LVOTO Flashcards
Different levels of LVOTO?
Valvular (75% of all LVOTO)
Subvalvular
Supravalvular
Bicuspid aortic valve epidemiology
Prevalence 1-2% of general population
3M:1F
What is a functional bicuspid valve?
2 leaflets fused
What gene mutation has been related to BAV?
NOTCH I gene mutation
Which bicuspid AV patients have a faster progression?
Those with greater closure line eccentricity and anteroposterior-oriented line of closure
Prognosis in BAV
Good
SCD is rare in asymptomatic patients with good ET, even is AS is severe
Symptoms of Valvular AS
Angina, dyspnoea, syncope
Cardiac mortality in patients with BAV
0.3% per patient-year of follow-up
Frequency of aortic dissection in patients with BAV
0.1%
Frequency of endocarditis in patients with BAV
0.3%
What is the Vmax (m/s), MPG (mmHg), AVA (cm2) and indexed AVA (cm2/m2 BSA) for patients with moderate AS?
Vmax: 3.0-3.9 m/s
MPG: 30-49 mmHg
AVA: 1.0-1.5 cm2
AVAi: 0.6 - 0.9 cm2/m2 BSA
Clinical findings of AS
ESM over Aortic area, radiating to carotid arteries Palpable thrill Narrow pulse pressure Slow rising pulse LVH
ECG findings in patients with AS
LVH with or without strain
In what patients is exercise testing recommended?
asymptomatic, severe AS to confirm asymptomatic status and evaluate exercise tolerance, BP response and arrhythmias for risk stratification and timing of surgery
In what patients is low-dose DSE useful?
AS with impaired LV (low flow, low gradient)
What medical treatment options are available for patients with AS?
Medical treatment for HF is reserved for non-operable patients
Statins show no benefit in retarding progression of AS
What treatment options are available?
BAV
Mechanical AVR
Tissue AVR
Ross procedure
Percutaneous valve implantation is an alternative for treating stenosis of PV homograft
TAVI currently has no role in treatment of congenital AS
For which patients can the Ross procedure be considered?
Patients of child-bearing age wanting to avoid anticoagulation, but has significant re-operation rate after the first post-operative decade
How often should patients with bicuspid aortic valve be followed-up?
Lifelong and regular follow-up is required, intervals depend upon degree of stenosis severity.
After valve intervention - annual follow-up
What imaging modalities are recommended after valve surgery?
TTE; CMR of aorta in patients with BAV, even after surgery
Exercise/sport recommendations in patients with valvular stenosis
Severe symptomatic and asymptomatic AS and those with moderate AS due to BAV and dilated aorta should avoid strenuous or isometric exercise and competitive sports. In mild and moderate AS sport is allowed. A prior exercise test for counselling is recommended
Pregnancy recommendations in patients with AS
Contraindicated in severe symptomatic AS. Treatment by either balloon valvotomy or surgery should be performed before conception.
In asymptomatic patients with severe AS and normal exercise test, pregnancy may be possible but is controversial.
BAV-related aortic dilatation may be induced and progress during pregnancy with a risk of dissection
What is the rate of recurrence of CHD?
> 5%
IE prophylaxis in patients with AS
Only for high risk patients
What patients should undergo valve surgery?
- Severe symptomatic AS
- Asymptomatic patients with severe AS, symptomatic on exercise testing
- Severe AS with LVEF<50% (even if asymptomatic)
- Severe AS undergoing any other open heart surgery
What patients should be considered for surgery?
- If ascending aorta >50mm anon other indications for cardiac surgery (regardless of symptoms)
- Asymptomatic with severe AS with drop in BP during ET
- Asymptomatic patients with severe AS and moderate-severe calcification and rate of peak velocity progression >/= 0.3m/s/year
- Moderate AS undergoing any other open heart surgery
- Severe AS with low gradient (<40mmHg) and LVSD with or without contractile reserve
- Asymptomatic patients with severe AS and LVH (>/= 15mm) unless due to HTN
