Valve Disease Flashcards
Parameters of severe MR
vena contracta > /= 0.7 RVol >/= 60mL RF >/= 50% ERO >/= 0.4cm^2 LV dilation (LV ESD > 40mm) for a central jet, jet area >/= 50% of LA
A truncated, triangular, early peaking MR CW doppler jet contour signifies what
high LA pressures, as can be seen in acute severe MR
What’s the formula for MR Regurgitant Volume calculation using doppler method
RegV = (0.785 x MA diameter^2 x MA VTI) – (0.785 x LVOT diameter^2 x LVOT VTI)
What’s the equation for MR Regurgitant Fraction
RF = (RegV / MA vol) x 100
What’s the formula to calculate MR Regurgitant volume using combined 2D-doppler method?
RegV = total LV SV (biplane method) – LVOT SV
What’s the equation for EROA?
EROA = Regurgitant Volume / VTI of MR jet
List the definition, valve anatomy, valve hemodynamics (MVA, PG, velocities), hemodynamic consequences and symptoms for Stage A mitral stenosis
Stage A: at risk for mitral stenosis, mild valve doming in diastole, normal transmitral flow velocity, no pulmonary HTN or LAE, no symptoms
List the definition, valve anatomy, valve hemodynamics (MVA, PG, velocities), hemodynamic consequences and symptoms for Stage B mitral stenosis
Stage B: progressive mitral stenosis, commissural valve fusion and diastolic doming of leaflets, increased transmitral flow velocities but with MVA >/= 1.5cm2 and PHT < 150ms, normal resting RVSP, mild to moderate LAE, no symptoms
List the definition, valve anatomy, valve hemodynamics (MVA, PG, velocities), hemodynamic consequences and symptoms for Stage C and D mitral stenosis
Stage C: severe asymptomatic, commissural fusion and diastolic doming, MVA = 1.5cm2, PHT >/= 150ms, severe LAE, RVSP > 30, no symptoms
Stage D is severe symptomatic and has all the same features except with symptoms
What are the MVA and PHT seen in very severe MS?
MVA = 1, PHT >/= 220 (remember that MVA=220/PHT thus a MVA of 1 will give a PHT of 220)
What indicates absent flow reserve in DSE for LFLG aortic stenosis? What does minimal reserve by DSE signify?
Change in LVOT VTI <20% with dobutamine; signifying that the DSE cannot distinguish between pseudo severe and severe AS
What is the equations for mitral valve area using PHT and DT?
MVA= 220/PHT and MVA= 759/DT
Name the max velocity and pressure gradient cutoffs for mild, moderate and severe PS?
mild: max velocity < 3m/s, PG < 36mmHg
mod: max velocity 3-4m/s, PG 36-64mmHg
sev: max velocity >4m/s, PG > 64mmHg
What is the threshold for normal stroke volume index?
> 35mL/m2
For asymptomatic severe AR, what LV parameters and values should prompt AVR?
LVEF < 50% (Class I recommendation)
LVESD > 5 with EF > 50% (Class IIa)
LVEDV > 6.5 with EF > 50% (Class IIb)
What change do you expect to see after a PVC for AS vs HOCM on intracardiac pressure waveforms?
Post PVC there is increased contractility due to higher calcium accumulation and decreased afterload due to depletion/runoff of Ao volume; leads to higher pulse pressure (higher Ao systolic pressure) for AS and lower pulse pressure for HOCM (Brockenborough/Braunwald sign) with “spike and dome” waveform
What is the Aortic Regurgitation Index (after TAVR)? How is it used?
[(DBP-LVEDP)/SBP] x 100
Less than or equal to 25% suggests at least moderate PVL which would need intervention (like additional balloon angioplasty)
What happens to carotid upstroke and murmur for HOCM after a PVC?
Carotid upstroke is diminished and murmur is louder after PVC due to increased contractility and decreased afterload.
What is the threshold for contractile reserve in DSE for AS? What does it tell you about the patient/prognosis?
> /= 20% increase in stroke volume with dobutamine
Patients with contractile reserve do better with SAVR; patients with no contractile reserve have higher perioperative mortality but should still undergo AVR as long term EF tends to improve and symptoms/mortality goes down (consider TAVR because that increased perioperative mortality is not there with TAVR)
What’s a normal LVOT VTI?
18-22cm
What is the equation for dimensionless index?
DI = LVOT peak velocity / AoV peak velocity
In aortic stenosis, what is the peak to peak gradient?
the pressure difference between peak LV systolic pressure and peak aortic systolic blood pressure
What’s a trick for determining mean gradient across AoV if all you have is peak velocities?
mean PG is roughly 60% of peak PG
For mitral valve, what is considered rapid E wave deceleration time?
< 160 ms
what does the mitral inflow CW profile look like for cor triatriatum?
continuous anterograde flow in both systole and diastole resulting in 3 distinct anterograde envelopes (systolic, E wave and A wave)
when calculating orifice area by PISA, which of the two Nyquist limits should you use?
use the Nyquist limit that is in the same direction as the flow through the orifice
when calculating Ao valve mean PG, when does the proximal (LVOT) velocity need to be included in the simplified Bernoulli equation?
when V1 is > 1m/s or V2 is < 3m/s both velocities must be used:
maximum PG= 4(V2^2 - V1^2)
what’s the equation for projected Ao valve area with normal flow rate?
projected AVA= AVA rest + [(AVApeak- AVA rest)/(Qpeak - Qrest)] x (250mL/s - Q rest)
note that Q= stroke volume/ ejection time
list the criteria that define severe AI
- EROA >/= 0.3cm^2
- Regurgitant fraction >/= 50%
- Regurgitant volume >/= 60mL/beat
- vena contracta > 0.6cm
- ratio of regurgitant jet width to LVOT diameter >/= 65%
- holodiastolic flow reversal in descending aorta
When should pulmonic stenosis be intervened upon?
Symptomatic with mean PG >/=30
Asymptomatic with mean PG >/=40
what is the indexed effective orifice area cutoff for aortic valve patient-prosthetic mismatch?
indexed EOA = 0.85cm^2/m^2
severe PPM is = 0.65cm^2/m^2
what is the indexed effective orifice area cutoff for mitral valve patient-prosthetic mismatch?
indexed EOA = 1.2cm^2/m^2
