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ACCSAP > Valves > Flashcards

Valves Flashcards

1
Q

Splitting of S2
Physiological

Parodoxical

A

during inspiration, A2 before P2, increased venous return delays P2, decreased return to the L quickens A2
during expiration, delayed closure of the aortic valve (AS, HOCM, LBBB)

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2
Q

Persistent S2 splitting

A

splitting throughout the respiratory cycle, increased during inspiration
early A2 or delayed P2 (severe MR/VSD or RBBB, pulm htn, pulmonic stenosis)

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3
Q

Fixed S2 splitting

A

always split, not increased in inspiration

delayed P2 only (increased flow across valve)- ASD

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4
Q

mitral stenosis in American elderly

A

senile calcific MS
calcification of mitral annulus and leaflets-> narrow annulus, rigid leaflets, no commissural fusion
no role for percutaneous mitral balloon or surgical commissurotomy
delay intervention until symptoms are severely limiting
treat with diuresis and HR control

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5
Q

causes of MS

A

rheumatic heart disease
senile calcific MS
congenital disease (parachute mitral valve, mitral chordae attached to a single or dominant papillary muscle-> a component of the Shone complex: supramitral rings, valvular or subvalvular AS, and aortic coarctation)
tumors, obstruction

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6
Q

treatment of acute severe MR

A

surgery
temporize with diuresis and afterload reduction (vasodilator->nitroprusside, ACEI/ARB/ARNI/nifedipine, IABP)
Do not use vasoconstrictors

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7
Q

prominent v waves

A

TR

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8
Q

brief, high-pitched sound after S2 followed by a low-pitched rumble, best heard at the apex at held expiration.

A

opening snap with MS

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9
Q

Percutaneous balloon mitral commissurotomy vs surgical

A

preferred as long as the valve is mobile, relatively thin, and free of calcium and there is no left atrial clot or more than mild mitral regurgitation (MR)
TEE before to eval MR and r/o clot
surgery if perc is CI+ low-intermediate risk for surgery+ severe MS

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10
Q

exercise testing with doppler or invasive hemodynamics in MS when

A

discrepancy between resting Doppler echocardiographic findings and clinical symptoms or signs.

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11
Q

Percutaneous mitral balloon commissurotomy indicated in

A

symptomatic severe MS or asymptomatic with pulmonary hypertension, moderate or severe stenosis and favorable valve morphology in the absence of left atrial thrombus or moderate to severe mitral regurgitation.
meds are preferred if preggo

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12
Q

high gradient+ small EOA
functional-> patient prosthesis mismatch

pathologic (thrombus/pannus)

A

prosthetic valve obstruction
indexed EOA <0.65, acceleration time < 100ms, DVI>0.25
acceleration time > 100 ms

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13
Q

flushing, diarrhea, hypervolemia, elevated 5-HIAA

carcinoid heart

A

carcinoid

TR, hepatic vein flow reversal if severe TR

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14
Q

Causes of primary TR

A

Ebstein’s (apical displacement of leaflets >8 in comparison to mitral leaflets)
endocarditis
implanted devices (eccentric, restricted septal leaflet)
carcinoid (thickened leaflets)
radiation
rheumatic heart disease

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15
Q

Systolic notching of the pulmonic valve

A

pulm htn

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16
Q

Pulmonary vein flow reversal

A

severe MR

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17
Q

severe MS

A

MVA <1.5, T1/2> 150ms

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18
Q

warfarin preg

A

if <5 mg, can continue
switch to UFH for delivery
if >5, discontinue in first trimester for any heparin

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19
Q

medical mgmt of MS

A

diuretic, beta blocker

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20
Q

apex is HYPERDYNAMIC, grade 2/6 systolic murmur and grade 2/4 diastolic murmur along the left sternal border
m-mode

A

AR

fluttering of anterior mitral leaflet, early closure of mitral valve due to increased LV pressure in diastole

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21
Q

chronic vs acute AR

A

wide pulse pressure

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22
Q

treatment of severe AR

A

surgery

DO NOT USE IABP OR BETA BLOCKERS (tachycardia is appropriate) OR phenylephrine (increases afterload)

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23
Q

valve choice in bleeders

A

bioprosthetic (reasonable in 50-70 yo) over mechanical

consider bioprosthetic in anyone at increased risk of bleeding even just from high risk activities such as motorcycling

24
Q

early surgery in IE indications

A

heart failure, perivalvular extension, and embolic events

repair preferred

25
Q

AS treatment

A

replace if severe and symptomatic / asymptomatic+severe+reduced EF/
very severe but asymptomatic/
rapid progression/
at time of other cardiac surgery

26
Q

early systolic click+ crescendo-decrescendo systolic murmur + decrescendo diastolic murmur

A

bicuspid aortic valve with AR

27
Q

high pitched sound after S1

pulmonary ejection sound

A

ejection click due to dilated aorta or pulmonary artery or bicuspid or flexible stenotic aortic or pulmonary valve
decreases with inspiration

28
Q

AS vs MR

HCM murmur

A

handgrip (increases afterload): decreases vs increases
valsalva/abrupt standing (decreases VR): increases due to decreased size of LVOT and increased gradient
squatting (increases VR)

29
Q

Periop bridging for patients with mechanical valve if

A

atrial fibrillation, mitral valve position, previous thromboembolism, hypercoagulable condition, older-generation mechanical valves [ball-cage or tilting disc], left ventricular systolic dysfunction, or >1 mechanical valve
don’t even hold if low bleeding risk- cataract surgery

30
Q

severe AR

replace

A

vena contracta > 0.6/ holodiastolic aortic flow reversal/ RVol> 60/ RF>50%/ ERO> 0.3
severe symptomatic AR or (asympt + EF <50%/ LVS diameter > 50mm/ diastolic > 65)

31
Q

TEE in IE

A

change in clinical signs or symptoms (e.g., new murmur, embolism, persistent fever, heart failure [HF], abscess, or atrioventricular heart block) and in patients at a high risk of complications (e.g., extensive infected tissue/large vegetation on initial echocardiogram or staphylococcal, enterococcal, fungal infections).

32
Q

Abnormal conduction in aortic valve IE

A

valve ring between the right and noncoronary cusp; this anatomic site overlies the intraventricular septum that contains the proximal ventricular conduction system.

33
Q

Mechanical mitral valve antithrombotic

bioprosthetic valve

A

aspirin (CI if active bleeding/intolerant) + warfarin (INR 2.5-3.5), higher if thrombotic event on AC
any mechanical valve= aspirin+ warfarin
low dose aspirin, can add warfarin in 90 days after TAVR and 180 days after surgery if not at increased risk for bleeding, can do plavix+asa for 6 months after TAVR if unable to AC

34
Q

Antibiotic prophylaxis for endocarditis prior to dental procedures that involve manipulation of the gingival tissues, the periapical region of the teeth, or perforation of oral mucosa indications

A

prosthetic material
prior history of infective endocarditis
cardiac transplant recipients with valvulopathy, completely repaired congenital heart disease (CHD) in the previous 6 months
repaired CHD with residual shunts or defects unrepaired cyanotic CHD

35
Q

Meds for IE prophylaxis
can’t take PO
allergic to -cillins

A

amoxicillin
cefazolin/ ampicillin/ ceftriaxone
cephalexin/ clinda/ azithro

36
Q

LFLG AS

management

A

due to reduced EF or low stroke volume with preserved EF

AVR if there is contractile reserve-> find out and confirm AS on dobutamine stress

37
Q

Measure of MR severity in late systolic, asymptomatic MR

Holosystolic MR

A 
Regurgitant volume (discrepancy between EROA and Rvol)
other measures such as PISA, vena contracta, jet area
38
Q

worsening AS murmur

A

the ejection sound and the intensity of A2 diminish; the murmur peaks later in systole. The AS murmur increases after a premature ventricular contraction.
AS= single S2 due to delayed closure of aortic valve, louder after PVC/brady/pause

39
Q

Dilated aortic root or ascending aorta

A

Evaluate for AR or bicuspid valve with TTE

Cath if large enough to warrant repair (>5.5)

40
Q

STS score for TAVR

A

> 8%

41
Q

Gallavardin phenomenon

vs MR

A

AS, a harsh murmur at the base with a musical murmur at the apex
vs holosystolic

42
Q

Increased pulmonary artery (PA) oxygen saturation

A

due to L-R shunt like VSD

43
Q

secondary MR

treatment

A

due to adverse LV remodeling

improve ventricular function and volume status (DO NOT REPLACE/REPAIR.)

44
Q

rheumatic heart disease secondary prevention abx

residual valvular disease

no residual disease
fever without carditis

A

oral penicillin V twice daily, monthly benzathine penicillin G intramuscular injection, or daily sulfadiazine
penicillin prophylaxis for 10 years from the last episode of acute rheumatic fever or until the age of 40
10 years or age 21 (whichever is longer)
5 years or age 21

45
Q

severe asymptomatic surveillance

A

6 months to 1 year if velocity is >4
1-2 years if velocity is 3.0-3.9 m/sec
3-5 years if velocity is 2.0-2.9 m/sec

46
Q

severe asymptomatic AS surveillance

A

6 months to 1 year if velocity is >4
1-2 years if velocity is 3.0-3.9 m/sec
3-5 years if velocity is 2.0-2.9 m/sec

47
Q

single S2

A

pulmonic stenosis, severe aortic stenosis, congenital absence of the pulmonic valve, transposition of the great arteries, or pulmonary htn

48
Q

Types of MR

A

I: normal leaflet motion (primary)
II: excessive leaflet motion (flail, prolapse, primary)
IIIa: restricted leaflet motion (MAC/ rheumatic disease, primary)
IIIb: restricted due to LV dysfunction (secondary, lateral wall hypokinesis, tethered pap muscle)

49
Q

Post valve implant care

A

TTE 6 weeks-3 months after
then annual exam
in bioprosthetics, routine TTE starting at 10 years (no routine TTE for mechanical)

50
Q

BAV and an ascending aortic aneurysm >4.5 cm surveillance

A

annual imaging

also if increase >0.5cm/year or family history of aortic dissection

51
Q

HTN in chronic AR treatment

A

dihydropyridine calcium channel blockers or ACEI/ARB

52
Q

inferior wall MI pap muscle rupture

A

posteromedial

53
Q

asymptomatic primary severe MR + (LVEF of 30-60% or LVESD of 40 mm)

A

repair

54
Q

new HF+ h/o valve replacement

A

evaluate for valve dysfunction

55
Q

BAV+ aortopathy surgery

A

> 5.5 cm, >0.5 cm/year, or family history of dissection

56
Q

asymptomatic severe AS

A

normally wouldn’t intervene BUT exercise test if not highly active. Intervene if SBP does not rise by 20 or symptoms develop

ACCSAP (11 decks)

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