Valvular Heart Disease 2014

Question 1

Name and describe the stages of progression of valvular heart disease.

Answer 1

Stage Definition Description

A At risk Patients with risk factors for development of VHD

B Progressive: Patients with progressive VHD (mild-to-moderate severity and asymptomatic)

C Asymptomatic severe: Asymptomatic patients who have the criteria for severe VHD:

C1: Asymptomatic patients with severe VHD in whom the left or right ventricle remains compensated C2: Asymptomatic patients with severe VHD, with decompensation of the left or right ventricle

D Symptomatic severe Patients who have developed symptoms as a result of VHD

Question 2

Name the time interval for repeat TTE recommended for periodic monitoring for asymptomatic patients with valvular heart disease with normal LV function.

Answer 2

AS (normal stroke volume), AI, MR:

Mild – repeat echo every 3 to 5 years.

Moderate – repeat echo every 1 to 2 years.

Severe – repeat echo every 6 to 12 months

AI or MR: if dilated LV, repeat more frequently.

MS:

mild: >1.5cm² – repeat echo every 3 to 5 years Moderate: 1.5- 1.0 cm²– repeat echo every 1 to 2 years

Severe: <1.0cm² – repeat echo every year

Question 3

Name Class I indications for TTE in valvular heart disease.

Answer 3

1. TTE is recommended in the initial evaluation of patients with known or suspected VHD to confirm the diagnosis, establish etiology, determine severity, assess hemodynamic consequences, determine prognosis, and evaluate for timing of intervention(19–20). (Level of Evidence: B)
2. TTE is recommended in patients with known VHD with any change in symptoms or physical examination findings. (Level of Evidence: C)

Question 4

Name the Class I indications for cardiac cath in valvular heart disease.

Answer 4

1. Symptomatic patients when noninvasive tests are inconclusive.
2. When there is a discrepancy between the findings on noninvasive testing and physical examination regarding severity of the valve lesion. (Level of Evidence: C)

Question 5

When should you recommend exercise testing to assess valvular heart disease? What Class and level of evidence?

Answer 5

Class IIa. Reasonable in selected patients with asymptomatic severe VHD to…

1) Confirm the absence of symptoms, or
2) Assess the hemodynamic response to exercise, or
3) Determine prognosis. (Level of evidence B)

Question 6

Class I recommendation for antibiotic prophylaxis in valvular heart disease.

Answer 6

Secondary prevention of rheumatic fever is indicated in patients with rheumatic heart disease, specifically mitral stenosis (level of evidence C).

Question 7

Class II recommendations for antibiotic prophylaxis in valvular heart disease.

Answer 7

Before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa(41–42)(Level of Evidence: B): •Patients with prosthetic cardiac valves;

• Patients with previous IE;
• Cardiac transplant recipients with valve regurgitation due to a structurally abnormal valve; or
• Patients with CHD with:

○Unrepaired cyanotic CHD, including palliative shunts and conduits;

○Completely repaired congenital heart defect repaired with prosthetic material or device, whether placed by surgery or catheter intervention, during the first 6 months after the procedure; or

○Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device.

Question 8

Specifically, when is antibiotic prophylaxis not recommended in valvular heart disease?

Answer 8

Class III: No Benefit

Prophylaxis against IE is not recommended in patients with VHD who are at risk of IE for nondental procedures (e.g., TEE, esophagogastroduodenoscopy, colonoscopy, or cystoscopy) in the absence of active infection(44). (Level of Evidence: B)

Question 9

When is low dose dobutamine stress testing for patients with aortic stenosis?

Answer 9

Class IIa

Low-dose dobutamine stress testing using echocardiographic or invasive hemodynamic measurements is reasonable in patients with stage D2 AS with all of the following(46–47)(Level of Evidence: B): a.Calcified aortic valve with reduced systolic opening; b.LVEF less than 50%; c.Calculated valve area 1.0 cm2or less; and d.Aortic velocity less than 4.0 m per second or mean pressure gradient less than 40 mm Hg.

Question 10

When is exercise testing utilized in aortic stenosis?

Answer 10

Class IIa Exercise testing is reasonable to assess physiological changes with exercise and to confirm the absence of symptoms in asymptomatic patients with a calcified aortic valve and an aortic velocity 4.0 m per second or greater or mean pressure gradient 40 mm Hg or higher (stage C)(27,37,38,49). (Level of Evidence: B)

Question 11

When should exercise testing not be performed in aortic stenosis?

Answer 11

Class III: Harm Exercise testing should not be performed in symptomatic patients with AS when the aortic velocity is 4.0 m per second or greater or mean pressure gradient is 40 mm Hg or higher (stage D)(50). (Level of Evidence: B)

Question 12

How should hypertension be treated in patients who are asymptomatic with aortic stenosis?

Answer 12

Class I

Hypertension in patients at risk for developing AS (stage A) and in patients with asymptomatic AS (stages B and C) should be treated according to standard GDMT, started at a low dose, and gradually titrated upward as needed with frequent clinical monitoring(51–52).(Level of Evidence: B)

Question 13

Is there medical therapy for patients with severe decompensated AS?

Answer 13

Class IIb

Vasodilator therapy may be reasonable if used with invasive hemodynamic monitoring in the acute management of patients with severe decompensated AS (stage D) with New York Heart Association (NYHA) class IV heart failure (HF) symptoms. (Level of Evidence: C)

Question 14

True/False: Initiating statin therapy to prevent the progression of aortic stenosis has found to be benificial in some patients.

Answer 14

Class III: No Benefit

Statin therapy is not indicated for prevention of hemodynamic progression of AS in patients with mild-to-moderate calcific valve disease (stages B to D). (Level of Evidence: A)

Question 15

Name the class I indications for aortic valve replacement in aortic stenosis.

Answer 15

Class I
1.AVR is recommended in symptomatic patients with severe AS (stage D1) with(10,57–58)(Level of Evidence: B):

a. Decreased systolic opening of a calcified or congenitally stenotic aortic valve; and
b. An aortic velocity 4.0 m per second or greater or mean pressure gradient 40 mm Hg or higher; and
c. Symptoms of HF, syncope, exertional dyspnea, angina, or presyncope by history or on exercise testing.

2. AVR is recommended for asymptomatic patients with severe AS (stage C2) and an LVEF less than 50% with decreased systolic opening of a calcified aortic valve with an aortic velocity 4.0 m per second or greater or mean pressure gradient 40 mm Hg or higher(60,61). (Level of Evidence: B)
3. AVR is indicated for patients with severe AS (stage C or D) when undergoing cardiac surgery for other indications when there is decreased systolic opening of a calcified aortic valve and an aortic velocity 4.0 m per second or greater or mean pressure gradient 40 mm Hg or higher(62,63). (Level of Evidence: B)

Question 16

Name the Class IIa indications for aortic valve replacement for aortic stenosis.

Answer 16

Class IIa

1. AVR is reasonable for asymptomatic patients with very severe AS (stage C1) with(64,65)(Level of Evidence: B):
   a. Decreased systolic opening of a calcified valve;

b. An aortic velocity 5.0 m per second or greater or mean pressure gradient 60 mm Hg or higher; and
c. A low surgical risk.
2. AVR is reasonable in apparently asymptomatic patients with severe AS (stage C1) with(27,38)(Level of Evidence: B):

a. A calcified aortic valve;
b. An aortic velocity of 4.0 m per second to 4.9 m per second or mean pressure gradient of 40 mm Hg to 59 mm Hg; and
c. An exercise test demonstrating decreased exercise tolerance or a fall in systolic blood pressure (BP).

3.AVR is reasonable in symptomatic patients with l_ow-flow/low-gradient severe AS with reduced LVEF_ (stage D2) with a(66–67)(Level of Evidence: B):

a. Calcified aortic valve with reduced systolic opening;
b. Resting valve area 1.0 cm2or less;
c. Aortic velocity less than 4.0 m per second or mean pressure gradient less than 40 mm Hg;
d. LVEF less than 50%; and
e. A low-dose dobutamine stress study that shows an aortic velocity 4.0 m per second or greater or mean pressure gradient 40 mm Hg or higher with a valve area 1.0 cm2or less at any dobutamine dose.

4.AVR is reasonable in symptomatic patients with low-flow/low-gradient severe AS (stage D3) with an LVEF 50% or greater, a calcified aortic valve with significantly reduced leaflet motion, and a valve area 1.0 cm2or less only if clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms and data recorded when the patient is normotensive (systolic BP <140 mm Hg) indicate (Level of Evidence: C):

a. An aortic velocity less than 4.0 m per second or mean pressure gradient less than 40 mm Hg; and
b. A stroke volume index less than 35 mL/m2; and
c. An indexed valve area _0.6 cm2/m2_or less.

5.AVR is reasonable for patients with moderate AS (stage B) with an aortic velocity between 3.0 m per second and 3.9 m per second or mean pressure gradient between 20 mm Hg and 39 mm Hg who are undergoing cardiac surgery for other indications. (Level of Evidence: C)

Question 17

Name the class IIb indication for aortic valve replacement in aortic stenosis.

Answer 17

Class IIb

AVR may be considered for asymptomatic patients with severe AS (stage C1) with an aortic velocity 4.0 m per second or greater or mean pressure gradient 40 mm Hg or higher if the patient is at low surgical risk and serial testing shows an increase in aortic velocity 0.3 m/s or greater per year. (Level of Evidence: C)

Question 18

Which alternative imaging modality has a class I recommendation in patients with aortic regurgitation and syboptimal echo images?

Answer 18

CMR is indicated in patients with moderate or severe AR (stages B, C, and D) and suboptimal echocardiographic images for the assessment of LV systolic function, systolic and diastolic volumes, and measurement of AR severity. (Level of Evidence: B)

Question 19

Class I recommendations for treatement of hypertension in aortic regurgitation.

Answer 19

Class I

Treatment of hypertension (systolic BP >140 mm Hg) is recommended in patients with chronic AR (stages B and C), preferably with dihydropyridine calcium channel blockers or angiotensin-converting enzyme (ACE) inhibitors/angiotensin-receptor blockers (ARBs)(83,88).(Level of Evidence: B)

Question 20

CLASS IIA recommendations for medical management of severe AR and LV dysfunction.

Answer 20

Class IIa

Medical therapy with ACE inhibitors/ARBs and beta blockers is reasonable in patients with severe AR who have symptoms and/or LV dysfunction (stages C2 and D) when surgery is not performed because of comorbidities(89,90). (Level of Evidence: B)

Question 21

Class I indications for valve replacement in aortic regurgitation.

Answer 21

Class I

1. AVR is indicated for symptomatic patients with severe AR regardless of LV systolic function (stage D)(33,91,92). (Level of Evidence: B)
2. AVR is indicated for asymptomatic patients with chronic severe AR and LV systolic dysfunction (LVEF <50%) at rest (stage C2) if no other cause for systolic dysfunction is identified(91,93–94). (Level of Evidence: B)
3. AVR is indicated for patients with severe AR (stage C or D) while undergoing cardiac surgery for other indications. (Level of Evidence: C)

Question 22

Class IIa indications for valve replacement in severe aortic regurgitation.

Answer 22

Class IIa

1. AVR is reasonable for asymptomatic patients with severe AR with normal LV systolic function (LVEF ≥50%) but with severe LV dilation (LV end-systolic dimension [LVESD] >50 mm or indexed LVESD >25 mm/m2) (stage C2)(96–97). (Level of Evidence: B)
2. AVR is reasonable in patients with moderate AR (stage B) while undergoing surgery on the ascending aorta, coronary artery bypass graft (CABG), or mitral valve surgery. (Level of Evidence: C)

Question 23

Class IIb recommendations for valve replacement in aortic regurgitation.

Answer 23

Class IIb

AVR may be considered for asymptomatic patients with severe AR and normal LV systolic function at rest (LVEF ≥50%, stage C1) but with progressive severe LV dilatation (LV end-diastolic dimension >65 mm) if surgical risk is low. (Level of Evidence: C)

Question 24

Bicuspic aortic valve and aortopathy: class I recommendations for imaging follow up.

Answer 24

Class I

1. An initial TTE is indicated in patients with a known bicuspid aortic valve to evaluate valve morphology, to measure the severity of AS and AR, and to assess the shape and diameter of the aortic sinuses and ascending aorta for prediction of clinical outcome and to determine timing of intervention(99–100). (Level of Evidence: B)
2. Aortic magnetic resonance angiography or CT angiography is indicated in patients with a bicuspid aortic valve when morphology of the aortic sinuses, sinotubular junction, or ascending aorta cannot be assessed accurately or fully by echocardiography. (Level of Evidence: C)
3. Serial evaluation of the size and morphology of the aortic sinuses and ascending aorta by echocardiography, CMR, or CT angiography is recommended in patients with a bicuspid aortic valve and an aortic diameter greater than 4.0 cm, with the examination interval determined by the degree and rate of progression of aortic dilation and by family history. In patients with an aortic diameter greater than 4.5 cm, this evaluation should be performed annually. (Level of Evidence: C)

Question 25

Bicuspid aortic valve and aortopathy: Class I recomendations for surgery.

Answer 25

Class I Operative intervention to repair the aortic sinuses or replace the ascending aorta is indicated in patients with a bicuspid aortic valve if the diameter of the _aortic sinuses or ascending aorta_ is greater than **5.5 cm** (Level of Evidence: B)

Question 26

Bicuspid aortic valve and aortopathy: Class IIa recomendations for surgery.

Answer 26

Class IIa Operative intervention to repair the aortic sinuses or replace the ascending aorta is reasonable in patients with bicuspid aortic valves if the diameter of the aortic sinuses or ascending aorta is _greater than 5.0 cm and a risk factor for dissection is present_ (family history of aortic dissection or if the rate of increase in diameter is ≥0.5 cm per year). (Level of Evidence: C) 2.Replacement of the ascending aorta is reasonable in patients with a bicuspid aortic valve who are undergoing aortic valve surgery because of severe AS or AR if the diameter of the ascending aorta is greater than 4.5 cm. (Level of Evidence: C)

Question 27

Name the Class I indications for valve replacement _choice_ in aortic stenosis.

Answer 27

Class I 1. Surgical AVR is recommended in patients who meet an indication for AVR (4.4) with _low or intermediate surgical risk_ (Section 2.5in the full-text guideline)(69,70). (Level of Evidence: A) 2. For patients in whom TAVR or high-risk surgical AVR is being considered, a _Heart Valve Team_ consisting of an integrated, multidisciplinary group of healthcare professionals with expertise in VHD, cardiac imaging, interventional cardiology, cardiac anesthesia, and cardiac surgery should collaborate to provide optimal patient care. (Level of Evidence: C) 3. TAVR is recommended in patients who meet an indication for AVR (4.4) who have a prohibitive risk for surgical AVR (Section 2.5in the full-text guideline) and a predicted post-TAVR survival greater than 12 months(71,72). (Level of Evidence: B)

Question 28

Name the Class IIa recommendations for valve replacement choice in aortic stenosis.

Answer 28

Class IIa TAVR is a reasonable alternative to surgical AVR in patients who meet an indication for AVR (4.4) and who have high surgical risk for surgical AVR (Section 2.5in the full-text guideline)(73,74). (Level of Evidence: B)

Question 29

What is available if valve replacement could not be performed right away.

Answer 29

Class IIb. Percutaneous aortic balloon dilation may be considered as a bridge to surgical AVR or TAVR in patients with severe symptomatic AS. (Level of Evidence: C)

Question 30

Class I recs with respect to Diagnosis and Follow up of Mitral Stenosis.

Answer 30

1. TTE is indicated in patients with signs or symptoms of MS to establish the diagnosis, quantify hemodynamic severity (mean pressure gradient, mitral valve area, and pulmonary artery pressure), assess concomitant valvular lesions, and demonstrate valve morphology (to determine suitability for mitral commissurotomy)(9,115–116). (Level of Evidence: B) 2. TEE should be performed in patients considered for percutaneous mitral balloon commissurotomy to assess the presence or absence of left atrial thrombus and to further evaluate the severity of mitral regurgitation (MR)(116,124–125). (Level of Evidence: B) 3. Exercise testing with Doppler or invasive hemodynamic assessment is recommended to evaluate the response of the mean mitral gradient and pulmonary artery pressure in patients with MS when there is a discrepancy between resting Doppler echocardiographic findings and clinical symptoms or signs. (Level of Evidence: C)

Question 31

Class I recommendations for medical therapy in Mitral Stenosis.

Answer 31

Anticoagulation (vitamin K antagonist [VKA] or heparin) is indicated in patients with 1) MS and AF (paroxysmal, persistent, or permanent) 2) MS and a prior embolic event, or 3) MS and a left atrial thrombus(127–128). (Level of Evidence: B)

Question 32

Class IIa recommendations for medical therapy in Mitral stenosis.

Answer 32

Heart rate control can be beneficial in patients with MS and AF and fast ventricular response.

Question 33

Class IIb recommendations for medical therapy in Mitral stenosis.

Answer 33

Heart rate control may be considered for patients with MS in normal sinus rhythm and symptoms associated with exercise(134,135). (Level of Evidence: B)

Question 34

Class I indications for intervention in mitral stenosis.

Answer 34

1. PMBC is recommended for symptomatic patients with severe MS (MVA ≤1.5 cm2, stage D) and favorable valve morphology in the absence of contraindications I A 2. Mitral valve surgery is indicated in severely symptomatic patients (NYHA class III/IV) with severe MS (MVA ≤1.5 cm2, stage D) who are not high risk for surgery and who are not candidates for or failed previous PMBC (I B) 3. Concomitant mitral valve surgery is indicated for patients with severe MS (MVA ≤1.5 cm2, stage C or D) undergoing other cardiac surgery (I C)

Question 35

Class IIa recommendations for intervention in patients with mitral valve stenosis.

Answer 35

1. PMBC is reasonable for asymptomatic patients with very severe MS (MVA ≤1.0 cm2, stage C) and favorable valve morphology in the absence of contraindications. IIa C 2. Mitral valve surgery is reasonable for severely symptomatic patients (NYHA class III/IV) with severe MS (MVA ≤1.5 cm2, stage D), provided there are other operative indications. IIa C

Question 36

Class IIb recommendations for intervention in patients with mitral valve stenosis.

Answer 36

1. PMBC may be considered for asymptomatic patients with severe MS (MVA ≤1.5 cm2, stage C) and favorable valve morphology who have new onset of AF in the absence of contraindications. IIb C 2. PMBC may be considered for symptomatic patients with MVA \>1.5 cm2 if there is evidence of hemodynamically significant MS during exercise. IIb C 3. PMBC may be considered for severely symptomatic patients (NYHA class III/IV) with severe MS (MVA ≤1.5 cm2, stage D) who have suboptimal valve anatomy and are not candidates for surgery or at high risk for surgery IIb C. 4. Concomitant mitral valve surgery may be considered for patients with moderate MS (MVA 1.6–2.0 cm2) undergoing other cardiac surgery IIb C 5. Mitral valve surgery and excision of the left atrial appendage may be considered for patients with severe MS (MVA ≤1.5 cm2, stages C and D) who have had recurrent embolic events while receiving adequate anticoagulation IIb C.

Question 37

Define primary and secondary chronic MR. What other names are they known by.

Answer 37

Primary MR (degenerative): pathology of ≥1 of the components of the valve (leaflets, chordae tendineae, papillary muscles, annulus) causes valve incompetence with systolic regurgitation of blood from the left ventricle to the LA Secondary MR (functional): he mitral valve is usually normal (Table 14). Instead, severe LV dysfunction is caused either by CAD, related myocardial infarction (ischemic chronic secondary MR), or idiopathic myocardial disease (nonischemic chronic secondary MR).

Question 38

True or False? In patients with secondary MR, adverse outcomes are associated with a smaller calculated effective regurgitant orifice compared to primary MR.

Answer 38

True

Question 39

Class I recommendations for diagnosis and follow up of chronic primary MR.

Answer 39

Class I 1. TTE is indicated for baseline evaluation of LV size and function, right ventricular (RV) function and left atrial size, pulmonary artery pressure, and mechanism and severity of primary MR (stages A to D) in any patient suspected of having chronic primary MR(6,23,146–147). (Level of Evidence: B) 2. CMR is indicated in patients with chronic primary MR to assess LV and RV volumes, function, or MR severity and when these issues are not satisfactorily addressed by TTE(157,163,164). (Level of Evidence: B) 3. Intraoperative TEE is indicated to establish the anatomic basis for chronic primary MR (stages C and D) and to guide repair(165,166). (Level of Evidence: B) 4. TEE is indicated for evaluation of patients with chronic primary MR (stages B to D) in whom noninvasive imaging provides nondiagnostic information about severity of MR, mechanism of MR, and/or status of LV function. (Level of Evidence: C)