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Mayo Cardiology Core Competencies > Track 7: Prosthetic Valve > Flashcards

Track 7: Prosthetic Valve Flashcards

1
Q

Takes native pulmonary valve and replaces it in the aortic position
Take homograft or heterograft and put this in the pulmonary position

A

Ross procedure

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2
Q

Cons of mechanical valve

A
  • Lifelong anticoagulation with warfarin
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3
Q

Pros of mechanical valve

A
  • Lasts forever
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4
Q

Pros of bioprosthesis

A
  • Only requires anticoagulation for 3 months (unless with concomitant AF)
  • Option for transcatheter approach
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5
Q

Cons of bioprosthesis valve

A
  • Breakdown/early degeneration (especially true in younger patients
  • Ie 40 yo will like see degeneration in 8-10 years
  • Older patient 70s-80s, might see slower degeneration. maybe 15-20 years
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6
Q

Pros and cons of Ross procedure

A

Pros
- Valve holds up well with time

Cons
- When valve does degenerate, not only do you have an aortic valve issue you may have pulmonary problems as well
- Traded in one valve problem for 2 valve problems

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7
Q

Aortic valve replacement
Age < 50
Patient can tolerate OAC
Valve?

A
  • Mechanical valve (likely has survival benefit)
  • Ross procedure
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8
Q

Aortic valve replacement
Age > 65
Valve?

A
  • Bioprosthetic (degeneration will be slower in older patients)
  • Won’t require lifelong OAC
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9
Q

At what age is a bioprosthetic aortic valve preferred over mechanical

A

> 65
if < 50 and can tolerate OAC then mechanical preferred

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10
Q

Aortic valve replacement
Age 50-65
Valve?

A

Shared decision making process

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11
Q

Mitral valve replacement
Age < 65
Valve?

A

Mechanical

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12
Q

Mitral valve replacement
Age > 65
Valve?

A

Bioprosthetic

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13
Q

“closing click” during closure

A

Mechanical prosthesis

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14
Q

no click
mild stenosis

A

Bioprosthetic valve

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15
Q

S1 normal
S2 crisp closing click

A

Mechanical aortic valve

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16
Q

S1 crisp closing click
S2 normal

A

Mechanical mitral valve

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17
Q

Normal S1, S2
Slight systolic ejection murmur

A

Bioprosthetic aortic valve
*Each replacement valve has small degree of intrinsic obstruction

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18
Q

Normal S2, S2
Slight early diastolic rumble

A

Bioprosthetic mitral valve

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19
Q

Mechanical valve
Lose closing click

A

Bad sign
Usually indicates thrombosis or something else is inhibiting valve closure

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20
Q

In a mechanical valve you always want to hear what?

A

closing click
bad sign if not hearing this

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21
Q

Mechanical aortic position
Loud systolic ejection murmur ≥ 3/6, extending to second heart sound

A

Bad sign
Usually indicates obstruction

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22
Q

Mechanical mitral position
Loud diastolic murmur

A

*Not should not hear a murmur with mechanical mitral
Indicates significant stenosis

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23
Q

Bioprosthesis aortic position
Very loud systolic murmur extending to S2
OR
Bioprosthesis mitral position
Very loud diastolic rumble

A

Bad sign
Suggests stenosis of bioprosthesis

24
Q

You suspect something is wrong with the aortic prosthesis, what is your next line test?

You suspect something is wrong with the mitral prosthesis, what is your next line test?

Mechanical prosthesis you suspect is malfunctioning, next test?

A

TTE

TEE
- Because of acoustic shadowing, need to get TEE to clearly evaluate mitral prosthesis

Fluoroscopy or 3D CT scan

25
Q

Mechanical OR bioprosthetic aortic prosthesis
Diastolic decrescendo murmur

A

Bad sign
Suspect regurgitation

26
Q

Mechanical bioprosthetic mitral prosthesis
Holosytolic murmur present

A

Bad sign
Suspect regurgitation

27
Q

Bioprosthetic aortic valve
What next test to evaluate if malfunction suspected?

A

TTE

28
Q

Bioprosthetic mitral valve
What next test to evaluate if malfunction suspected?

A

TEE
(d/t acoustic shadowing, TTE will be nondiagnostic)

29
Q

Mechanical mitral or aortic valve
What next test to evaluate if malfunction suspected?

A

Fluoroscopy or 3D CT scan

30
Q

Low risk anticoagulation criteria for prosthetic valve

INR goal?

Bridging?

A

AVR
New generation (St judes, on-x)
No prior embolic event
NSR
Normal EF

Target INR 2.5
No longer require ASA unless indicated for other cause

Stop warfarin
Let INR drift
Once sub-therapeutic, surgery
Ideally restart the night of the surgery

31
Q

High risk anticoagulation criteria for prosthetic valve

INR goal

A

MVR
Prior embolic event
AF
Decreased EF

Target 3.0

32
Q

Low risk anticoagulation patient
INR goal

A

Target 2.5

33
Q

High risk anticoagulation patient
INR goal

A

Target 3.0

34
Q

On-X aortic valve
Trials have shown you can go as low as what INR?

A

1.5-2.0

35
Q

Warfarin bridging in patient with low risk anticoagulation prosthetic valve

(AVR
New generation (St judes, on-x)
No prior embolic event
NSR
Normal EF)

A

Stop warfarin
Let INR drift
Once sub-therapeutic, surgery
Ideally restart the night of the surgery

36
Q

Warfarin bridging in patient with high risk anticoagulation prosthetic valve

(MVR
Prior embolic event
AF
Decreased EF)

A

Stop warfarin
Once INR < 2.0 bridge with LMWH (outpatient) or UFH (inpatient)
At least 6 hours prior to operation stop UFH
At least 12 hours prior to operation stop LMWH
(if spinal surgery stop LMWH at least 24 hours)
Restart warfarin as soon as possible post surgery

37
Q

For patient with AF and native valve heart disease (except rheumatic mitral stenosis) or who received a bioprosthetic valve > 3 months prior, what is the recommended anticoagulation?

A

DOAC is an effective alternative to VKA
Should be administered on the basis of the pt’s CHADS2-VASc

Class I

38
Q

For patients with AF and rheumatic MS, what anticoagulation is recommended

A

Longterm VKA
Class I

39
Q

For patients with new onset AF ≤ 3 months after surgical or transcatheter bioprosthetic valve replacement, anticoagulation with?

A

VKA
Class 2a (Moderate)

40
Q

In patients with mechanical heart valves with or without AF who require long term anticoagulation, which anticoagulation is recommended and which is not recommended

A

VKA recommended

DOAC not recommended
Class III (Harm)

41
Q

Under what circumstances should pt with VHD and AF be treated with VKA (DOAC unsafe)

A

Mechanical valve
Rheumatic mitral stensosis

42
Q

DOAC is a reasonable option in patients with AF and native VHD with the exception of:

A

Rheumatic MS (then VKA indicated)

43
Q

Patients with postoperative AF in the first 3 months after surgical or trancatheter bioprosthetic valve implantation should be anticoagulated with?

A

VKA
May be some evidence that DOACs are safe, but data still being compiled

44
Q

Outline the OAC plan

Pt with VHD (rheumatic MS) and AF

A

VKA

45
Q

Outline the OAC plan

Pt with VHD (native valve disease, NOT rheumatic MS) and AF

A

DOAC or VKA based on CHADS2VASc

46
Q

Outline the OAC plan

  1. Pt with VHD (bioprosthetic valve) > 3 months after procedure and AF
  2. Pt with VHD (bioprosthetic valve) < 3 months after procedure and AF
A
  1. DOAC or VKA based on CHADs2VASC
  2. VKA
47
Q

Pt with mechanical bileaflet or current-generation single-tilting disk AVR AND NO risk factors for thromboembolism

OAC plan?

A

VKA w/ INR of 2.5
(Class I)

48
Q

Mechanical AVR and additional risk factors for thromboembolism (ie AF, previous thromboembolism, LV dysfunction, hypercoaguable state) or an older generation prosthesis (ie ball in cage)

OAC plan?

A

VKA w/ INR of 3.0
(Class I)

49
Q

Mechanical mitral valve

OAC plan?

A

VKA w/ INR of 3.0
(Class I)

50
Q

Bioprosthetic TAVI (3+ months out)
No other indications for anticoagulation

Plan?

A

ASA 75-100 mg
(Class 2a)

51
Q

Bioprosthetic SAVR or mitral valve replacement and no other indications for anticoagulation

Plan?

A

ASA 75-100 mg
(Class 2a)

52
Q

Bioprosthetic SAVR or mitral valve replacement and low risk for bleeding

Short term OAC plan?

A

VKA to achieve INR of 2.5 for at least 3 months and for as long as 6 months after surgical replacement
(Class 2a)

53
Q

Mechanical SAVR or mitral valve replacement who are managed with VKA and have an indication for antiplatelet therapy

Plan?

A

Addition of ASA 75-100 mg so long as bleeding risk is low
Class 2b

54
Q

Mechanical On-X AVR and no thromboembolic risk factors

OAC plan?

A

VKA w/ targeted lower INR (1.5-2.0) starting ≥ 3 months after surgery with continuation of ASA 75-100 mg
Class 2b

55
Q

Bioprosthetic TAVI, low risk of bleeding

Plan?
Alternative plan?

A

DAPT w/ ASA 75-100 mg and clopidogrel 75 mg for 3-6 months after valve implantation
Class 2b

Anticoagulation with VKA w/ INR of 2.5 may be reasonable for 3 months after implantation
Class 2b

56
Q

Mechanical valve prosthesis, anticoagulation with direct thrombin inhibitor, dabigitran?

A

Contraindicated
Class 3, Harm

57
Q

Mechanical valve prosthesis, anticoagulation with anti-Xa direct oral anticoagulant?

A

Class 3, Harm
Has not been assessed yet and is not currently recommended

Mayo Cardiology Core Competencies (14 decks)

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