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
