in RMS) but is a result of increased resistance at the level of the leaflet base and annulus level as well as reduced opening angle of the calcified leaflet base

MAC ---------- Extensive calcium can obscure the valve orifice out- lines so planimetry is difficult

The difference in shape of the stenosed valve (dome shape in RMS and _____ shape in DMS) can have differential effects on pressure loss and result in different effective MVAs or gradients.

Tubular funnel shape

_____ testing might help clarify the hemodynamic effects of DMS in patients with symptoms but unclear severity of DMS

Exercise

MAC is commonly seen in patients with ____ (50% have MAC and 11% to 18% have MS, majority due to DMS), and associated DMS, even if mild, affects short- and long-term outcomes, including stroke, with or without intervention for AS

A premature beat has less of an impact on LA pressures. Long RR intervals allow more complete LA emptying, and significantly lower LA pressure, and the gradient is appreciably ______ during diastasis, something that is not usually seen in severe rheumatic MS

Reduced

DMS is associated with poor survival, mainly a consequence of the _____, with 1-year mortality in the 32% range

Extensive comorbidities

The majority of patients (60%) with severe DMS in a contemporary series had symptoms, with _____ being the most common, while asymptomatic patients developed symptoms at the rate of 7% to 8% per year. Adverse events are fairly common (47% at 1 year, almost 75% over longer follow-up), and almost 50% of the patients died during the short follow-up of 2.8 ± 3.0 years.

Dyspnea

____ is not an option in DMS given that the abnormality does not involve commissural fusion.

BMV

Medical therapy, in the form of _____, is commonly used in symptomatic DMS. How- ever, mortality remains high with medical therapy.

Diuretics Beta blockers to slow the heart rate

There are no effective methods to decalcify MAC and replacing the valve, either _____ are the only choices at this time.

(1) Surgically (2) Transcatheter valve in MAC (ViMAC) using a transcatheter aortic valve device

Surgical options have suboptimal results due to _____.

(1) Difficulty in suturing the new valve into heavily calcified segments (2) Extensive debriding of the annulus to adequately seat a valve is often associated with adverse outcomes including AV groove disruption.

TMVR is feasible in patients with severe MAC but is associated with high 30-day and 1-year mortality, with _____ being the most dreaded complication (11.2%).

LV outflow tract (LVOT) obstruction

Valvular heart disease, including MS, is a _____-dependent complication of chest radiation,particularly when using protocols that did not adequately shield nontarget structures.

Time and dose dependent ----------- Radiation-associated MS is often accompanied by involvement of the aortic valve as well as restrictive myocardial disease.

In radiation-induced MS, severe calcification of the fibrous skeleton, especially in the _____, is common but is **not accompanied by subvalvular involvement or commissural fusion.**

Aortomitral curtain Anterior annulus Anterior leaflet Triple A

About one-quarter to one-third of patients develop mitral valve gradients greater than ____ mm Hg after transcatheter edge-to-edge mitral clip procedures

5 mm Hg (most in the 5 to 10 mm Hg range) Predictors of development of this gradient: Preprocedure MVA <4 cm2 Preexisting gradients Significant leaflet calcification Implanting >2 clips

_____ MS, especially in patients with primary MR, has poorer long-term outcomes including risk of death, AF, and reintervention

Clip-related MS

The combination of MS and AF poses considerable risk for embolic events; patients with MS and AF are many times more likely to have embolic complications than MS without AF or AF without MS, and risk may be as high as patients with prosthetic valves—consequently, OACs ( _________ and not direct acting OACs) are strongly recommended in such patients irrespective of lesion severity or CHADS2VASc scores.

Warfarin

The European guidelines even recommend considering OACs in patients with RMS in sinus rhythm if they have dense spontaneous LA echocardiographic contrast and/or LA dilation. Based on 2021 ESC VHD Guidelines: OAC should be given if with hstory of systemic embolism or a thrombus is present in the LA and should also be considered when TOE shows dense spontaneous echocardiographic contrast or an enlarged LA (M-mode diameter _____ or LA volume ____ )

LA M-mode diameter >50 mm LAVI > 60ml/m2

Rate control is difficult to achieve in RMS but strategies are similar to those in the other patients with AF. ________ has been used with some success. Restoring sinus rhythm is more likely in the presence of a ______, ______, _______. Rhythm control improves quality of life and exercise tolerance, especially in those with small LA and durable results.

Ivabradine (una pa rin BB) Small LA, short duration of AF, and less severe MS

Unless needed urgently, electrical cardioversion is best done _____. AF with MS has a high recurrence after cardioversion and antiarrhythmic drugs, especially amiodarone, are often needed for maintaining sinus rhythm.

After BMV Restoring sinus rhythm with a surgical maze procedure increases chances of remaining in sinus rhythm and reduces risk of embolism. AF does not appreciably affect success of BMV but adversely influences long-term event-free survival.

Smaller bioprosthetic valves (<23 mm) with stenosis may perhaps be best treated with ____ to avoid higher gradients after transcatheter valve-in-valve.

Surgery