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Cardiology EECC > Valvular Heart Disease > Flashcards

Valvular Heart Disease Flashcards

1
Q

Aortic Regurgitation Types

A

Type 1- dilated aortic root with impaired coaption and central jet

Type 2 - cusp prolapse with eccentric jet

Type 3 - retraction with poor cusp tissue quality with large central or eccentic jet

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2
Q

Severe Aortic Regurgitation Echo Criteria

A
  • Qualitative
    Valve morphology - abnormal / flail / large coaptation defect
    Colour flow regurgitant jet area - large in central jets, variable in eccentric jets
    CW doppler signal - dense
    Other - holodiastolic flow reversal in descending aorta (EDV >20cm/s)
  • Semi-quantitative
    Vena contra width - >6mm
    Pressure half time - <200ms
  • Quantitative
    EROAmm2 - ≥30
    Regurgitant Volume ≥60
    LV dilatation
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3
Q

Indications for Aortic Valve Replacement in Severe Aortic Regurgitation

A
  1. Symptomatic patients regardless of LV function
  2. Asymptomatic patients with: LVESD > 50mm, LVESD/BSA >25mm/m2 in small patients (<BSA 1.68m2), LVEF ≤50%
  3. Symptomatic or asytmptomaic severe AR undergoing CABG or other valve surgery
  4. Consider in asymptomatic LVESD≥20mm/m2 or LVEF <55% if low risk surgery
    5.Consider repair in experienced centres
  5. Consider when LVEDD >65mm
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4
Q

Indications for Aortic Root or Tubular Ascending Aorta Surgery

A
  1. Valve sparing root replacement surgery in young patients in experienced centres
  2. Marfans with ascending aorta maximum diameter ≥50mm
  3. Consider in all patients with maximum aortic diameter ≥55mm in all patients; ≥45mm in patients with Marfans and additional risk (>3mm per year, want pregnancy, FHx aortic dissection, prev vascular dissection, sev AR or MR or uncontrolled HTN), or patients with TGFBR1 or 2 (inc Loeys-Dietz); ≥50mm in biscuspid with additional risk or coarctation
  4. If surgery indicated for valve, consider root replacement if ≥45mm
  5. Turners - ≥25mm/m2 + RF (HTN, biscuspid valve, elongation of the transverse aorta, coarctaton) - surgery
  6. Coarctation repair with gradient ≥20mmHg - preference for stenting
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5
Q

Severe Aortic Regurgitation - Medical Therapy

A
  • For symptoms in patients who can’t have surgery - ACEi or DHP-CCB
  • Post surgery but ongoing heart failure - ACEi and BB
  • Marfan’s pre or post surgery - BB (or ARBs)
  • Biscuspid Valve pre or post surgery - BB (or ARBs)
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6
Q

Aortic Regurgitation - Serial Testing

A
  • Asymptomatic severe AR - at least yearly
  • Asymptomatic severe AR, first presentation, significant change or borderline LV - 3-6 monthly. Significant LV dilatation (LVEDD >65mm or progressive LV dysfunction -> surgery
  • Mild - moderate AR - review annually, echo every 2 years
  • Aorta >40mm - CT or CMR to confirm. Follow up with echo / CMR. If >3mm growth, confirm with CT/CMR
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7
Q

Aortic Regurgitation - Special Populations

A
  • If severe primary or secondary MR - MVR in same operation
  • If moderate AR having CABG or MVR, consider AVR with heart team, consider cause of AR (generally slow AR progression in absence of root dilatation)
  • Biscuspid valve - echo screening for first degree relatives
  • Aortic aneurysm with connective tissue disease - imaging and genetics of first degree relatives
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8
Q

Aortic Stenosis - High Flow, High Gradient

A
  • Mean gradient - ≥40mmHg
  • Peak velocity (Vmax) - ≥4m/s
  • Valve area ≤1.0cm2 or ≤0.6cm2/m2)
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9
Q

Aortic Stenosis - Low Flow (SVi <35ml/m2), Low Gradient, Reduced LVEF

A
  • Mean gradient <40mmHg
  • Valve Area ≤1.0cm2
  • LVEF <50%
  • SVi <35ml/m2
  • Low dose dobutamine stress echo recommended to distinguish between true severe and pseudo severe AS and identify patients with no (or low) contractile reserve
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10
Q

Aortic Stenosis - Low flow (SVi <35ml/m2), Low Gradient, Preserved LVEF

A
  • Mean gradient <40mmHg
  • Valve Area ≤1.0cm2
  • LVEF >50%
  • SVi <35ml/m2

Usually elderly, hypertensive patients with marked LVH and low LV cavity volume.

Also other low stroke volume states: severe MR, severe TR, severe MS, large VSD, severe RV dysfunction

CT calcium score useful
High Likely = men >3000, women >1600
Likely = men >2000, women >1200
Unlikely = men <1600, women <800

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11
Q

Aortic Stenosis - Normal Flow, Low Gradient

A
  • Mean Gradient <40mmHg
  • Valve Area <1.0cm2
  • SVi >35ml/m2
  • LVEF >50%

These patients usually only have moderate aortic stenosis

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12
Q

Aortic Stenosis - Indications for intervention - SYMPTOMATIC

A
  • Severe, high gradient - intervene
  • Severe, low flow, low gradient, LVEF <50%, contractile reserve - intervene
  • Severe, low flow, low gradient, LVEF <50%, NO contractile reserve - consider intervention, esp if CT calcium score confirms severe
  • Severe, low flow, low gradient, LVEF >50% - consider intervention after confirming AS is truly severe
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13
Q

Aortic Stenosis - Indications for intervention ASYMPTOMATIC

A
  • Intervene if LVEF <50% if no other cause
  • Intervene if symptoms on exercise testing
  • Consider if LVEF <55% if no other cause
  • Consider if SBP drop >20mmHg on exercise testing
  • Consider if LVEF >55%, low procedural risk AND: very severe AS (mean gradient >60mmHg or Vmax >5m/s), severe valve calcification on CT and progression of >0.3m/s/year, very high BNP >3x ULN)
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14
Q

Aortic Stenosis - Mode of Intervention

A
  • SAVR - <75 AND STS/Prom/EUROScoreII <4%, or operable and unsuitable for TAVI
  • TAVI in ≥75 AND STS/Prom/EUROScoreII >8%
  • Remaining patients SAVR or TAVI depending on patient factors
  • Consider non-femoral TAVI if inoperable and TF TAVI not suitable
  • Consider BAV if haemodynamically unstable as a bridge to TAVI or SAVR or for patients recuiring urgent non-cardiac surgery
  • SAVR for patients with severe AS undergoing CABG
  • Consider SAVR for patients with moderate AS undergoing CABG
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15
Q

Aortic Stenosis - Serial Testing

A
  • Severe, asymptomatic, normal LVEF - education (prompt symptoms reporting), regular follow up (6 months or earlier)
  • Moderate AS - at least annually
  • Mild AS, young patients, low valve calification - 2-3 yearly
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16
Q

Severe Mitral Regurgitation Criteria

A
17
Q

Primary Mitral Regurgitation - indications for intervention in severe PMR

A
  • MV repair is prefered technique where durable results expected
  • Surgery is indicated when symptomatic, operable and non-high risk, LVEF >30%
  • Surgery is indicated in asymptomatic patients with LV dysfunction (LVESD ≥45mm and or LVEF ≤60%)
  • Consider in asymptomatic, preserved LV and AF secondary to MR OR pulmonary HTN (SPAP at rest >50mmHg)
  • Consider in asymptomatic patients with preserved LV if low-risk , durable repair likely, performed in Heart Valve Centre and at least 1 of (1) dilated LA (volume ≥60mm2/m2 or dimension ≥55mm) or (2) flail leaflet
  • Consider if symptomatic, severe LV dysfunction (LVEF <30%), LVESD >55mm, refractory to medical therapy when high likelihood successful repair and comorbidity low
  • Consider TEER in patients who fulfill echo criteria but inoperable but procedure not futile
18
Q

Primary Mitral Regurgitation - Serial Testing

A
  • Asymptomatic severe PMR, LVEF ≥60% - 6 month follow up with echo. Extra data with BNP, CMR, Holter, exercise echo for risk stratification
  • Asymptomatic moderate PMR, LVEF ≥60% - yearly follow up, echo every 1-2 years
19
Q

Primary Mitral Regurgitation - Management

A
20
Q

Secondary Mitral Regurgitation - Management

A
  • Intervention only indicated in severe SMR in patients who remain symptomatic despite GDTM including CRT where indicated
  • Surgery for SMR recommended if need concomittant CABG - If not fit for surgery consider PCI and TEER
  • Consider TEER if not fit for surgery and fit COAPT criteria (more severe MR with less dilated LV)
21
Q

Rheumatic Mitral Stenosis - Management

A

Contraindications to PMC in rheumatic MS
* MVA ≥1.5cm2
* LA thrombus
* More than mild MR
* Severe or bicommisural calcification
* Absence of commisural fusion
* Severe concomitant valve or coronary disease requiring surgery

Unfavourable PMC characteristics - clinical:
- Old age
- Previous PMC
- NYHA IV
- pulmonary HTN
- Permanent AF

Unfavourable PMC characteristics - anatomical:
- Echo score 8
- Cromier 3
- Very small MVA
- Severe TR

22
Q

Rheumatic Mitral Stenosis - Medical Therapy

A
  • Symptoms - diuretics, BBs, Non-DHP CCBs, Ivarbradine
  • Mod-severe MS with AF - Warfarin - INR 2-3
  • DONT do AF ablation or DCCV before valve intervention as AF recurs
  • If sinus rhythm but system embolism or spontaneous echo contrast or significant LA enlargement (LA volume ≥60ml/m2 or M mode diameter >50mm) consider warfarin

Serial testing
Asymptomatic, severe - annual
Asymptomatic, moderate - 2-3 years

23
Q

Degenerative Mitral Stenosis with Mitral Annular Calcification

A
  • Poor prognosis, LA and LV remodelling
  • Can have MVR after Heart Team
  • Transmitral gradient may persist post MVR due to LA and LV remodelling
  • TAVI in MAC may be an option in appropriate centres
24
Q

Tricuspid Regurgitation - Echo Criteria

A

Causes of Primary TR - Carcinoid, infective endocarditis, iatrogenic, rheumatic heart disease, Myxomatous disease, Congenital (Ebstein’s Anomaly), endomyocardial fibrosis, AF

Secondary TR - left heart disease (valve or myocardial)

25
Q

Tricuspid Regurgitation - Management

A
26
Q

Primary Tricuspid Regurgitation - Recommendations

A
  • Surgery for severe TR if having left sided surgery. Consider if moderate
  • Surgery for symptomatic severe TR without severe RV dysfunction
  • Consider if asymptomatic or mild symptoms and RV dilatation but appropriate for surgery
27
Q

Secondary Tricuspid Regurgitation - Recommendations

A
  • Surgery if severe secondary TR having left sided valve surgery
  • Consider if mild-moderate TR having left sided valve surgery with dilated annulus ≥40mm or ≥20mm/m2
  • Consider if severe seconary TR who are symptomatic OR have RV dilatation without RV dysfunction or severe pulmonary HTN
  • Consider transcatheter repair in severe symptomatic TR in inoperable patients
28
Q

Tricuspid Stenosis

A
  • Causes: rheumatic, congenital, endocarditis, carcinoid, drug-induced, Whipples, large RA tumour
  • Surgery if severe and symptomatic
  • Surgery if severe and having left sided surgery
  • Biopeosthetic preferred to mechanical
29
Q

Mechanical Valves - INR targets

A
30
Q

Antithrombotic therapy for valve prostheses

A
31
Q

Aortic Stenosis in Non-Cardiac Surgery

A
32
Q

Indications for Coronary Angiography Prior to Valvular Surgery

A
  • History of CAD
  • Suspected myocardial ischaemia
  • LV systolic dysfunction
  • Men >40 and post menopausal women
  • ≥1 CV risk factor

Recommended in assessment of mod-sev secondary MR
Consider CTCA where low risk of CAD or invasive angiogram high risk

33
Q

Scores relating to Mitral Valve

A
34
Q

Structural Valve Dysfunction

A

Cardiology EECC (17 decks)

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