Laflamme- Chapter 4 (Valvular Heart Disease) Flashcards
What % of patients have BAV? What is most common morphology?
1-2%
Fusion of RCC and LCC, followed by RCC and NCC
What congenital abnormality is associated with Supravalvular AS?
Williams syndrome
What is physical exam hallmarks on supravalvular stenosis (3)
- BP difference between arms
- Loud A2
- Murmur to right carotid
Echo surveillance for Mild, mod, severe AS
- Severe: 6-12months
- Mod: 1-2 years
- Mild: 3-5 years
Progression of AS based on AVA and MG?
- AVA: 0.1cm / year
- MG: 7mmhg / year
Definition of LFLG AS?
- AVA < 1
- MG < 40mmhg
- SVI < 35
What are the Class 1 indications for AVR? Class IIa?
Class 1
- Severe symptomatic AS
- Going for other OR with severe
- Severe with LVEF < 50%
Class IIa
- Very severe 5m/s
- BNP 5x normal
- Moderate other OR (IIb)
- EST SBP drop > 10mmhg
- > 0.3/year progression
What are 3 anatomic contraindications to TAVR?
- Aortic annulus diameter <18mm and >29mm
- Coronary ostia < 10-11mm from aortic annulus
- Femoral vascular access issues (<6 mm space, to accommodate a 7mm catheter)
What is the risk of PPM with TAVI?
- 5-10% Sapien
- 20% corevalve
What is 30 day mortality post TAVI?
-3-5%
What are 8 echo features of severe AR?
- VC > 6cm
- ERO > 0.3cm
- RF > 50%
- Rvol > 60cc
- PHT < 200 msec
- > 65% LVOT in PLAX
- Flow reversal TA
- LVEDD 65, LVESD 50
Indications for AVR in AR?
- Symptomatic severe
- LVEF < 55%
- LVEDD > 65, LVESD > 50
- Severe and other OR
What are 5 causes of LV inflow obstruction?
- MS
- PV stenosis
- LA tumor
- MV vegetation
- LA thrombus
How can MS cause hoarse voice?
-Recurrent laryngeal nerve compression by dilated LA
What is rate of MS progression per year?
0.09 cm/year
What defines successful balloon valvuloplasty in MS?
- MVA > 1.5m LA pressure < 18mmhg
3 indications for MVR/Valvuloplasty in Mitral Stenosis?
- Symptoms with mod-severe MS
- MVA < 1
- De novo AF
- Other surgery planned
9 features of severe MR on echo?
- VC 0.7
- RF 50%
- Rvol 60cc
- ERO 0.4
- E wave triangular
- E wave > 1.2c,
- Systolic flow reversal
- LA and LV dilation
- Jet > 10 cm2, >40% LA, Coanda effect
What are 5 features that promote favorable chance to Mitral valve repair?
- MVP, posterior leaflet
- DMR
- Annular Dilation
- Papillary muscle dysfunction
- ruptured chordae
- Leaflet perforation
What anatomic features are favorable for mitra clip?
- Malcoaptation of A2-P2
- Depth of Coaptation < 11mm
- Vertical length of coaptation > 2mm
Name 5 systemic diseases that are associated with MVP?
- Marfans
- Ehlers Danlos
- Osteogenesis Imperfecta
- Holt-Oram syndrom
- Ebsteins
What are 6 causes of TS?
- Carcinoid
- Rheumatic Valve disease
- Radiation
- PPM lead
- Endocarditis
- RA tumor
What are 6 echo findings of Severe TR?
- Jet area > 10cm2
- VC > 7mm
- PISA > 9mm
- Tricuspid E > 1
- Dense doppler envelope with triangular peak
- holosystolic flow reversal in hepatic vein
What is definition of severe PS?
-Peak gradient > 64 mmhg
What congenital syndrome is associated with PS?
-Noonan Syndrome
What is the echo feature for severe PR?
-Dense envelope, marked deceleration, early end of diastolic flow
What is Graham Steel Murmur?
- Decrescendo high pitched diastolic murmur in the presence of dilatation of the pulmonary annulus secondary to PHTn
- Accentuated P2, starts after A2
6 reasons to go for tissue valve?
- Bleeding risk
- Difficult anticoagulation
- > 70 years
- Small LVOT
- Woman of childbearing potential
- Patient preference
What is TE risk for mechanical valves in Mitral and Aortic valves?
- Mitral: 2-3/100 patient years
- Aortic: 1-2/100 patient years
What is % of structural deterioration at 10 years?
- 30% at 10 years (only 10% at ten years in patients greater than 65)
What are three indications for urgent surgery in Prosthetic thrombus?
- Left heart prosthesis (class 1)
- NYHA III/V (class 1)
- Mobile/Large thrombus ( > 0.8 cm2)
What are 4 indications for UFH +/- thrombolysis in patients with Prosthetic valve thrombus?
- Thrombosis < 14 days
- NYHA 1 or 2
- Thrombus < 0.8cm2
- Right heart prosthesis
What patients with mechanical valves should get INR 2-3 with aspirin?
- MVR
- AVR with AF, LV dysfunction, TE history, Hypercoagulable state
How to reverse life threatening bleed on excessive anticoagulation?
- Prothrombin complex/FPP
- Vitamin k
Echo follow up for tissue prosthesis?
- 2-4 weeks after DC
- 10 years post, annual after
Echo follow up for mechanical valve?
-Baseline 2-4 weeks post OR, never again in absence of symptoms
What are top 3 microbes for native valve IE?
- Staph Aureus
- CONS
- Step viridans
Name all of the HACEK organisms
Hemophilus
Actinobacillus
Cardiobacterium
Eikenella
Kingella
What are the 4 most common microbes for early (<12 months) post valve surgery?
- SA
- CONS
- GNB
- Fungi (Candida)
How does last PVE IE (>12 months) micro differ from early?
Same as native (SA, CONS, Strep) , no Fungal/GNB
2 major criteria for DUKE score?
- Positive blood culture: Causative agent, sustained: 3/3 or majority of 4 when taken an hour apart OR 2 positive q12h apart
- Endocardial: either Positive echo for vegetation OR de novo valvular regurgitation
What are 5 minor criteria for DUKE score?
- Predisposition
- Fever
- Vascular
- Immunologic
- Micro evidence not meeting
- Major criteria
Abx for IE for Strep?
CTX x 4 week (Vanco x 4 week)
ABx for Strep for PVE?
-Add Gentamicin for first 2 weeks
Abx for IE for MSSA? PVE?
- Cloxacillin x 6 weeks
- Clox + Rifampin + Gentamicin
Abx for MRSA? PVE?
- Vanco x 6 weeks
- Vanco + Rifampin + Gentamicin
Abx for Enterococcus?
-Amp + Gentamicin x 6weeks
Abx for HACEK?
CTX x 4-6 weeks
4 population for IE prophylaxis?
- PV
- Hx IE
- Transplant with regurgitant or structurally abnormal valve
- CHD: Unrepaired cyanotic heart disease, complete repair with prosthetic material < 6 months, repair with residual defect close to prosthesis
What is antibiotics for IE prophylaxis?
- Amoxicillin 2g PO
- Cephalexin 2g PO
- Azithromycin 500mg
- Clinda 600mg
- Ancef 1g IV
What are 6 indications for surgery for bacterial endocarditis?
Symptomatic HF
Highly resistant organism
Complicated (by block or abscess)
Persistent infection (> 5-7 days despite appropriate antibiotics)
Recurrent emboli
Vegetation > 10mm
What are the three micro for CIEDs?
-CONS > MSSA > MRSA
Management of Superficial skin infection?
-Oral abx for staph for 7-10 days
Management for pocket infection/skin erosion?
-Complete removal of the system and antibiotics
Management of system infection? Lead endocarditis
-Remove system, Abx for 2-6 weeks -> reimplant
What is optimal timing for reimplantment of the device after CIED: + blood culture, Valve endocarditis
- +BCx: 72h
- Endocarditis: 14 days
What are the 5 major JONES criteria?
- Carditis and valvulitis
- Migratory arthritis
- Sydenhams chorea
- Erythema marginatum
- Subcutaneous nodules
When do you need to start Abx for GAS to prevent Rheumatic fever?
- < 10 days
Penicillin V 500mg PO BID x 10 days
How do you give secondary prevention post rheumatic fever? (Penicillin 200mg PO BId, or Sulfasiazine 1g PO daily)
- No carditis: > 5 years since episode until age 21
- Carditis but no sequelae: >10 years since episode until age 21
- Valvular disease: > 10 years since last episode until 40 years.
What is the mortality per year for symptomatic AR in the absence of intervention?
-10% / year
