Valve disease Flashcards
Mitral Valve repair
MR - LVEF<60%, LVEDD>4.0cm, severe ERO >0.4cm^2
If <50% posterior leaflet damage -> MV repair (not replacement)
Severe MR VC>0.7cm RVol>60cc RF>50% ERO>0.4cm^2 LV dilation LVEDD>4.0cm Repair if <50% posterior leaflet damage
STS Scoring
- Low risk: STS PROM <4.0% AND no evidence for frailty AND no other major organ system dysfunction AND no procedural specific impediment.
- Intermediate risk: STS PROM 4-8% OR at least one index of frailty (mild) OR one organ system involvement OR a possible procedural impediment.
- High risk: STS PROM >8.0% OR two or more indices of frailty (moderate-severe) OR up to two major organ systems compromised OR probable procedural impediment.
- Prohibitive risk: Predicted surgical risk or major morbidity at 1 year of >50% OR three or more major organ systems compromised OR severe procedural impediment.
Aortic aneuysm associated with…
BAV
Marfans
Loeys-Dietz
Ehrlos danols
Bicuspid Aortic Valve
MC=
70% RCC/LCC
20% NCC/RCC
RARE NCC/LCC
Valve Endocarditis PPX
2gm amoxicillin 20-60 min pre-dental procedure
1) prosthetic cardiac valve or prosthetic valve repair material
2) prior history of infective endocarditis
3) cardiac transplant recipients with valvulopathy
4) completely repaired congenital heart disease with percutaneous or surgical repair occurring within the previous 6 months
5) repaired congenital heart disease with residual shunts or defects that impair endothelialization of prosthetic material
6) unrepaired cyanotic congenital heart disease.
* *manipulation of gums, incision in respiratory tissues, or GU/skin/GI procedures in infected areas
Mitral Stenosis workup
Balloon mitral valvuloplasty would be preferred over surgical valve replacement due to the pliable nature of the lesion and the low echo score (Wilkens <=8)
AVR indications
Asymptomatic Severe AS
-excercise testing (ECG Stress) - unless VERY severe ie v>5m/s (positive if any symptoms, hypotension or lack of BP>20mm increase, ST changes)
Indication for MVR
Severe: 4- ERO>40mm 5- Regurg Fraction >50% 6 - Regurg Vol >60cc 7 - Vena Contract >0.7cm
Replace with Sx: Progressive dypnea Pulm HTN AF LV dilation Systolic dysfxn
ASX Indication for surgery LV Systolic dysfxn (<60%) LVESD >40mm New onset AF Pulm HTN (PASP>50)
BAV
associated with aortopathy - possible aortic dissection/aortic aneurysm - need CT Chest screening of aorta prior to AV replacement
Screening TTE intervals for asymptomatic AS
1) Severe/ >4m/s - 1 year
2) Moderate - 3-3.9 1-2 years
3) Mild - 2-2.9 3-5 years
Brockenback sign
HOCM
Post systolic beat - DECREASE pulse pressure, increased gradient (LV and aortic curve farther apart, aortic wave higher therefore PP increased and gradient increases
Aortic valve area with significant AR
CANNOT determine in cath lab
both fick and TD CO assumes no significant shunt
Fick output would be erroneously low
Hakki AVA=CO/sqrt(mean AV gradient)
Pulmonary stenosis
Peak gradient >60mm Hg (mean>40) without sx
Peak gradient >50 with sx (Mean >30)
with less than moderate PR
no infundibular hypertrophy
Tissue prosthesis
increased risk of structural degeneration in younger patients
Stented tissue prostheses have a smaller effective orifice area and typically higher residual gradients than mechanical valves.
Re-op surgical risk of 2-3x higher than initial operation
Stentless tissue valves have better hemodynamic profile than stented valves but harder to place
Aortic Regurgitation AVR guidelines
LVESD>5.0cm LVEDD>6.5 cm EF<50% OR Symptoms
Acute AR
surgical emergency No BB (inc'd HR needed to maintain CO)
Paradoxial low gradient severe AS with normal EF
AVA<1.0 but gradient low 2/2 low SV (<35cc) with normal LVEF (low SV from high afterload, small ventricle, hypertrophy)
Outcomes worse than high gradient, severe AS normal EF patients
Low gradient Low EF severe AS
differentiate Psedo AS (Low gradient from low SV/contractility)
from true AS -> dob stress
EF<40% and mAS gradient <30mm Hg
<20% increase in SV is POOR prognosis (low contractile reserve)
Indications for AVR in AR
Class I: Sx patients with severe AR regardless of LV fxn ASx patients with severe AR EF<50%, Pt with chronic severe AR undergoing other CT Surgery Dx Sev AR ERO >0.3 RF >50% RV >60cc VC >0.6cm
Endocarditis
CHB - Class I indication for AVR Urgent CHF highly resistant organsim infeffective antibx therapy paravalvular abscess large vegetations
In hospital mortality 20%
Echo shows preclosure of mitral valve due to rapidly rising LV diastolic pressure from severe AR 2/2 endocarditis
Soft diastolic murmur in acute AR as little difference between LV and aortic diastolic pressures
Chronic AR - LV used to pressure and vol overload so LV diastolic pressures not as high
In acute AR sudden increase in LVEDP causes little difference between LVEDP and aortic diastolic pressure so little murmur - no wide pulse pressure as in chronic AR
No BB in acute AR
Low output low gradient AS
AVA<1.0cm^2 but lower peak and mean AV gradients
can be decreased contractility that leads to decrease in valve opening or real AS - need dobutamine stress echo
if mean gradient gets to >40mm Hg then real severe AS
If pseduo AS then dobutamine will cause increase in contractility and CO and increase calculated valve area
Do not do excercise studies on patients to rule out AS
Thrombosed Mech Valve
NYHA III/IV - emergency surgery removal of thrombus
NYHA I/II - TPA/lytics
PPM/ICD lead TV leaflet impingement
Signs of RHF
but PAP normal so no secondary (ie PH) cause of TR
No support for constrictive pericarditis (no expiratory reversal of hepatic vein flow)
Constrictive pericarditis
expiratory flow reversal of hepatic veins
ventricular discordance in pressures
equalization of diastolic pressures
Acute MR
Sudden inc in LA/LV vol in absense of chamber dilation
No murmur - rapid equalization of pressure since LA doesn’t have time to adapt
hypotension from sudden reduction in forward SV
No third heart sound
Acute MR from IE
Replacement
1) HF
2) extensive valve destruction
3) Large vegetation
4) paravalvular abscess
5) ineffective abx
6) highly resistant organism
7) recurrent emboli on abx therapy
Carpentier MR Classification
- Isolated annular dilation (no leaflet issue) or leaflet perforation from IE
- Flail (motion atrial to annulus)
- Restriction - IIIa - both systole and diastole - fibrosis
or IIIb - systole only - 2/2 ishemic HD with papillary muscle fibrosis and chordal restriction
MS
1) Direct planimetry
2) Doppler pressure gradient - 4(v)^2 - not reliable with MR >10mm Hg significant
3) PHT - 220/PHT - inaccurate in AR, abn in LA/LV compliance or Mitral valvuloplasty
Wilkins score
<8= candidate for MV balloon valvuloplasty Mobility Thickening of valve Calcificiation of valve Subvavular thickening
NO ACCOUNTING FOR MR…
Sev AR indications for surgery for ASX patient
LV dysfxn LVESD>5.0 LVEDD>6.5 other cardiac surgery PHT<200 = sev AR if doesn't meet - tte q6-12mo
Mechanical Valve Anti-thrombosis
INR 2.5-3.5 + ASA 81mg daily (NO NOAC)
Med therapy AR
if not surgical candidate or need bridge - vasodilators ie ACE/ARB (sev AR with Sx or LV dysfxn)
Bicuspid AVR
if indicated to repair BAV
replace aorta if >4.5cm
If no BAV replacement
aortic repair if >5.5cm
If other risk foactors for dissection
replace at 4.5cm
Prosthetic valve eval
TEE preferred - more sensitive for vegetations
Surgery if: HF Dehiscence progressive valve deg bacteremia persistent emboli
IE Criteria
Duke Criteria
2 Major
1 major 3 minor
5 minor
Major:
1. Typical microbes in 3/3 cultures, or single of cox burneti
2. Evidence of endocardial involvement (veg, abcess, valve dehiscence
Minor
1. Predisposition to endocarditis (prev IE, IVDU, prostehetic valve, MVP, cyanotic congenital HD, other cardiac lesions with turb flow
2. Fever
3. vasc phenomenoa - emboic events, mycotic aneurysm, janeway lesio
4. Immune phenomena - sero markers, roth spots, oslner node, glomerulnephritis
5. microb evidence not meetin gmajor criteria
Subaortic membrane stenosis criteria for surgery
Asx = Surgery mean gradient >30mm Hg Peak gradient >50mm Hg Progressive AR LVESD>50mm LVEF<50%
Balloon aortic valvuloplasty
ONLY as bridge to TAVR or SAVR - never alone…
Mixed valve disease
base decision on worse valve problem (ie if Sev AS and mild AR then base on AS)
Pulmonic stenosis murmur
changes with respiration, inc’d JVP - pulmnoic ejection click decreases with inpiration
BAV murmur
systolic ejection click - often with AR
Chronic AR
LV vol o/l
wide Pulse pressure
S3
laterally displaced apical impulse
MS Epidemiology
Survival
10 year mortality 33-70%
20 year mortality - 80-87%
5 year mortality 50% after no intervention
MS Physical exam
Diastolic rumbling murmur
inc’d 1st heart sound
S2->OS interval decreases with severe MS (the more severe the stenosis, the higher the LA pressure, the sooner the MV opens after S2 following aortic valve closure) - diastolic murmur following OS
Tricuspid valve repair
Class I - at time of left sided surgery
not atiral arrytnmias
Not pulmonary HTN
Mechanical valves
bileaflet/medtronic hall valves aortic only with NO high risk features (dec LVEF, AF, prior VTE, hypercoag)
ASA+warfarin INR 2-3
If high risk, star edwards or disc valve in addition to medtronic hall - ASA + coumadin 2.5-3.5
Discordant physical exam and echo with AS
likely BAV
Echo shows moderate AS
Symptoms suggest severe
PE suggests severe AS (loss of ej sound, late peaking aortic murmur, loss of A2, parvus tardus carotid)
Needs cath hemodynamic valve study
FXN MR with reduced EF
optimize med therapy
carvediolol
Surgical therapy does not decrease mortality (only palliates sx)
Asymptomatic severe AS
if not SUPER severe (ie >5m/s) -> obtain excercise test to see if truly asx
Positive if: hypotension or lack of inc in BP >20mm hg, ST abn
Can be PPM - too small a prosthesis
severe PPM AVA <0.65cm^2
Surveillance BAV +- aortic aneurysm
With Asc Ao >4.5cm - yearly echo
Without Asc Ao <4.5 and mild AS - TTE 3-5yr
Severe asx AS TTE yearly
Mod AS Asx TTE 1-2 years
Root replacement if >5.5cm
If Fhx dissection root replacement >5.0cm
If AVR then root replacement if >4.5cm
Tricuspid stenosis/regurg
Severe TS - PHT>190, TVA<1.0 >7mm Hg gradient
surgical replacement
BioTVR - increased thromboembolic complications with mech valve in TV position
PPX for endocarditis
only with dental procedures
NO PPX with resp tract, GI or GU procedures unless infection present
PPX for rheumatic fever
benzathine PCN
Secondary ppx
Rheum fever with carditis and residual heart dz - 10 years or until pt is 40yo
Rheum feveer with carditis and no residual heart dz - 10 years or until pt 21yo
Rheum fever WITHOUT carditis - 5 years or until patient 21yo
MS and afib
Warfarin only - no NOAC or ASA
Mitral stenosis severity
Progressive MS - area >1.5cm^2, PHT<150ms, normal PAP, mild to mod LAE
Asx severe MS - area <1.5cm^2, PHT>150ms, severe LAE, PASP>30mm Hg
VERY SEVERE area <1.0, PHT>220ms, PASP>30mm Hg
Strep bovis
a/w GI malignancy - needs colonoscopy
Aortic stenosis
If clinical exam severe, echo not severe
needs hemodynamic cath to break discrepancy
Source of echo error
poor alignment of doppler jet from AS (underestimation of gradient)
Sampling LVOT velocity integral too close to LVOT (overestimation of LVOT VTI)
Dob study only if CO is low…
