Valvular disease Flashcards
most common mechanism of TR.
leaflet restriction and eccentric regurgitation.
redundant tissue
annular dilatation.
leaflet restriction and eccentric regurgitation.
myxomatous degeneration
Endocarditis early surgery for:
HF
Persistent bacteremia or fevers lasting >5 days after onset of appropriate antimicrobial therapy;
Heart block, annular or aortic abscess, or destructive penetrating lesions;
Highly resistant organisms (e.g., Staphylococcus aureus, fungal, Pseudomonas aeruginosa, Brucella, enterococci, and other gram-positive cocci)
Recurrent emboli.
Severe AI.
Intervene (SAVR only) if
vena contracta >0.6 cm, RF >50%, and RVol >60 mL.
LVESD >50 mm/ LVESDi >25/ LVEF <55% or symptomatic
Mechanical mitral valve AC
Warfarin only with goal INR of 3. Can add aspirin if atrial fibrillation, previous thromboembolism, LV dysfunction, hypercoagulable state
greatest likelihood of successful mitral valve repair
localized prolapse of P2 and A2
low likelihood of successful mitral valve repair
prolapse involving three or more scallops, extensive annular/leaflet calcification, destructive lesions of the leaflets, and mitral annulus diameters >50 mm
MVP MR assessment
CMR
Acute hemorrhagic stroke
no anticoagulation at all
Marfan characteristics
mitral valve prolapse, pectus carinatum, pneumothorax, scoliosis, skin striae, severe myopia, retrognathia, malar hypoplasia, enophthalmos, aortic disease (main cause of M&M).
Decreased preload (sitting, standing)-> earlier click, louder. Increased afterload (squatting)-> later click, decreased murmur.
Louder on valsalva.
Other MR murmurs do the opposite.
Most common cause of aortic valve pathology in elderly
Degenerative (sclerocalcific) disease
PDA echo
diastolic flow reversal in the aorta
Vasodilators for AI
Asymptomatic + SBP > 140
Severe MR.
Intervene if.
Chronic primary MR meds
EROA >0.4, RF >50%, Rvol > 60 ml
Symptomatic/ LVEF ≤60% or LVESD ≥40 mm/ pulmonary hypertension/ afib.
None, can treat htn.
Provoke symptoms in valvular disease with
exercise, not dobutamine
Impact of TAVR paravalvular leak.
TAVR vs SAVR advantages
increased mortality.
lower transvalvular gradients, larger effective orifice areas, and less patient–prosthetic mismatch
diastolic decrescendo murmur along the LSB, systolic murmur at the right USB and an Austin Flint murmur (apical diastolic murmur due to the AR jet restricting opening of the anterior mitral leaflet).
AI
Severe primary MR treatment
surgical repair. If high or prohibitive surgical risk and suitable anatomy for the procedure-> mitraclip.
Severe MS
Incongruent symptoms vs echo
MVA < 1.5
Exercise echo/RHC: PA wedge pressure >25 mm Hg or mean MV gradient >15 mm Hg
prolonged AT (>100 msec)
intrinsic abnormality of valve. Degeneration is chronic, thrombus is acute
severe PPM aortic.
severe PPM mitral
indexed EOA <0.65 cm2/m2. associated with a lack of regression of LVH following valve replacement.
<.9,
capillary nail bed pulsations (known as Quincke’s sign), retinal arteriolar pulsations (Becker’s sign), water hammer pulses (Corrigan’s pulse), head bobbing (De Musset’s sign), and uvula pulsations (Muller’s sign).
AI
Duroziez sign elicited by
compressing the femoral artery with the diaphragm of the stethoscope, If severe aortic regurgitation is present, a diastolic murmur from retrograde flow will then be heard.
Surgical Bioprothestic mitral valve med
3-6 mos: warfarin, INR goal of 2.5
lifelong aspirin
TAVR AC
DAPT for 6 months
TMVR
high or prohibitive surgical risk and/or secondary MR
No benefit of mitraclip
left ventricular end-diastolic dimension (LVEDD) 75 mm, PASP >70
Pre mitral balloon valvuloplasty
Get TEE to look for LA thrombus and quantify MR
EOA prosthetic valve
elevated velocity for aortic bioprosthetic valve
LVOT area * DVI
>3 m/s
valve stenosis
DVI < 0.25
AS replacement if
severe AS in symptomatic patients, asymptomatic patients with a reduced ejection fraction (<50%), and patients requiring other cardiac surgery.
Severe secondary MR treatment
Optimize GDMT (optimize treatment of underlying LV dysfunction-cath/CRT if needed), then consider mitraclip. If anatomy is not favorable-> surgical repair
Antibiotic ppx
Prior history of endocarditis, prosthetic valves or material, congenital heart disease, transplanted heart with primary valvular disease.
Use amoxicillin or IV ampicillin
endocarditis first step
blood cultures, then antibiotics and TTE
most likely endocarditis patient to derive benefit from urgent surgery
heart failure (HF)
normal LVOT VTI
20 cm
prosthetic aortic valve high velocity (3 m/s)
start with DVI
>0.25= PPM (iEOA < 0.85), high flow state (LVOT VTI high)
<0.25= thrombus (more acute) or pannus (AT will be more than 100 for both)
>0.25 + AT > 100= subvalvular narrowing or improper measurement
most important risk factor for development of calcific aortic stenosis
age
very severe AS
peak aortic valve (AoV) velocity of 5 m/sec. Intervene regardless of symptoms
most common congenital valvular lesion
bicuspid aortic valve
endocarditis with device involvement/ presence?
extraction
Valvular afib
Warfarin, not DOAC. Same if prior embolic event/LAA thrombus.
severe TR
VC 0.7, EROA 0.4, Systolic hepatic vein flow reversal
prominent descent of the V wave, venous systolic thrill, and tender hepatomegaly
strep bovis endocarditis
also get colonoscopy, repeat in 4-6 months
pulmonary stenosis intervention
valvuloplasty first line if there’s no PR, surgical repair if needed
surgical replacement if marked valvular dysplasia or hypoplasia of the annulus
warfarin reversal
dabigatran reversal
other DOACS
prothrombin complex concentrate (PCC)
Idarucizumab
Andexanet alpha
Lambl’s excresence management
no further testing, observation
fibrosis and fusion of the mitral chordae, calcified leaflet tips.
calc of annulus and the base of the mitral leaflets.
Congenital absence of a papillary muscle.
rheumatic MS.
calcific MS.
parachute mitral valve.
TAVR preprocedural planning
Cardiac and aortic CT angiography (TEE if CT would be harmful)
invasive or CT coronary angiography, dental examination to rule out potential infection sources
most common etiology of TS [tricuspid stenosis].
severe TS.
rheumatic disease, associated with mitral disease.
mean pressure gradient >5 mm Hg, [PHT] ≥190 [msec], valve area ≤1.0 cm2 (continuity equation)
asymptomatic moderate AS/AI/MR surveillance
1-2 years
6-12 mos for severe disease
severe MS auscultation.
narrowing of the A2–opening snap interval, <80 msec.
bring out the MS rumble by having the patient perform sit-ups
Bicuspid risk of associated disease
AI is highest, then AS, then ascending aortic aneurysm, then coarctation, then dissection
end-stage renal disease on dialysis substantially increases surgical mortality risk.
prosthetic mitral valve high velocity (E velocity >2), mean gradient > 5
iEOA < 0.9= severe PPM
PHT > 200 = stenosis
most likely defect in Turner syndrome
bicuspid aortic, then coarctation
Fungal (candida, aspergillus) endocarditis
surgery
Valvular surgery follow up
TTE at 6-12 weeks
most common cause of a flail leaflet
myxomatous disease
MR poor prognosis
elevated BNP
Avoid SAVR
STS> 8%, highly calcified aorta, prior chest radiation, severe lung, liver, or renal disease.
Hill’s sign
systolic BP in the leg >40 mm Hg higher than in the arm: severe AI
Aortic root repair in bicuspids
root >5.5 cm OR
root >5 cm if additional risk factors are present (family history of dissection, growth >0.5 cm in 1 year, coarctation) OR
root >4.5 cm if performing AVR anyway.
staph UTI
think staph bacteremia despite no other signs of infection, could be subacute
