Cardiovascular Conditions B Flashcards
1
Q
Atrioventricular Block - Description
A
disrupted electrical conduction of AV node
2
Q
Atrioventricular Block - Risk Factors (8)
A
1) >50 years old (tissue fibrosis)
2) male
3) increases vagal tone
4) AV node blocking agents (βB, CCB, digoxin)
5) hypertension
6) ischaemic heart disease (inf. MI —> Mobitz I, ant. MI —> Mobitz II)
7) cardiomegaly
8) heart failure
3
Q
Atrioventricular Block - Types (4)
A
1) 1st degree
2) 2nd degree Mobitz I
3) 2nd degree Mobitz II
4) 3rd degree
4
Q
Atrioventricular Block - Pathophysiology (1st Degree) (1)
A
1) delayed atrioventricular conduction
5
Q
Atrioventricular Block - Pathophysiology (2nd Degree) (1)
A
1) decreased atrioventricular conduction
6
Q
Atrioventricular Block - Pathophysiology (3rd Degree) (2)
A
1) no atrioventricular conduction
2) ventricular conduction maintained by escape rhythms
7
Q
Atrioventricular Block - Symptoms (7)
A
1) asymptomatic
2) syncope
3) fatigue (esp. exertional)
4) dyspnoea (esp. exertional)
acute symptoms
5) chest pain
6) nausea
7) palpitations
8
Q
Atrioventricular Block - Signs (3)
A
1) bradycardia (<40bpm - emergency)
2) hypertension (inc. wide pulse pressure)
3) hypotension (emergency)
9
Q
Atrioventricular Block - Complications (1)
A
1) bradycardia
10
Q
Atrioventricular Block - Investigations (3/2)
A
initial 1) ECG* 2) UnE (abnormal K+, Ca2+) 3) troponin assay (may be elevated) consider 1) ambulatory monitoring (24 hours) 2) chest x-ray
11
Q
Atrioventricular Block - Investigations (ECG) (4)
A
1) 1st degree —> PR interval>200ms
2) 2nd degree Mobitz I —> PR interval progressively increasing
3) 2nd degree Mobitz II —> PR interval constant, QRS complex occasionally missed
4) 3rd degree —> P wave and QRS complex completely dissociated
12
Q
Atrioventricular Block - Management (2/1/1)
A
conservative 1) stop AV node blocking agents (βB, CCB, digoxin) 2) monitor (1st, 2nd I) medical 1) atropine (2nd II, 3rd) surgery 1) pacemaker
13
Q
Right Bundle Branch Block - Description
A
heart block before right His bundle branch
14
Q
Right Bundle Branch Block - Causes (5)
A
1) ischaemic heart disease
2) right ventricular hypertrophy
3) pulmonary embolism
4) atrial septal defect
5) ventricular septal defect
15
Q
Right Bundle Branch Block - Pathophysiology (2)
A
1) heart block of right His bundle branch
2) left ventricle contracts before right ventricle
16
Q
Right Bundle Branch Block - Symptoms (2)
A
1) asymptomatic
2) syncope
17
Q
Right Bundle Branch Block - Signs (1)
A
1) wide S2 heart sound split (A2 then P2))
18
Q
Right Bundle Branch Block - Complications (1)
A
1) bradycardia
19
Q
Right Bundle Branch Block - Investigations (1/0)
A
initial
1) ECG*
20
Q
Right Bundle Branch Block - Investigations (ECG) (4)
A
1) QRS complex >120ms
2) deep S wave in I, V5, V6
MarroW
3) M QRS complex in V1
4) W QRS complex in V6
21
Q
Right Bundle Branch Block - Management (0/1/0)
A
medical
1) treat underlying cause
22
Q
Left Bundle Branch Block - Description
A
heart block before left His bundle branch
23
Q
Left Bundle Branch Block - Causes (4)
A
1) ischaemic heart disease
2) left ventricular hypertrophy
3) aortic regurgitation
4) aortic stenosis
24
Q
Left Bundle Branch Block - Pathophysiology (2)
A
1) heart block of left His bundle branch
2) right ventricle contracts before left ventricle
25
Left Bundle Branch Block - Symptoms (2)
1) asymptomatic
| 2) syncope
26
Left Bundle Branch Block - Signs (1)
1) paradoxical S2 heart sound split (P2 then A2)
27
Left Bundle Branch Block - Complications (1)
1) bradycardia
28
Left Bundle Branch Block - Investigations (1/0)
initial
| 1) ECG*
29
Left Bundle Branch Block - Investigations (ECG) (4)
1) QRS complex > 120ms
2) deep S wave in V1, V2
WilliaM
3) W QRS complex in V1
4) M QRS complex in V6
30
Left Bundle Branch Block - Management (0/1/0)
medical
| 1) treat underlying cause
31
Sinus Tachycardia - Description
increased heart rate (>100bpm)
32
Sinus Tachycardia - Causes (7)
1) exertion
2) anxiety
3) pain
4) fever
5) anaemia
6) hyperthyroidism
7) hypovolaemia
33
Sinus Tachycardia - Symptoms (4)
1) asymptomatic
2) dyspnoea
3) fatigue
4) presyncope-->syncope
34
Sinus Tachycardia - Investigations (7/1)
```
initial
1) ECG (sinus rhythm, >100bpm)
2) Holter monitoring
3) event monitoring
4) FBC
5) UnE
6) TFT
7) troponin assay
consider
1) implantable loop recorder
```
35
Sinus Tachycardia - Management (2/3/0)
```
conservative
1) none
2) vagal manoeuvres
medical
1) treat underlying cause
2) IV adenosine
3) rate controller (e.g. βB, CCB)
```
36
Atrial Fibrillation - Description
irregularly irregular heart beat, type of supraventricular tachycardia
37
Atrial Fibrillation - Causes (10)
1) idiopathic (5-10%)
2) ischaemic heart disease
3) heart failure
4) hypertension
5) mitral stenosis
6) mitral regurgitation
7) chronic obstructive pulmonary disease
8) asthma
9) hyperthyroidism
10) alcohol
38
Atrial Fibrillation - Pathophysiology (4)
1) ectopic pulmonary vein discharge
2) dysfunctional electrical signalling
3) ectopic atrial beats
4) uncoordinated atrial contraction
39
Atrial Fibrillation - Symptoms (5)
1) asymptomatic
2) chest pain
3) dyspnoea
4) palpitations
5) syncope
40
Atrial Fibrillation - Signs (3)
1) irregularly irregular heart beat
2) apical pulse rate faster than radial pulse rate
3) tachycardia
41
Atrial Fibrillation - Complications (5)
1) atrial flutter
2) bradycardia (iatrogenic)
3) stroke
4) heart failure
5) hypotension
42
Atrial Fibrillation - Investigations (4/2)
```
initial
1) ECG*
2) U&E
3) TFT
4) chest x-ray
consider
1) LFT
2) echocardiogram (left atrial enlargement, mitral valve disease)
```
43
Atrial Fibrillation - Investigations (ECG) (5)
1) absent P waves
2) irregular RR intervals
3) narrow QRS complexes
4) atrial rate 350-600bpm
5) ventricular rate 100-180bpm
44
Atrial Fibrillation - Management (0/3/2)
medical
1) anticoagulant or antiplatelets (e.g. warfarin or aspirin)
2) antiarrhythmic (amiodarone or flecainide)
3) rate control (βB or CCB or digoxin)
surgery
1) DC cardioversion
2) catheter ablation (pulmonary vein)
45
Atrial Flutter - Description
intermittent increased atrial rate, type of supraventricular tachycardia
46
Atrial Flutter - Causes (10)
1) idiopathic (30%)
2) ischaemic heart disease
3) heart failure
4) hypertension
5) mitral stenosis
6) mitral regurgitation
7) chronic obstructive pulmonary disease
8) asthma
9) hyperthyroidism
10) alcohol
47
Atrial Flutter - Pathophysiology (4)
1) accessory conduction pathway
2) electrical impulse persists
3) atria recontract after refractory period
4) increased atrial contraction
48
Atrial Flutter - Symptoms (6)
1) chest pain
2) dyspnoea
3) palpitations
4) syncope
5) fatigue
6) worsening heart failure or pulmonary symptoms
49
Atrial Flutter - Signs (1)
1) tachycardia
50
Atrial Flutter - Complications (3)
1) atrial fibrillation
2) stroke
3) heart failure
51
Atrial Flutter - Investigations (4/2)
```
initial
1) ECG*
2) U&E
3) TFT
4) chest x-ray
consider
1) spirometry
2) echocardiogram (left atrial enlargement, mitral valve disease)
```
52
Atrial Flutter - Investigations (ECG) (3)
1) absent P waves --> F waves (sawtooth)
2) atrial rate : ventricular rate --> 2:1 or 4:1
3) atrial rate 240-320bpm
53
Atrial Flutter - Management (3/2)
medical
1) anticoagulants (warfarin + heparin)
2) antiarrhythmic (amiodarone or flecainide)
3) rate control (βB or CCB or digoxin)
surgery
1) DC cardioversion
2) catheter ablation (cavotricuspid isthmus) (refractory)
54
Aortic Aneurysm - Description
permanent dilation of aorta (>50%)
55
Aortic Aneurysm - Risk Factors (8)
1) family history
2) Ehlers-Danlos syndrome
3) Marfan syndrome
4) hypertension
5) hypercholesterolaemia
6) smoking
7) age
8) male
56
Aortic Aneurysm - Pathophysiology (2)
1) abnormal elastin and collagen
| 2) permanent dilation of aorta
57
Aortic Aneurysm - Symptoms (1)
1) asymptomatic (unruptured)
58
Aortic Aneurysm - Signs (1)
1) pulsatile abdominal swelling
59
Aortic Aneurysm - Complications (3)
1) aortic aneurysm
2) haemorrhagic shock
3) death
60
Aortic Aneurysm - Investigations (1/2)
```
initial
1) chest, abdominal ultrasound*
consider
1) FBC
2) CT angiogram
```
61
Aortic Aneurysm - Management (0/1/1)
medical
1) prophylactic wide spectrum antibiotics
surgery
1) endovascular aneurysm repair
62
Aortic Dissection - Description
blood in between aortic walls
63
Aortic Dissection - Risk Factors (9)
1) family history
2) Ehlers-Danlos syndrome
3) Marfan syndrome
4) hypertension
5) hypercholesterolaemia
6) smoking
7) age
8) male
9) aortic aneurysm
64
Aortic Dissection - Pathophysiology (4)
1) tear in aortic intima
2) blood under pressure enters aortic wall
3) haematoma separating intima and adventitia
4) false lumen created
65
Aortic Dissection - Symptoms (4)
1) acute severe tearing chest pain (thoracic)
2) acute severe tearing interscapular pain (abdominal)
3) diaphoresis
4) presyncope-->syncope
66
Aortic Dissection - Signs (5)
1) hypotension
2) left/right blood pressure differential
3) left/right pulse differential
4) pulse deficit
5) diastolic murmur
67
Aortic Dissection - Complications (3)
1) cardiac tamponade
2) haemorrhagic shock
3) death (80%)
68
Aortic Dissection - Investigations (4/2)
```
initial
1) CT angiogram*
2) chest x-ray
3) ECG (exclude MI)
4) troponin assay (exclude MI)
consider
1) D dimer
2) echocardiogram
```
69
Aortic Dissection - Management 0/2/2)
```
medical
1) antihypertensive (βB + CCB)
2) analgesia (opioid)
surgery
1) open surgery (ascending aorta)
2) stent graft (descending aorta)
```
70
Peripheral Vascular Disease - Description
stenosis arteries distal to aortic arch
71
Peripheral Vascular Disease - Causes (1)
1) atherosclerosis
72
Peripheral Vascular Disease - Risk Factors (8)
1) age
2) family history
3) hypertension
4) hypercholesterolaemia
5) diabetes mellitus
6) smoking
7) obesity
8) sedentary lifestyle
73
Peripheral Vascular Disease - Pathophysiology (3)
1) artery atherosclerosis
2) narrowing of artery
3) ischaemia of area supplied by artery
74
Peripheral Vascular Disease - Symptoms (4)
1) asymptomatic
2) intermittent claudication (cramping leg pain during exercise)
3) critical limb ischaemia (cramping leg pain during rest)
4) erectile dysfunction
75
Peripheral Vascular Disease - Signs (5)
1) absent femoral pulse
2) absent popliteal pulse
3) absent foot pulse
4) cold legs
5) white legs
76
Peripheral Vascular Disease - Complications (3)
1) ulcers (leg/foot)
2) gangrene
3) infection
77
Peripheral Vascular Disease - Investigations (1/4)
```
initial
1) ankle-brachial index
consider
1) toe-brachial index
2) Doppler ultrasound
3) CT angiogram*
4) MR angiogram*
```
78
Peripheral Vascular Disease - Management (4/2/2)
```
conservative
1) dietary advice
2) regular advice
3) weight loss
4) smoking cessation
medical
1) aspirin
2) cilostazol (intermittent claudication)
surgery
1) revascularisation
2) amputation (last resort)
```
79
Acute Pericarditis - Description
acute inflammation of pericardium (<4-6 weeks)
80
Acute Pericarditis - Causes (5)
1) idiopathic (80-90%)
2) viral
3) tuberculosis
4) autoimmune
5) Dressler's syndrome (post-MI)
81
Acute Pericarditis - Pathophysiology (3)
1) inflammation of pericardium
2) fluid accumulation in pleural cavity (pleural effusion)
3) fluid accumulation in pericardial cavity (pericardial effusion-->cardiac tamponade)
82
Acute Pericarditis - Symptoms (8)
1) severe pleuritic chest pain
2) pain radiates to shoulder, arm
3) pain relieved by sitting forward
4) pain exacerbated by lying down
5) pain exacerbated by inspiration
6) dyspnoea
7) cough
8) fever
83
Acute Pericarditis - Signs (5)
1) pericardial rub (high pitched squeaky rub heard at left sternal edge)
2) Kussmaul's sign (JVP paradoxically rising with inspiration
3) pulsus paradoxus (SBP paradoxically falling with inspiration)
4) tachycardia
5) hypotension
84
Acute Pericarditis - Complications (3)
1) pleural effusion
2) pericardial effusion --> cardiac tamponade
3) constrictive pericarditis
85
Acute Pericarditis - Investigations (7/0)
initial
1) ECG* (depressed PR segment, saddle shaped elevated ST segment)
2) echocardiogram* (pleural effusion)
3) chest x-ray
4) FBC (leucocytosis)
5) troponin assay (mildly elevated)
6) high CRP + ESR
7) blood/pericardial fluid culture
86
Acute Pericarditis - Diagnosis (4)
2 of:
1) pleuritic chest pain
2) pericardial rub
3) saddle shaped elevated ST segment (ECG)
4) pleural effusion (echocardiogram)
87
Acute Pericarditis - Management (1/4/3)
```
conservative
1) restrict exercise
medical
1) treat underlying cause
2) NSAID
3) colchicine (reduces recurrence by 50%)
4) PPI
surgery
1) thoracentesis (pleural effusion)
2) pericardiocentesis (cardiac tamponade)
3) pericardiectomy (high risk)
```
88
Constrictive Pericarditis - Description
limited diastolic filling due to pericardium fibrosis
89
Constrictive Pericarditis - Causes (1)
1) chronic pericarditis
90
Constrictive Pericarditis - Symptoms (3)
1) dyspnoea
2) cough
3) fatigue
91
Constrictive Pericarditis - Signs (5)
1) pericardial rub (high pitched squeaky rub heard at left sternal edge)
2) Kussmaul's sign (JVP paradoxically rising with inspiration
3) pulsus paradoxus (SBP paradoxically falling with inspiration)
4) tachycardia
5) hypotension
92
Constrictive Pericarditis - Complications (4)
1) pleural effusion
2) pericardial effusion --> cardiac tamponade
3) heart failure
4) atrial fibrillation
93
Constrictive Pericarditis - Investigations (3/0)
initial
1) chest x-ray
2) echocardiogram
3) serum BNP (high)
94
Constrictive Pericarditis - Management (0/0/1)
surgery
| 1) pericardectomy (high risk)
95
Cardiac Tamponade - Description
fluid accumulation in pericardial cavity
96
Cardiac Tamponade - Causes (5)
1) pericarditis
2) trauma
3) malignancy
4) aortic dissection
5) iatrogenic (cardiothoracic surgery)
97
Cardiac Tamponade - Symptoms (3)
1) dyspnoea
2) chest pain
3) abdominal pain
98
Cardiac Tamponade - Signs (7)
1) pericardial rub (high pitched squeaky rub heard at left sternal edge)
2) Kussmaul's sign (JVP paradoxically rising with inspiration
3) pulsus paradoxus (SBP paradoxically falling with inspiration)
4) tachycardia
5) hypotension
6) soft/absent heart sounds
7) neck vein distension
99
Cardiac Tamponade - Complications (4)
1) myocardial infarction
2) shock
3) recurrent pericarditis
4) recurrent pericardial effusion --> cardiac tamponade
100
Cardiac Tamponade - Investigation (6/0)
initial
1) ECG* (depressed PR segment, saddle shaped elevated ST segment)
2) echocardiogram
3) chest x-ray
4) FBC (leucocytosis)
5) troponin assay (mildly elevated)
6) high CRP + ESR
101
Cardiac Tamponade - Management (0/4/1)
```
medical
1) treat underlying cause
2) NSAID
3) colchicine (reduces recurrence by 50%)
4) PPI
surgery
1) pericardiocentesis
```
102
Infective Endocarditis - Description
infection of endocardium, e.g. heart valves
103
Infective Endocarditis - Causes (7)
1) Staphylococcus aureus (most common)
2) Staphylococcus epidermidis (<2 months prosthetic valve)
3) Streptococcus viridans (dental)
4) Streptococcus bovis
5) Enterococci
6) Candida
7) Aspergillus
104
Infective Endocarditis - Risk Factors (5)
1) IV drug abuser (esp. tricuspid valve)
2) immunocompromised
3) prosthetic valves
4) congenital heart defect
5) dental treatment
105
Infective Endocarditis - Symptoms (3)
septic symptoms
1) fever (inc. night sweats, rigors)
2) malaise
3) weight loss
106
Infective Endocarditis - Signs (5)
1) new murmur
2) Roth spots (retinal haemorrhages with pale centres)
3) Osler's nodes (tender lesions on fingers/toes)
4) Janeway lesions (non-tender on palms/soles)
5) splinter haemorrhages (haemorrhage of vertical blood vessels under nails)
107
Infective Endocarditis - Complications (8)
1) myocardial infarction
2) heart failure
3) arrhythmia
4) valve disease
5) kidney disease
6) systemic emboli (e.g. stroke, pulmonary embolism)
7) mycotic aneursym
8) osteomyelitis
108
Infective Endocarditis - Investigations (6/0)
initial
1) blood cultures* (x3 from different sites)
2) FBC
3) high CRP + ESR
4) urine dipstick (haematuria)
5) ECG
6) echocardiogram)
109
Infective Endocarditis - Diagnosis (Duke Criteria) (2/5)
2 major OR 1 major + 3 minor OR 5 minor
major
1) 2 separate positive blood cultures
2) endocardium involved (echocardiogram)
minor
1) fever
2) IV drug abuser or predisposing heart conditioni
3) immunological phenomoena (e.g. Osler's nodes, Roth's spots)
4) vascular phenomenon (e.g. Janeway lesions, mycotic aneurysm)
5) ambiguous blood culture)
110
Infective Endocarditis - Management (1/2/1)
conservative
1) oral hygiene
medical
1) benzylpenicillin + gentamicin (Staph.)
2) benzlypenicillin + amoxicillin (Strep.)
surgery
1) valve repair/replacement
111
Mitral Regurgitation - Description
blood blackflow from LV to LA during systole
112
Mitral Regurgitation - Causes (6)
1) rheumatic heart disease
2) infective endocarditis
3) Ehlers-Danlos syndrome
4) Marfan syndrome
5) mitral valve prolapse
6) ischaemic heart disease (chordae tendineae, papillary muscle)
113
Mitral Regurgitation - Pathophysiology (6)
1) blood backflow from LV to LA
2) blood volume overload in LA
3) progressive LA enlargement
4) progressive LV hypertrophy
5) progressive LV enlargement
6) progressive heart failure
114
Mitral Regurgitation - Symptoms (2)
1) dyspnoea (esp. exertional)
| 2) fatigue
115
Mitral Regurgitation - Signs (4)
1) pan systolic murmur
2) soft S1 heart sound
3) S3 heart sound
4) peripheral oedema
116
Mitral Regurgitation - Complications (5)
1) congestive heart failure
2) infective endocarditis
3) atrial fibrillation
4) stroke
5) pulmonary hypertension
117
Mitral Regurgitation - Investigations (3/0)
initial
1) ECG
2) chest x-ray
3) echocardiogram*
118
Mitral Regurgitation - Management (1/2/1)
```
conservative
1) serial endocardiograms
medical
1) ACEi
2) βB
surgery
1) valve replacement (+anticoagulant) (severe)
```
119
Mitral Stenosis - Description
obstruction of LV inflow
120
Mitral Stenosis - Causes (3)
1) rheumatic heart disease (95%)
2) infective endocarditis
3) senile calcification
121
Mitral Stenosis - Pathophysiology (7)
1) narrowing of mitral valve
2) increased LA pressure
3) progressive LA hypertrophy
4) progressive LA enlargement
5) progressive LV hypertrophy
6) progressive LV enlargement
7) progressive heart failure
122
Mitral Stenosis - Symptoms (3)
1) dyspnoea (esp. exertional)
2) haemoptysis
3) fatigue
123
Mitral Stenosis - Signs (5)
1) mid diastolic murmur
2) loud S1 heart sound (opening snap)
3) peripheral oedema
4) neck vein distension
5) malar cheek flush
124
Mitral Stenosis - Complications (5)
1) congestive heart failure
2) infective endocarditis
3) atrial fibrillation
4) stroke
5) pulmonary hypertension
125
Mitral Stenosis - Investigations (3/0)
initial
1) ECG
2) chest x-ray
3) echocardiogram*
126
Mitral Stenosis - Management (1/2/2)
```
conservative
1) serial endocradiograms
medical
1) prophylactic antibiotics (infective endocarditis)
2) loop diuretic (e.g. furosemide)
surgery
1) percutaneous balloon valvuloplasty (non-surgical candidate)
2) valve replacement (+ anticoagulant)
```
127
Aortic Regurgitation - Description
blood backflow from aorta to LV during diastole
128
Aortic Regurgitation - Causes (6)
1) rheumatic heart disease
2) infective endocarditis
3) Ehlers-Danlos syndrome
4) Marfan syndrome
5) bicuspid aortic valve
6) ascending aorta dissection
129
Aortic Regurgitation - Pathophysiology (5)
1) blood backflow from aorta to LV
2) blood volume overload in LV
3) progressive LV hypertrophy
4) progressive LV enlargement
5) progressive heart failure
130
Aortic Regurgitation - Symptoms (4)
1) dyspnoea (esp. exertional)
2) angina
3) syncope
4) fatigue)
131
Aortic Regurgitation - Signs (3)
1) early diastolic murmur
2) wide pulse pressure
3) collapsing pulse
132
Aortic Regurgitation - Complications (4)
1) congestive heart failure
2) infective endocarditis
3) atrial fibrillation
4) stroke
133
Aortic Regurgitation - Investigations (3/0)
initial
1) ECG
2) chest x-ray
3) echocardiogram
134
Aortic Regurgitation - Management (2/3/1)
```
conservative
1) reassurance
2) serial echocardiograms
medical
1) dopamine (emergency)
2) ACEi
3) CCB
surgery
1) valve replacement (+ anticoagulant) (severe)
```
135
Aortic Stenosis - Description
obstruction of aorta inflow
136
Aortic Stenosis - Causes (5)
1) rheumatic heart disease
2) infective endocarditis
3) senile calcification (most common >65 years old)
4) bicuspid aortic valve (most common <65 years old)
5) ascending aorta dissection
137
Aortic Stenosis - Pathophysiology (6)
1) narrowing of aortic valve
2) increased aortic pressure
3) increased afterload
4) progressive LV hypertrophy
5) progressive LV enlargement
6) progressive heart failure
138
Aortic Stenosis - Symptoms (4)
1) dyspnoea (esp. exertional)
2) angina
3) syncope
4) fatigue
139
Aortic Stenosis - Signs (6)
1) ejection systolic murmur
2) soft S2 heart sound
3) S4 heart sound
4) narrowpulse pressure
5) pulsus tardus (late)
6) pulsus parvus (weak)
140
Aortic Stenosis - Complications (2)
1) congestive heart failure
| 2) infective endocarditis
141
Aortic Stenosis - Investigations (3/0)
initial
1) ECG
2) chest x-ray
3) echocardiogram
142
Aortic Stenosis - Management (1/1/2)
conservative
1) serial echocardiogram
medical
1) prophylactic antibiotics (infective endocarditis)
surgery
1) percutaneous balloon valvuloplasty (non-surgical candidate)
2) valve replacement (+ anticoagulant)
