Valve Disease Flashcards
Bicuspid incidence
1-2% general population
Majority never develop stenosis
Associated with coarctation
Bicuspid aortic stenosis
Look for AI and aortic dissection
Aortic stenosis
May be atherosclerotic
Severe stenosis late peaking with obscure s2
Pulses parvus tardus
Valve area
Cardiac out put/ heart rate x SEP x 44.3x square root of the gradient
Hakki
Cardiac out put/ square root of the gradient
Aortic stenosis
Mild velocity 1.5
Severe velocity >4m/sec gradient >40 valve area <1.0
Severe a symptomatic AS
Stress test is reasonable
AS follow up Change in symptoms Asymptomatic Yearly for severe AS Every 2 years got moderate AS Every 5 for mild
Expect
Jet velocity increase 0.3 m/sec
Gradient increSe 7 mmhg/ year
Valve area decrease 0.1 cm per year
AS symptoms and survival
Angina 5 years
Syncope 3 years
Failure 2 years
Low flow low gradient
10% cases
Dibutamine echo
Low flow Gorlin formula is wrong
Pseudo stenosis due to after load mismatch
Treatment of AS
Statin no benifit by saltire trial
Acei poss effect on inflammation
AVR
2-4% mortality in low risk
15-20% in high risk
TAVR indications
Severe AS
STS greater than 8%
Inoperable high risk
Life expectancy greater than 1 year
Bicuspid and aortic root
Replace aorta greater than 5.5 cm
Greater than 5 for rapid progression
Aorta greater than 4.5 with severe AS
AI severity
Vena contracts 0.6
Pressure half time mild >450 severe central jet width 65%,flow reversal > 0.6m/sec, Regurgitant volume >60ml, Regurgitant fraction > 55% EROA 0.3
Pressure half time 200 vena contracts >0.6 cm2
Acute AI
Tachycardia
Pulm edema
Short murmur
Diastolic MR
No IABP use nipride
AI presentation
Dyspnea
Angina due to decreased reserve
AI low EF
Need AVR
AI symptoms
Symptoms 25% a year
After symptoms death 10% a year
Chronic AI
Nifedipine and acei class 1
AI operative mortality
EF >50% 3.7%
35%. 6.7%
<35% 14%
AI indication for surgery
Symptoms
LV dysfunction 50
EDD>70(2b)
LVESD>55
MS
Evaluate for afib
MS severity
Mild gradient 1.5
Severe gradient >10 PAP >50 area <1.0
MS
OS
Loud S1
Survival of MS
No symptoms 10 year survival 80-100%
Limiting symptoms 10 year 0-15%
Pulm HTN < 3 years
MR severe
Jet area >0.5 Regurgitant volume >60 Regurgitant fraction >55% Vena contracts >0.7 cm ERO >0.4 Normal LA the MR is not severe
MR types
Type 1 dilated root
Type 2 prolapse
Type 3 pap dysfunction
3b ischemic
Increase MR
DecreAse survival
Increase CV events
LV gram is still gold standard
Moderate MR
Annual echo
Indication for mitral surgery
EF >30% ESD 55 if chordal preservation likely, medical therapy if chordate can’t be preserved
Severe MR EF < 60% or ESD >40 mm
New onset afib or pulm HTN
Do early before symptoms worsen
MR
Repair if possible
Pulm stenosis
Isolated Tetralogy Rubella Carcinoid Gradient >4m/sec Treatment valvuloplasty
Pulm regurgitation
Carcinoid Tetralogy Endocarditis RV overload Bio prosthetic
TRicuspid stenosis
Rheumatic Carcinoid Congenital Fabry Drugs ergot Valve area 1 cm2 balloon or bio prosthetic
TR
Pulm HTN Cardiomyopathy Left sided valve disease Rheumatic Ebstein Radiation
Surgery severe TR
Severe TR in peopke undergoing left sided valve surgery
Less than severe TR with left sided valve surgery if there is pulm HTN
Severe TR with symptoms
Primary TR with RV failure
MS and AI
Pressure half time of MS will be long and pressure half time of AI will be short
Carcinoid
Primary GI Cardiac involvement 50% Check 24 hour urine 5-HIAA Octreo scan Ergot Diet drugs
Radiation effects
10-15 years after radiation
Coronaries valves and pericardium
Concomitant chemo
MR and AI
Antiphospholipid antibody
Superficial thrombosis
Non bacterial endo
Regurgitation MR AI
Endocarditis
Blood cultures single for coxiella
Evidence if vegetation
Echo evidence
Endocarditis
DX 2major
1 major 3 minor
5 minor
Prophylaxis
Prosthetic valves Prior endo Unrepaired cyanotic congenital Repaired with residual Transplant with Regurgitant lesions
Bio prosthetic after 70
Routine yearly echo class 2b Regurgitation detected every 3/6 mos
Mechanical valves and Coumadin
Stroke untreated 4-8% a year
Treated 1-2% year
Bio prosthesis 1-2% a year
Anticoag guide lines
Afib
Previous CVA
Hypercoagulable state
EF <30%
Asa 75 all mechanical and bio
INR 2-3 mechanical AVR and 3 MIs for bio
INR 2.5-3.5 for the rest
Short term interruption of Coumadin
Bi leaflet AVR no bridge Bridge all the rest with UFH Lmwh is ok now FFP urgent cases No vit K
Bio prosthetic
20-30% dysfunction in 10 yrs
50% by 15 years
Increase in young pregnancy and RF
Look for patient valve mismatch
Valve thrombosis
2% per year
Thrombolysis effective 70-90% More on the right sided Mortality 4-12 % with lysis Surgery for large clot class 3-4 Small clot class 1-2 consider lysis
Endocarditis
Mitral more common
0.5% even with antibiotics
Stable endo no surgery needed
Hemolysis may need to be replaced
AS surgery
Symptomatic
EF less than 50% no symptoms
Worsening gradient
Abnormal stress test
MS
Symptomatic survivsl 50%
Valvuloplasties symptomatic or asymptomatic with moderate to severe disease with pulm HTN
Tricuspid stenosis
Gradient 7mm hg area 1 cm2
TR severity
Jet width 0.7
Pisa 0.9
Vena contracta >0.7
Central jet >10cm2
