Valve Disease

Question 1

Parameters of severe MR

Answer 1

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

Question 2

A truncated, triangular, early peaking MR CW doppler jet contour signifies what

Answer 2

high LA pressures, as can be seen in acute severe MR

Question 3

What’s the formula for MR Regurgitant Volume calculation using doppler method

Answer 3

RegV = (0.785 x MA diameter^2 x MA VTI) – (0.785 x LVOT diameter^2 x LVOT VTI)

Question 4

What’s the equation for MR Regurgitant Fraction

Answer 4

RF = (RegV / MA vol) x 100

Question 5

What’s the formula to calculate MR Regurgitant volume using combined 2D-doppler method?

Answer 5

RegV = total LV SV (biplane method) – LVOT SV

Question 6

What’s the equation for EROA?

Answer 6

EROA = Regurgitant Volume / VTI of MR jet

Question 7

List the definition, valve anatomy, valve hemodynamics (MVA, PG, velocities), hemodynamic consequences and symptoms for Stage A mitral stenosis

Answer 7

Stage A: at risk for mitral stenosis, mild valve doming in diastole, normal transmitral flow velocity, no pulmonary HTN or LAE, no symptoms

Question 8

List the definition, valve anatomy, valve hemodynamics (MVA, PG, velocities), hemodynamic consequences and symptoms for Stage B mitral stenosis

Answer 8

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

Question 9

List the definition, valve anatomy, valve hemodynamics (MVA, PG, velocities), hemodynamic consequences and symptoms for Stage C and D mitral stenosis

Answer 9

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

Question 10

What are the MVA and PHT seen in very severe MS?

Answer 10

MVA = 1, PHT >/= 220 (remember that MVA=220/PHT thus a MVA of 1 will give a PHT of 220)

Question 11

What indicates absent flow reserve in DSE for LFLG aortic stenosis? What does minimal reserve by DSE signify?

Answer 11

Change in LVOT VTI <20% with dobutamine; signifying that the DSE cannot distinguish between pseudo severe and severe AS

Question 12

What is the equations for mitral valve area using PHT and DT?

Answer 12

MVA= 220/PHT and MVA= 759/DT

Question 13

Name the max velocity and pressure gradient cutoffs for mild, moderate and severe PS?

Answer 13

mild: max velocity < 3m/s, PG < 36mmHg
mod: max velocity 3-4m/s, PG 36-64mmHg
sev: max velocity >4m/s, PG > 64mmHg

Question 14

What is the threshold for normal stroke volume index?

Answer 14

> 35mL/m2

Question 15

For asymptomatic severe AR, what LV parameters and values should prompt AVR?

Answer 15

LVEF < 50% (Class I recommendation)
LVESD > 5 with EF > 50% (Class IIa)
LVEDV > 6.5 with EF > 50% (Class IIb)

Question 16

What change do you expect to see after a PVC for AS vs HOCM on intracardiac pressure waveforms?

Answer 16

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

Question 17

What is the Aortic Regurgitation Index (after TAVR)? How is it used?

Answer 17

[(DBP-LVEDP)/SBP] x 100

Less than or equal to 25% suggests at least moderate PVL which would need intervention (like additional balloon angioplasty)

Question 18

What happens to carotid upstroke and murmur for HOCM after a PVC?

Answer 18

Carotid upstroke is diminished and murmur is louder after PVC due to increased contractility and decreased afterload.

Question 19

What is the threshold for contractile reserve in DSE for AS? What does it tell you about the patient/prognosis?

Answer 19

> /= 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)

Question 20

What’s a normal LVOT VTI?

Answer 20

18-22cm

Question 21

What is the equation for dimensionless index?

Answer 21

DI = LVOT peak velocity / AoV peak velocity

Question 22

In aortic stenosis, what is the peak to peak gradient?

Answer 22

the pressure difference between peak LV systolic pressure and peak aortic systolic blood pressure

Question 23

What’s a trick for determining mean gradient across AoV if all you have is peak velocities?

Answer 23

mean PG is roughly 60% of peak PG

Question 24

For mitral valve, what is considered rapid E wave deceleration time?

Answer 24

< 160 ms

Question 25

what does the mitral inflow CW profile look like for cor triatriatum?

Answer 25

continuous anterograde flow in both systole and diastole resulting in 3 distinct anterograde envelopes (systolic, E wave and A wave)

Question 26

when calculating orifice area by PISA, which of the two Nyquist limits should you use?

Answer 26

use the Nyquist limit that is in the same direction as the flow through the orifice

Question 27

when calculating Ao valve mean PG, when does the proximal (LVOT) velocity need to be included in the simplified Bernoulli equation?

Answer 27

when V1 is > 1m/s or V2 is < 3m/s both velocities must be used:
maximum PG= 4(V2^2 - V1^2)

Question 28

what’s the equation for projected Ao valve area with normal flow rate?

Answer 28

projected AVA= AVA rest + [(AVApeak- AVA rest)/(Qpeak - Qrest)] x (250mL/s - Q rest)

note that Q= stroke volume/ ejection time

Question 29

list the criteria that define severe AI

Answer 29

1. EROA >/= 0.3cm^2
2. Regurgitant fraction >/= 50%
3. Regurgitant volume >/= 60mL/beat
4. vena contracta > 0.6cm
5. ratio of regurgitant jet width to LVOT diameter >/= 65%
6. holodiastolic flow reversal in descending aorta

Question 30

When should pulmonic stenosis be intervened upon?

Answer 30

Symptomatic with mean PG >/=30

Asymptomatic with mean PG >/=40

Question 31

what is the indexed effective orifice area cutoff for aortic valve patient-prosthetic mismatch?

Answer 31

indexed EOA = 0.85cm^2/m^2

severe PPM is = 0.65cm^2/m^2

Question 32

what is the indexed effective orifice area cutoff for mitral valve patient-prosthetic mismatch?

Answer 32

indexed EOA = 1.2cm^2/m^2