Cards: valvular

Question 1

What is the impact of aortic stenosis on heart function?

Answer 1

Aortic stenosis causes chronic pressure overload that typically leads to concentric left ventricular (LV) hypertrophy with increased wall thickness and normal chamber size to compensate for increased LV afterload.

Question 2

What is the impact of chronic aortic regurg on heart function?

Answer 2

Chronic aortic regurgitation causes increased LV preload and afterload, leading to increased LV volume and mass.

Question 3

What is the impact of mitral stenosis on heart function?

Answer 3

Mitral stenosis causes increased pressure within the left atrium (LA), leading to increased pulmonary venous pressure, pulmonary hypertension, and atrial dilation.

Question 4

What is the impact of chronic mitral regurg on heart function?

Answer 4

Chronic mitral regurgitation causes volume overload (increased preload) of the LV and LA, leading to increased LA size and pressure and LV dilation.

Question 5

What happens to right versus left sided murmurs with breathing?

Answer 5

For example, in general, right-sided murmurs increase with inspiration and left-sided murmurs increase with expiration.

Question 6

What is the impact of the Valsalva maneuver on heart murmurs?

Answer 6

A Valsalva maneuver decreases the length and intensity of most murmurs, except for systolic murmurs associated with hypertrophic obstructive cardiomyopathy and mitral valve prolapse.

Question 7

How does exercise impact the murmur of mitral stenosis?

Answer 7

Exercise causes the murmur of mitral stenosis to get louder,

Question 8

How do isometric maneuvers impact regurgitant murmurs?

Answer 8

isometric maneuvers, such as handgrip, increase the intensity of regurgitant murmurs such as aortic and mitral regurgitation.

Question 9

How can you differentiate the murmur of HCM and mitral valve prolapse from other murmurs?

Answer 9

Postural maneuvers are ideal for differentiating hypertrophic obstructive cardiomyopathy and mitral valve prolapse from other murmurs as they are louder with standing and softer with squatting.

Question 10

When is a TTE indicated for a murmur?

Answer 10

TTE is indicated for patients with the following (see Figure 26 ):

Systolic murmurs ≥grade 3/6 or late or holosystolic murmurs
Diastolic or continuous murmurs
Murmurs with accompanying symptoms

Question 11

What are your systolic and diastolic murmurs of left side of heart?

Answer 11

Systolic:
Aortic Stenosis
Mitral Regurg

Diastolic:
Mitral Stenosis
Aortic Regurg

Question 12

Causes of aortic stenosis?

Answer 12

Aortic stenosis is the most common type of valvular heart disease in the United States and is typically caused by calcific degeneration of an otherwise normal aortic valve. Other causes include bicuspid aortic valve and rheumatic valve disease, the latter of which remains common worldwide and is almost always accompanied by mitral valve disease

Question 13

In aortic stenosis, what valve area do symptoms begin? What is the prognosis once symptoms begin?

Answer 13

Although variable, symptoms of heart failure, angina, or syncope generally begin once the valve area is below 1.0 cm2. Once symptoms develop, prognosis is poor without valve replacement, with an average survival of less than 10% over the next 2 to 3 years.

Question 14

Diagnostically, how is aortic stenosis assessed?

Answer 14

• TTE
• Then, TEE if needed
• Cardiac CT if no good pictures of valve from the above

Question 15

Aortic stenosis management:
Valve area <1.0cm
Valve area >1.0 cm OR maximum aortic jet velocity below 4 m/s

Answer 15

Valve area <1.0cm–aortic valve replacement

Valve area >1.0 cm OR maximum aortic jet velocity below 4 m/s-medical management

Question 16

How do you manage patients with asymptomatic aortic stenosis?

Answer 16

n asymptomatic patients with aortic stenosis, identifying those who are in higher risk subgroups is important, as these patients may benefit from earlier intervention.

Question 17

When do you use exercise testing for asymptomatic aortic stenosis and why do you use it?

Answer 17

Exercise treadmill testing is reasonable in patients with asymptomatic severe aortic stenosis to identify those who actually do have symptoms with exercise, have ST-segment changes on ECG, or have an abnormal blood pressure response (lack of increase in systolic blood pressure by at least 20 mm Hg above baseline), as these patients may benefit from earlier surgery.

Question 18

When is aortic valve replacement indicated for those who are asymptomatic?

Answer 18

Aortic valve replacement is indicated for asymptomatic patients with severe aortic stenosis and LV systolic dysfunction (LV ejection fraction <50%) as well as for those patients with severe aortic stenosis who are undergoing coronary artery bypass grafting or surgery on the aorta or other heart valves.

Question 19

When is aortic valve replacement indicated?

Answer 19

Surgical aortic valve replacement is the treatment of choice for patients with asymptomatic or symptomatic severe aortic stenosis when surgical risk is low or intermediate. It is also recommended in symptomatic patients with severe aortic stenosis at high surgical risk.

Question 20

What is the role of balloon valvuloplasty in aortic stenosis? When is it used?

Answer 20

Balloon aortic valvuloplasty (BAV) has a limited role in the treatment of adult aortic stenosis. Whereas BAV does result in reduction in gradient and increase in valve area, these results typically last only for a few months. Recently, BAV in the adult has been used successfully as a bridge to definitive treatment (surgical or transcatheter aortic valve replacement [TAVR]) or to differentiate symptoms in high-risk patients with comorbid conditions such as COPD.

Question 21

What is the target population for TAVR?

Answer 21

It is estimated that fewer than half of patients with symptomatic, severe aortic stenosis undergo surgical aortic valve replacement because of comorbid medical conditions that increase surgical risk. This population has become the target for TAVR.

Question 22

What is the survival rates in comparison to medical therapy for TAVR in its target population?

Answer 22

The 3-year follow-up results of the PARTNER trial indicate that TAVR has a survival benefit similar to that of surgical replacement for high-risk patients (PARTNER A cohort). TAVR is superior to medical therapy in patients thought not to be surgical candidates (PARTNER B cohort), as 1-year mortality was 30.7% in the TAVR arm versus 50.7% in the medical therapy arm.

Question 23

What is the indication for TAVR based on guidelines?

Answer 23

TAVR is recommended for symptomatic patients who have been determined by a cardiac surgeon to be inoperable or at high risk for death or major morbidity with open aortic valve replacement and in whom existing comorbidities would not preclude the expected benefit from correction of the aortic stenosis. Additionally, TAVR is a reasonable alternative in patients with symptomatic severe aortic stenosis at intermediate surgical risk (class IIa recommendation).

Question 24

What are the most common causes of aortic regurgitation?

Answer 24

Acute severe aortic regurgitation usually is caused by infective endocarditis or aortic dissection (typically in a setting of hypertension or Marfan syndrome). Chronic severe aortic regurgitation is most commonly associated with a dilated ascending aorta from hypertension or primary aortic disease, calcific aortic sclerosis, bicuspid aortic valve, or rheumatic disease. Calcific aortic sclerosis can progress to significant stenosis and is associated with a mild degree of aortic regurgitation.

Question 25

How is acute severe aortic regurgitation managed?

Answer 25

Urgent or emergent surgical valve replacement is indicated for acute severe aortic regurgitation.

Question 26

When is aortic valve replacement indicated for aortic regurgitation?

Answer 26

For chronic severe aortic regurgitation, valve replacement is indicated for symptomatic patients regardless of LV systolic function (see Table 34 ). Valve replacement also is indicated for asymptomatic patients with chronic severe aortic regurgitation and LV systolic dysfunction and for patients with chronic severe aortic regurgitation undergoing coronary artery bypass graft surgery or surgery on the aorta or other heart valves.

Question 27

In patients with a bicuspid aortic valve, how often should they be monitored?

Answer 27

In general, older, asymptomatic patients with a bicuspid aortic valve and severe aortic valve stenosis or regurgitation require yearly echocardiography; those with mild aortic stenosis or regurgitation require echocardiography every 3 to 5 years.

Question 28

When should screening for bicuspid aortic valve occur?

Answer 28

Echocardiography of first-degree relatives of patients with a bicuspid aortic valve is indicated to screen for bicuspid aortic valve or aortic aneurysms.

Question 29

When is aortic surgery indicated for bicuspid aortic valve?

Answer 29

Patients with a bicuspid aortic valve are predisposed to aortopathy, and aortic surgery is indicated when the aortic root diameter is greater than 5.5 cm.

Question 30

What are the common causes of mitral stenosis?

Answer 30

The primary cause of mitral stenosis is rheumatic carditis. Improved hygiene and the routine use of antibiotics for group A streptococcal pharyngitis have greatly reduced the incidence of rheumatic heart disease in the United States and developed countries. Rarely, functional mitral stenosis occurs as a result of outflow obstruction from tumor (such as myxoma) or left atrial thrombus. Other causes of mitral stenosis include congenital disease (such as parachute mitral valve, wherein the mitral chordae insert into one instead of two papillary muscles) and mitral annular calcification.

Question 31

What procedure is indicated for all symptomatic patients with mitral stenosis?

Answer 31

Percutaneous mitral balloon valvotomy is indicated for symptomatic patients (New York Heart Association [NYHA] functional class II, III, or IV) with severe mitral stenosis (see Table 34 ) and favorable valve morphology.

Question 32

What is the role of TEE in preparing people for valvuloplasty?

Answer 32

TEE plays an important role in assessment of patients being considered for percutaneous balloon valvotomy to evaluate for potential contraindications, including left atrial appendage clot or significant (moderate to severe) mitral regurgitation.

Question 33

When is mitral valve surgery indicated for mitral stenosis?

Answer 33

Mitral valve surgery (repair if possible) is indicated in patients with symptomatic (NYHA functional class III–IV) severe mitral stenosis when balloon valvotomy is unavailable, unsuccessful, or contraindicated or when the valve morphology is unfavorable.

Question 34

What medical therapy is used for mitral stenosis to improve symptoms?

Answer 34

Medical therapy for mitral stenosis consists of diuretics or long-acting nitrates, which may help improve symptoms such as dyspnea. In addition, β-blockers or nondihydropyridine calcium channel blockers can lower heart rate and improve LV diastolic filling time.

Question 35

What are causes of mitral regurgitation?

Answer 35

Abnormalities in any of the structures of the mitral valve apparatus, including anterior and posterior mitral leaflets, the annulus, the papillary muscles, and the chordae tendineae, can result in mitral regurgitation. Organic, or primary, mitral regurgitation refers to processes involving the leaflets, such as mitral valve prolapse, myxomatous degeneration (the abnormal accumulation of proteoglycans), collagen vascular disease, and infective endocarditis. Processes that affect the support structures, such as coronary artery disease and LV remodeling in the setting of LV dysfunction, result in functional, or secondary, mitral regurgitation.

Question 36

What procedure is preferred for management of mitral regurg?

Answer 36

In general, mitral valve repair is preferred to valve replacement, as it is associated with improved survival in retrospective studies. Chordal preservation is preferred when replacement is needed, as it is associated with improved left ventricular geometry and long-term function.

Question 37

How is mitral regurg managed medically? What does an intra-aortic balloon pump do to help?

Answer 37

Nitrates and diuretics reduce filling pressures in patients with acute severe mitral regurgitation, and sodium nitroprusside and an intra-aortic balloon pump reduce afterload and regurgitant fraction.

Question 38

When is tricuspid valve surgery indicated?

Answer 38

Tricuspid valve surgery is indicated in patients with severe tricuspid regurgitation who are undergoing left-sided valve surgery and can be considered in patients with severe primary tricuspid regurgitation refractory to medical therapy.

Question 39

When is surgery indicated for endocarditis?

Answer 39

Early surgery is indicated for patients with acute infective endocarditis presenting with valve stenosis or regurgitation resulting in heart failure; left-sided infective endocarditis caused by Staphylococcus aureus, fungal, or other highly resistant organisms; infective endocarditis complicated by heart block, annular or aortic abscess, or destructive penetrating lesion; and infective endocarditis with persistent bacteremia or fever lasting longer than 5 to 7 days after starting antibiotic therapy.

Question 40

Who gets prophylaxis for infective endocarditis?

Answer 40

Infective endocarditis prophylaxis should be limited to those with a prosthetic cardiac valve; previous cardiac valve repair using prosthetic material; a history of infective endocarditis; unrepaired cyanotic congenital heart disease or repaired congenital heart defect with prosthesis or shunt (≤6 months post-procedure) or residual defect; or valvulopathy following cardiac transplantation.

Question 41

Anticoagulation for a mechanical valve?

Answer 41

Lifelong oral anticoagulation with warfarin is recommended for all patients with a mechanical prosthetic heart valve.

Question 42

Anticoagulation for a bioprosthetic valve?

Answer 42

Oral anticoagulation should be considered for the first 3 months after implantation for patients with a bioprosthetic mitral or tricuspid valve and for the first 3 months after bioprosthetic mitral valve repair.

Question 43

Is routine echo surveillance needed after valve replacement?

Answer 43

Routine echocardiography is not recommended for patients with mechanical valves or those with recently implanted biologic valves in the absence of any change in symptoms or examination findings.