cardiac misc (incl misc AHA e.g. gen valve, arrhythmia, anticoag, endocarditis incl ppx, HOCM) Flashcards
only class 1 recommendation for infxn ppx
Secondary Prevention of Rheumatic Fever
“In patients with rheumatic heart disease, secondary prevention of rheumatic fever is indicated.”
2° ppx = PCN G IM Q4W or PCN V PO BID
for whichever is longer of:
- rheumatic fever (RF) + carditis + residual valvular dz = 10y OR >40yo
- RF + carditis + NO valvular dz = 10y OR >21yo
- RF + NO carditis = 5y OR >21yo
“In pts with documented valvular heart disease, the duration of rheumatic fever prophylaxis should be ≥10 y or until the patient is 40 y of age (whichever is longer).
Lifelong prophylaxis may be recommended if the patient is at high risk of group A streptococcus exposure. Secondary rheumatic heart disease prophylaxis is required even after valve replacement.”
Which types of dental procedures may require abx ppx for endocarditis?
“dental procedures that involve:
- manipulation of gingival tissue,
- manipulation of the periapical region of teeth, or
- perforation of the oral mucosa”
Which valvular dz entities require endocarditis abx ppx for dental procedures?
involving manipulation of gingival tissue, manipulation of periapical region of teeth, or perforation of the oral mucosa
- h/o previous IE
- prosthetic valves incl TAVI & homografts Prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts.
- non-valve prostheses Prosthetic material used for cardiac valve repair, such as annuloplasty rings, chords, or clips.
- un-rx cyanotic congenital dz OR rx with residual shunts or regurg at/near prothetic material Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device.
- structural regurg in transplanted heart Cardiac transplant with valve regurgitation attributable to a structurally abnormal valve.
endocarditis abx ppx PO regimens
amoxicillin 2g x1
PCN/ampicillin allergy: Keflex 2g OR azithro 500mg OR clarithro 500mg OR doxy 100mg x1
30-60min before procedure
endocarditis abx ppx non-PO regimens
- ampicillin
- Ancef/ceftrx if PCN allergy
ampicillin 2g IM/IV x1
PCN/ampicillin allergy:
Ancef OR ceftrx 1g IM/IV x1
30-60min before procedure
preferred/default endocarditis abx ppx PO regimen
amoxicillin 2g x1
30-60min before procedure
endocarditis abx ppx PO regimens with PCN/ampicillin allergy
one of:
- Keflex 2g
- azithro OR clarithro 500mg
- doxy 100mg
x1
30-60min before procedure
Do high-IE-risk pts need endocarditis abx ppx for non-dental procedures (e.g. TEE, EGD, C-scope) in the absence of active infection?
NO
(3: no benefit)
Does a dental procedure that involves manipulation of gingival tissue require endocarditis abx ppx?
YES
(2a)
Does a dental procedure that involves manipulation of the periapical region of teeth require endocarditis abx ppx?
YES
(2a)
Does a dental procedure that involves perforation of the oral mucosa require endocarditis abx ppx?
YES
(2a)
Do patients with prosthetic valves incl TAVI & homografts require endocarditis abx ppx for high-risk dental procedures?
involving manipulation of gingival tissue, manipulation of periapical region of teeth, or perforation of the oral mucosa
YES
(2a)
Prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts.
Do patients with non-valve prostheses require endocarditis abx ppx for high-risk dental procedures?
involving manipulation of gingival tissue, manipulation of periapical region of teeth, or perforation of the oral mucosa
YES
(2a)
Prosthetic material used for cardiac valve repair, such as annuloplasty rings, chords, or clips.
Do patients with previous IE require endocarditis abx ppx for high-risk dental procedures?
involving manipulation of gingival tissue, manipulation of periapical region of teeth, or perforation of the oral mucosa
YES
(2a)
Do patients with un-rx cyanotic congenital dz require endocarditis abx ppx for high-risk dental procedures?
involving manipulation of gingival tissue, manipulation of periapical region of teeth, or perforation of the oral mucosa
YES
(2a)
OR rx with residual shunts or regurg at/near prothetic material
Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device.
Do patients with rxed congenital heart dz with residual shunts or regurg at/near prothetic material require endocarditis abx ppx for high-risk dental procedures?
involving manipulation of gingival tissue, manipulation of periapical region of teeth, or perforation of the oral mucosa
YES
(2a)
OR un-rx cyanotic congenital dz
Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device.
Do patients with structural regurg in a transplanted heart require endocarditis abx ppx for high-risk dental procedures?
involving manipulation of gingival tissue, manipulation of periapical region of teeth, or perforation of the oral mucosa
YES
(2a)
Cardiac transplant with valve regurgitation attributable to a structurally abnormal valve.
post-valve-intervention periodic imaging
baseline post-proc TTE + periodic interval monitoring (1)
“In asymptomatic patients with any type of valve intervention, a baseline postprocedural TTE followed by periodic monitoring with TTE is recommended, depending on type of intervention, length of time after intervention, ventricular function, and concurrent cardiac conditions.”
initial evaluation/imaging study for suspected HCM
TTE
(1)
initial evaluation for suspected HCM
EKG (1)
TTE (1)
24-48h Holter (1)
SCD risk assessment (1)
± exercise stress test (2a)
FH (1) + cascade genetic testing (1)
“exercise stress testing is reasonable to determine functional capacity and to provide prognostic information as part of initial evaluation.”
initial evaluation/non-imaging study(ies) for suspected HCM
EKG (1)
24-48h Holter (1)
± exercise stress test (2a)
“exercise stress testing is reasonable to determine functional capacity and to provide prognostic information as part of initial evaluation.”
ongoing/subsequent imaging monitoring in HCM pts
(assuming no change in clinical status)
TTE Q1-2Y
(1)
to assess myocardial hypertrophy, dynamic LVOTO, MR, & myocardial fxn
ongoing/subsequent non-imaging monitoring in HCM pts
(assuming no change in clinical status)
EKG Q1-2Y (1)
24-48h Holter (1)
ongoing/subsequent monitoring in HCM pts
(assuming no change in clinical status)
EKG Q1-2Y (1)
24-48h Holter Q1-2Y (1)
TTE Q1-2Y (1)
SCD risk assessment Q1-2Y (1)
to assess myocardial hypertrophy, dynamic LVOTO, MR, & myocardial fxn
evaluation of clinical change or new event in HCM pt
TTE
(1)
further evaluation of HCM pts with resting LVOT gradient <50mmHg
TTE with provocative maneuvers
(1)
initial screening imaging for 1° relatives of HCM pts
TTE
(1)
initial screening for 1° relatives of HCM pts
EKG (1)
TTE (1)
cascade genetic testing (1)
further evaluation of sx HCM pts with resting & provoked LVOT gradient <50mmHg
exercise TTE
(1)
for detection & quantification of dynamic LVOTO
further evaluation of asx HCM pts with resting & provoked LVOT gradient <50mmHg
exercise TTE
(2a)
imaging during surgical septal myectomy
intraop TEE
(1)
to assess MV anatomy & fxn + myectomy adequacy
f/u imaging after septal redux tx
EtOH septal ablation OR septal myectomy
TTE within 3-6mo
(1)
to evaluate procedural results
ongoing/subsequent monitoring for 1° relatives of HCM pts who are genotype-positive, phenotype-negative
serial exam, EKG, TTE:
Q1-2Y <18yo
Q3-5Y adults
+ PRN clinical change
(1)
additional/further imaging evaluation of HCM pts if TTE is inconclusive OR pre-proc planning
TEE
(2a)
“TEE can be useful if TTE is inconclusive in clinical decision-making regarding medical therapy, and in situations such as planning for myectomy, exclusion of subaortic membrane or MR 2/2 structural abnormalities of the valve apparatus, or in the assessment of feasibility of EtOH septal ablation.”
additional/further imaging evaluation of HCM pts if ECHO is inconclusive
cardiac MRI
(1)
“For patients suspected to have HCM in whom echocardiography is inconclusive, CMR imaging is indicated for diagnostic clarification.”
additional/further imaging evaluation of HCM pts if alternative dxs are suspected
cardiac MRI
(1)
“For patients with LVH in whome there is a suspicion of alternative diagnoses, including infiltrative or storage disease as well as athlete’s heart, CMR imaging is useful.”
additional/further imaging evaluation of HCM pts not otherwise high-risk or decision still uncertain for ICD
cardiac MRI
(1)
to assess for LV wall thickness, EF, LV apical aneurysm, & LGE extent
LGE = fibrosis, ≥15% of LV mass = high-risk
additional/further imaging evaluation of HCM pts if anatomic mechanism of obstruction is inconclusive on ECHO
cardiac MRI
(1)
to inform selection & planning of septal redux tx
ongoing/subsequent imaging of HCM pts for SCD risk stratification
cardiac MRI Q3-5Y
(2b)
to eval Δs in LGE, EF, morphology incl apical aneurysm or LV thickness
“for the purpose of SCD risk stratification”
additional/further imaging evaluation of HCM pts if ECHO is inconclusive & cardiac MRI is not available
cardiac CT
(2b)
evaluation of new palpitations or lightheadedness in HCM pts
>24h Holter
(1)
“extended (>24h) EKG monitoring or event recording is recommended, which should not be considered diagnostic unless pts have had symptoms while being monitored.”
evaluation of HCM pts who may be candidates for SRT but with uncertainty re: presence or severity of LVOTO on non-invasive imaging studies
cardiac cath
(1)
for invasive hemodynamic assessment
evaluation of HOCM pts who are being considered for SRT but with uncertainty re: fxnal capacity or sx status
exercise stress test
(2b)
may be reasonable
ongoing/subsequent evaluation of HCM pts in whom fxnal capacity or sx status is uncertain
exercise stress test Q2-3Y
(2b)
may be reasonable
ICD indications in HCM pts
h/o cardiac arrest, VF, sustained VT (1)
OR at least 1 of: (2a)
- h/o unexplained syncope
- FH SCD
- massive LVH (≥3cm)
- apical aneurysm
- EF<50%
OR NSVT in children (2a) / in adults (2b)
OR extensive LGE (≥15% of LV mass) on cardiac MRI (2b)
class 1 ICD indication(s) in HCM pts
h/o cardiac arrest, VF, sustained VT (1)
class 1 ICD indication(s) in HCM pts
(1)
h/o cardiac arrest, VF, sustained VT (1)
class 2a ICD indication(s) in HCM pts
at least 1 of: (2a)
- h/o unexplained syncope
- FH SCD
- massive LVH (≥3cm)
- apical aneurysm
- EF<50%
- NSVT in children (2a)
class 2a ICD indication(s) in HCM pts
(6)
at least 1 of: (2a)
- h/o unexplained syncope
- FH SCD
- massive LVH (≥3cm)
- apical aneurysm
- EF<50%
- NSVT in children (2a)
class 2b ICD indication(s) in HCM pts
NSVT in adults (2b)
OR extensive LGE (≥15% of LV mass) on cardiac MRI (2b)
class 2b ICD indication(s) in HCM pts
(2)
NSVT in adults (2b)
OR extensive LGE (≥15% of LV mass) on cardiac MRI (2b)
class 3 ICD recommendation(s) in HCM pts
(2)
without risk factors
[and/]OR for sole purpose of competitive sports participation
(3: HARM)
class 3 ICD recommendation(s) in HCM pts
without risk factors
[and/]OR for sole purpose of competitive sports participation
(3: HARM)
SCD risk factors in HCM pts
- h/o cardiac arrest, VF, sustained VT
- h/o unexplained syncope
- FH SCD
- massive LVH
- apical aneurysm
- EF<50%
- NSVT in children (2a) / in adults
- extensive LGE on cardiac MRI
SCD risk factors in HCM pts
(8)
- h/o cardiac arrest, VF, sustained VT
- h/o unexplained syncope
- FH SCD
- massive LVH
- apical aneurysm
- EF<50%
- NSVT in children (2a) / in adults
- extensive LGE on cardiac MRI
ICD type in HCM
SDM for transvenous single-chamber OR subQ (1)
with single-coil leads (1)
based on preferences, lifestyle, expected need for brady or VT pacing
versus dual-coil leads
HOCM medical mgmt
in order of preference
- β-blockers
- non-dihydropyridine Ca channel blockers (e.g. verapamil, diltiazem)
- disopyramide (in combo with #1 or #2)
“1. [In patients with HOCM and symptom attributable to LVOTO], nonvasodilating beta-blockers, titrated to effectiveness or maximally tolerated doses, are recommended. (1)”
“2. […], for whom beta-blockers are ineffective or not tolerated, substitution with non-dihydropyridine calcium channel blockers (e.g., verapamil, diltiazem) is recommended. (1)
“3. […persistent severe symptoms…] despite beta-blockers or non-dhydropyridine calcium channel blockers, either adding disopyramide in combination with 1 of the other drugs, or SRT performed at experienced centers, is recommended. (1)”
“6. For patients with HOCM and severe dyspnea at rest, hypotension, very high resting gradients (e.g., >100mmHg), as well as all children <6w old, verapamil is potentially harmful. (3: HARM)”
pressor of choice in HOCM
Neo (phenylephrine)
(1)
after failure to respond to fluids; alone or with β-blocker
cardiac drugs to avoid in HOCM
vasodilators & digoxin
(2b)
vasodil e.g. ACE-Is, ARBs, dihydropyridine calcium channel blockers
can worsen sxs 2/2 dynamic LVOTO
indications for surgical SRT in HOCM
- severe sxs despite GDMT† (1)
- sx + concomitant cardiac surgery† (1)
- NYHA II + severe & progressive pHTN OR LA enlargement with ≥1 episode sx afib OR poor fxnal capacity on treadmill exercise testing OR young with very high resting gradients (>100mmHg)‡ (2b)
- severe sxs as an alternative to escalation of medical tx† (2b)
†at experienced (primary HCM) centers
‡at comprehensive HCM centers
expected/goal
SRT in primary/comprehensive HCM centers:
30d mortality
with surgery & with EtOH
≤1% & ≤1%
expected/goal
SRT in primary/comprehensive HCM centers:
30d morbidity
with surgery & with EtOH
“adverse complications (tamponade, LAD dissection, infection, major bleeding)”
≤10% & ≤10%
expected/goal
SRT in primary/comprehensive HCM centers:
30d PPM
with surgery & with EtOH
≤5% myectomy & ≤10% ablation
expected/goal
SRT in primary/comprehensive HCM centers:
MVR ≤1y
with surgery & with ablation
≤5% & N/A
not specified for ablation
expected/goal
SRT in primary/comprehensive HCM centers:
≥mod residual MR
with surgery & with ablation
≤5% & ≤5%
expected/goal
SRT in primary/comprehensive HCM centers:
repeat proc rate
with surgery & with ablation
≤3% & ≤10%
expected/goal
SRT in primary/comprehensive HCM centers:
improvement ≥1 NYHA class
with surgery & with ablation
>90% & >90%
expected/goal
SRT in primary/comprehensive HCM centers:
rest & provoked LVOT gradient <50mmHg
with surgery & with ablation
>90% & >90%
2 main outcomes differences in EtOH septal ablation v surgical myectomy
in EtOH ablation compared to myectomy:
1. PPM rate ≥2x
2. repeat proc rate ≥3x
PPM: ≤5% v ≤10% / repeat proc: ≤3% v ≤10%
highest risk factor for complete heart block / PPM after septal myectomy for HOCM
RBBB
(which can be caused by EtOH septal ablation)
⇒10-33% risk (SESATS)
because LBB can be resected in myectomy
post-septal myectomy LVOT gradient threshold to re-resect
> 25mmHg (provoked)
recommendation re: mild- to moderate-intensity recreational exercise in HCM
YES
beneficial to improve cardioresp fitness, physical fxn, QoL, & overall health
(1)
recommendation re: moderate- to high-intensity competitive sports OR high-intensity recreational exercise in HCM
may be considered after comprehensive eval & SDM
(2b)
initial + repeated annually with an expert provider
who conveys that the risk of sudden death and ICD shocks may be increased
recommendation re: low-intensity competitive sports in HCM
is reasonable
(2a)
recommendation re: any intensity competitive sports in genotype-positive, phenotype-negative HCM
is reasonable
(2a)
class 1 recommendation(s) re: planned valve surgery in pts with afib
potential benefits & added procedural risk of concomitant arrhythmia surgery should be discussed
(1)
class 2a recommendation(s) re: planned valve surgery in pts with sx paroxysmal or persistent afib
concomitant PVI or maze
can be beneficial
(2a)
to reduce sxs & prevent recurrent arrhythmia
class 2a recommendation(s) re: planned valve surgery in pts with afib or aflutter
LAA lig/exc
is reasonable
(2a)
to reduce risk of thromboembolic events
recommendation re: postop anticoag after LA arrhythmia surgery and/or LAAL/LAAE
“LA surgical ablation of atrial arrhythmias and/or LAA lig/excision”
anticoag ≥3mo
is reasonable
(2a)
“anticoagulation therapy” NOS
Do indications for valve intervention in severe valvular dz differ before planned pregnancy?
NO
(1)
“In symptomatic women with severe VHD who are considering pregnancy, intervention before pregnancy is recommended on the basis of standard indications.”
HOWEVER, there are 3 class <1 recs that conflict with this guideline.
indication(s) for valve intervention in asx women considering pregnancy
- severe rheumatic MS with favorable morphology: PMBC @ CVC (2a)
- severe AS: “intervention” (2a)
- severe MR suitable for rx: MVRx @ CVC (2b)
indication(s) for valve intervention in asx women considering pregnancy
(3)
- severe rheumatic MS with favorable morphology: PMBC @ CVC (2a)
- severe AS: “intervention” (2a)
- severe MR suitable for rx: MVRx @ CVC (2b)
recommendation re: valve choice in women of childbearing age
bp > mech d/t increased maternal & fetal risks a/w mech during preg (2a)
can still choose mechanical (SDM valve choice=class 1)
How is PPM (patient-prosthesis mismatch) measured/assessed?
iEOA = indexed effective orifice area ≈ AVA:BSA
- mild >0.85
- mod 0.65-0.85
- sev <0.65
iEOA (~AVA:BSA) <0.65
severe PPM
iEOA (~AVA:BSA) = 0.65-0.85
moderate PPM
iEOA (~AVA:BSA) >0.85
mild PPM / “at risk”
location of Manouguian root enlargement
L-non (LCC-NCC) commissure into the inter-leaflet triangle & AMC
https://drive.google.com/file/d/10U7clNgAMS3P8ZZUWH4j–aytUB02oQ1/view
https://drive.google.com/file/d/10dvR70BSSF7sNMwU1PtJQ_bkkV9KBrFI/view
location of Manouguian root enlargement
L-non (LCC-NCC) commissure into the inter-leaflet triangle, aorto-mitral curtain, and anterior mitral valve leaflet
1-1.5cm into the leaflet; do not enter LA roof (sweep away from root)
https://drive.google.com/file/d/10U7clNgAMS3P8ZZUWH4j–aytUB02oQ1/view
https://drive.google.com/file/d/10dvR70BSSF7sNMwU1PtJQ_bkkV9KBrFI/view
farthest proximal (deepest) extent of Manouguian root enlargement
onto the anterior mitral valve leaflet
1-1.5cm into the leaflet; do not enter LA roof (sweep away from root)
https://drive.google.com/file/d/10U7clNgAMS3P8ZZUWH4j–aytUB02oQ1/view
https://drive.google.com/file/d/10dvR70BSSF7sNMwU1PtJQ_bkkV9KBrFI/view
farthest proximal (deepest) extent of Manouguian root enlargement
onto the anterior mitral valve leaflet
1-1.5cm into the leaflet; do not enter LA roof (sweep away from root)
https://drive.google.com/file/d/10U7clNgAMS3P8ZZUWH4j–aytUB02oQ1/view
https://drive.google.com/file/d/10dvR70BSSF7sNMwU1PtJQ_bkkV9KBrFI/view
maximum increase in annular size achievable with Manouguian root enlargement
4mm
maximum increase in valve size achievable with Manouguian root enlargement
+2 valve sizes
location of Nicks root enlargement
through the midpoint of non (NCC) sinus
https://drive.google.com/file/d/10rQzLHVuQDElGEBX91M-yoY-k2DrAAHq/view
location of Nicks root enlargement
through the midpoint of non (NCC) sinus into the fibrous subaortic curtain
https://drive.google.com/file/d/10rQzLHVuQDElGEBX91M-yoY-k2DrAAHq/view
farthest proximal (deepest) extent of Nicks root enlargement
up to but not into mitral valve
“as far as the origin of the mitral valve”
https://drive.google.com/file/d/10gKWb9g-ToZNXP3VNAQ5KcvluEPe8uO-/view
maximum increase in annular size achievable with Nicks root enlargement
2mm
maximum increase in valve size achievable with Nicks root enlargement
+1 valve size
location of Konno root enlargement
through R (RCC) sinus (4-5mm lateral to/leftward of RCA) into interventricular septum + 2nd incision in anterior wall of RVOT
What structure do you have to worry about under the L-non (LCC-NCC) AV commissure?
anterior mitral valve leaflet / aorto-mitral curtain
What structure do you have to worry about under the R-non (RCC-NCC) AV commissure?
membranous septum, which contains LBB/bundle of His
What structure do you have to worry about behind the non sinus / non-R (NCC-LCC) commissure?
AV node
AVR sutures (normal)
pledgeted horizontal mattress from ventricular->aortic
AVR sutures at a root enlargement patch
pledgeted horizontal mattress from outside->in
standard quantity of Del Nido cardioplegia (total)
1200mL
interval to re-dose Del Nido cardioplegia
Q1H
quantity of Del Nido cardioplegia for retrograde
500mL
quantity of Del Nido cardioplegia for antegrade
700mL
quantity of Del Nido cardioplegia for ostial
RCA: 300mL
LCA: 400mL
total: 700mL
ONLY valve(s) for which intervention on moderate regurg is indicated
AR
- concomitant <3 surg (2a)
TR
- progressive + concomitant <3 L valve surg + annulus EDD>40mm OR prior RH fail sxs (2a)
ONLY valve(s) for which intervention on moderate dysfxn is indicated
AS
- concomitant <3 surg (2b)
AR
- concomitant <3 surg (2a)
TR
- concomitant <3 L valve surg + annulus EDD>40mm (2a)
- concomitant <3 (L valve) surg + prior RH fail sxs (2a)
MS
- NYHA ≥II + MVA>1.5 + PAWP>25 OR mean grad >15 with exercise ⇒ PBMC (2b)
ONLY valve(s) for which intervention on moderate stenosis is indicated
AS
- concomitant <3 surg (2b)
MS
- NYHA ≥II + MVA>1.5 + PAWP>25 OR mean grad >15 with exercise ⇒ PBMC (2b)
ONLY valve(s) for which intervention outside of concomitant <3 surg on moderate dysfxn is indicated
MS
- NYHA ≥II + MVA>1.5 + PAWP>25 OR mean grad >15 with exercise ⇒ PBMC (2b)
only AHA recommendation for warfarin over DOAC for anticoag for afib
afib + rheumatic MS (1)
AHA recommendation for anticoag for afib with rheumatic MS
warfarin (1)
AHA recommendation for anticoag for afib with any valvular dz except rheumatic MS
DOAC (1)
(per CHADS-VASc score)
STS risk score (%):
low-risk
<4%
STS risk score (%):
intermediate-risk
4-8%
STS risk score (%):
high-risk
>8%
STS risk score = risk of what outcome/endpoint (for risk-stratification)
death
Modified Duke criteria for definite endocarditis dx
definite IE criteria:
- 2 major
- 1 major + 3 minor
- 5 minor
Modified Duke criteria for possible endocarditis dx
poss IE criteria:
- 1 major + 1 minor
- 3 minor
Modified Duke major criteria for endocarditis dx
- ⊕blood cxs x2 with common bx
- ECHO (updated: or cardiac CT) signs (veg, leaflet perf, valve aneurysm, abscess, pseudoaneurysm, intracard fistula, NEW regurg, new partial dehisc of prosthetic valve)
Modified Duke minor criteria for endocarditis dx
- predisposition: incl heart condition, IVDU, h/o endocarditis, prosthetic valve, h/o valve rx, CHD, HOCM
- fever >100.4°F (38°C)
- vascular phenomena: septic emboli (incl Janeway lesions), mycotic aneurysm
- immunologic phenomena: glomerulonephritis, Osler’s nodes, Roth’s spots, rheumatoid factor
- micro: ⊕blood cx not meeting major criterion OR ⊕serology for organism c/w IE
AHA indication(s) for “early surgery” in endocarditis
early = during initial hospitalization & before abx course completed
- valve dysxfn ⇒ HF sxs (1)
- L-sided highly-resistant organism (S. aureus, fungus) (1)
- heart block / annular or Ao abscess / destructive penetrating lesions (1)
- persistent bacteremia or fevers >5d after abx (1)
- recurrent emboli/persistent veg (2a)
- L-sided native valve with mobile veg >1cm length (2b)
AHA “early surgery (during initial hospitalization and before completion of a full therapeutic course of antibiotics)”
AHA mgmt of permanent/implanted cardiac devices in definite endocarditis
complete removal (incl all leads & generator)
(1)
mgmt of relapsing prosthetic valve endocarditis (i.e. recurrent bacteremia after abx course & blood cx clearance)
“surgery”
(1)
recommendation re: consideration of redo surgery in endocarditis with ongoing IVDU
addiction med c/s re: long-term prognosis
(1)
AHA recommendation for timing of endocarditis surgery in setting of stroke
- non-major & no ICH: no delay (2b)
- major stroke and/or ICH: if HDS, delay ≥4w (2b)
“11. In patients with IE and an indication for surgery who have suffered a stroke but have no evidence of intracranial hemorrhage or extensive neurological damage, operation without delay may be considered. (2b)
\12. For patients with IE and major ischemic stroke with extensive neurological damage or intracranial hemorrhage, if the patient is hemodynamically stable, delaying valve surgery for at least 4 weeks may be considered. (2b)”
AATS recommendation for timing of endocarditis surgery in setting of stroke (with neuro deficits)
- non-hemorrhagic/no ICH: delay 1-2w (2a)
- hemorrhagic/ICH: delay 3-4w (2a)
(surgery 1-7d after ischemic stroke NOT a/w ￪ in-hosp mort)
“In patients with stroke and neurologic deficits, timing is decided by weighing the need for cardiac surgery against the risk of expanding the stroke or provoking intracranial bleeding during the operation.”
AHA definition of “early surgery” in endocarditis
during initial hospitalization and before completion of a full therapeutic course of antibiotics
AATS recommendation for timing of surgery in endocarditis
“within days” (1)
earlier surgery i.e. emergent or ≤48h for high embolism risk (2a)
“Once an indication for surgery is established, the patient should be operated on within days. (1)
Earlier surgery (emergency or within 48 hours) is reasonable for patients with large mobile vegetations at imminent risk of embolism. (2a)”
“Once an indication for surgery has been established and effective antimicrobial therapy initiated, there is little reason to delay operation. Surgery to prevent embolism mainly is relevant early, during the first few days after antimicrobial therapy is initiated, when the risk of embolism is greatest.”
AATS indication(s) for surgery in endocarditis
- valve dysxfn ⇒ HF sxs† (1)
- highly-resistant organism (S. aureus, fungus)† (1)
- heart block / annular or Ao abscess / destructive penetrating lesions† (1)
- persistent bacteremia or fevers >5-7d after abx† (1)
- recurrent systemic emboli/persistent veg‡ (2a)
- mobile veg >1cm length with e/o embolic phenomena‡ (2b)
- R-sided + severe valve dysfxn + HF sxs + veg >2cm length + persistent bacteremia or fevers >5-7d OR septic PE (2b)
- relapsing prosthetic valve infxn (2a)
† during initial hospitalization
‡ urgent or emergent
AHA “early surgery (during initial hospitalization and before completion of a full therapeutic course of antibiotics)”
AATS recommendation for coronary imaging before endocarditis surgery
guided by normal criteria
with lg AV veg, coronary CTA is an alternative
(1)
“The need for preoperative coronary angiography should be guided by normal criteria. This is particularly important if the patient has had coronary artery bypass grafting. In patients with large aortic valve vegetations, CT angiography is an alternative to assess the coronary arteries. (1)”
AATS mgmt of permanent/implanted cardiac devices in endocarditis
- infected: complete removal (1)
- resistent organisms: complete removal reasonable (2a)
- any organisms: complete removal reasonable (2b)
- R-sided + affected TV: complete removal (?)
- L-sided without convincing device infxn: optional/reasonable (?)
- epicardial lead implantation can be considered (2b)
- “Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is indicated as part of the early management plan in patients with IE and likely infection of the device or leads. (1)
- Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients with right- or left-sided valvular IE caused by S. aureus or fungi, even without evidence of device or lead infection. (2a)
- Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients undergoing surgery for valvular IE caused by any organism. (2b)”
- “At the time of surgery for IE, implantation of a new pacemaker system with epicardial leads may be considered when the patient is pacer dependent and has effective antimicrobial coverage. (2b)”
“If infected, and in right-sided IE affecting the tricuspid valve, leads and pacemaker should be removed. In the case of left-sided IE with no convincing evidence of pacemaker and lead involvement, removal is still reasonable but adds to complexity postoperatively and the question of if, when, and how the system should be replaced.”
endocarditis R-sided veg size indication for surgery
>2cm
endocarditis L-sided veg size indication for surgery
>1cm
INR goal for standard [modern] mech AVR
modern = bileaflet or current-generation single-tilting disk
2.5
(2.0-3.0)
(1)
“For patients with a mechanical bileaflet or current-generation single-tilting disk AVR and no risk factors for thromboembolism, anticoagulation with a VKA to achieve an INR of 2.5 is recommended. (1)”
INR goal for On-X mech AVR
≥3mo postop:
1.5-2.0 + ASA81
(early postop: still 2.5 / 2.0-3.0 + ASA81 x3mo)
(2b)
“For patients with a mechanical bileaflet or current-generation single-tilting disk AVR and no risk factors for thromboembolism, anticoagulation with a VKA to achieve an INR of 2.5 is recommended. (1)”
“In patients without risk factors who receive a mechanical On-X aortic heart valve, targeting the INR to a lower goal (1.5–2.0) in conjunction with aspirin 81 mg daily may be a strategy for long-term management. Warfarin dosing is targeted to an INR of 2.5 (range, 2.0–3.0) for the first 3 months after surgery, during which low-dose aspirin is also used. This recommendation is based on a single RCT of lower- versus standard-intensity VKA therapy (with low-dose aspirin) in patients undergoing On-X AVR. The lower-intensity INR group experienced significantly less major and minor bleeding, whereas the rates of stroke, transient ischemic attack, total neurological events, and all-cause mortality were similar between the 2 groups.”
INR goal for older-gen mech AVR with add’l TE risk factors
e.g. afib, previous thromboembolism, LV dysfxn, hypercoag state
older-generation = ball-in-cage
[modern = bileaflet or current-generation single-tilting disk]
3.0
(2.5-3.5)
(1)
“For patients with a mechanical AVR and additional risk factors for thromboembolism (eg, AF, previous thromboembolism, LV dysfunction, hypercoagulable state) or an older-generation prosthesis (eg, ball-in-cage), anticoagulation with a VKA is indicated to achieve an INR of 3.0. (1)”
INR goal for mech MVR
3.0
(2.5-3.5)
(1)
anticoag for bp TAVI
ASA81
(2a)
anticoag for bp SAVR
ASA81
(2a)
anticoag for bp MVR
ASA81
(2a)
optional early postop anticoag for bp TAVI at low bleeding risk (2 options)
- DAPT (ASA81 + Plavix) x3-6mo (2b)
- warfarin with INR goal 2.5 (2.00-3.0) x3+mo
- “For patients with a bioprosthetic TAVI who are at low risk of bleeding, dualantiplatelet therapy with aspirin 75 to 100 mg and clopidogrel 75 mg may be reasonable for 3 to 6 months after valve implantation. (2b)
- For patients with a bioprosthetic TAVI who are at low risk of bleeding, anticoagulation with a VKA to achieve an INR of 2.5 may be reasonable for at least 3 months after valve implantation. (2b)”
optional early postop anticoag for bp SAVR at low bleeding risk
warfarin with INR goal 2.5 (2.0-3.0) x3-6mo (2a)
optional early postop anticoag for bp MVR at low bleeding risk
warfarin with INR goal 2.5 (2.0-3.0) x3-6mo (2a)
anticoag contraindicated in bp TAVI
low-dose rivaroxaban (10mg QD) + ASA81
3: HARM
indication(s) for bridging mech valve anticoag when holding for non-cardiac procedure
- mech AVR + risk factors (2a)
- mech MVR (2a)
RFs=older-gen valve, afib, previous TE, hypercoag state, LV dysfxn
anticoag when warfarin is already indicated for a mech valve (either AVR or MVR) & there are concurrent indications for ASA, at low bleeding risk
warfarin with same INR goal + ASA81 (2b)
procedures in which holding mech valve anticoag is indicated
major procedures and/or in which bleeding may not easily be controlled
“For patients with a bileaflet mechanical AVR and no other risk factors for thromboembolism who are undergoing invasive procedures, temporary interruption of VKA anticoagulation, without bridging agents while the INR is subtherapeutic, is recommended. (1)”
RFs=older-gen valve, afib, previous TE, hypercoag state, LV dysfxn
procedures in which holding mech valve anticoag is NOT indicated
minor procedures in which bleeding is easily controlled
(e.g. dental extractions, cataracts)
“For patients with mechanical heart valves who are undergoing minor procedures (eg, dental extractions or cataract removal) where bleeding is easily controlled, continuation of VKA anticoagulation with a therapeutic INR is recommended. (1)”
reversal of mech valve anticoag (warfarin)
4-factor PCC
prothrombin complex concentrate
“For patients with a mechanical valve prosthesis receiving VKA therapy who require immediate/emergency noncardiac surgery or an invasive procedure, administration of 4-factor prothrombin complex concentrate (or its activated form) is reasonable. (2a)”
mech valve anticoag recommendation for major procedures and/or in which bleeding may not easily be controlled
HOLD & NO bridge (1)
unless RFs: hold & BRIDGE (2a)
RFs=older-gen valve, afib, previous TE, hypercoag state, LV dysfxn, MVR
“For patients with a bileaflet mechanical AVR and no other risk factors for thromboembolism who are undergoing invasive procedures, temporary interruption of VKA anticoagulation, without bridging agents while the INR is subtherapeutic, is recommended. (1)”
“For patients who are undergoing invasive procedures and have 1) a mechanical AVR and any thromboembolic risk factor, 2) an older-generation mechanical AVR, or 3) a mechanical mitral valve replacement, bridging anticoagulation therapy during the preoperative time interval when the INR is subtherapeutic is reasonable on an individualized basis, with the risks of bleeding weighed against the benefits of thromboembolism prevention. (2a)”
mech valve (with no addl’ RFs) anticoag recommendation for major procedures and/or in which bleeding may not easily be controlled
HOLD & NO bridge (1)
RFs=older-gen valve, afib, previous TE, hypercoag state, LV dysfxn, MVR
“For patients with a bileaflet mechanical AVR and no other risk factors for thromboembolism who are undergoing invasive procedures, temporary interruption of VKA anticoagulation, without bridging agents while the INR is subtherapeutic, is recommended. (1)”
mech valve (with add’l RFs) anticoag recommendation for major procedures and/or in which bleeding may not easily be controlled
RFs=older-gen valve, afib, previous TE, hypercoag state, LV dysfxn, MVR
hold & BRIDGE (2a)
RFs=older-gen valve, afib, previous TE, hypercoag state, LV dysfxn, MVR
“For patients who are undergoing invasive procedures and have 1) a mechanical AVR and any thromboembolic risk factor, 2) an older-generation mechanical AVR, or 3) a mechanical mitral valve replacement, bridging anticoagulation therapy during the preoperative time interval when the INR is subtherapeutic is reasonable on an individualized basis, with the risks of bleeding weighed against the benefits of thromboembolism prevention. (2a)”
mech valve anticoag recommendation for minor procedures in which bleeding is easily controlled
(e.g. dental extractions, cataracts)
CONTINUE
(1)
“For patients with mechanical heart valves who are undergoing minor procedures (eg, dental extractions or cataract removal) where bleeding is easily controlled, continuation of VKA anticoagulation with a therapeutic INR is recommended. (1)”
INR goal for mech AVR with systemic embolic event (incl stroke) while therapeutic
increase by 0.5:
2.5 (2.0-3.0)
OR add ASA81
“In patients with a mechanical AVR who experience a stroke or systemic embolic event while in therapeutic range on VKA anticoagulation, it is reasonable to increase the INR goal from 2.5 (range, 2.0–3.0) to 3.0 (range, 2.5–3.5) or to add daily low-dose aspirin (75–100 mg), with assessment of bleeding risk. (2a)”
INR goal for mech AVR with systemic embolic event (incl stroke) while therapeutic
increase by 0.5:
3.0 (2.5-3.5)
OR add ASA81
“In patients with a mechanical mitral valve replacement who experience a stroke or systemic embolic event while in therapeutic range on VKA anticoagulation, it is reasonable to increase the INR goal from 3.0 (range, 2.53.5) to 4.0 (range, 3.5–4.0) or to add daily low-dose aspirin (75–100 mg), with assessment of bleeding risk. (2a)”
anticoag for bp AVR (either TAVI or SAVR) with systemic embolic event (incl stroke) while on α-PLT tx
warfarin (usu INR goals)
(2b)
“In patients with a bioprosthetic surgical or transcatheter aortic valve or bioprosthetic mitral valve who experience a stroke or systemic embolic event while on antiplatelet therapy, VKA anticoagulation, instead of antiplatelet therapy may be considered after assessment of bleeding risk. (2b)”
mgmt of thrombosed L-sided mech valves with sxs of valve obstruction
urgent slow-infusion low-dose thrombolysis
OR
emergency surgery
(1)
mgmt of thrombosed bp valves that are HDS
warfarin
(2a)
recommendation for risk-stratification before valve intervention
risk calculator
i.e. STS risk score
(1)
typical adequate/minimum AVR size for men/women
♀21mm
♂23mm
AVR size range available
19-29mm
(technically 17 avail but is TINY)
21mm still pretty small, but 21 may be OK for most ♀, 23 for most ♂
typical adequate/minimum MVR size for men/women
♀/♂ 27mm
25mm still pretty small, 27+ prob OK for most, both ♀/♂
(range: 23?-33mm)
typical adequate/minimum MVRx band size for men/women
♀30-32mm
♂32-34mm
How do you size an AVR?
using the manufacturer’s sizers, to the annulus
How do you size a MVR?
using the manufacturer’s sizers, to the annulus
How do you size a MVRx?
using the manufacturer’s sizers, to the anterior leaflet
MVR size range available
23?-33mm
25mm still pretty small, 27+ prob OK for most, both ♀/♂
STS risk score low/intermediate/high cutoffs
<4% = low-risk
4-8% = intermediate risk
>8% = high-risk
(by risk of death)
standard/default ECMO (VA) cannula sizes
17Fr arterial
21-25Fr venous (multi-stage)
7Fr DPC
standard/default bicaval venous cannula sizes
28Fr x2 OR
28Fr SVC + 32Fr IVC
Are peripheral cannula sizes odd or even?
odd
Are central cannula sizes odd or even?
even
standard/default central CPB cannula sizes
20Fr aortic
32/40-36/42Fr venous (dual-stage)
BTK: 21Fr arterial
28Fr venous (dual-stage)
standard/default LH bypass cannula sizes
20Fr LAA/LSPV
17Fr distal aortic (periph cannula)
standard/default axillary artery cannulation graft size
8-10mm
Qp:Qs
(formula/how to calculate)
Qp/Qs = systemic extremes / pulmonary extremes:
arterial sat - mixed venous sat
-——————————————
PV sat - PA sat
(OR arterial sat - Swan PA sat)
quotient over quotient
so instead of P/S, it’s:
1/P / 1/S
= S/P
= extremes systemic / extremes Pulmonary
(e.g. 100-60 / 100-80 for 60 SVC sat & 80 PA sat = 40/20 = 2:1)
initial heparin dose for wires/sheaths/cannulas
10,000u
to ACT≥250
heparin dose before going on bypass
300u/kg
adequate retrograde cardioplegia pressure/flow
coronary sinus pressure = 40mmHg
(for both continuous & intermittent)
50-100mL/min (BTK)
v 150-200 mL/min??? (Julie)
- Delivered through the coronary sinus, should not exceed the pressure of 50mmHg
appropriate RCP pressure/flow
CVP = 25-35 (BTK: <25)
300mL/min (BTK: 500mL-1.5L/min)
OR ~5-10mL/kg/min
appropriate ACP pressure/flow
R radial a-line MAP = 50-70 (~60) (CTS 2e: 40-50)
500mL/min
OR ~10-15mL/kg/min
check contralateral carotid for backbleeding
adequate/appropriate antegrade cardioplegia pressure/flow
minimum = enough to close AV
line pressure < 300
200-300mL/min
adequate/appropriate ostial cardioplegia pressure/flow
???
100-150mL/min per coronary ostium
standard MAP goal on CPB
65-70
MAP goal on CPB with special concerns e.g. carotid stenosis
75-80
Where can you find the L SVC?
base of LA appendage, often draining into coronary sinus
(involuted L SVC = ligament of Marshall = fibrous connxn bet/ LA & L PVs)
mgmt of patent LIMA (or SVG) during redo sternotomy
dissect out & clamp (with risk of inj)
OR
cool to 28°C (moderate hypothermia) +:
frequent (at least Q20min Del Nido) cardioplegia
OR continuous retrograde cardioplegia
± systemic KCl
outcomes may be better without dissecting it out, likely d/t risk of injury during dissxn or clamping
redo sternotomy precxns
- redo pads (external defibrillator pads)
- blood X-matched & in the room
- groin access (at least sheaths)
type of saw for redo sternotomy (i.e. entering anterior then posterior table separately)
oscillating saw
type of saw for usual sternotomy (i.e. opening in one cut)
reciprocating saw
OS (all-comers) after emergency (VA-???)ECMO
~50%
(per Davis lecture)
Which is more common: systolic or diastolic murmurs?
systolic (almost everything)
Are systolic murmurs always pathological, or sometimes benign?
NO
sometimes benign
Are diastolic murmurs always pathological, or sometimes benign?
ALWAYS pathological
only cause of a continuous murmur
PDA
(systemic to pulmonary or systemic to RH shunts)
only causes of diastolic murmur (specific)
- AR
- PR
- MS
- TS
only causes of diastolic murmur (general/big-picture)
valvular dz causing abnormal flow into the ventricles during diastole:
- ventric outflow valve regurg (AR,PR)
- ventric inflow valve stenosis (MS,TS)
VSD murmur
loud/harsh
holosystolic
@ precordium/L lower sternal border (TV ausc window)
PDA murmur
machine-like
continuous
@ precordium/L lower sternal border (TV ausc window)
MR murmur (non-prolapse)
high-pitched, “blowing”
holosystolic
@ apex
radiating to axilla
AS murmur
harsh, crescendo-decrescendo
systolic ejection, following ejection/opening click
@ R upper sternal border
radiating to carotids & apex
ASD murmur
mid-systolic
pulmonary ejection
@
with wide, fixed split S2
MR murmur (r/t prolapse)
high-pitched, “blowing”
late/mid-systolic
@ apex
radiating to axilla
fixed split S2
ASD
murmur(s) ￪ with valsalva (￬venous return/preload)
HOCM
murmur(s) ￪ with hand grip/fist clench (￪SVR/afterload)
MR,AR
VSD
AR murmur
high-pitched, “blowing,” decrescendo
immediate/early diastolic
@ L sternal border/Erb’s point
HOCM murmur
high-pitched, crescendo-decrescendo
mid-systolic
@ L sternal border/Erb’s point
NOT radiating to carotids (v AS)
￪ with valsalva (￬venous return/preload)
MS murmur
low-pitched, rumbling
late diastolic after opening snap
@ apex
effect of inspiration on murmurs
⇒ ￬intrathoracic pressure ⇒ ￪venous return ⇒ ￪RH preload & ￬LH preload ⇒ ￪RH sounds (& ￪HOCM)
effect of expiration on murmurs
⇒ ￪intrathoracic pressure ⇒ ￬venous return ⇒ ￬RH preload & ￪LH preload (from inspiration? incr pulm venous return?) ⇒ ￪LH sounds (& ￬HOCM)
effect of hand grip/fist clench on murmurs
⇒ ￪SVR ⇒ ￪afterload ⇒ ￪LV pressure (& ￪MR,VSD)
effect of valsalva on murmurs
⇒ ￬venous return ⇒ ￬most murmurs (except ￪HOCM)
Are there any indications for valvular stenosis based on ventricular morphology (e.g. LVESD, LVEDD)?
NO
For which valve pathologies is consideration of LVESD or LVEDD part of the indications for intervention?
AR (severe)
- LVESD>50mm (2a)
- progressive on 3 studies ￪LVEDD to >65mm (2b)
1° MR (severe)
- LVESD≥40 (1)
- progressive on 3 studies: ￪LVESD (2b)
LVESD threshold for severe AR
>50mm (2a)
LVEDD threshold for severe AR
progressive on 3 studies to >65mm (2b)
LVESD threshold for severe MR
≥40 (1)
OR progressive ￪ on 3 studies (2b)
For which valve(s) pathology is LVEDD considered in the indications for intervention?
AR
- progressive on 3 studies ￪LVEDD to >65mm (2b)
For which valve(s) pathology is LVESD considered in the indications for intervention?
AR
- LVESD>50mm (2a)
1° MR
- LVESD≥40 (1)
- progressive on 3 studies: ￪LVESD (2b)
which of LVEDD & LVESD is considered in AR & MR
LVEDD = AR
LVESD = MR + AR
(A & D closer in alphabet;
M & S closer in alphabet)
but want more excuses to operate on AV
indication(s) for intervention in [isolated] secundum ASD (adult)
- ￬fxnal capacity AND
- RA and/or RV enlargement AND
- L🠆R shunt ⇒ physio sequelae / Qp:Qs≥1.5
if:
NO cyanosis AND
PASP < 50% SBP AND
PVR < 1/3 SVR
rx (transcath OR surgical) ⇒ ￬RV vol & ￪exercise tolerance (1)
same if asx (2a)
same if asx & no RA/RV dil with concomitant <3 surg (2a)
can consider with ￪PASP/PVR if < 2/3 SBP/SVR (2b)
indication(s) for intervention in VSD (adult)
- LV overload AND
- L🠆R shunt ⇒ physio sequelae / Qp:Qs≥1.5
if:
PASP < 50% SBP AND
PVR < 1/3 SVR
rx (transcath OR surgical) (1)
same if no LV overload (2b)
surgical rx if perimembranous or supracristal causing worse AR (2a)
surgical rx if h/o IE attributable to VSD (2b)
contraindication(s) intervention in of ASD (adult)
relative:
PASP > 50% SBP
PVR > 1/3 SVR
absolute:
PASP > 2/3 SBP
PVR > 2/3 SVR
R🠆L shunt
(3: HARM)
contraindication(s) intervention in of VSD (adult)
relative:
PASP > 50% SBP
PVR > 1/3 SVR
absolute:
PASP > 2/3 SBP
PVR > 2/3 SVR
R🠆L shunt
(3: HARM)
contraindication(s) for intervention in AVSD (adult)
relative:
PASP > 50% SBP
PVR > 1/3 SVR
absolute:
PASP > 2/3 SBP
PVR > 2/3 SVR
R🠆L shunt
(3: HARM)
contraindication(s) for intervention in ASD (relative), VSD (relative), AVSD (relative), PAPVR, sinus venosus, coronary sinus defect (adult)
- PASP > 50% SBP
- PVR > 1/3 SVR
relative contraindication(s) for intervention in ASD/VSD/AVSD (adult)
- PASP > 50% SBP
- PVR > 1/3 SVR
absolute contraindication(s) for intervention in ASD/VSD/AVSD (adult)
- PASP > 2/3 SBP
- PVR > 2/3 SVR
- R🠆L shunt
(3: HARM)
indication(s) for intervention in primum ASD/sinus venosus/coronary sinus defect (adult)
- ￬fxnal capacity AND
- RA and/or RV enlargement AND
- L🠆R shunt ⇒ physio sequelae / Qp:Qs≥1.5
if:
NO cyanosis AND
PASP < 50% SBP AND
PVR < 1/3 SVR
surgical rx (1)
primum ASD only: can consider with ￪PASP/PVR if < 2/3 SBP/SVR (2b)
indication(s) for intervention in PAPVR incl scimitar vein (adult)
- ￬fxnal capacity AND
- RV enlargement/overload AND
- L🠆R shunt ⇒ physio sequelae / Qp:Qs≥1.5
if:
PASP < 50% SBP AND
PVR < 1/3 SVR
surgical rx (1)
or PAPVR with concomitant ASD/sinus venosus rx (1)
or if asx (2a)
indication(s) for intervention in severe L AV valve regurg in AVSD (adult)
same as for regular MR (1)
indication(s) for intervention in AVSD (adult)
surgical rx of primary AVSD/residual shunts (1) if:
* L🠆R shunt with Qp:Qs≥1.5 AND
* PASP < 50% SBP AND
* PVR < 1/3 SVR
can consider with ￪PASP/PVR if < 2/3 SBP/SVR (2b)
surgical rx of LVOTO if max gradient ≥50mmHg OR <50 with HF sxs or mod+ MR or AR (2a)
indication(s) for intervention in PDA (adult)
- LA or LV enlargement (attributable to PDA) AND
- L🠆R shunt ⇒ physio sequelae / Qp:Qs≥1.5
if:
PASP < 50% SBP AND
PVR < 1/3 SVR
rx (1)
can consider with ￪PASP/PVR if < 2/3 SBP/SVR (2b)
“Pulmonary blood flow and thus Qp:Qs can be difficult to calculate accurately because of differences in right/left PA blood flow caused by the flow from the PDA. […] Surgical closure can be performed but is potentially hazardous in adults because of calcification and tissue fragility.”
indication(s) for intervention in subaortic stenosis (subAS) (adult)
- attributable sxs + LVOT max gradient ≥50mmHg (1)
- HF or ischemic sxs OR attributable LV systolic dysfxn + <50mmHg (1)
- asx <50mmHg + mild+ AR ⫤ AR progression (2b)
“Pulmonary blood flow and thus Qp:Qs can be difficult to calculate accurately because of differences in right/left PA blood flow caused by the flow from the PDA. […] Surgical closure can be performed but is potentially hazardous in adults because of calcification and tissue fragility.”
indication(s) for intervention on PR s/p rx of PS (adult)
PVR for:
* sxs + ≥mod PR + RV enlargement/dysfxn (1)
* asx + ≥mod PR + progressive RV enlargement/dysfxn OR progressive ￬exercise capacity (2b)
serial f/u for any PR not meeting above criteria
AHA ACHD guideline
Figure 3. Isolated PR after repair of PS
https://drive.google.com/file/d/12YEO9s5RsgP5NWqfCRqR-V4VhDFJKXrJ/view
*Significant PR causes RV dilation. If a patient has moderate or greater PR and normal RV size, most likely the estimation of PR severity is inaccurate or there may be restrictive RV physiology, which would warrant further investigation.
†Symptoms may include dyspnea, chest pain, and/or exercise intolerance referable to PR or otherwise unexplained.
mgmt of PR s/p rx of PS (adult)
- ECHO for PR severity & RV size/fxn:
- mild PR & RV enlargement ⇒ surveil (1)
- ≥mod PR & RV enlargement: - sxs (incl exercise test):
- +sxs ⇒ PVR (1)
- asx ⇒ more w/u - cMRI + CPET:
- progressive RV dil/dysfxn and/or progressive ￬exercise capacity ⇒ PVR (2b)
- stable ⇒ surveil
PVR for:
* sxs + ≥mod PR + RV enlargement/dysfxn (1)
* asx + ≥mod PR + progressive RV enlargement/dysfxn OR progressive ￬exercise capacity (2b)
serial f/u for any PR not meeting above criteria
AHA ACHD guideline
Figure 3. Isolated PR after repair of PS
https://drive.google.com/file/d/12YEO9s5RsgP5NWqfCRqR-V4VhDFJKXrJ/view
*Significant PR causes RV dilation. If a patient has moderate or greater PR and normal RV size, most likely the estimation of PR severity is inaccurate or there may be restrictive RV physiology, which would warrant further investigation.
†Symptoms may include dyspnea, chest pain, and/or exercise intolerance referable to PR or otherwise unexplained.
What determines R/L heart dominance?
PDA origin off RCA v LCx > LAD
= R v L dominant
= 90% v 9% v 1% co-dominant
What is the most common heart dominance (coronary circulation)?
R-dominant = 90%
L = 9%
co- = 1%
imaging recommendation for evaluating post-rx ToF
cMRI to quantify ventric size/fxn, PV fxn, PA anatomy, LH abnormalities (1)
mandatory pre-intervention testing before RV-PA conduit stenting or transcatheter PVR
coronary artery compression testing (1)
indication(s) for intervention on PR in ToF (adult/post-rx)
PVR (surgical or transcatheter) for ≥mod PR AND:
➢ +CV sxs (1)
⇒ ￬sxs
➢ asx + ≥2 of: (2a)
- ≥mild RV/LV dysfxn
- RV dil
(RVEDVI≥160mL/m2 /
RVESVI≥80mL/m2 /
RVEDV ≥2x LVEDV)
- RVSP 2/2 RVOTO ≥2/3 SBP
- progressive ￬exercise tolerance
⇒ preserve RV size/fxn
➢ sustained [ventricular] tachyarrhythmias (2b)
➢ surg PVR for concomitant <3 surg (other residual lesions requiring surgical rx) (2b)
AHA ACHD guideline
Figure 4. Pulmonary valve replacement in patients with TOF repair and PR
https://drive.google.com/file/d/12bncSXwY_LVaRkXGWUbrYB0nL2J7lqgv/view
indication(s) for ICD in ToF (adult/post-rx)
multiple RFs: ICD ⇒ 1° ppx of SCD (2a)
RFs:
- LV systolic or diastolic dysfxn
- non-sustained VT
- QRS≥180
- extensive RV scarring/fibrosis (on CMR)
- inducible sustained VT on EP
indications for RV-PA conduit intervention (adult)
- ≥mod PR/PS + ￬fxnal capacity OR arrhythmia (2a)
- asx + severe PR/PS + ￬RV RF or RV dil (2b)
“classic”/old definition of PAH/pHTN
mPAP≥25 & PVR≥3.0 Wu
mean PA pressure (mPAP) ≥ 25 mmHg + pulmonary vascular resistance (PVR) ≥ 3.0 Woods units (WU)
new/current definition of PAH/pHTN
mPAP>20 & PVR>2.0 Wu
mean PA pressure (mPAP) > 20 mmHg + pulmonary vascular resistance (PVR) > 2.0 Woods units (WU)
indication(s) to operate on anomalous aortic origin of coronary artery (AAOCA)
LCA from R sinus: YES
- +sx/exercise test/ischemia (1)
- asx (2a)
RCA from L sinus: PROB
- +sx/exercise test/ischemia (1)
- +ventric arrhythmias (2a)
- asx (2b) OR obs (2b)
AHA ACHD guideline
Figure 5. Anomalous aortic origin of the coronary artery
https://drive.google.com/file/d/137Gl6zTGTsGJNG_poFug5pePohBSIlMh/view
indication(s) to operate on anomalous aortic origin of R coronary artery (R AAOCA)
RCA from L sinus: PROB
- +sx/exercise test/ischemia (1)
- +ventric arrhythmias (2a)
- asx (2b) OR obs (2b)
AHA ACHD guideline
Figure 5. Anomalous aortic origin of the coronary artery
https://drive.google.com/file/d/137Gl6zTGTsGJNG_poFug5pePohBSIlMh/view
indication(s) to operate on anomalous aortic origin of L coronary artery (L AAOCA)
LCA from R sinus: YES
- +sx/exercise test/ischemia (1)
- asx (2a)
AHA ACHD guideline
Figure 5. Anomalous aortic origin of the coronary artery
https://drive.google.com/file/d/137Gl6zTGTsGJNG_poFug5pePohBSIlMh/view
w/u for anomalous aortic origin of coronary artery (AAOCA)
- any or all of: CTA > LH cath (coronary angio) > cMRI (1)
- “anatomic & physiologic” eval for LCA from R sinus OR RCA from L sinus (1)
clinical considerations for risk of sudden cardiac death (SCD) in anomalous aortic origin of coronary artery (AAOCA)
- <35yo (relative)
- slit-like/fish-mouth-shaped orifice (more common with RCA from L sinus)
- acute
- acute angle take-off
- intramural course
- interarterial course
- hypoplasia of prox coronary artery
- LCA from R sinus (less common than RCA from L but ? ∝ higher risk of SCD; LCA from R also ∝ myocardial fibrosis)
- SCD ∝ exercise
- age: “AAOCA is more commonly invoked as the cause of SCD in patients <35 y of age than in patients >35 y of age, in whom atherosclerotic coronary disease becomes a more prevalent cause. However, death has been attributed to AAOCA in patients of all ages; there does not seem to be an age beyond which the AAOCA may not be relevant, even in the setting of atherosclerotic coronary disease and other concomitant conditions.”
- anatomy: “Slit-like/fish-mouth-shaped orifice, acute angle takeoff, intramural course, interarterial course and hypoplasia of the proximal coronary artery have all been proposed as reasons for symptoms, ischemia and SCD in patients with AAOCA. The slitlike orifice is more commonly seen in anomalous right coronary artery arising from the left sinus. Each of these anatomic findings offers a pathophysiological mechanism for intermittent ischemia, particularly at times of high cardiac output and/or increased aortic wall tension, such as during exercise.”
- anomalous origin: “Left coronary artery arising from the right cusp is less common than the right coronary artery arising from the left cusp but is more often found in autopsy series of SCD. This suggests that anomalous origin of the left coronary artery from the right cusp is more likely to cause SCD than anomalous origin of the right coronary artery from the left cusp. This may be due either to anatomic features that make anomalous aortic origin of the left coronary artery prone to coronary compromise or because a larger proportion of myocardium is supplied by the left coronary artery, or both.” / “Anomalous left coronary from the right sinus is less common than anomalous right coronary from the left sinus, but anomalous left coronary artery from the right is more commonly found in autopsy series of athletes and military recruits who had nontraumatic death than right coronary from the left sinus. The overrepresentation of the anomalous left coronary from the right sinus suggests a higher risk of SCD, particular at extremes of exertion and in patients <35 years of age.”
- exercise: “Autopsy series suggest a most patients die during, or in close temporal association with, exercise.”
- ischemia: “Autopsy series demonstrate myocardial fibrosis in a significant number of patients whose deaths were attributed to AAOCA, particularly in patients with anomalous left coronary artery arising from the right cusp. Surgical series describe patients with ischemia or MI before surgical repair in the absence of other CAD, suggesting a relation of the coronary anomaly to the ischemia. This suggests that had perfusion imaging been obtained before SCD, ischemia would have been found in such patients. However, other data indicate that a normal stress test does not preclude a SCD event, with the proviso that most of those studies used only stress ECG, rather than the more sensitive and specific modalities of nuclear perfusion imaging or stress echocardiography. In addition, postoperative studies have shown that ischemia may be found after surgical repair in the distribution not supplied by the abnormal coronary artery and may not persist on repeat testing.” / “However, there are patients in whom a SCD event occurred despite normal stress ECG, and consequently absence of ischemia is not reassuring. Autopsy series show that many patients whose death is attributed to anomalous coronary arteries are young, thus management of patients should take age into account, with heightened concern about the risk of sudden death in younger patients.”
-
symptoms: “In autopsy and surgical series, a significant number of patients reported cardiovascular symptoms, including before SCD events. Symptoms are more commonly reported in patients in whom the left coronary artery arises from the right sinus. Surgical series have described improvement in symptoms after surgical repair.”
Table 34. Factors That May Relate to the Clinical Importance of AAOCA and Risk of SCD https://drive.google.com/file/d/1312p1L2P2nXBnWRC0DiHgfFpr8FMswI-/view
approach(es)/intervention(s) for anomalous aortic origin of coronary artery (AAOCA)
AHA: unroofing OR coronary revascularization (bypass) for concomitant fixed obstruction
OR re-implantation???
indication(s) to operate on anomalous origin of L coronary artery from PA (ALCAPA)
YES (1)
indication(s) to operate on anomalous origin of R coronary artery from PA (ARCAPA)
+sx (1)
asx + ventric dysfxn or attributable myocardial ischemia (2a)
approach(es)/intervention(s) for anomalous origin of L/R coronary artery from PA (ALCAPA/ARCAPA)
AHA: aortic reimplantation ± interposition graft OR ligation/closure @ level of PA + bypass (CABG: LIMA-LAD or RIMA-RCA/PDA)
annual rate of stroke in CHA2DS2-VASc score = 2 ♂ / 3 ♀
>2%
(considered high, v 1-2% intermediate & <1% low)
indication(s) for percutaneous LAAO (LA appendage occlusion)
afib + mod-high stroke risk (CHA2DS2-VASc≥2):
- + contraindication to long-term anticoag (2a)
- + high risk of major bleeding (2b)
(as alternative to anticoag)
indication(s) for surgical LAAE (LA appendage exclusion/excision)
afib + concomitant <3 surg + CHA2DS2-VASc score≥2 or equivalent stroke risk:
- in add’n to anticoag ⇒ ￬stroke,syst embo (1)
- without ongoing anticoag (2b: uncertain)
[LAAE surgical technique should ⇒ ∅flow & stump <1cm by intraop TEE (1)]
indication(s) for surgical ablation (Cox maze) for afib
- afib + concomitant <3 surg (2a) ⇒ ￬recurrent afib
- sx, persistent, Rx-refrx afib: hypbrid epicardial + endocardial ablation ⇒ ￬recurrent atrial arrhythmia (2b)
“Among patients with AF or AFL, concomitant surgical ablation at the time of cardiac surgery has been shown to reduce the risk of recurrent atrial arrhythmia. However, it is associated with an increased risk of renal dysfunction and pacemaker placement.”
minimum ACT to go on bypass
480
minimum ACT to cannulate
200-250
OR empiric hep dose of 5000-10000u OR 100u/kg
OR 300 (CTS 2e)
200 = Salim (“to manipulate the arch/prox Ao”)
250 = ???
5k empiric = BTK??? + JT or Julie
10k empiric = Kim
100u/kg = ~7k typical 70kg pt = Salim
STICH
???
aneurysm rx no benefit
reduced EF benefit
STICH-ES
???
BARI
???
multivessel diabetic
SYNTAX
???
CABG v PCI
steps if ACT inadequate after heparin
- give more heparin
- check for a “bad batch”/new vial
- ATIII > FFP
mgmt of air embolus on CPB
- STOP BYPASS (clamp lines)
- head down (reverse T) + 100% FiO2 + steroids ± barbiturate ± mannitol
- de-air circuit & resume CPB + cool to 18°
- RCP with aortic root vent on
- hyperbaric O2 if within 5h of OR
minimum stenosis to use a radial artery bypass graft
90% R
80% L
minimum stenosis to use a radial artery bypass graft on a R-sided lesion
90%
minimum stenosis to use a radial artery bypass graft on a L-sided lesion
80%
location/course of persistent L SVC
origin: L IJ & L subclv jxn
course: to L of desc Ao, crosses behind LA
drainage: coronary sinus
incidence of persistent L SVC
~3%
protamine dose
1mg/100u hep
endovascular interventional wire sizing
diameter (in) x length (cm)
most common cause of/etiology underlying spontaneous bloody/hemorrhagic pericardial effusion
CA (~1/3)
SESATS: “The presence of a hemorrhagic effusion is most likely due to malignancy. In a series of large symptomatic pericardial effusion, this was the cause in 1/3 of cases. Chronic-idiopathic (14%), acute pericarditis (12%), trauma (12%), and uremia (6%) were other causes of this type of effusion.”
idiopathic(/viral) pericarditis mgmt
- NSAIDS (ASA650/ibu800 TID) + colchicine (0.6 QD/BID) ￫ taper NSAIDS once improved, complete 3mo colchicine
- steroids only if NSAIDS contraindicated or fails
UpToDate:
The daily maintenance dose of colchicine is weight-based:
●≥70 kg = 0.5 to 0.6 mg BID
●<70 kg = 0.5 to 0.6 mg QD
“Duration of treatment is based upon the resolution of symptoms, which usually occurs in two weeks or less, with tapering once the patient is symptom-free for at least 24 hours.”
“Failure to respond to aspirin or NSAID therapy within one week (defined as persistence of fever, pleuritic chest pain, a new pericardial effusion, or worsening of general illness) suggests that a cause other than idiopathic or viral pericarditis is present.”
“Recurrent pericarditis is manifested by recurrence of the symptoms and signs of acute pericarditis after a symptom-free interval of at least four to six weeks.”
“Symptoms of recurrent pericarditis occur at a variable time after the initial attack, but usually within 18 months.”
recurrent idiopathic(/viral) pericarditis mgmt
same as 1st episode:
1. NSAIDS (ASA650/ibu800 TID) + colchicine (0.6 QD/BID) ￫ taper NSAIDS once improved, complete 3mo colchicine
2. steroids only if NSAIDS contraindicated or fails
SESATS:
“Recurrent pericarditis is a challenging problem for clinicians and is a disabling issue for patients. The most common presenting symptoms of recurrent pericarditis are generally the same as those which are seen during the initial episode. Recurrence after initially successful treatment typically occurs within 18 months and often adversely affects the patient’s quality of life.
While no specific clinical feature of an initial episode of acute pericarditis consistently predicts recurrence, an initial successful treatment with aspirin or NSAIDs is associated with a reduced risk of recurrence. In contradistinction, initial therapy with glucocorticoids is associated with a greater risk of recurrence. Most patients with recurrent pericarditis can be managed effectively with medical therapy on an outpatient basis.
Combination therapy with colchicine and NSAIDs for recurrent pericarditis has been evaluated in 3 randomized, placebo-controlled trials as well as 2 systematic reviews and shown to significantly benefit patients. Furthermore, it has been shown to lower the risk of further recurrent episodes. Intrapericardial steroids achieve high local steroid concentrations while limiting systemic toxicity, however, this treatment is viewed as a last resort, especially in patients who experienced severe side effects of systemic therapy. In the small amount of patients who do not respond to conventional therapy or who do not tolerate first- and second-line medications, the addition of immune therapy can be considered in the form of azathioprine, anakinra, or human IVIg.”
differentiating features of constrictive pericarditis & restrictive cardiomyopathy
constrictive pericarditis v restrictive CM, respectively:
- ￪resp var in ventric filling v minimal
- rapid early diastolic filling v slow
- “square root” sign of rapid filling then rapid stop v gradual
- equalization of ventricular pressures v L>R
- ventricular interdependence v not
https://drive.google.com/file/d/19PZ8DYC_G3iDUAqdiGt6er67itYLA_Li/view
diagnosis of CTEPH
- PAP>25
- PCWP<15
- mult chronic/organized occlusive thrombi/emboli in PAs after ≥3mo anticoag
- V/Q scan showing ≥1 segmental+ perfusion defect(s)
predictors of afib recurrence after Cox maze
- age
- duration of preop afib
- LA dil
freedom from recurrent afib after concomitant Cox maze with MVRx
>80%
(SESATS: 3/6/12mo = 85%/81%/84%)
risk of PPM with Cox maze (standalone/no concomitant procedures)
~5%
(￪ with add’l proc)
risk of PPM with biatrial v L atrial Cox maze
14% v 6%
SESATS: “The need for permanent pacemaker (PPM) insertion after lone Cox Maze IV (CMIV) has been reported as 5% and increases when the CMIV is performed as a concomitant procedure, most commonly after valvular heart surgery. While many centers only offer surgical ablation as a biatrial procedure in order to address atrial fibrillation (AF) originating from the right atria, many centers offer a left atrial CMIV lesion set only. This reserves biatrial procedures to patients with prolonged AF history or with rightsided heart disease and right atrial enlargement. The biatrial lesion set is associated with an increased need for PPM (13.6% compared with 6.3%, P= 0.028).
Left atrial diameter and duration of atrial fibrillation are predictors of recurrent atrial fibrillation but are not predictors of the pacemaker requirement.
The primary indication for PPM after a biatrial lesion set after a CMIV was sinoatrial node dysfunction (40%–68%). Atrioventricular (AV) block, when present after concomitant surgical ablation, is typically reflective of AV nodal injury, which is most commonly attributed to the valvular procedure that is performed. Concomitant coronary artery bypass grafting does not increase the risk of pacemaker requirement.”
ppx abx before cardiac surgery
- 1st-gen ceph
- +vanc if implanting prosthetic OR pt high-risk for Staph
amount of aortic root you can repair before having to replace (e.g. in endocarditis)
up to 1/3 (BTK)
max re-warming rate coming off DHCA
1°C/2min / 0.5°C/1min
max arterial outflow : venous inflow ∆ = 10°C
(BTK: max core : periph temp ∆ ≤5°C)
SESATS: “When cooling and rewarming, the temperature gradient from the arterial outlet to the venous blood temperature should not exceed 10° C to prevent the formation of gaseous emboli. The maximum arterial temperature should be 37° C to prevent cerebral hyperthermia. The maximum rewarming rate should be less than 0.5° C per minute.”
mgmt of acute L-sided mech valve thrombosis +sx
urgent slow-infusion, low-dose fibronlysis (tPA) OR emergency surgery
mgmt of bp valve thrombosis, hemodynamically stable
hep drip ￫ warfarin
ECHO criteria in order of increasing #s for regurgitant valve criteria (in general/all 3)
alphabetical:
1. EROA
(0.1-0.3/0.2-0.4x2)
2. jet
(25-65/20-40/>50)
3. RF
(30-50/30-50/X)
4. RVol
(30-60/30-60/30-45)
5. vena contracta
(0.3-0.6/0.3-0.7x2)
peak gradient in mild RVOTO
<36
peak gradient in moderate RVOTO
36-64
peak gradient in severe RVOTO
>64
peak gradient in severe RVOTO
>64
vmax in mild RVOTO
<3
vmax in moderate RVOTO
3-4
vmax in severe RVOTO
>4
secondary lesion a/w PA sling
tracheal stenosis/complete tracheal rings
Cox maze IV lesions
Pulmonary vein box
LAA
Crossing mitral valve
SVC IVC
RAA
Crossing tricuspid valve
Corinary sinus?
configuration of PA sling
ring around trachea only
- L PA anomalously arises from R PA instead of main PA & courses between trachea & esophagus (=R&posterior)
- normal R PA (=anterior)
- ligamentum arteriosum (=L)
only ring/sling that courses between trachea & esophagus
only ring/sling that creates anterior compression of esophagus
- https://drive.google.com/file/d/1DD4xt3c3yaYBj3GN0K6AlgDw24xsOKP7/view
- https://drive.google.com/file/d/1DEm-GXr3rW1JYlc-FG-TVGGXpOiGv_Wy/view
- https://drive.google.com/file/d/1DFXtxr8JzewSV7q9mxk-duvDX-mKWltF/view
indication(s) for rx of recurrent CoA (coarcation) in adult
- peak to peak gradient >20
- HTN
mgmt of recurrent CoA (coarctation) in adult
stent > balloon
stent > surgery
SESATS: “The incidence of recoarctation is between 5% – 14%. It is most common when the repair is done in neonates (<30 days) and to a lesser extent infants (<1yo). The presence of hypoplasia in the transverse arch also increases the chance of recurrent arch gradient. Indications for intervention in the setting of recurrent coarctation include hypertension and a peak-topeak gradient across the area of stenosis >20 mmHg, both of which are present in the patient described. Guidelines from the American College of Cardiology and the American Heart Association recommend percutaneous catheter intervention as the preferred treatment of choice for the management of discrete recoarctation. This is based, in part, on the fact that mortality for re-operation is significant at 1% – 3%, and it can be as high as 5% – 10% if there is significant left ventricular dysfunction.”
PAPi definition
PA pulsatility index = PAPP (pulse pressure) ÷ CVP
= “how much pressure is the RV able to generate relative to RA pressure” (BTK)
PAPi normal limit
≥5.5
SVR normal limit
800-1200
definition of cardiogenic shock
CI<2.2
PCWP normal limit
4-12
type of valvular dysfxn with a diastolic murmur
regurg
type of valvular dysfxn with a systolic murmur
stenosis
= systolic
Where is the central fibrous body & what structures comprise it?
NCC base/nadir
membranous septum + R trigone
