Valve Disease Flashcards
Aetiology of AS
<70yrs = bicuspid and rheumatic >70yrs = degenerative and bicuspid
Grading of severity of AS
ECG: LVH
TTE: Severe = valve area <1 or mean gradient >40
Concern with low flow severe AS where poor LV function –> low valve gradient due to poor output. Low dose dobutamine challenge or balloon valvuloplasty can be used to assess
Sign of poor prognosis with AS
HEART FAILURE +++
2nd = syncope 3rd = angina
Prognosis for AS
If asymptomatic SCD = <1% annually. BUT must do exercise assessment to determine if really asymptomatic
If symptomatic then 5yr survival is <50% = intervention is required
Surgical mortality for AS
1% for patients under 70yrs
4-8% for patients > 80yrs
What about balloon valvuloplasty?
Children = benefit
Adults = buy time or to assess symptom benefit for high risk surgical patients
Indications for AS surgery
Symptomatic severe AS
Severe AS and having other cardiac surgery
Surgical Vs TAVI replacement
Surgical = mainstay of treatment
TAVI = high surgical risk (>10% mortality) but have suitable anatomy and life expectancy >1yr and likely to have symptomatic benefit
Medical management = poor life expectancy due to comorbidities
Complications of TAVI?
BLEEDING +++
Vascular injury
30 day mortality = 10%
Causes of AR?
Acute severe = dissection or endocarditis –> emergent surgery
Chronic = HTN, Degeneration due to AS, previous endocarditis, bicuspid and Marfans
Mortality from AR?
Chronic severe symptomatic AR - mortality = 10-20%/yr
Chronic severe Asymptomatic AR + LV dysfunction = 20%/yr
Clinical signs of AS?
Low diastolic BP, high SBP
Duration of murmur = severity
S3
LVF
What surgery for AR?
Valve replacement usually
May have valve repair but expect to reoperate
Surgical indications for AR?
Severe symptomatic AR
Asymptomatic with LVEF<50%
Having other heart surgery
Asymptomatic with normal EF but dilated LV
What about aortic root surgery?
Marfans with root >50
Bicuspid >50 with risk factors
Everything else at >55
Medical therapy in aortic disease?
Beta blockers to reduce rate of aortic dilation
?ARBs
Screening of relatives with Marfans and bicuspid valves with dilated aortic roots
Causes of Mitral stenosis?
Severe = RHEUMATIC HD
Calcific rarely becomes severe
Clinical signs of MS?
Loud S1 - opening snap and diastolic rumble
DURATION OF MURMUR = Severity
Pulmonary HTN and RV failure
ECG = AF CXR = LA enlargement
Indications for intervention for MS
Severe symptomatic MS
Severe MS + pulmonary HTN
Asymptomatic patient who them become symptomatic when in AF
Surgical options for MS?
Percutaneous mitral balloon commisurotomy = usually for younger patients
Surgical replacement = elderly due to concomitant MR
Indications for Surgery for MS
Symptomatic MS
If MR = surgical, if not = PMC
Signs of MR?
LV dysfunction - displaced apex beat, S3, LV failure
Early short murmur = acute MR
Late murmur in MVP
SEVERE = RHF
Causes of MR?
Acute severe = papillary muscle rupture post MI, endocarditis or trauma
Chronic severe MR =
- Primary = intrinsic problem with the leaflets or chordae
- Secondary = functional due to distortion of subvalvular apparatus = WORSE OUTCOMES
Treatment of MR?
Chronic severe MR without symptoms = valve repair
Symptomatic severe chronic MR = surgery
Causes of TR?
Almost always secondary to other pathology
Fix underlying path = fix TR
Causes of TS?
Presentation?
Treatment?
RARE
Rheumatic HD
Carcinoid
Poorly tolerated –> RHF
Treatment = Surgery for severe
Mechanical Vs Bioprosthetic valve
Mechanical = lasts longer BUT needs anticoagulation Bioprosthetic = shorter life
AR = bioprosthetic if >60yrs MR = bioprosthetic if >65yrs
If needs anticoagulation anyway = mechanical valve
Anticoagulation bridging?
INR must be <1.5 for most major surgery = stop warfarin and bridge with unfractionated heparin
Management of valve obstruction?
Diagnosis = TTE/TOE/Fluoroscopy
Check INR - usually always subtherapeutic = optimise
If obstructive and patient critical = surgery or thrombolyse and transfer for surgery
If obstructive and stable = heparin and aspirin and close surveillance
Severe AS and non-cardiac surgery?
Symptomatic severe AS = AVR first unless emergency surgery
Asymptomatic severe AS and low risk surgery = proceed with surgery
Asymptomatic severe AS and high risk surgery = AVR first
Valve disease and pregnancy
Severe MS –> worse –> symptoms
Treatment = bed rest, beta blocker and vavuloplasty at 20 weeks
Severe AS = rare. Valvuloplasty if deteriorates
Chronic AR and MR are usually okay in pregnancy as long as LV function is okay
C-P bypass = 20-30% fetal loss rate
