Valvular Heart Disease Flashcards
What are the echocardiographic indications for surgery in chronic AR?
EF <50%
LVESD >5cm
LVEDD >6.5cm
Rapid progression/deterioration
What is the Wilkins Score and what is its use?
Predicts procedural success for mitral valvuloplasty based on valve structure. <8 predicts favourable result.
What are the scores used to predict outcomes after valve surgery?
Euroscore 2
STS score
At what aortic diameter in a female with marfans or bicuspid Aortic valve would you recommend against pregnancy?
> 50mm
What is the medical therapy for chronic AR?
ACE/ARB
Beta Blocker
What is the progression of moderate AR without concurrent aortic dilation?
Slow
What is the use of MSCT in the setting of AS?
Useful to characterise likelihood of severity in the setting of low flow, low gradient AS in patients with HFPEF
What are the risk factors post cardiac valve surgery not considered in the ES2 and STS scores?
Porcelain aorta
Frailty
Sequelae of chest radiotherapy
In what valve disease does exercise testing provide information on prognosis and management?
Aortic stenosis
Mitral regurgitation
What is the Carpentier classification?
Used to characterise mitral valve anatomy in preparation for surgery
Describe the types in the carpentier classification.
Type 1 - normal leaflet motion, jet directed centrally
Type 2 - excessive leaflet motion, jet eccentric and directed away from pathological leaflet
Type 3 - restricted leaflet motion
A - restricted in systole and diastole
B - restricted in diastole
What are the most common causes of MR based on the Carpentier classification?
Type 1 - secondary MR, endocarditis with perforation
Type 2 - degenerative Disease
Type 3a - rheumatic heart disease
Type 3b - ischaemic MR
What are the most common causes of MR?
Degenerative (60-70%)
Functional (25%)
Rheumatic (15%)
What are the indications on echocardiography for surgery in the setting of asymptomatic severe primary mitral regurgitation?
EF - <60%
LVESD >45mm
SPAP >50mmhg
(new onset AF)
What are the independent predictors of failed mitral valve repair?
Operative - Surgical inexperience
Pathological - Infective endocarditis
Mitral Valve Anatomy - Absence of annular dilation, Mitral stenosis/sclerosis, leaflet calcification, annular calcification
What are the benefits of MV repair over replacement?
Reduced peri-operative mortality (ARR 3-4%)
Better 20 year survival (ARR 20%)
Reduced re-operation
What is the medical therapy for acute mitral regurgitation?
Diuretics and Nitrates to reduce filling pressures
+/- inotropic agents and IABP
When is a patient with severe MR considered to have a low EF and would warrant Href therapy?
<60%
In asymptomatic patients with severe primary MR and EF >60% and LVESD 40-45, what are the Echo findings that should make one consider surgery?
Flail leaflet
LA dilatation >60ml/m2 in sinus rhythm
What additional investigations can be useful in the assessment of secondary mitral regurgitation when it is unclear if surgery will be of benefit?
Stress echocardiography
Why must a TOE be performed prior to mitral valve comissurotomy?
Exclude left atrial thrombus
When is it appropriate to utilise stress echocardiography in the setting of MS?
Asymptomatic or symptoms discordant with severity of MS
What are the contraindications to mitral valve commisurotomy?
Mitral Valve Area >1.5 Left atrial thrombus Moderate to severe MR Severe/bi commissural calcification Absence of commissural fusion Concomitant CAD requiring bypass Severe aortic valve disease/severe TR and TS requiring surgery
What is the medical therapy for mitral stenosis?
Diuretics
Beta Blockers
Consider digoxin/calcium channel blockers to control rate
What are the echo criteria for significant prosthetic valve degeneration?
Mean Transvalvular gradient - >20mmhg
EOA decrease - >0.6cm2
Doppler velocity index decrease - >0.15
In patients with mitral stenosis in sinus rhythm, when would you consider anticoagulation?
Spontaneous echo contrast in LA
LA volume >60ml/m2
When would you consider intervention on an asymptomatic patient with mitral stenosis with MVA <1.5?
High thromboembolism risk (previous stroke, LA SEC, new AF)
High risk of haemodynamic decompensation - SPAP >50mmhg, desire for pregnancy, major non cardiac surgery
Need to have favourable clinical and echo characteristics
What is the rate of TV bioprosthetic valve dysfunction at 10 years?
42%
What types of valve degeneration are seen with porcine and bovine valves?
Bovine - stenosis
Porcine - regurgitation
What are the risk factors for structural valve degeneration?
PATIENT Higher BMI Lower Age DISEASE Smoking Diabetes Hyperparathyroidism Chronic kidney disease ANATOMY Prosthesis patient mismatch Incomplete expansion (Percutaneous valves)
What are the patient related risk factors for thromboembolism in the setting of mechanical heart valve replacement?
Mitral replacement Tricuspid replacement Previous thromboembolism Atrial fibrillation Mitral stenosis of any degree EF <30%
What are the potential management options for patients with prosthetic valve obstructive thrombus?
- Surgery - severe symptoms, mobile veg >3mm or non mobile veg >10mm
- Fibrinolytics - right sided
- Anticoagulation - left sided no indication for surgery
- Palliative care
What is the investigative approach to prosthetic valve thrombus?
Transthoracic echo
Transoesophageal echo
4D CT
What are the echo criteria for prosthetic valve thrombosis?
BOTH
- Impaired cusp mobility
- Cusp thickness >2mm (soft echodensity on echo and hypoattenuation on CT)
- more likely on downstream side of valve
- valve calcification >mild more likely associated with degeneration
What are the considerations that alter the management of a patient with obstructive valve thrombosis?
Age and comorbidities Symptoms Cause of obstruction Valve location Thrombus size Thrombus mobility
What are the factors that favour fibrinolysis for management of obstructive prosthetic valve thrombosis?
High surgical risk No contraindication to fibrinolysis First episode valve thrombosis NYHA1-2 Non mobile clot <1cm Mobile clot <0.3cm No other indication for cardiac surgery Right sided valve involved
What are the factors that favour surgical management of obstructive prosthetic valve thrombosis?
Imaging features with concurrent pannus Low surgical risk Large or mobile clot Other indication for cardiac surgery Contraindication to thrombolytics
What are the indications for PMC in a pregnant female with MS and what is the timing?
Valve area <1.5cm2
Symptomatic NYHA3-4
SPAP >50mmhg
Occur after 20 weeks gestation
Valve prolapse is more common in which mitral valve? And why?
Posterior leaflet
Lax annulus with less fibrous tissue
What is the difference between the primary secondary and tertiary cords?
Primary cords - mitral valve tip attachment
Secondary cords - mitral valve body attachment
Tertiary cords - mitral valve base attachment
Which papillary muscle is more prone to ischaemia and prone to contribute to secondary MR?
Posterolateral pap muscle
Only one artery vs two arteries for anterolateral pap muscle
In the setting of severe AS with functional MR, what tenting area is associated with improvement with Aortic replacement alone?
<2.5cm2
