VHD

Question 1

Etiologies

Answer 1

Mitral Stenosis: RHEUMATIC FEVER

Mitral Regurgitation: Ischemia/Infarcts

Aortic Stenosis: Aging

Aortic Regurgitation: Idiopathic

Question 2

Aortic Stenosis: Meds Prior to Surgery

Answer 2

1. BP drugs (RAAS)
2. Cholesterol drugs (statins)

Question 3

Aortic Regurgitation: Tx

Answer 3

1. Acute = surgery
2. Chronic
   -Healthy lifestyle (diet, exercise)
   -ACEI/ARNI/ARBs

Question 4

Mitral Stenosis: Tx

Answer 4

AF, LA thrombus, embolic event = Warfarin

Heart rate control

Question 5

Mitral Regurgitation: Acute + Chronic Tx

Answer 5

Acute
1. Vasodilator (Nicardipine or Nitroprusside)
2. Intra-aortic balloon pump
3. MV repair/replacement with DAPT after for 1-6 mo

Chronic
-Standard GDMT for HF

Question 6

Prosthetic Heart Valves

Answer 6

Mechanical = lifelong Warfarin

Bio/Tissue = no long-term AC needed

Question 7

A bioprosthetic valve is recommended when…

Answer 7

Patients of any age requiring valve replacement for whom anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired

Question 8

The “NOs”

Answer 8

If bioprosthetic TAVI
-NO RIVA/ASP

If mechanical
-NO DABI
-NO XA DOAC

Question 9

Mechanical Valve: Guidelines

Answer 9

AVR + no other risk factors
-INR goal of 2.5
-Add ASA 75-100 mg
-No bridging needed

AVR + risk factors or MVR
-INR goal of 3
-Add ASA 75-100 mg
-Bridging necessary

Question 10

Bioprosthetic Valve: Guidelines

Answer 10

Bioprosthetic AVR or MVR
-Initial 3-6 mo: INR goal of 2.5
-Lifelong: ASA 75-100 mg

TAVI
-Initial 3-6 mo: ASA 75-100 mg with Clopidogrel 75 mg OR Warfarin INR goal of 2.5
-Lifelong: ASA 75-100 mg

Question 11

AC for On-X AVR

Answer 11

First 3 mo: Goal INR 2-3
+ ASA 81

After 3 mo: Goal INR 1.5-2 (if no TE RF)
+ ASA 81

Question 12

Bridging Therapy

Answer 12

IV UFH or LMWH
-therapeutic dosing (Xa 0.3-0.7 or aPTT 50-77)

Question 13

How do we manage thromboembolic events in patients with prosthetic heart valves?

Answer 13

Mechanical AVR
-Increase INR goal to 3 (2.5-3.5) or add ASA 81 daily

Mechanical MVR
-Increase INR to 4 (3.5-4.5) or add ASA 81 daily

Bioprosthetic/Transcatheter
-Consider warfarin

Question 14

Pregnancy: Tx

Answer 14

Bioprosthetic preferred
-BB, diuretics (NO ACEI/ARB = CI)

AC
-Warfarin < 5: continue W for all 3 tris or LMWH for 1 tri then W for 2-3 try
-Warfarin > 5: LMWH for 1 tri then W for 2-3 try or LMWH for all 3 tri
*If can’t monitor LMWH with anti-Xa: use UFH for 1 tri and W for 2-3 tri