Valvular Heart Disease

Question 1

Aortic Stenosis: Medical Therapy Prior to Surgery

Answer 1

1. Antihypertensive drugs
   -RAAS blocking agents
2. Cholesterol lowering drugs
   -Statins

Question 1

Aortic Stenosis

Answer 1

Etiology: aging

Sx: syncope, swollen ankles, SOB, chest pain, fluttering heartbeat

Mild/No sx: maintain a healthy lifestyle

Question 2

Aortic Regurgitation

Answer 2

Leaking valve allows blood to flow in 2 directions

Sx: palpitations, chest pain, SOB, fainting, difficulty breathing when lying down

Question 3

Aortic Regurgitation: Medical Therapy Prior to Surgery

Answer 3

Acute AR
-LV after load reduction
-Emergent surgery

Chronic AR
-Nonpharm: weight loss, healthy diet, exercise, smoking cessation, stress reduction

Asym: tx of htn

Sev/Sym: acei/arb/arni
*LVEF =< 55

Question 4

Mitral Stenosis

Answer 4

Sx: HF sx, dyspnea, fatigue, hoarseness, hemoptysis

Causes: rheumatic fever, non-rheumatic calcified mitral valve

Question 5

Mitral Stenosis: Medical Therapy

Answer 5

-Rheumatic MS (with AF/embolic event/LA thrombus) = LEA = Warfarin

-Rheumatic MS (with AF/RVR) = Heart Rate Control can be beneficial

-Rheumatic MS (NSR with sx/tachy) = Heart Rate Control can be beneficial

Question 6

Mitral Regurgitation: Acute

Answer 6

Treatment: MRNN DR
-Vasodilator therapy = Nicardipine or Nitroprusside
-Intra-aortic balloon pump
-MV repair (mitraclip) or replacement = DAPT for 1-6 months after insertion

Question 7

Mitral Regurgitation: Chronic

Answer 7

Primary MR
-GDMT for systolic dysfunction

Secondary MR
-Standard GDMT for HF with ACEI/ARB/BB/ALD/ARNI

Question 8

Prosthetic Heart Valves

Answer 8

Mechanical
-Lifelong ac with Warfarin

Biprosthetic/Tissue
-No long-term ac needed

Question 9

AC After Valve Replacement

Answer 9

*Warfarin still for mechanical heart valves
*Caution with mono/DAPT

The NOs
-Bioprosthetic: Riva + Asp = NO
-Mechanical: Dabi or anti-Xa DOAC = NO

Question 10

AC for On-X AVR

Answer 10

First 3 months
-Warfarin (INR 2-3) and ASA 81

After
-If no TE RF, may reduce intensity (INR 1.5-2) and ASA 81

Question 11

Bridging Therapy

Answer 11

Agent
-IV UF Heparin or LMWH
(anti-Xa 0.3-0.7, aptt 50-77 - lmwh 0.5-1)

Bridging done for mechanical MVR or AVR with additional TE RF

Question 12

How do we manage thromboembolic events in patients with prosthetic heart valves?

Answer 12

-MA = Mechanical AVR: increase INR to 3 (2.5-3.5) or add daily ASA 81

-MM = Mechanical MVR: increase INR to 4 (3.5-4.5) or add ASA 81

-Bio surgical/MV/transcather AV: consider Warfarin

Question 13

PHV Becomes Thrombosed

Answer 13

Mechanical
-Slow infusion, low dose fibrinolytic therapy or surgery

Bio/Tissue
-Warfarin

Question 14

Pregnancy

Answer 14

Bioprosthetic valve preferred

Rec
-Beta blockers
-Diuretics (if sx)
*NO ACEI/ARBS! CI in pregnancy

AC
-Warfarin < 5: continue warfarin for all 3 OR LMWH for 1 then warfarin for 2-3
-Warfarin > 5: LMWH for 1 then warfarin for 2-3 OR LMWH for all 3
-If can’t monitor LMWH with anti-Xa: use UFH for 1 and warfarin for 2-3

Question 15

Summary Slide

Answer 15

MECH
-AVR: 2.5, no bridging
-AVR RF or MVR: 3, bridging

BIO
-Bio: 3-6 months Warfarin 2.5
lifelong ASA 81
-TAVI: 3-6 months Warfarin 2.5 OR ASA 81 + CLOP 75
lifelong ASA 81