Valvular Heart Disease

Question 1

Causes of mitral stenosis? (5+)

Answer 1

Rheumatic fever (most common)

Carcinoid

SLE

RA

Fabry

Whipples

Question 2

What are you looking for in TTE in patients with MS? (4)

Answer 2

Size of MV orifice, transvalvular gradient

Ventricular/atrial chamber size

PA pressure

LA thrombus

Question 3

Goals of Mx - Mitral stenosis? (3)

Answer 3

Reduce recurrence of Rheumatic fever

Minimise symptoms of pulmonary congestion

Prevent complications: AF, VTE, infective endocarditis

Question 4

Specific management of mitral stenosis?

Answer 4

Rheumatic MS - ABx prophylaxis for secondary prevention.

If asymptomatic - monitor with regular TTE (1-3 yearly based on MV area)

For symptomatic (NYHA III-IV) and severe MS (MVA <1.5cm²), options are MV valvotomy or MV surgery (repair, commissurotomy [cut it to make it wider] or replacement)

Mitral valvotomy - patient need to have favorable morphology, no LA thrombus, no moderate-sev MR

Surgery who are a surgical candidate or failed percutaneous mitral valvotomy or those who are having CTx for other indications (e.g. CABG)

In Asymptomatic patient the evidence is very limited, but generally recommended to perform MV valvotomy with those with severe MS and new onset AF.

Question 5

What is the choice of drug for valvular AF? (i.e. MS patient with AF)

Answer 5

Warfarin. NOACS are only approved for non-valvular AF.

Question 6

in acute severe AR, how can you support the patient until surgical intervention occur?

Answer 6

Aim is to reduce the afterload & duration of diastole and augment CO.

Reduce afterload with Sodium Nutroprusside (only if hypertensive)

Shorten diastole + increase Cardiac output with Dobutamine