Valve Disease Flashcards

1
Q

Aetiology of AS

A
<70yrs = bicuspid and rheumatic
>70yrs = degenerative and bicuspid
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2
Q

Grading of severity of AS

A

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

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3
Q

Sign of poor prognosis with AS

A

HEART FAILURE +++

2nd = syncope
3rd = angina
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4
Q

Prognosis for AS

A

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

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5
Q

Surgical mortality for AS

A

1% for patients under 70yrs

4-8% for patients > 80yrs

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6
Q

What about balloon valvuloplasty?

A

Children = benefit

Adults = buy time or to assess symptom benefit for high risk surgical patients

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7
Q

Indications for AS surgery

A

Symptomatic severe AS

Severe AS and having other cardiac surgery

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8
Q

Surgical Vs TAVI replacement

A

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

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9
Q

Complications of TAVI?

A

BLEEDING +++
Vascular injury

30 day mortality = 10%

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10
Q

Causes of AR?

A

Acute severe = dissection or endocarditis –> emergent surgery

Chronic = HTN, Degeneration due to AS, previous endocarditis, bicuspid and Marfans

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11
Q

Mortality from AR?

A

Chronic severe symptomatic AR - mortality = 10-20%/yr

Chronic severe Asymptomatic AR + LV dysfunction = 20%/yr

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12
Q

Clinical signs of AS?

A

Low diastolic BP, high SBP
Duration of murmur = severity
S3
LVF

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13
Q

What surgery for AR?

A

Valve replacement usually

May have valve repair but expect to reoperate

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14
Q

Surgical indications for AR?

A

Severe symptomatic AR
Asymptomatic with LVEF<50%
Having other heart surgery
Asymptomatic with normal EF but dilated LV

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15
Q

What about aortic root surgery?

A

Marfans with root >50
Bicuspid >50 with risk factors
Everything else at >55

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16
Q

Medical therapy in aortic disease?

A

Beta blockers to reduce rate of aortic dilation
?ARBs
Screening of relatives with Marfans and bicuspid valves with dilated aortic roots

17
Q

Causes of Mitral stenosis?

A

Severe = RHEUMATIC HD

Calcific rarely becomes severe

18
Q

Clinical signs of MS?

A

Loud S1 - opening snap and diastolic rumble
DURATION OF MURMUR = Severity
Pulmonary HTN and RV failure

ECG = AF
CXR = LA enlargement
19
Q

Indications for intervention for MS

A

Severe symptomatic MS
Severe MS + pulmonary HTN
Asymptomatic patient who them become symptomatic when in AF

20
Q

Surgical options for MS?

A

Percutaneous mitral balloon commisurotomy = usually for younger patients

Surgical replacement = elderly due to concomitant MR

21
Q

Indications for Surgery for MS

A

Symptomatic MS

If MR = surgical, if not = PMC

22
Q

Signs of MR?

A

LV dysfunction - displaced apex beat, S3, LV failure
Early short murmur = acute MR
Late murmur in MVP

SEVERE = RHF

23
Q

Causes of MR?

A

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
24
Q

Treatment of MR?

A

Chronic severe MR without symptoms = valve repair

Symptomatic severe chronic MR = surgery

25
Q

Causes of TR?

A

Almost always secondary to other pathology

Fix underlying path = fix TR

26
Q

Causes of TS?
Presentation?
Treatment?

A

RARE
Rheumatic HD
Carcinoid

Poorly tolerated –> RHF

Treatment = Surgery for severe

27
Q

Mechanical Vs Bioprosthetic valve

A
Mechanical = lasts longer BUT needs anticoagulation
Bioprosthetic = shorter life 
AR = bioprosthetic if >60yrs
MR = bioprosthetic if >65yrs

If needs anticoagulation anyway = mechanical valve

28
Q

Anticoagulation bridging?

A

INR must be <1.5 for most major surgery = stop warfarin and bridge with unfractionated heparin

29
Q

Management of valve obstruction?

A

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

30
Q

Severe AS and non-cardiac surgery?

A

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

31
Q

Valve disease and pregnancy

A

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