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Valvular Disease Flashcards

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USMLE® Step 1 flashcards
1
Q

What are the indications for PMBC?

A
  • Progressive MS (MVA > 1.5 cm2, T1/2 < 150 ms)
    • PMBC at CVC (Class IIb)
      • Exertional symptoms →
      • Stress test with hemodynamically significant MS →
      • Pliable valve, no clot, < 2+ MR →
  • Severe MS (MVA « 1.5 cm2, T1/2 « 150 ms)
    • PMBC at CVC (Class I)
      • Symptomatic +
      • Pliable valve, no clot, < 2+ MR
    • PMBC at CVC (Class IIb)
      • Symptomatic +
      • Pliable valve, no clot, < 2+ MR (does not meet) +
      • Severe symptoms, NYHA III-IV
      • NOT Surgical candidate
    • PMBC at CVC (Class IIa)
      • Asymptomatic
      • Pliable valve, no clot, > 2+ MR​
      • PASP > 50 mmHg
    • PMBC at CVC (Class IIb)
      • Asymptomatic
      • Pliable valve, no clot, > 2+ MR
      • New onset A-fib
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2
Q

What are the indications for MVR in MS?

A
  • Severe MS (MVA « 1.5 cm2 and T 1/2 ► 150 ms)
    • Symptomatic –>
    • No Favorable valve morphology, No LAA clot, < Mild MR
    • Severe symptoms - NYHA Class III-IV symptoms
    • Surgical candidate

***Class I recommendation

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3
Q

What are the contraindications to PMBV?

A
  • Persistent LA or LAA thrombus
  • Obstruction of IVC
    • tumor, thrombus, therapeutic ligation, filter placement
  • Bleeding diatheses
  • Anatomic deformity resulting in rotation of the heart
    • severe kyphoscoliosis
    • previous pneumonectomy
  • > Moderate MR
  • Massive or bicommisural calcification
  • Severe concomitant aortic valve disease
  • Severe TS
  • Severe functional TR with enlarged annulus
  • Severe concomitant CAD requiring CABG
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4
Q

What is the recommended duration of Rheumatic Fever Prophylaxis?

  • Rheumatic fever with carditis
  • Residual heart disease (persistent valvular disease)
A

10 years

or

Until 40 years of age

  • whichever is longer
  • sometimes lifelong prophylaxis
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5
Q

What is the recommended duration of Rheumatic Fever Prophylaxis?

  • Rheumatic fever with carditis
  • No residual heart disease
A

10 years

or

until 21 years of age

  • whichever is longer
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6
Q

What is the recommended duration of Rheumatic Fever Prophylaxis?

  • Rheumatic fever without carditis
A

5 years

or

until 21 years of age

  • whichever is longer
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7
Q

What are the medical treatment options for rheumatic fever prophylaxis?

A
  • Benzathine PCN G
  • PCN VK
  • Sulfadizine
  • Macrolide or Azalide
    • only if allergic to PCN and Sulfadiazine
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8
Q

What is the medical therapy for chronic, primary MR?

A

no pharmacologic agent has been shown to slow progression toward surgical intervention

  • ACE/ARBs –> decreased Regurgitant volume but no difference in clinical event rates
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9
Q

Why is MV repair recommended over MVR in primary MR?

A
  • preservation of LV function
  • lower operative mortality rate
  • lower rate of long term complications associated with prosthetic valves
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10
Q

What subgroups of patients with primary MR have been found to have higher event rates or clinical deterioration?

A
  • EROA ► 0.40 cm2 or
  • Flail leaflets
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11
Q

What is the recommended medical therapy?

  • chronic, primary MR
  • LVEF < 60%
  • surgery is not planned
A
  • ACE/ARBs
  • Vasodilator agents

****Class IIa recommendation

*****not indicated for normotensive, asymptomatic, LVEF ► 60%

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12
Q

Describe the management of chronic, severe MR

  • Primary, Severe MR
  • Asymptomatic
A
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13
Q

Describe the management of chronic, severe MR

  • Primary, Severe MR
  • Symptomatic
A
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14
Q

Describe the management of chronic, severe MR

  • Primary, Severe MR
  • Asymptomatic
A
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15
Q

What factors are required to proceed with TEER in primary severe MR?

A
  • High or prohibitive surgical risk
  • Anatomy favorable for transcatheter approach
  • Life expectancy > 1 year
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16
Q

Describe the management of severe secondary MR

A
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17
Q

Describe the management of chronic, severe MR prior to proceeding with any surgical/procedural intervention

A
  • Treat comorbidities:
    • CAD Rx
    • HF Rx
    • AFib Rx
    • Consider CRT
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18
Q

What is the treatment for acute, severe MR?

A
  • Afterload reduction (may improve hemodynamic status by)
    • reducing RV
    • increasing LV forward SV
    • increasing CO
  • Sodium nitrorpusside
  • Hypotension –> IABP
  • Emergent Surgery = definitive therapy
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19
Q

What is the preferred treatment for chronic, secondary MR prior to surgical intervention?

A
  • Medical therapy
    • ACE, BB, Aldosterone antagonists –> treat LV systolic dyfunction and/or CAD
    • reduces preload, afterload and reduces adverse LV remodeling –> secondary MR
  • CRT
    • to improve severe LV dysfunction with mechanical dyssynchrony
    • may reduce MR severity
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20
Q

When is transcatheter (edge-to-edge) MV repair considered in chronic, severe, secondary MR?

A
  • LV dysfunction (LVEF < 50%)
  • NYHA class III-IV symptoms
    • despite optimal therapy for CHF
    • including Bi-V pacing
  • Anatomy (favorable)
    • LVEF 20-50%
    • LVESD < 70 mm
    • PASP < 70 mm

****Class IIa

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21
Q

EKG definition:

  • Pacemaker malfunction, not constantly capturing (atrium or ventricle) “failure to capture”
A
  • Pacemaker stimulus without appropriate depolarization
    • at a time when the myocardium refractory
  • May be caused by:
    • lead fracture
    • increased pacing threshold secondary to myocardial scar
    • medications (flecainide, amiodarone)
    • perforation
    • electrolyte abnormalities
    • displacement
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22
Q

What are causes of “failure to capture” in pacemaker malfunction?

A
  • lead fracture
  • increased pacing threshold secondary to myocardial scar
  • medications (flecainide, amiodarone)
  • perforation
  • electrolyte abnormalities
  • displacement
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23
Q

What are the age cutoff’s for mechanical over bioprosthetic valve replacement?

A
  • Aortic
    • < 50 years –> mechanical
    • 50-65 years –> either
    • > 65 years –> bioprosthetic
  • Mitral
    • < 65 years –> mechanical
    • > 65 years –> bioprosthetic
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24
Q

What are risk factors for poor outcomes in severe AR?

A
  • Symptoms
  • Increased LVEDD
    • > 65 mm
  • Increased LVESD
    • > 50 mm
  • Reduced exercise EF
    • < 50%
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25
Q

What test should be ordered in a patient with incidental finding of dilated aortic root (4.2 cm)?

Why?

A
  • TTE
  • Bicuspid aortic valve
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26
Q

Describe the risk categories in selection of TAVR vs. SAVR

A
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27
Q

What mechanical prosthetic valves require bridging anticoagulation?

A
  • Bileaflet aortic valve with increased thromboembolic risk factors
  • Caged ball or tilting disc prosthesis
  • Mitral valve prosthesis
  • Recent CVA/TIA
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28
Q

What mechanical prosthetic valves do not require bridging anticoagulation?

A

Bileaflet AV without other risk factors of thromboembolism

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29
Q

What are risk factors for thromboembolism in the setting a mechanical valve?

A
  • Hypercoaguable condition
  • A-Fib
  • LV dysfunction
  • Thromboembolism (previous)
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30
Q

When is a target INR 3.0 (2.5-3.5) recommended in regards to mechanical prosthesis?

A
  • Mechanical AVR + risk factors for TE
  • Older generation mechanical AVR
    • ball in cage
  • Mechanical MVR
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31
Q

What are the INR recommendations for On-X valve in the aortic position?

A

VKA + ASA

  • First 3 months –> INR 2.5
  • > 3 months –> INR 2.0
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32
Q

What are the recommended anticoagulation strategies in pregnancy and prosthetic valves?

A
  • Continued VKA
  • 1st Trimester UFH or LMWH –> VKA (sequential therapy)
  • UFH/LMWH (entire pregnancy)

*******UFH prior to delivery

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33
Q

What is the first step in assessment of prosthetic valve (AV or MV) with high gradients after surgery?

A

Calculate Indexed EOA

  • Indicate Patient-Prosthesis mismatch:
    • Aortic = EOA < 0.85 cm2 / m<strong>2</strong> (severe = < 0.65 )​
    • Mitral = EOA < 1.2 cm2 / m2 (severe = < 0.9 )
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34
Q

What is the second step in assessment of prosthetic valve (AV or MV) with high gradients after surgery?

A

TTE, TEE, Cinefluor –> to identify

  • Gradient increased during follow-up
    • Aortic > 10 mmHg
    • Mitral > 5 mmHg
  • abnormal leaflet morphology / mobility
  • DVI:
    • Aortic < 0.30
    • Mitral > 2.2
  • Difference between measured EOA and reference EOA > 0.30 - 0.4 cm2
  • EOA and DVI decreased during follow up

YES –> consider prosthesis stenosis

NO –> consider

  • High flow state
  • Technical error
  • Localized high gradient (bileaflet valve)
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35
Q

Describe the risk/benefits in anticoagulation strategies used in pregnancy with prosthetic valves?

A
  • VKA
    • Lowest likelihood of maternal complications
    • Highest likelihood of fetal complications (1st trimester (particularly) + dose > 5 mg) –>
      • miscarriage
      • fetal death
      • congenital abnormalities
    • Reduced dose < 5mg/day –> decreased (not eliminated) fetal complications
    • Reduced thromboembolic complications (compared to UFH/LMWH)
  • UFH/LMWH
    • increased maternal complications
    • greatest number of successful live births
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36
Q

What are the anticoagulation recommendations following bioprosthetic valve placement?

A
  • ASA daily
    • indefinitely if no contraindication
  • SAVR
    • VKA –> 3-6 months (Class IIb)
  • TAVR
    • VKA –> 3 months (Class IIb) or
    • DAPT –> 3-6 months (Class IIb)
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37
Q

What is the recommended anticoagulation strategy in patients receiving TAVR who are unable to be anticoagulated?

A

DAPT x 6 months

  • dc Clopidogrel after 6 months and continue ASA indefinitely
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38
Q

What is the recommendation regarding ASA in patients with valve replacement?

A

ASA daily (indefinitely) + VKA

  • decreases incidence of:
    • major embolism or death (1.9% vs. 8.5% per year; p < 0.001)
    • stroke rate (1.3% vs. 4.2% per year)
    • overall mortality (2.8% vs. 7.4% per year)
  • Increased bleeding (not statistically significant)
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39
Q

What findings on exercise stress testing, in a patient with asymptomatic, severe AS, would merit intervention?

A

Symptoms

or

Inability to augment BP by 20mmHg

or

Decrease in BP at peak exercise

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40
Q

What murmur is related to the Gallavardian phenomenon?

Describe the murmur

A
  • AS (degenerative or age-related)
  • harsh murmur at the base + musical murmur at the apex
    • due to the high-frequency components of the AS murmur radiating to the LV apex
    • often confused with MR
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41
Q

How can these murmurs be differentiated?

  • AS (age-related or degenerative)
  • MR
A
  • AS (age-related or degenerative)
    • ​Systolic ejection murmur​
      • harsh at base
      • musical at apex
    • increases with bradycardia or after a pause (PVC)
  • MR
    • holosystolic
    • not affected by HR, PVC
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42
Q

Describe the valvular lesion associated with these hemodynamic findings

  • Large LV to aorta pressure gradient
A

AS

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43
Q

Calculate posthetic valve EOA

A

CSA LVOT x VTI LVOT

VTI jet

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44
Q

Describe the valvular lesion associated with these hemodynamic findings

  • large V wave on PCWP
A

MR

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45
Q

Describe the valvular lesion associated with these hemodynamic findings

  • large V wave on the RA
A

TR

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46
Q

Describe the valvular lesion associated with these hemodynamic findings

  • increased PA O2 saturation
A

Left-to-right shunt / VSD

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47
Q

Describe the valvular lesion associated with these hemodynamic findings

  • large RVOT to PA pressure gradient
A

PS

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48
Q

Describe the effects on cardiac auscultation and murmur as AS worsens

A
  • diminished ejection sound/intensity of A2
  • murmur peaks later in systole

*****PVC –> murmur increases

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49
Q

What can cause the murmur of AS to intensify or worsen?

A

PVC

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50
Q

Describe key differences between the murmurs:

  • Acute AR
  • Chronic AR
A
  • Acute AR
    • diastolic murmur may be short
    • mitral valve might close prematurely (S1 softens) and
    • mid-diastolic rumble of relative mitral stenosis (Austin-Flint murmur) may occur
  • Chronic AR
    • holodiastolic murmur
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51
Q

Describe the effects of cardiac auscultation/murmur with worsening MS

A
  • A2-opening snap interval in MS shortens –>
  • as LA pressure rises and
  • approaches that of the aortic early diastolic pressure
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52
Q

What is one finding of bicuspid aortic valve fusion that carries prognostic implications?

A

Right-Noncoronary cusp fusion –> higher incidence of aortic dilation

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53
Q

What is the monitoring recommendation for BAV?

A

Annually (if)

  • significant aortic dilatation > 4.5 cm
  • rapid rate of change in aortic diameter > 0.5 cm/year
  • FH of aortic dissection
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54
Q

What is the cutoff for aortic imaging with Echo?

A

visualization of the aorta up to 4 cm distal to the valve

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55
Q

What are the indications for surgical intervention in regards to aortic abnormalities in BAV?

A
  • Class I
    • aortic diameter > 5.5 cm
  • Class IIa
    • ​aortic diameter 5.1 - 5.5 cm + rapid growth ( > 0.5 cm/year) or FH aortic dissection
    • aortic diameter 4.5 cm + valve surgery (severe AS or AR)
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56
Q

What is recommendation regarding Warfarin use throughout pregnancy?

A

Continued throughout pregnancy if dose « 5 mg/day

  • embryopathy from warfarin appears to be dose dependent
  • switch to UFH just prior to delivery
  • Class IIa recommendation
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57
Q

What equation can be used to obtain MVA during cardiac catheterization?

A
  • Hakki equation
    • MVA = CO (L/min) / √mean pressure gradient (mm Hg)
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58
Q

What are common errors / problems when obtaining MVA during cardiac catheterizaton (Hakki equation)?

A
  • subject to errors in estimation of CO
  • failure to simultaneously measure left atrial (LA) and LV pressure
  • Concomitant regurgitation
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59
Q

What is the problem when utilizing PCWP in place of LA pressure to determine MVA during cardiac catheterization (Hakki equation)?

A

measurement of PCWP in place of LA pressure may

  • overestimate gradient and
  • underestimate MVA
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60
Q

Define patient prosthesis mismatch (PPM)

A

effective orifice area (EOA) of a prosthesis is too small

relative to the patients body size –>

resulting in abnormally high postoperative gradients

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61
Q

What are two situations in which bioprosthetic valves are utilized over mechanical valves?

A
  • Pregnancy (anticipating)
  • History of IVDA
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62
Q

What are 3 priniciples that must be understood by both sonographer and interpreting echocardiographer in the assessment of prosthetic vavles?

A
  • All prosthetic valves have some inherent obstruction (which varies based on valve type and size), which can make differentiating between normal and pathologic gradients challenging.
  • Prosthetic valves have inherent transprosthetic regurgitation that must not be confused with pathologic regurgitation.
  • Acoustic shadowing and other artifacts such as reverberations can make evaluation of the structure of the valve and presence/degree of regurgitation difficult
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63
Q

What is the EOA (indexed) cutoff in regards to PPM for a prosthesis in the aortic position?

A

EOA indexed ≤ 0.85 cm2 / m2

  • smaller areas –> rapid increase in transvalvular gradients
64
Q

What is the EOA (indexed) cutoff for severe PPM for a prosthesis in the aortic position?

A

EOA indexed ≤ 0.65 cm2 / m2

65
Q

What are the major adverse outcomes associated with PPM?

A

short-term and long-term survival

  • particularly if associated with LV dysfunction
66
Q

What peak velocity should prompt further evaluation in assessment of aortic prosthetic valves?

A

> 3 m/s

67
Q

What is the severity scale for aortic prosthetic valves?

  • Peak velocity
A
  • Normal < 3 m/s
  • Possible stenosis 3-4 m/s
  • Significant stenosis > 4 m/s
68
Q

Assessment of peak and mean gradients across the mitral/tricuspid valve prostheses are greatly dependent upon this?

A

Heart rate

  • gradients across mitral and tricuspid prostheses are very HR dependent
69
Q

What is the severity scale for mitral prosthetic valves?

  • Peak velocity
A
  • Normal < 1.9 m/s
  • Possible stenosis 1.9-2.5 m/s
  • Significant stenosis > 2.5 m/s
70
Q

What is the severity scale for mitral prosthetic valves?

  • Mean gradient
A
  • Normal ≤ 5 mmHg
  • Possible stenosis 6-10 mmHg
  • Significant stenosis > 10 mmHg
71
Q

What is the severity scale for aortic prosthetic valves?

  • Mean gradient
A
  • Normal < 20 mmHg
  • Possible stenosis 20-35 mmHg
  • Significant stenosis > 35 mmHg
72
Q

What is the severity scale for aortic prosthetic valves?

  • DVI
A
  • Normal ≥ 0.30
  • Possible stenosis 0.29 - 0.25
  • Significant stenosis ≤ 0.25
73
Q

What is the severity scale for mitral prosthetic valves?

  • VTIPrMV / VTILVOT
A
  • Normal < 2.2
  • Possible stenosis 2.2 - 2.5
  • Significant stenosis > 2.5
74
Q

What is the severity scale for mitral prosthetic valves?

  • EOA
A
  • Normal ≥ 2cm2
  • Possible stenosis 1-2 cm2
  • Significant stenosis < 1 cm2
75
Q

What is the severity scale for aortic prosthetic valves?

  • EOA
A
  • Normal > 1.2 cm2
  • Possible stenosis 1.2 - 0.8 cm2
  • Significant stenosis < 0.8 cm2
76
Q

What is the severity scale for mitral prosthetic valves?

  • PHT
A
  • Normal < 130 ms
  • Possible stenosis 130 - 200 ms
  • Significant stenosis > 200 ms
77
Q

What is the severity scale for aortic prosthetic valves?

  • Acceleration time (AT)
A
  • Normal < 80 ms
  • Possible stenosis 80 - 100 ms
  • Significant stenosis > 100 ms
78
Q

What are findings suggestive of prosthetic TS?

A
  • PV ≥ 1.7 m/s
  • MG ≥ 6 mmHg
  • PHT ≥ 230 ms
79
Q

What is the severity scale for aortic prosthetic valves?

  • jet velocity contour
A
  • Normal - triangular, early peaking
  • Possible stenosis - triangular to indeterminate
  • Significant stenosis - rounded, symmetrical contour
80
Q

What do microcavitations (in harmonic imaging) indicate in prosthetic valve assessment?

A

normal prosthetic valve

81
Q

What prosthetic valves demonstrate the greatest degree of pressure recovery?

A

Bileaflet (small)

and

Ball and cage

82
Q

Define Ejection clicks

A
  • high-pitched sounds that occur at the moment of maximal opening of the aortic or pulmonary valves
  • heard just after the first heart sound
  • sounds occur in the presence of:
    • a dilated aorta or pulmonary artery of in the presence of
    • a bicuspid or flexible stenotic aortic or pulmonary valve
83
Q

What are the recommendations in regards to PHT in assessment of prosthetic valves?

A

Should not be used / Inaccurate

84
Q

In which mitral valve prosthesis is the largest degree of physiologic regurgitation seen?

A

Bileaflet valves

  • central and peripheral jets
85
Q

Describe EKG findings in hyperkalemia (K 6.5 - 7.5)

A
  • 1st degree AV block
  • flattening and widening of the P wave
  • ST-depression
  • QRS widening
86
Q

What is recommended whenever paravalvular regurgitation is suspected?

A

TEE

  • essential to the evaluation of paravavular regurgitation
87
Q

What are mimickers of constriction?

A
  • Restrictive cardiomyopathy
  • Severe TR
  • Ventricular interdependence (other causes)
88
Q

Describe the algorithm in evaluating aortic prosthesis with PV > 3 m/s

A
89
Q

Describe the timing of heart sounds

A
90
Q

In which mitral valve prosthesis is a large central jet most consistent with normal valve function?

A

Medtronic-Hall single disc valve

91
Q

What is the diagnosis and next best step?

  • 52 year old man with prior Type A aortic dissection s/p mAVR and root repair presents with 1 week of progressive dyspnea and orthopnea
  • HR 92 bpm, BP 148/92, RR 22, O2 90% on RA
  • PE: elevated JVP, rales and scattered wheezing, distant heart sounds, 1+ LE edema
  • EKG: NSR with lateral ST depressions
  • Labs: Cr 1.2, INR 2.2, BNP 1200, Troponin 0.40
  • TTE: Normal LVEF with poor windows
  • CXR: bilateral, patchy infiltrates
A
  • TEE
    • ​TTE (class I) indication –> TEE utilized due to poor windows
    • TEE more sensitive for the detection of valve dysfunction and thrombosis
    • CCTA (Class IIa) can also be utilized
  • Valve thrombosis
    • ​suspect in patients with interrupted anticoagulation or subtherapeutic INR
92
Q

What is the most helpful distinguishing feature of a pulmonary ejection sound?

A

Inspiration –> decreased intensity / dissappearnce

  • inspiration –> increased venous return –> partial opening of the pulmonary valve prior to systole –> lack of a sharp opening movement of the pulmonary valve
  • maximal intensity of the ejection sound
    • expiration –> valve opens rapidly from its fully closed position –> sudden “halting” of this rapid opening –> maximal intensity of ejection sound
      *
93
Q

What are four criteria used to identify constrictive pericarditis?

A
  • Ventricular inderdependence (septal motion abnormality)
  • Mitral inflow velocity ≥ Grade 2
  • Mitral annulus medial e’ ≥ 8 cm/s
  • Hepatic vein diastolic expiratory flow reversal
94
Q

Why is severe AS associated with a single S2 heart sound?

A

A2 component of the second heart sound (due to AV closure) is delayed –>

occurs simultaneously with the pulmonic component (P2)

95
Q

When does S2 become paradoxically split in AS?

A

severe AS + LV dysfunction

96
Q

Describe the frequency of monitoring in AR

A
  • Progressive (stage B)
    • Mild –> every 3-5 years
    • Moderate –> every 1-2 years
  • Severe (stage C)
    • Severe –> every 6-12 months
    • Dilating LV –> more frequently
97
Q

Describe the frequency of monitoring in MS

A
  • Progressive (stage B)
    • MVA > 1.5 cm2 –> every 3-5 years
  • Severe (stage C)
    • MVA 1 - 1.5 cm2 –> every 1-2 years
  • Very severe
    • MVA < 1.0 cm2 –> every 1 year
98
Q

Describe the frequency of monitoring in MR

A
  • Progressive (stage B)
    • Mild –> every 3-5 years
    • Moderate –> every 1-2 years
  • Severe (stage C)
    • Severe –> every 6-12 months
    • Dilating LV –> more frequently
99
Q

Describe the findings

A

Parachute mitral valve

  • mitral valve attached to a single papillary muscle with
  • redundant leaflet tissue
100
Q

Describe the findings

A

Severe AR on M-Mode –> early surgical intervention

  • rapidly rising LV diastolic pressure –>
    • premature closure of the mitral valve
    • soft S1 heart sound
101
Q

Describe the valvular abnormality:

  • Prominent carotid pulsations
  • apical impulse is slightly enlarged and laterally displaced to the anterior axillary line
  • S1, S2 are normal
  • S3 present
  • early systolic click that does not change with inspiration
  • left sternal border
    • soft (grade 2/6) crescendo-decrescendo systolic murmur
    • soft (grade 2/4) decrescendo diastolic murmur
A

Bicuspid aortic valve with regurgitation

  • sudden cessation of valve opening –> ejection click
  • findings of AR / volume overload
    • enlarged and laterally displaced apical impulse
    • wide aortic pulse pressure
    • S3 gallop
102
Q

What test should be performed prior to AVR in S. Bovis endocarditis?

Why?

A
  • Colonoscopy
  • Colon cancer screening
103
Q

What is the next best step?

  • 30 year old female with progressive SOB worsening over 2 years
  • PE: opening snap with low-frequency murmur
  • Echo:
    • thickening of mitral valve leaflets with doming
    • MG 5 mmHg (HR 60 bpm)
A

Exercise Stress Echo

  • helpful when discrepancy between:
    • symptoms
    • Doppler echo findings
  • Positive test findings: increased
    • MG
    • PASP
104
Q

What is the next best step?

  • Aysmptomatic, BAV s/p repair 20 years ago
  • Echo:
    • LVEF 57%
    • LVEDD 6.5 cm
    • LVESD 4.2 cm
    • Severe AR (RV 70 mL, RF 60%, AR diameter 4.2 cm)
A

Serial monitoring - TTE in 6-12 months

  • Asymptomatic, severe AR –> surgery only if:
    • LVEF < 50% (class I)
    • Other cardiac surgery (class I)
    • LVESD > 50 mm (class IIa)
    • Progressive decline on 3 consecutive studies:
      • LVEF < 55-60% or
      • LVEDD > 65 mm
        • low surgical risk (class IIb)
105
Q

What accounts for the majority of cases of severe TR?

A

80% are functional (secondary) due to RV remodeling

  • Result of pressure and/or volume overload –>
    • leaflet tethering
    • annular dilation
106
Q

Describe EKG findings in hyperkalemia (K 5.5 - 6.5)

A
  • Tall, peaked, narrow-based T waves
  • QT interval shortening
  • Reversible LAFB or LPFB
107
Q

What are findings consistent with severe TR secondary to Carcinoid syndrome?

A
  • 5-HIAA –> unique characteristic findings of the RV
    • short, thick, retracted leaflets (posterior and septal) with systolic and diastolic restriction
108
Q

What are common causes of TR

A

80% are secondary (functional)

109
Q

What leads to increased S1?

A
  • maximal opening of the MV and TV leaflets at the onset of ventricular systole
  • Loud closure sound requires a mobile valve and at least moderate excursion
110
Q

What are causes of increased S1?

A
  • MS
  • MVP
  • Short cycles in A-Fib
  • Short PR interval
  • Rapid HR (anemia, thyrotoxicosis)
111
Q

What is the only right-sided ausculatory event that diminishes with inspiration?

A

Pulmonary ejection click - associated with PS

112
Q

What is the “sail sound?”

When is it seen?

A
  • midsystolic click in Ebstein’s anomaly
  • sound emanating from the broad anterior TV leaflet
113
Q

Describe EKG findings in hyperkalemia (K > 7.5 )

A
  • Dissappearance of P-waves
  • LBBB, RBBB, or markedly widened and diffuse IVCD resembling a sine wave pattern
  • Arrhytyhmias and conduction disturbances
    • VT, VF, Idioventricular rhythm, Asystole
114
Q

What leads to decreased S1?

A

reduced mobility of the MV or TV

or

early partial closure

115
Q

What are causes of decreased S1?

A
  • worsening MS
  • Acute AR with preclosure of the MV
  • Long P-R interval
  • LBBB
  • Body habitus issues (obesity, large breasts)
116
Q

What leads to early systolic sounds?

A
  • generally from the semilunar valves (aortic or pulmonary)
  • due to sudden abrupt cessation of a doming valve
117
Q

What are causes of early systolic sounds?

A
  • BAV
  • PS
  • Dilated aorta
  • Abnormal (or stiff) AV from systemic hypertension
  • Abnormal (or stiff) PV from pulmonary hypertension
118
Q

What causes mid-late systolic sounds?

A
  • emanate from the MV (most commonly) or TV
  • clicks coincide with the maximal MV excursion into the LA
  • thought to be due to abrupt tensing of the redundant leaflets or chordae
  • at times, multiple clicks are audible
119
Q

What are causes of mid-late systolic sounds?

A
  • MVP
  • Ebstein’s anomaly
  • Pericardial rub
120
Q

What is the indication and recommendation for PMBV in pregnant patients?

A
  • Severe MS (MVA < 1.5 cm2, PHT > 150 ms)
  • favorable valve morphology
  • NYHA Class III or IV HF symptoms + despite medical therapy
  • PMBV - (Class IIa) if:
    • < Mild MR
    • Favorable Wilkins score « 8
121
Q

Describe the findings:

A

A. - A4C vies

B. - Color-flow display

C. - Measure of PISA

D. - CW doppler of TR jet allowing calculation of EROA and RVol

122
Q

Describe the findings:

A

Hepatic vein flow reversal in Severe TR

  • A and B
    • Color Doppler demonstrating systolic flow reversal into the vena cava ad hepatic vein
  • C
    • spectral doppler recording from the hepatic vein
    • also showing the systolic retrograde flow
123
Q

Describe the findings

A

Diastolic gradient RA-RV should be noticed (associated TR)

and

absence of A wave due to A-fib

124
Q

When is the Dobutamine infusion stopped in LF-LG, reduced EF, AS evaluation?

A
  • Maximum dose of Dobutamine reached
  • Positive result obtained
  • HR rises 10-20 bpm over baseline or exceeds 110 bpm
  • Symptoms, BP drop or concerning arrhythmias
125
Q

Describe the mumur:

  • Heart murmur since childhood
  • Normal JVP and contour
  • high-pitched sound just after S1, followed by a murmur
  • auscultation along left sternal border
A

Pulmonary stenosis

  • Right-sided ejection click and ejection murmur
126
Q

What are considered positive results for Dobutamine stress echo in LF-LG, reduced EF, AS evaluation?

A
  • Pseudostenosis
    • Increase in effective AVA > 1.0 cm2
  • True stenosis
    • PV > 4.0 m/s or MG > 40 mmHg +
    • AVA < 1.0 cm2 (at any flow rate)
  • Absence of contractile reserve
    • failure to exceed stroke volume by > 20%
    • predicts poor surgical outcomes
127
Q

What are causes of a single S2?

A
  • Congenital absence of the pulmonic valve
  • Transposition of the great vessels
  • Inaccurate auscultation
    • body habitus, emphysema, pericardial effusion
  • Pulmonary HTN
  • PS
  • Severe AS
128
Q

When should TTE monitoring be performed following valve implantation?

Why?

A
  • 6 weeks - 3 months
  • establish baseline for comparison should complications or deterioration occur later
129
Q

What is the only right-sided ausculatory event that diminishes with inspiration?

A

Pulmonary stenosis

130
Q

What is the recommendation regarding perioperative anticoagulation management?

  • mechanical (bileaflet) AVR
  • no TE risk factors
  • Surgery: nephrectomy
A
  • discontinue VKA 3-4 days prior to surgery
  • continue ASA 81mg daily
131
Q

What is the differential?

  • paced P-wave is not followed by either a paced or native QRS complex
  • Dual-chamber PPM programmed to DDD mode
A
  • failure of ventricular output
    • sensing is appropriate but the pacemaker is not able to deliver a packemaker spike owing to a problem internal to the pacemaker
  • oversensing
    • the pacemaker senses something in the AV interval that it misidentifies as ventricular activity, such as a T wave or external artifact
  • failue to capture
    • pacemaker spike is generated at the appropriate time but fails to capture the ventricle
132
Q

Why do transvalvular gradients increase during pregnancy?

A
  • increased HR
  • increased plasma volume
  • increased stroke volume
133
Q

Describe the treatment algorithm for:

  • Severe AS
  • Asymptomatic
A
134
Q

Describe the treatment algorithm for:

  • Severe AS
  • Symptomatic
A
135
Q

Describe the treatment algorithm for:

  • Abnormal aortic valve with reduced systolic opening
  • Moderate AS
  • Asymptomatic
A
136
Q

What is the rate of progression of aortic stenosis?

  • PV
  • MG
A
  • PV
    • 0.1 - 0.4 m/sec/year
  • MG
    • 3-7 mmHg / year
137
Q

Describe the stepwise approach for AS Severity

A
138
Q

Describe stepwise approach for diagnosing severe AS:

  • Low Gradient
  • Normal LVEF
A
139
Q

Describe the treatment algorithm:

  • Moderate AR
A
140
Q

Describe the treatment algorithm:

  • Severe AR
A
141
Q

Describe imaging interval for BAV

A
142
Q

Describe TR treatment algorithm:

  • Progressive TR
A
143
Q

Describe the treatment algorithm

  • Severe TR
  • Asymptomatic
A
144
Q

Describe the prosthetic valve treatment algorithm:

  • Valve thrombosis/suspected thrombosis or
  • TE event
A
145
Q

Describe the treatment algorithm

  • Severe TR
  • Symptomatic
A
146
Q

Describe the treatment algorithm

  • Progressive TR
A
147
Q

Describe the treatment algorithm

  • Severe TR
  • Right Heart Failure
A
148
Q

Describe Echo criteria for severe TR

A
  • VC ≥ 0.7 cm
  • RVol ≥ 45 mL
  • EROA ≥ 0.4 cm2
149
Q

Surgical correction of which valvular abnormality would result in the following change in the PV loop?

A

Mitral Regurgitation

  • decrease preload
    • fixing the valvular abnormality
  • decreased SV
    • increased afterload after removing low pressure atrial offloading
      *
150
Q

What is the major pathophysiologic abnormality?

A

Increased afterload, normal preload

  • severe AS
151
Q

Describe the findings and effect on LV filling pressure?

  • Valsalva maneuver performed
A

High Filling Pressures - Square wave response

  • Valsalva initiated (normal filling pressured)
    • Preload drops (beats 4, 5, 6, 7) → SV drops → PP drops → BP drops
  • Valsalva initiated (elevated filling pressure) = flat starling curve
    • Preload drops ( beats 4, 5, 6, 7) →
    • negligible drop in SV, PP, BP
152
Q

Describe the phases of the Valsalva maneuver

A
  • Phase I - Early phase - Bearing down
    • increase in intrathoracic pressure
    • Preload to LV not affected
    • Pressure increases
  • Phase 2 - Strain phase
    • continuous decrease in preload to the LV →
      • SV and PP decreases
    • Reflex tachycardia
  • Phase 3 - Release phase
    • intrathoracic pressure drops
    • LV pressure drops
  • Phase 4
    • Overshoot
    • Preload returns to LV - SV, PP returns to normal
153
Q

Describe the management:

  • Prosthetic heart valve
  • Thromboembolic event
A
154
Q

Describe the management:

  • Prosthetic heart valve
  • Suspected mechanical valve thrombosis
A
  • Urgent TTE, TEE, Fluoro and/or CT imaging
  • Left-sided mechanical obstruction
    • TPA
      • urgent slow-infusion
    • Emergency surgery
155
Q

Describe the management:

  • Prosthetic heart valve
  • Suspected bioprosthetic valve thrombosis
A
  • 3D TEE or 4D CT imaging
  • VKA treatment

****2a recommendations

156
Q

Differentia factors favoring each in prosthetic valve thrombosis

  • TPA
  • Surgery
A

Medical (69 decks)

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