Lecture 9; Valves

Question 1

Prophylaxis for endocarditis

Answer 1

According to the 2017 AHA/ACC focused update on VHD, prophylaxis is recommended for patients with (1) a prosthetic cardiac valve; (2) prosthetic material used for cardiac valve repair, including annuloplasty rings and chords; (3) a previous episode of infective endocarditis; (4) congenital heart disease, including unrepaired cyanotic congenital heart disease, a completely repaired congenital heart defect with prosthetic material or device during the first 6 months after the procedure, and repaired congenital heart disease with residual defects; or (5) valvulopathy following cardiac transplantation.

Question 2

which procedures prophylaxis is required

Answer 2

prophylaxis should be administered prior to dental procedures that involve manipulation of gingival tissue or the periapical region of the teeth or perforation of the oral mucosa, and biopsy of respiratory tract

Question 3

who should get mechanical prosthesis

Answer 3

AVR or MVR in patients <50 y of age who do not have a contraindication to anticoagulation

Question 4

who should get bioprosthetic

Answer 4

patients of any age for whom anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired

Question 5

anticoagulation prosthetic valves

Answer 5

Lifelong oral anticoagulation with warfarin is recommended for all patients with a mechanical prosthesis and those with bioprostheses with other indications for anticoagulation.

Question 6

INR valves

Answer 6

he target INR is based upon prosthesis location, with a target of 2.5 for patients with a mechanical aortic prosthetic valve and 3.0 for patients with a mechanical mitral prosthetic valve and those patients with a mechanical aortic prosthetic valve and risk factors (atrial fibrillation, LV dysfunction, previous thromboembolism, hypercoagulable condition, or older-generation mechanical aortic valve replacement). The addition of aspirin, 75 to 100 mg/d, is recommended as well.

Question 7

bioprosthetic valves Anticoagulation

Answer 7

Oral anticoagulation should be considered for at least 3 months and as long as 6 months after implantation of a mitral or aortic bioprosthesis in patients at low risk for bleeding

Question 8

MCC bugs endocarditis

Answer 8

• Staph aureus/epidermitis

Question 9

Duke’s criteria

Answer 9

BE FIVE PM

Blood culture positive for IE
Endocardial involvement

Fever > 38ºc
Immunologic phenomena (glomerulonephritis, Osler’s nodes, Roth’s spots, Rheumatoid factor)
Vascular Emboli (major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjuntival hemorrhage, Janeway lesions)
Predisposition (heart condition or IV drug user)
Microbiologic evidence (Positive blood culture but not meeting major criteria or serologic evidence of active infection with organism consistet with IE)

Question 10

surgery referral for endocarditis indications

Answer 10

1. HF
2. Left sided IE with S. aura, fungal, or highly resistant
3. abscess, heart block
4. 5-7 days despite abx
5. recurrnet emboli despite antibiotics
6. prochetic valve and relapsing infections

Question 11

indications for ICD in HOCM

Answer 11

1. Hx of syncope
2. Hx of V-tach
3. Hx of fam with sudden dealth
4. Hx of > 3 cm septum
5. Hypotension to exercize`

Question 12

follow up for AS

Answer 12

mild AS - 3-5 years
Moderate - 1-2 years
severe - 6-12 months

Question 13

tx HOCM

Answer 13

non-vasodilating BB (meto, prop, atenolol) or CCB

Question 14

murmors that lengthen/louder with valsalva

Answer 14

MVP and HOCM

same with amiyl nitrate and standing

Question 15

PDA murmor

Answer 15

continuous murmur in the left clavicle

Question 16

widened pulse pressure with bounding pulses

Answer 16

PDA

Question 17

complications if PDA is not repaired

Answer 17

Eisenmeinger's syndrome
PDA arteritis (endocarditis related)

Question 18

contraindication to mitral valve balloon valvotomy

Answer 18

left atrial appendage or mod-severe mitral regurg

Question 19

mitral regurgitation murmur

Answer 19

holosystolic apex murmur radiating to axilla

Question 20

VSD murmur

Answer 20

holosystolic at left 3-4th ribs with palpable thrill

Question 21

holosystolic murmur that increases with inspiration

Answer 21

tricuspid regurg

Question 22

mechanical valve anticoagulation

Answer 22

ASA + warfarin
Aortic without additional INR 2-3

All Mechanical mitral or high risk aortic (Afib, CHF, prior thromboembo) 2.5-3.5

Question 23

mitral stenosis murmur

Answer 23

loud first heart sound, opening snap after S2, and low pitched diastolic rumble heard at the cardiac apex with bell

Question 24

tricuspid regurgitation murmur

Answer 24

holosystolic murmur heard along the left sternal border that increases with inspirtation

Question 25

Kussumal sign

Answer 25

lack of decline in JVP with inspiration - constrictive pericarditis

Question 26

prominent c-v wave

Answer 26

pulmonary hypertnesion.

Question 27

alcohol septal ablation for HOCM

Answer 27

severe LVOT obstructon (> 50 gradient) and heart failure symptoms refractory to treatment

Question 28

ICD for HOCM

Answer 28

wall thickness > 30 mm and fx history of SCD due to HCM or personal hx of symptoms due to vfib

Question 29

what murmur do you get after tetralogy of fallot repair

Answer 29

pulmonary reguritation

Question 30

continious murmur

Answer 30

PDA

Question 31

right sided ejection click that gets softer on inspiration

Answer 31

pulmonary stenosis

Question 32

when to close VSD

Answer 32

1. 2:1 stunt or pulmonary hypertension
2. left heart enlargement
3. affecting the vavles
   4 .hx of endo

Question 33

Harsh holosystolic murmor

Answer 33

VSD

Question 34

what med do you avoid in cyanotic heart disease

Answer 34

avoid vasodilators

Question 35

main problems with cyanotic heart

Answer 35

1. cyanosis
2. paradoxical cerebral emboli
3. polycythemia

Question 36

when to repair anomalous coronary artery

Answer 36

1. symptoms

2. when the left main runs between the aorta and pulm trunk - gets squished