Valvular Disorders Flashcards
Endocarditis prophylaxis
High risk conditions :
•Prosthetic cardiac valve or prosthetic material
-Cardiac valve repair with devices, including annuloplasty, rings, or clips
-Left ventricular assist devices or implantable heart
-History of endocarditis
- Heart transplant with abnormal valve function
- Certain congenital heart defects
—Unrepaired cyanotic congenital coronary heart disease, including palliative shunts and conduits
—Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by transcatheter during the first six months after the procedure
—Repaired congenital heart disease with residual defects at the site of or adjacent to the site of a prosthetic patch or prosthetic device
-Surgical or transcatheter pulmonary artery valve or conduit placement such as Melody valve and Contegra conduit
High risk procedures
•Dental procedures that involve manipulation of either gingival tissue or the periapical region of teeth or perforation of the oral mucosa; this includes routine dental cleaning.
•Procedures of the respiratory tract that involve incision or biopsy
•Gastrointestinal (GI) or genitourinary (GU) procedures in patients with ongoing GI or GU tract infection
•Procedures on infected skin, skin structure, or musculoskeletal tissue
•Surgery to place prosthetic heart valves or prosthetic intravascular or intracardiac materials
Treatment of fungal endocarditis
In patients with native or prosthetic valve Candida endocarditis, we suggest a combined approach that utilizes both antifungal agents and valve replacement rather than antifungal therapy alone
Rheumatic fever secondary prevention
For individuals with RHD with persistent asymptomatic valvular disease, secondary prophylaxis is suggested for 10 years after the last attack or at least until 40 years of age (whichever is longer). For patients with more severe valvular damage (eg, causing heart failure [HF]) or after valve surgery, lifelong secondary prophylaxis is suggested. For individuals with RH and carditis but no residual heart disease continue prophylaxis for 10 years or until 21 (whichever is longer). With RH and no carditis then 5 years or until 21 (whichever is longer).
Pulmonic regurgitation surgical management
Surgical pulmonary valve replacement is recommended for symptomatic, severe PR. In addition, we suggest pulmonary valve replacement for asymptomatic severe PR in the setting of any two of the following criteria:
(1) mild or moderate RV or LV systolic dysfunction
(2) Severe RV dilation (RV end-diastolic volume index [RVEDVI] ≥160 mL/m2, or RV end-systolic volume index [RVESVI] ≥80 mL/m2, or RVEDV greater than or equal to two times the LV end-diastolic volume)
(3) RV systolic pressure due to RV outflow tract obstruction greater than or equal to two-thirds the systemic pressure
(4) Progressive reduction in objective exercise tolerance.
We also suggest pulmonary valve replacement for patients with severe PR and progressive tricuspid valve regurgitation, although evidence is more limited to support this approach.
In patients undergoing surgical pulmonic valve replacement, bioprosthetic valves are generally preferred over mechanical valve prostheses with longevity up to approximately 15 years after implantation.
Simultaneous tricuspid annuloplasty is recommended in patients with moderate or worse tricuspid valve regurgitation due to tricuspid annular dilatation, while tricuspid valve replacement should be considered in cases of structurally abnormal valve due to damage from prior endocarditis or iatrogenic injury resulting in flail leaflet or leaflet perforation.
Anticoagulation for prosthetic valves in pregnancy
Bioprosthetic valve – For patients with a bioprosthetic (surgical or transcatheter) valve, we suggest continuing low-dose aspirin (75 to 100 mg/day; eg, 81 mg/day) during pregnancy
Mechanical valve – For pregnant patients with mechanical prosthetic valves, we recommend low-dose aspirin (75 to 100 mg/day; eg, 81 mg/day) along with whichever anticoagulant is selected (VKA, LMWH, or UFH).
For mechanical valve with risk factor for valve thrombosis – For patients with a mechanical prosthetic valve with one or more risk factors for prosthetic valve thrombosis/thromboembolism (eg, mechanical mitral valve, mechanical tricuspid valve, atrial fibrillation or flutter, previous thromboembolic complications, or multiple mechanical heart valves), we suggest continuing VKA (eg, warfarin) with close international normalized ratio (INR) monitoring throughout pregnancy until 36 weeks.
For mechanical valve without risk factors for prosthetic valve thrombosis –
-During the first trimester :
-If baseline VKA dose is relatively low (warfarin dose ≤5 mg/day, phenprocoumon ≤3 mg/day, or acenocoumarol ≤2 mg/day), the main anticoagulation options are continuing VKA with close INR monitoring throughout the first trimester or dose-adjusted SC LMWH from 5 to 12 weeks (dosed twice daily; target anti-Xa level 1.0 to 1.2 units/mL for mitral valve and 0.8 to 1.0 units/mL for aortic valve replacement at four to six hours post-dose, with trough activity ≥0.6 units/mL). If the patient declines VKA use and LMWH with appropriate monitoring is unavailable, UFH is an option of last resort.
-For patients whose baseline VKA dose is high (defined as warfarin >5 mg/day, phenprocoumon >3 mg/day, or acenocoumarol >2 mg/day), we suggest switching to dose-adjusted twice-daily SC LMWH throughout the first trimester (Grade 2C).
-During the second and third trimesters – For most women with mechanical valves, we suggest VKA (adjusted to INR goal) during the second and third trimesters until 36 weeks (Grade 2C).
Treatment of mitral stenosis in pregnancy
With appropriate care including judicious use of beta blockers and/or diuretics, most women with MS can undergo pregnancy without the need for invasive interventions.
Intervention during pregnancy (preferably by percutaneous mitral balloon valvotomy) is reserved for those patients with severe symptoms despite maximal medical therapy and admission to hospital.
Symptomatic patients with moderate to severe MS (mitral valve area ≤1.5 cm2) should undergo intervention, preferably percutaneous balloon mitral valvotomy, before pregnancy.
Indications for mitral valve surgery in mitral regurgitation
Primary MR
- Any symptoms Class II- IV
- LV <60%, ESD >40 mm (60/40 rule)
- consider severe asymptomatic with low operative mortality and high chance of successful repair
Severe Aortic Stenosis Calcium Score
Men > 2000
Women > 1300
Indication for aortic dilation repair
> 5.5 cm - for dilation itself
5.0 cm - if FH or rapid growth or low risk
4.5 cm - replace aorta if AVR is indicated
Severe Aortic stenosis
Peak Velocity >= 4 m/s
Mean gradient >= 40 mm Hg
Av area <= 1.0
Calcium Score:
Men >2000
Women >1300
Hakki Equation
AVA = CO / Sroot (P -P gradient)
Indications for AV Replacement in AS
Symptomatic
- operate at onset of any symptoms regardless of LV function
Asymptomatic
- Operate when EF <50% (<60% on 3 serial studies)
- with very severe AS >5 ms or BNP >3x normal, or rapid progression
- For asymptomatic severe AS with normal LVEF think treadmill stress test
Preop Angiogram
- Men > 40
- Premenopausal women >40 with risk factors
- Post menopausal women
TTE Frequency for Asymptomatic AS
Stage B
2.0- 2.9, q 3-5 yrs
3.0- 3.9, q 1-2 yrs
Stage C
>4, asymptomatic, q 6-12 months
Indications to operate for severe AR
- Any symptoms
- LV dysfunction: EF <55% (50/50 rule)
- LV dilation : ESD >50 mm, EDD >65 mm and enlarging
- Aortic regurgitation velocity > 25 mm/m2 think diastolic flow reversal in aorta
Mitral stenosis severity by valve area
Stage B: Progressive > 1.5
C: Severe <= 1.5
D: Very severe < 1.0
