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RACP Cardio AT > Valvular Heart Disease > Flashcards

Valvular Heart Disease Flashcards

1
Q

What are the echocardiographic indications for surgery in chronic AR?

A

EF <50%
LVESD >5cm
LVEDD >6.5cm
Rapid progression/deterioration

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2
Q

What is the Wilkins Score and what is its use?

A

Predicts procedural success for mitral valvuloplasty based on valve structure. <8 predicts favourable result.

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3
Q

What are the scores used to predict outcomes after valve surgery?

A

Euroscore 2

STS score

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4
Q

At what aortic diameter in a female with marfans or bicuspid Aortic valve would you recommend against pregnancy?

A

> 50mm

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5
Q

What is the medical therapy for chronic AR?

A

ACE/ARB

Beta Blocker

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6
Q

What is the progression of moderate AR without concurrent aortic dilation?

A

Slow

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7
Q

What is the use of MSCT in the setting of AS?

A

Useful to characterise likelihood of severity in the setting of low flow, low gradient AS in patients with HFPEF

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8
Q

What are the risk factors post cardiac valve surgery not considered in the ES2 and STS scores?

A

Porcelain aorta
Frailty
Sequelae of chest radiotherapy

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9
Q

In what valve disease does exercise testing provide information on prognosis and management?

A

Aortic stenosis

Mitral regurgitation

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10
Q

What is the Carpentier classification?

A

Used to characterise mitral valve anatomy in preparation for surgery

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11
Q

Describe the types in the carpentier classification.

A

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

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12
Q

What are the most common causes of MR based on the Carpentier classification?

A

Type 1 - secondary MR, endocarditis with perforation
Type 2 - degenerative Disease
Type 3a - rheumatic heart disease
Type 3b - ischaemic MR

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13
Q

What are the most common causes of MR?

A

Degenerative (60-70%)
Functional (25%)
Rheumatic (15%)

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14
Q

What are the indications on echocardiography for surgery in the setting of asymptomatic severe primary mitral regurgitation?

A

EF - <60%
LVESD >45mm
SPAP >50mmhg
(new onset AF)

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15
Q

What are the independent predictors of failed mitral valve repair?

A

Operative - Surgical inexperience
Pathological - Infective endocarditis
Mitral Valve Anatomy - Absence of annular dilation, Mitral stenosis/sclerosis, leaflet calcification, annular calcification

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16
Q

What are the benefits of MV repair over replacement?

A

Reduced peri-operative mortality (ARR 3-4%)
Better 20 year survival (ARR 20%)
Reduced re-operation

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17
Q

What is the medical therapy for acute mitral regurgitation?

A

Diuretics and Nitrates to reduce filling pressures

+/- inotropic agents and IABP

18
Q

When is a patient with severe MR considered to have a low EF and would warrant Href therapy?

A

<60%

19
Q

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?

A

Flail leaflet

LA dilatation >60ml/m2 in sinus rhythm

20
Q

What additional investigations can be useful in the assessment of secondary mitral regurgitation when it is unclear if surgery will be of benefit?

A

Stress echocardiography

21
Q

Why must a TOE be performed prior to mitral valve comissurotomy?

A

Exclude left atrial thrombus

22
Q

When is it appropriate to utilise stress echocardiography in the setting of MS?

A

Asymptomatic or symptoms discordant with severity of MS

23
Q

What are the contraindications to mitral valve commisurotomy?

A 
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
24
Q

What is the medical therapy for mitral stenosis?

A

Diuretics
Beta Blockers
Consider digoxin/calcium channel blockers to control rate

25
Q

What are the echo criteria for significant prosthetic valve degeneration?

A

Mean Transvalvular gradient - >20mmhg

EOA decrease - >0.6cm2

Doppler velocity index decrease - >0.15

26
Q

In patients with mitral stenosis in sinus rhythm, when would you consider anticoagulation?

A

Spontaneous echo contrast in LA

LA volume >60ml/m2

27
Q

When would you consider intervention on an asymptomatic patient with mitral stenosis with MVA <1.5?

A

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

28
Q

What is the rate of TV bioprosthetic valve dysfunction at 10 years?

A

42%

29
Q

What types of valve degeneration are seen with porcine and bovine valves?

A

Bovine - stenosis

Porcine - regurgitation

30
Q

What are the risk factors for structural valve degeneration?

A 
PATIENT
Higher BMI 
Lower Age 
DISEASE
Smoking 
Diabetes 
Hyperparathyroidism 
Chronic kidney disease 
ANATOMY
Prosthesis patient mismatch 
Incomplete expansion (Percutaneous valves)
31
Q

What are the patient related risk factors for thromboembolism in the setting of mechanical heart valve replacement?

A 
Mitral replacement 
Tricuspid replacement 
Previous thromboembolism 
Atrial fibrillation 
Mitral stenosis of any degree 
EF <30%
32
Q

What are the potential management options for patients with prosthetic valve obstructive thrombus?

A
  1. Surgery - severe symptoms, mobile veg >3mm or non mobile veg >10mm
  2. Fibrinolytics - right sided
  3. Anticoagulation - left sided no indication for surgery
  4. Palliative care
33
Q

What is the investigative approach to prosthetic valve thrombus?

A

Transthoracic echo
Transoesophageal echo
4D CT

34
Q

What are the echo criteria for prosthetic valve thrombosis?

A

BOTH

  1. Impaired cusp mobility
  2. 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
35
Q

What are the considerations that alter the management of a patient with obstructive valve thrombosis?

A 
Age and comorbidities
Symptoms 
Cause of obstruction
Valve location
Thrombus size 
Thrombus mobility
36
Q

What are the factors that favour fibrinolysis for management of obstructive prosthetic valve thrombosis?

A 
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
37
Q

What are the factors that favour surgical management of obstructive prosthetic valve thrombosis?

A 
Imaging features with concurrent pannus
Low surgical risk 
Large or mobile clot 
Other indication for cardiac surgery 
Contraindication to thrombolytics
38
Q

What are the indications for PMC in a pregnant female with MS and what is the timing?

A

Valve area <1.5cm2
Symptomatic NYHA3-4
SPAP >50mmhg

Occur after 20 weeks gestation

39
Q

Valve prolapse is more common in which mitral valve? And why?

A

Posterior leaflet

Lax annulus with less fibrous tissue

40
Q

What is the difference between the primary secondary and tertiary cords?

A

Primary cords - mitral valve tip attachment
Secondary cords - mitral valve body attachment
Tertiary cords - mitral valve base attachment

41
Q

Which papillary muscle is more prone to ischaemia and prone to contribute to secondary MR?

A

Posterolateral pap muscle

Only one artery vs two arteries for anterolateral pap muscle

42
Q

In the setting of severe AS with functional MR, what tenting area is associated with improvement with Aortic replacement alone?

A

<2.5cm2

RACP Cardio AT (13 decks)

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