Valvular Disease Flashcards
Symptomatic MS- intervene if MVA is —-
1.5 or less
If MVA is less than 1 and pt asymptomatic what to do
If valve suitable for BMV-do it . IIb:Otherwise monitor
Severe MS is
MVA 1.5 or less- ACC/AHA-2014
Moderate MS is 1.6-2 cm2
Very Severe MS is 1 cm2 or less
Stage B or Progressive MS is MVA of
More than 1.5 and pressure half time < 150
ACC/AHA classification of VALVE diseases
Stage A-at risk;
B- progressive
C-Asymptomatic
D-Symptomatic
PASP for decisions on MS
50 mm Hg
MV replacement indications in MR i.e. The definite indications
- symptoms+EF>30
- Asymptomatic and LVESD at least 40
If in symptomatic pts EF 30 or less a weak recommendation is that Mitral Valve repair can be considered
Role of Afib and PASP in deciding MV surgery
Asymptomatic Severe MR with Afib or PASP >50 can consider REPAIR if success high
Mitral valve repair best with–//
Chordal rupture repair best with
Posterior leaflet
Posterior chordal rupture
Mitral valve cusp at intervalvular fibrosa
A3 cusp
Pml forms — part of annulus
5/8
But Total area of Aml and pml are same in systole
The name of commissures come from the papillary muscles - anterolateral and posteromedial
Most commonly fused cusps in Bicuspid Aortic valve
Right and left
Difference between rheumatic and degenerative AS in Echo is
Degen-near Aortic ring. Rheumatic less involvement near the ring
Effect of ARB or Betablocker in ascending aortopathy of Bicuspid Aortic valve
No studies demonstrated benefit.2014 ACC/AHA did not recommend any pharmacologic treatment in the absence of another indication like HTN
When to do Surgery for Aorta in Bicuspid Aortic valve
- > 5.5 cm at root or Asc Aorta
2. If growth rate >.5cm/year or if surgical risk <4%ie expert centre or families history of dissection consider at 5 cm
VCW in Severe MR
0.7 cm or more
0.3cm VCW is mild or mod MR
Moderate MR
E velocity in Severe MR
More than 1.4 cm/s
E/A ratio in Severe MR
2 or more
V wave cut off sign indicates
Severe MR in CWD
Surface velocity of PISA is
Equal to the chosen Aliasing velocity
Effectiveness of PISA in quantifying MR
Moderate accuracy
EROA by PISA eqn
2#r 2 x aliasing vel. / peak MV vel
Normal pulmonary venous flow during Doppler
Antegrade in both systole and diastole with systole dominant
With slight retrograde flow during atrial syst
In Severe MR-Systolic flow reversal
The mean gradient in MS is above
10 mm Hg
Oral penicillin prophylaxis for RHD
Penicillin V 250 mg BD
If allergic..Azithromycin 250 mg OD
In the absence of MS E velocity more than—— suggests Severe MR
More than 1.5 m/s
BMV during pregnancy is done at
AFTER 20 wks of gestation
How to get EROA by PISA
Measure PISA radius
Measure MR VTI
Machine will give you EROA and Regurgitant volume
To calculate RFraction –divide RV by RV + Aortic VTI
VCW in Severe AR
MORE than 6 mm
How to measure mitral Antero- Postr diameter
In PLAX view
Mitral annular dilatation Echo criteria
Mitral AP diameter/ Length of Anterior leaflet in diastole More than 1.3 or When diameter is more than 35
The normal decrease in Mitral annular area in systole is
25%
Acute rheumatic fever occurs —wks after GAS infection
2-4 wks
Clinical features of ARF( rheumatic fever)
ACCESS- Arthritis, Carditis, Chorea, Erythema marginatum, Subcutaneous nodules
Most common manifestation of ARF
Carditis -50-70%
Then Arthritis
Penicillin used for ARF prophylaxis
Penicillin G Benzathine
ORAL is Penicillin V 250 BD or Azithromycin 250 OD
Aortic finding in AR
proximal ABDOMINAL Aorta shows holodiastolic flow reversal in Severe AR
Role of M Mode in MVP diagnosis
No role
Indications for surgery in Severe AR
- Symptoms
- EF< 50%
- ESD >50mm
- EDD> 65 mm of low risk.
All are independent. Uptodate 2018
Mild Aortic stenosis
ASE 2017 Guidelines-2.5 or less is Aortic sclerosis
2.6 is mild Aortic stenosis
3m/s is Moderate or mean of 20 -40 is Moderate
41 Mean is Severe
Key parameter to diagnose low gradient normal EF Aortic stenosis
Stroke volume index < 35ml/m2
For low gradient low EF - do DSE
Life span of metallic prosthetic valve
20-30 yrs
TTK chitra is a
Tilting disc valve
Acute Rheumatic fever major criteria in order of frequency
CACSE
Carditis, Arthritis, Chorea, Subcutaneous nodules, Erythema marginatum
Doppler findings in Rheumatic Valvulitis
MR-2 views, 2 cm in length,peak velocity 3m/s And Pansystolic jet ( All 4 required)
AR- same as above but 1 cm length and pan diastolic
The Arthritis of ARF lasts for around…..with or without therapy
4 weeks
How long you will need NSAIDs for Arthritis treatment
1-2 weeks usually. Sometimes upto 8 weeks
CRP And ESR monitoring in ARF treatment
CRP twice weekly then every one to two weeks till normal
ESR may stay elevated for upto 2 months after a transient inflammatory stimulus. CRP normalizes over matter of days once inflammation subsided
Uptodate 2017
No of randomized trials done for TAVR vs surgery b/w 2012 and 2017
5
Aortic valve velocity in mild AS
ASE 2017 Guidelines-2.5 or less is Aortic sclerosis
2.6 is mild Aortic stenosis
ESC 2017 recommendation on TAVI - broadly speaking
TAVI for high risk
SAVR for low risk esp younger pts Intermediate risk- bla bla
Mean age of TAVI trials as of 2017
80 yrs
Can we apply this data to those below 70?
——-&——-are more in TAVI than SAVR
Paravalvular leak and need of PPI
ESC position on NOAC in MR and Aortic Valve disease
Can give
But contraindicated in MS and Mechanical valves
Penicillin used for RHD prophylaxis
Penicillin V 250 mg BD
All severe regurgitations have ……..shape in CW
Triangular with early peak .
Otherwise it’s meso(mid)systolic peak . May not be always. But triangular means severe
From Internet
Acute Rheumatic Arthritis may need treatment upto ….
8 weeks
Most will respond in 1-2 weeks. Then you can try reducing
In acute Rheumatic fever If response to Aspirin doesn’t occur in ….. hrs suspect the diagnosis
24-36 hours ( Chorea doesn’t respond)
Number of RCTs between 2012 and 2017 on TAVR
5 studies
Why TAVI not preferred in younger patients
- No long term data on durability of TAVI valves
- Trials were on pts with mean age of 80
- Paravalvular leak and need of PPI higher with TAVI.
ESC 2017
NOAC in valvular heart disease
Aortic valve disease and Mitral regurgitation -suffficient data to use.
ESC 2017
Not in significant MS
Most important risk factor for death and disability after successful correction of valvular lesion
Residual Pulmonary Hypertension
Which study showed Sildenafil is not effective in residual PAH in Valvular lesions
2017 SIOVAC trial
30 day all cause mortality after TAVI
Also 1 yr mortality rate
1 year- around 20%
30 day around 10%
Aortic sclerosis definition
Velocity < 2m/s with thickened Aortic Valve
Uptodate -seems to be wrong
ASE 2017 Guidelines-2.5 or less is Aortic sclerosis
2.6 is mild Aortic stenosis
Best view for VCW of mitral valve
PLAX
JACC article 2012
