valve management

Question 1

what is the key investigation in valve diagnosis

Answer 1

echo

Question 2

what can be seen on an echo to aid diagnosis (5)

Answer 2

severity of stenosis; degree of regurgitation; ventricular size and function; atrial size; estimated pulmonary artery pressure

Question 3

what is the definitive treatment for valve disease

Answer 3

surgery

Question 4

role of medical management in valve disease

Answer 4

treat heart failure; treat AF (prevents embolism); treatment of endocarditis (always suspect)

Question 5

surgeries for different valve diseases

Answer 5

mitral stenosis/aortic stenosis - valvotomy (temporary/palliative measure in AS);
tricuspid - surgical repair, percuatneous opening with a balloon;
mitral regurgitation - surgical repair
aortic regurgitation - TAVI (transcatheter aortic valve implantation)

Question 6

mechanical vs tissue vs repair vs catheter implanted

Answer 6

mechanical - durable but anticoag needed, long term monitoring required and lifestyle changes;
tissue - last round 15-20 yrs (and less in young), can be repaired via catheter, no anticoag needed unless AF;
repair - best if can be done but a more risky surgery (only mitral can be done percutaneously), long lasting, no anticoag needed, better function;
catheter - only aortic can be percuatneous, good alternative, avoids long term anticoag

Question 7

factors influencing risk of surgery (5)

Answer 7

age; general physical state + comorbidities; existing damage to heart (esp LV); renal function; cerebral and carotid arteries (determine stroke risk)

Question 8

what are the best valves for repair

Answer 8

those with leaflet prolapse and chordal rupture (almost always mitral)

Question 9

what is infective endocarditis

Answer 9

an infection of the inner surface of the heart

Question 10

what are the 2 main organisms that can cause IE

Answer 10

staph aureus (acute, 40% mortality); S.viridans (slow process, mortality 8-10%)

Question 11

main features to look out for IE (8)

Answer 11

F -fever
R - roth spots
O - osler nodes
M - murmur
J - janeway lesions
A - anaemia
N - nail splinters
E - emboli

Question 12

what sites are most commonly involved in IE

Answer 12

prosthetic valves; previously normal valves; congenital defects

Question 13

IE investigations (5)

Answer 13

bloods (DO PRIOR TO GIVING Abx) - check cultures, FBC, low grade anemia; urine dipstick; CXR; echo; ECG (conduction abnormalities)

Question 14

what criteria is used to differentiate IE

Answer 14

duke modified criteria - 2 major (+ve blood cultures, echo showing related abnormalities) or 1 major + 3 minor (predisposing factor, vascular factors, immunological phenomena e.g. roth sports etc.)

Question 15

why is endocarditis so deadly

Answer 15

antibody-antigen complexes damages small vessels; direct damage to heart valves; vegetations may embolise + destroy structures; heart wall may erode - holes, abscesses; renal damage; mycotic aneurysms

Question 16

complications of heart surgery (IE)

Answer 16

prosthetic endocarditis - serious complication, may make valve/device detach and come loose

Question 17

ESC IE guidelines (5)

Answer 17

1. prevention (prophylaxis when undergoing high risk procedures or in high risk pts (prosthetic valve, congenital defect etc.), good dental hygiene)
2. the endocarditis team
3. diagnosis
4. treatment
5. specific situations