Valvuloplasty and TranscatheterValve Repair and Replacement Flashcards

1
Q

What was the outcome of the PARTNER II trial regarding SAVR and TAVR?

A

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.

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2
Q

What does the 2017 Update of the ACC/AHA Guidelines recommend for symptomatic patients with severe aortic stenosis and intermediate surgical risk?

A

TAVR is a reasonable alternative to SAVR

This recommendation is based on findings from studies like PARTNER II and SURTAVI.

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3
Q

What is the current understanding of the long-term durability of transcatheter valves?

A

Long-term durability of transcatheter valves is not yet known

Short-term durability appears excellent and equivalent to surgical bioprosthesis.

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4
Q

True or False: DAPT’s impact on stroke rates after TAVR has been evaluated.

A

False

Research indicates that while EPDs may decrease embolic events seen on imaging, no reduction in clinical stroke rates has been demonstrated.

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5
Q

What is the definition of severe mitral regurgitation during mitral valvuloplasty?

A

Mitral regurgitation occurring in about 3% of patients

It is often due to rupture of a chord or a tear in the leaflet.

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6
Q

What scoring system is used to evaluate mitral valve morphology?

A

The Wilkins score

It includes four characteristics: leaflet mobility, valvular thickening, subvalvular thickening, and valvular calcification.

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7
Q

What is indicated by a total Wilkins score of ≤8?

A

A mobile valve readily amenable to percutaneous valvuloplasty

Higher scores result in less favorable outcomes after valvuloplasty.

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8
Q

What are the indications for balloon mitral valvuloplasty?

A

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.

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9
Q

What is the normal tricuspid valve area and how is severe tricuspid stenosis defined?

A

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.

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10
Q

What does spontaneous echo contrast typically represent?

A

Slow atrial flow

It is often associated with a higher risk for embolization but does not indicate circulating thrombi.

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11
Q

What is the latest guideline’s stance on endocarditis prophylaxis for patients with mitral valve stenosis?

A

Patients do not require endocarditis prophylaxis

The risk for endocarditis has not been shown to be reduced following mitral valvuloplasty.

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12
Q

What defines low-gradient, low-output aortic stenosis?

A

Mean gradient <30 mm Hg and AVA <1.0 cm2

Distinguishing true stenosis from pseudostenosis is essential in this condition.

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13
Q

What is the expected peak gradient reduction after a successful percutaneous balloon valvuloplasty of a classic domed pulmonary valve?

A

From about 90 mm Hg to about 29 mm Hg

The procedure has a low risk, generally in the range of 1% to 2%.

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14
Q

What is VIV TAVR indicated for?

A

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.

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15
Q

What is the definition of a successful pulmonary valvuloplasty procedure?

A

Gradient reduced to <20 mm Hg

The success rate is over 90% and complications are rare.

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16
Q

What does TAVR stand for?

A

Transcatheter Aortic Valve Replacement

TAVR is a minimally invasive procedure for aortic valve replacement.

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17
Q

What is the desired outcome of a successful TAVR procedure in terms of pressure gradient?

A

Gradient reduced to <20 mm Hg

This indicates a successful reduction in the obstruction caused by aortic stenosis.

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18
Q

What is the success rate of pulmonary valvuloplasty?

A

Over 90%

Complications are rare in this procedure.

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19
Q

What is the typical size to which the pulmonary artery is dilated during valvuloplasty?

A

1.2 to 1.4 times the measured anulus

This accounts for the elastic recoil of the pulmonary artery.

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20
Q

What is the peak aortic velocity gradient that indicates a need for intervention based on symptoms?

A

4.5 m/s

This corresponds to a peak instantaneous aortic valve gradient of 81 mm Hg.

21
Q

What is the average reduction in aortic gradient achieved by balloon aortic valvuloplasty in adolescents?

A

About 60

The procedure has a high success rate of 90% with a procedural mortality of <2%.

22
Q

True or False: Balloon aortic valvuloplasty is effective in elderly patients.

A

False

It has not proven to be effective in elderly patients.

23
Q

What hemodynamic changes occur during pregnancy?

A

25% increase in red blood cell mass, 30% to 50% increase in blood volume

This leads to relative anemia and changes in vascular resistance.

24
Q

What is the mitral valve area threshold for intervention in pregnant patients with severe mitral stenosis?

A

≤1.5 cm2

This is accompanied by severe symptoms despite medical therapy.

25
Q

What was the 1-year survival rate for patients undergoing transcatheter mitral valve repair with MitraClip compared to a control group?

A

76% vs. 55%

This was part of the EVEREST II High-Risk Registry.

26
Q

What is a common complication associated with aortic valvuloplasty?

A

57% of patients experienced complications

Serious adverse events occurred in 15.6% of patients.

27
Q

What was the 1-year mortality rate for patients randomized to TAVR in the PARTNER trial?

A

30.7%

Compared to 49.7% in medically treated patients.

28
Q

What access sites can be used for TAVR?

A

Iliofemoral vessels, ascending/descending aorta, subclavian, axillary, carotid arteries

TAVR can also be performed via a transseptal approach or LV apical approach.

29
Q

What were the results of the EVEREST II trial comparing MitraClip to surgical repair?

A

Surgery favored with 73% vs. 55% freedom from mitral valve dysfunction

However, MitraClip had a better procedural safety profile.

30
Q

What is the recommendation for transcatheter paravalvular leak closure according to the 2014 AHA/ACC guidelines?

A

Reasonable only for high-risk surgical patients with suitable anatomy

This is for severe CHF symptoms or refractory hemolysis.

31
Q

What is the primary indication for MitraClip in patients?

A

Symptomatic patients with severe degenerative mitral regurgitation at prohibitive surgical risk

Not approved for functional mitral regurgitation.

32
Q

What is the three-year survival rate following transcatheter paravalvular leak closure?

A

64.3%

Among survivors, 72% showed freedom from CHF symptoms or reoperation.

33
Q

What is a significant risk factor associated with hemolytic anemia post-valve surgery?

A

Residual paravalvular leak

Complete closure of the leak is necessary to resolve hemolytic anemia.

34
Q

What is the procedural mortality rate reported in aortic valvuloplasty?

A

1.6%

This includes various complications such as vascular complications and bleeding.

35
Q

What is the impact of access site on outcomes following TAVR?

A

Transfemoral TAVR shows greater improvement in quality of life

Access site choice can affect patient outcomes.

36
Q

Fill in the blank: The rate of paravalvular aortic insufficiency is approximately ______.

A

5% incidence of moderate or severe paravalvular AI

This is consistent across balloon-expandable and self-expanding valves.

37
Q

What is the primary cause of hemolytic anemia in the context of a paravalvular leak?

A

Destruction of red blood cells due to turbulence created through the paravalvular leak

Turbulence from the leak leads to hemolysis.

38
Q

What initial therapies may resolve mild hemolysis?

A

Folate, iron, and erythropoietin

These treatments may help in cases of mild hemolysis but were ineffective in the discussed patient.

39
Q

What interventions may be required for definitive repair in severe cases?

A

Surgical or transcatheter intervention

These should be considered for high-risk surgical patients with suitable anatomy.

40
Q

In what scenarios should surgical intervention for paravalvular leak be considered?

A

Severe CHF symptoms or refractory hemolysis

Intervention is recommended at centers with expertise.

41
Q

What risk does withholding warfarin pose for patients with a mechanical prosthetic valve?

A

Risk for thrombosis of the mechanical prosthetic valve

Withholding warfarin is not an appropriate strategy.

42
Q

What is the incidence of complications following transseptal puncture in experienced centers?

A

Less than 5%

Complications are uncommon in skilled hands.

43
Q

What immediate differential diagnoses should be considered following transseptal puncture?

A
  • 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.

44
Q

What heart rate change would indicate a vagal reaction?

A

Lower heart rate

A vagal reaction typically results in bradycardia.

45
Q

What heart rate change would suggest a retroperitoneal or access site bleed?

A

High heart rate

Tachycardia may indicate significant blood loss.

46
Q

What should be done before proceeding with a procedure if hypotension is present?

A

Determine the cause of the hypotension

It is crucial to identify the underlying issue before continuing.

47
Q

What does the ECG suggest in this instance?

A

Acute inferoposterior myocardial injury

This finding necessitates further investigation.

48
Q

What would be the appropriate next step if acute inferoposterior myocardial injury is suggested on ECG?

A

Coronary angiography

This procedure would help determine if there is a coronary embolus.