Valvuloplasty and TranscatheterValve Repair and Replacement Flashcards
What was the outcome of the PARTNER II trial regarding SAVR and TAVR?
There was no difference in all-cause death or disabling stroke between groups
The trial randomized patients with severe symptomatic aortic stenosis at intermediate surgical risk.
What does the 2017 Update of the ACC/AHA Guidelines recommend for symptomatic patients with severe aortic stenosis and intermediate surgical risk?
TAVR is a reasonable alternative to SAVR
This recommendation is based on findings from studies like PARTNER II and SURTAVI.
What is the current understanding of the long-term durability of transcatheter valves?
Long-term durability of transcatheter valves is not yet known
Short-term durability appears excellent and equivalent to surgical bioprosthesis.
True or False: DAPT’s impact on stroke rates after TAVR has been evaluated.
False
Research indicates that while EPDs may decrease embolic events seen on imaging, no reduction in clinical stroke rates has been demonstrated.
What is the definition of severe mitral regurgitation during mitral valvuloplasty?
Mitral regurgitation occurring in about 3% of patients
It is often due to rupture of a chord or a tear in the leaflet.
What scoring system is used to evaluate mitral valve morphology?
The Wilkins score
It includes four characteristics: leaflet mobility, valvular thickening, subvalvular thickening, and valvular calcification.
What is indicated by a total Wilkins score of ≤8?
A mobile valve readily amenable to percutaneous valvuloplasty
Higher scores result in less favorable outcomes after valvuloplasty.
What are the indications for balloon mitral valvuloplasty?
Severe mitral stenosis (MVA ≤1.5 cm2), absence of LA appendage thrombus, and <2+ mitral insufficiency
Class I indications include symptomatic mitral stenosis with favorable anatomy.
What is the normal tricuspid valve area and how is severe tricuspid stenosis defined?
Normal tricuspid valve area is about 10 cm2; severe tricuspid stenosis is diagnosed when mean gradient is >5 mm Hg
Severe tricuspid stenosis can lead to right heart failure.
What does spontaneous echo contrast typically represent?
Slow atrial flow
It is often associated with a higher risk for embolization but does not indicate circulating thrombi.
What is the latest guideline’s stance on endocarditis prophylaxis for patients with mitral valve stenosis?
Patients do not require endocarditis prophylaxis
The risk for endocarditis has not been shown to be reduced following mitral valvuloplasty.
What defines low-gradient, low-output aortic stenosis?
Mean gradient <30 mm Hg and AVA <1.0 cm2
Distinguishing true stenosis from pseudostenosis is essential in this condition.
What is the expected peak gradient reduction after a successful percutaneous balloon valvuloplasty of a classic domed pulmonary valve?
From about 90 mm Hg to about 29 mm Hg
The procedure has a low risk, generally in the range of 1% to 2%.
What is VIV TAVR indicated for?
Treatment of degenerated aortic bioprosthesis with resultant aortic stenosis or regurgitation
Short-term outcomes are acceptable, but outcomes depend on the size of the surgical bioprosthesis.
What is the definition of a successful pulmonary valvuloplasty procedure?
Gradient reduced to <20 mm Hg
The success rate is over 90% and complications are rare.
What does TAVR stand for?
Transcatheter Aortic Valve Replacement
TAVR is a minimally invasive procedure for aortic valve replacement.
What is the desired outcome of a successful TAVR procedure in terms of pressure gradient?
Gradient reduced to <20 mm Hg
This indicates a successful reduction in the obstruction caused by aortic stenosis.
What is the success rate of pulmonary valvuloplasty?
Over 90%
Complications are rare in this procedure.
What is the typical size to which the pulmonary artery is dilated during valvuloplasty?
1.2 to 1.4 times the measured anulus
This accounts for the elastic recoil of the pulmonary artery.
What is the peak aortic velocity gradient that indicates a need for intervention based on symptoms?
4.5 m/s
This corresponds to a peak instantaneous aortic valve gradient of 81 mm Hg.
What is the average reduction in aortic gradient achieved by balloon aortic valvuloplasty in adolescents?
About 60
The procedure has a high success rate of 90% with a procedural mortality of <2%.
True or False: Balloon aortic valvuloplasty is effective in elderly patients.
False
It has not proven to be effective in elderly patients.
What hemodynamic changes occur during pregnancy?
25% increase in red blood cell mass, 30% to 50% increase in blood volume
This leads to relative anemia and changes in vascular resistance.
What is the mitral valve area threshold for intervention in pregnant patients with severe mitral stenosis?
≤1.5 cm2
This is accompanied by severe symptoms despite medical therapy.
What was the 1-year survival rate for patients undergoing transcatheter mitral valve repair with MitraClip compared to a control group?
76% vs. 55%
This was part of the EVEREST II High-Risk Registry.
What is a common complication associated with aortic valvuloplasty?
57% of patients experienced complications
Serious adverse events occurred in 15.6% of patients.
What was the 1-year mortality rate for patients randomized to TAVR in the PARTNER trial?
30.7%
Compared to 49.7% in medically treated patients.
What access sites can be used for TAVR?
Iliofemoral vessels, ascending/descending aorta, subclavian, axillary, carotid arteries
TAVR can also be performed via a transseptal approach or LV apical approach.
What were the results of the EVEREST II trial comparing MitraClip to surgical repair?
Surgery favored with 73% vs. 55% freedom from mitral valve dysfunction
However, MitraClip had a better procedural safety profile.
What is the recommendation for transcatheter paravalvular leak closure according to the 2014 AHA/ACC guidelines?
Reasonable only for high-risk surgical patients with suitable anatomy
This is for severe CHF symptoms or refractory hemolysis.
What is the primary indication for MitraClip in patients?
Symptomatic patients with severe degenerative mitral regurgitation at prohibitive surgical risk
Not approved for functional mitral regurgitation.
What is the three-year survival rate following transcatheter paravalvular leak closure?
64.3%
Among survivors, 72% showed freedom from CHF symptoms or reoperation.
What is a significant risk factor associated with hemolytic anemia post-valve surgery?
Residual paravalvular leak
Complete closure of the leak is necessary to resolve hemolytic anemia.
What is the procedural mortality rate reported in aortic valvuloplasty?
1.6%
This includes various complications such as vascular complications and bleeding.
What is the impact of access site on outcomes following TAVR?
Transfemoral TAVR shows greater improvement in quality of life
Access site choice can affect patient outcomes.
Fill in the blank: The rate of paravalvular aortic insufficiency is approximately ______.
5% incidence of moderate or severe paravalvular AI
This is consistent across balloon-expandable and self-expanding valves.
What is the primary cause of hemolytic anemia in the context of a paravalvular leak?
Destruction of red blood cells due to turbulence created through the paravalvular leak
Turbulence from the leak leads to hemolysis.
What initial therapies may resolve mild hemolysis?
Folate, iron, and erythropoietin
These treatments may help in cases of mild hemolysis but were ineffective in the discussed patient.
What interventions may be required for definitive repair in severe cases?
Surgical or transcatheter intervention
These should be considered for high-risk surgical patients with suitable anatomy.
In what scenarios should surgical intervention for paravalvular leak be considered?
Severe CHF symptoms or refractory hemolysis
Intervention is recommended at centers with expertise.
What risk does withholding warfarin pose for patients with a mechanical prosthetic valve?
Risk for thrombosis of the mechanical prosthetic valve
Withholding warfarin is not an appropriate strategy.
What is the incidence of complications following transseptal puncture in experienced centers?
Less than 5%
Complications are uncommon in skilled hands.
What immediate differential diagnoses should be considered following transseptal puncture?
- Vagal reaction
- Perforation of a cardiac structure with pericardial tamponade
- Bleeding from the access site
- Coronary embolus (either thrombus or air)
These conditions should be evaluated if complications arise.
What heart rate change would indicate a vagal reaction?
Lower heart rate
A vagal reaction typically results in bradycardia.
What heart rate change would suggest a retroperitoneal or access site bleed?
High heart rate
Tachycardia may indicate significant blood loss.
What should be done before proceeding with a procedure if hypotension is present?
Determine the cause of the hypotension
It is crucial to identify the underlying issue before continuing.
What does the ECG suggest in this instance?
Acute inferoposterior myocardial injury
This finding necessitates further investigation.
What would be the appropriate next step if acute inferoposterior myocardial injury is suggested on ECG?
Coronary angiography
This procedure would help determine if there is a coronary embolus.
