Valvular (and ischaemic) heart disease – therapy

Question 1

What are the main surgical techniques for treating ischaemic heart disease (IHD)?

Answer 1

1️⃣ Coronary artery bypass grafting (CABG)
2️⃣ Percutaneous coronary intervention (PCI, aka angioplasty + stenting)
3️⃣ Minimally invasive direct coronary artery bypass (MIDCAB)

Question 2

What are the indications for CABG over PCI?

Answer 2

🔹 Left main coronary artery disease
🔹 Three-vessel disease (especially with diabetes)
🔹 Severe proximal LAD disease
🔹 Failed PCI or in-stent restenosis
🔹 Ongoing ischaemia despite optimal medical therapy

Question 3

What are the complications of CABG surgery?

Answer 3

📌 Early complications:

Bleeding
Graft occlusion
Arrhythmias (AF most common)
Stroke
MI
📌 Late complications:

Graft failure
Sternal wound infection (esp. in diabetics)
Chronic pain (nerve injury)

Question 4

What are the surgical procedures for complications of ischaemic heart disease?

Answer 4

1️⃣ Ventricular septal rupture → Surgical closure
2️⃣ Papillary muscle rupture → Valve replacement/repair
3️⃣ Left ventricular aneurysm → Aneurysmectomy
4️⃣ Cardiogenic shock (due to LV failure) → LV assist device, transplant

Question 5

What valvular defects are amenable to surgery?

Answer 5

🔹 Aortic stenosis → Valve replacement
🔹 Aortic regurgitation → Valve replacement or repair
🔹 Mitral stenosis → Valve replacement or percutaneous mitral commissurotomy
🔹 Mitral regurgitation → Valve repair or replacement

Question 6

What are the indications for valve replacement surgery?

Answer 6

✅ Aortic stenosis:

Symptomatic severe AS
Asymptomatic severe AS with LV dysfunction
Severe AS undergoing another cardiac surgery
✅ Aortic regurgitation:

Symptomatic severe AR
Asymptomatic severe AR with LV dysfunction
✅ Mitral regurgitation:

Symptomatic severe MR
Asymptomatic severe MR with LV dysfunction
✅ Mitral stenosis:

Symptomatic MS not amenable to balloon valvuloplasty

Question 7

What are the types of prosthetic valves commonly used?

Answer 7

🔹 Mechanical valves:

Advantages: Durable (lasts 20+ years)
Disadvantages: Requires lifelong anticoagulation (warfarin)
🔹 Bioprosthetic valves (Tissue valves):

Advantages: No lifelong anticoagulation
Disadvantages: Limited durability (~10–15 years)
🔹 Transcatheter Aortic Valve Implantation (TAVI):

Used for high-risk patients with aortic stenosis

Question 8

What are the early and late outcomes of valve surgery?

Answer 8

📌 Early outcomes:

Stroke, MI, arrhythmias
Valve thrombosis
Endocarditis

📌 Late outcomes:

Structural valve deterioration (esp. bioprosthetic valves)
Paravalvular leak
Chronic warfarin anticoagulation (for mechanical valves)

Question 9

What is the medical treatment of infective endocarditis (IE)?

Answer 9

💊 Empirical IV antibiotics:

Native valve, non-IVDU: Amoxicillin + Gentamicin
IVDU / MRSA risk: Vancomycin + Gentamicin
Prosthetic valve: Vancomycin + Gentamicin + Rifampicin

💊 Duration: 4-6 weeks of IV antibiotics

Question 10

What are the indications for surgery in infective endocarditis?

Answer 10

🔹 Severe heart failure
🔹 Large vegetation (>10mm) with embolism
🔹 Uncontrolled infection (persistent fever, abscess)
🔹 Prosthetic valve endocarditis

Question 11

Mnemonic for Valve Surgery

Answer 11

📌 “SURGICAL” for Valve Replacement Indications

Symptoms (Severe AS, MR, AR, MS)
Underlying LV dysfunction
Regurgitation severe
Growth (vegetations, endocarditis)
Intervention for other cardiac surgery
Calcific degeneration
Anticoagulation considerations
Life expectancy & risk-benefit