Week 11 heart valves Flashcards
What is aortic stenosis?
A1:
Aortic stenosis is a narrowing of the aortic valve due to calcification and stiffening.
This limits the valve’s ability to open fully, impeding blood flow from the left ventricle to the aorta.
Over time, the valve no longer seals properly, leading to regurgitation (backflow of blood into the left ventricle).
What are the primary causes of aortic stenosis?
A2:
Calcification of the aortic valve, where calcium deposits harden the valve.
Age-related wear and tear.
Sometimes caused by congenital valve defects, such as a bicuspid aortic valve.
What are the consequences of untreated severe aortic stenosis?
A3:
High mortality rate: 50-60% within two years.
Less than 30% survival rate after three years without treatment.
Leads to heart failure, arrhythmias, and even sudden death.
What are the two main types of aortic valve replacement options?
A4:
Surgical Aortic Valve Replacement (SAVR):
Involves thoracotomy (open-heart surgery) with multiple sutures ensuring a perfect fit.
Transcatheter Aortic Valve Replacement (TAVR/TAVI):
A less invasive method where a new valve is delivered via a catheter through the femoral or radial artery.
What are the characteristics of mechanical aortic valves?
A5:
Made from titanium or carbon.
Highly durable and long-lasting (lifetime).
Thrombogenic: Requires lifelong anticoagulation (e.g., warfarin) to prevent clotting.
Not suitable for patients planning future surgeries, pregnancy, or those with contraindications to warfarin.
Q6: What are the characteristics of tissue (bioprosthetic) aortic valves?
A6:
Derived from porcine or bovine pericardium.
Treated to reduce immunogenicity.
Blood compatible: No need for lifelong anticoagulation.
Shorter lifespan (3-15 years), with faster degeneration in younger patients.
Q7: What are the advantages of mechanical valves over tissue valves?
A7:
Mechanical valves last a lifetime and do not degrade like tissue valves.
Preferred in younger patients to avoid repeated surgeries.
Q8: What are the advantages of tissue valves over mechanical valves?
A8:
Do not require anticoagulation, making them ideal for patients where warfarin is contraindicated (e.g., pregnancy, high risk of bleeding).
Provide a more “natural” function but need replacement sooner.
What are the limitations of tissue valves?
A9:
Prone to accelerated calcification and degeneration, especially in younger patients.
Typically last 3-5 years in younger patients, longer in older patients.
Q10: What is TAVR and how does it differ from SAVR?
A10:
TAVR is a minimally invasive procedure, where a new valve is deployed via a catheter, usually in high-risk surgical patients.
SAVR is an open-heart surgery that involves removing the damaged valve and stitching in a new one.
TAVR has lower risks of death, stroke, and re-hospitalization but is more prone to complications like paravalvular leaks.
Q11: Why is TAVR not yet widely used for younger patients?
A11:
TAVR uses tissue valves, which degrade faster and may require earlier replacement.
Risk of paravalvular leak, where blood leaks around the valve due to a poor fit, is higher in TAVR compared to SAVR.
Q12: What is a paravalvular leak and why is it a concern in TAVR?
A12:
A paravalvular leak occurs when blood flows around the newly implanted valve due to improper sealing.
It’s caused by an imperfect fit in the irregular, calcified valve annulus.
Mild leaks occur in ~40% of TAVR patients and are linked to increased mortality over 3 years.
Q13: What are the current strategies to reduce paravalvular leaks in TAVR?
A13:
Oversizing the valve to ensure a snug fit.
Post-deployment balloon expansion to seal the valve better.
Valve-in-valve deployment for rescuing leaks.
New technologies like hydrogel seals that expand on contact with blood.
Q14: What are the limitations of minimally invasive valve replacement (TAVR)?
A14:
Only tissue valves can be used, as mechanical valves cannot be crimped and delivered through a catheter.
Risk of paravalvular leaks, which can undermine valve performance.
TAVR valves degrade faster than SAVR valves, limiting their use in younger patients.
Very high cost compared to SAVR (TAVR ≈ $35,000 vs. SAVR ≈ $3,000).
Q15: What are the benefits of minimally invasive TAVR over traditional SAVR?
A15:
Lower mortality, stroke, and re-hospitalization rates in the short term.
Faster recovery: Patients can often walk the day after the procedure.
Suitable for elderly and high-risk patients who may not tolerate open-heart surgery well.
Q16: What ongoing research aims to improve TAVR durability and effectiveness?
A16:
Development of better polymer-based valves that resist calcification and are blood-compatible.
Hydrogel-based technologies that seal gaps to prevent leaks.
New designs, like cross-linked polymers, aim to provide longer durability while fitting irregular annuli.
Q17: Why are mechanical valves not used in TAVR?
A17:
Mechanical valves cannot be crimped and delivered via catheter due to their rigid structure.
Only tissue valves, which can be folded and expanded, are currently viable for TAVR procedures.
Q1: A 75-year-old patient presents with severe aortic stenosis. They are otherwise healthy but concerned about the long-term effects of anticoagulation therapy. What type of valve replacement would be most suitable for this patient?
A1:
Tissue valve replacement is likely the best option for this patient.
Given their age, tissue valves tend to last longer before needing replacement, as calcification progresses slower in older adults.
Most importantly, tissue valves do not require lifelong anticoagulation, which is crucial for a patient concerned about the risks of anticoagulation therapy (e.g., bleeding complications).
Q2: A 40-year-old patient requires aortic valve replacement. They lead an active lifestyle and want to avoid future surgeries. What would be the most appropriate valve type?
A2:
A mechanical valve would be more suitable for this younger, active patient.
Mechanical valves are more durable and can last a lifetime, significantly reducing the likelihood of needing another surgery.
Although mechanical valves require lifelong anticoagulation therapy (e.g., warfarin), the patient’s preference for avoiding future surgeries makes this the better choice.
Q3: A patient has undergone a Transcatheter Aortic Valve Replacement (TAVR) but now presents with symptoms of heart failure. Imaging shows a paravalvular leak. What could be the cause, and what are potential solutions?
A3:
The likely cause is improper sealing of the valve due to the irregular shape of the calcified annulus, leading to paravalvular leak.
Possible solutions include:
Balloon post-dilation: Expand the valve further to improve the seal.
Valve-in-valve procedure: Insert a second valve to fill the gaps left by the first valve.
Hydrogel seals: These can expand upon contact with blood to close any remaining gaps.
Q4: A 68-year-old female is ineligible for traditional Surgical Aortic Valve Replacement (SAVR) due to her comorbidities and frailty. What would be an appropriate treatment option, and what are its benefits?
A4:
Transcatheter Aortic Valve Replacement (TAVR) is the appropriate choice for this patient.
Benefits of TAVR:
It’s minimally invasive, so it’s safer for high-risk patients or those who cannot undergo open-heart surgery.
The recovery time is significantly shorter, and the procedure is often performed without general anesthesia.
There is less risk of surgical complications, such as infection or excessive bleeding.
Q5: A young patient with severe aortic stenosis wishes to avoid open-heart surgery and chooses TAVR. What potential issues should be discussed with the patient regarding this choice?
A5:
Durability of the valve: TAVR uses tissue valves, which are prone to faster degeneration in younger patients. They may need a replacement valve within 5-10 years.
Risk of paravalvular leaks: Unlike SAVR, TAVR doesn’t use sutures, so there’s a higher risk of leaks around the valve, which could cause regurgitation or even require another intervention.
Future interventions: If the tissue valve fails, a repeat procedure may be needed, and TAVR is not yet fully proven in younger populations over long periods.
Q6: After a successful mechanical valve implantation in a patient with aortic stenosis, they experience recurrent bruising and minor bleeding. What is likely causing these symptoms, and how should their treatment be managed?
A6:
The patient is likely experiencing side effects from anticoagulation therapy (warfarin), which is necessary to prevent thrombosis on the mechanical valve.
Management may involve adjusting the warfarin dose or switching to a newer anticoagulant (if appropriate). Close monitoring of INR (International Normalized Ratio) is essential to maintain therapeutic levels and minimize the risk of bleeding.
Q7: A patient undergoing valve replacement surgery expresses concern about their physical activity post-surgery. How would the choice between a mechanical valve and a tissue valve influence their postoperative lifestyle?
A7:
Tissue valves: Allow for a more “normal” lifestyle post-surgery since they do not require anticoagulation. Patients can engage in sports or activities without the heightened risk of bleeding complications.
Mechanical valves: Require lifelong anticoagulation, which comes with activity restrictions (e.g., avoiding high-contact sports or activities with a high risk of injury) to reduce the risk of bleeding. Frequent monitoring of anticoagulation levels may also impact daily life.