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AA - Cardiac surgery COPY > Aortic Valve > Flashcards

Aortic Valve Flashcards

1
Q

What are the different surgical approaches for minimally invasive aortic valve replacement?

A

right anterior thoracotomy, upper versus lower partial sternotomy

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2
Q

Disadvantages of minimally invasive aortic valve replacement

A

Longer crossclamp and bypass times

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3
Q

advantages of minimally invasive aortic valve replacement

A

Cosmesis

Possible decrease blood loss, ventilator requirement, and hospital stay

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4
Q

Most common bicuspid aortic valve morphology

A

2 commissures oriented anteroposterior; giving left and right cusps

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5
Q

Most rare bicuspid aortic valve morphology

A

Fusion of the left and non-coronary cusps

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6
Q

Bicuspid aortic valve classification

A

Sievers classification; based on how many raphe

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7
Q

Sievers type 0

A

No raphe; true bicuspid

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8
Q

Sievers type 1

A

1 raphe; either L-R, R-N, N-L. This is the most common type. Likely to develop stenosis in adulthood.

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9
Q

Sievers type 2

A

2 raphe; either L-R, R-N. This usually leads to complication at a younger age

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10
Q

Mechanism of deterioration of prosthetic bovine pericardial valve

A

80% stenosis from dystrophic calcification

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11
Q

Mechanism of deterioration of prosthetic porcine pericardial valve

A

Leaflet tears and aortic regurgitation (80%) due to calcification

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12
Q

Which is better (bioprosthetic or mechanical valve) for patients >65 years

A

No difference

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13
Q

How long does a mechanical valve last?

A

15-25 years

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14
Q

How long does a bioprosthetic valve last?

A

10-14 years

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15
Q

Patients undergoing CABG with concomitant aortic stenosis should have AV replacement only if?

A

the aortic stenosis is moderate or severe (class I)

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16
Q

Patients undergoing CABG with concomitant mild aortic stenosis may have AV replacement only if?

A

there is evidence of rapid progression

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17
Q

Bioprosthetic valve lifespan

A

Tissue valves in the mitral position generally deteriorate more quickly than in the aortic position.

Also deteriorate more quickly in younger patients

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18
Q

Aortic valve replacement (AVR) stroke risk

A

~1.5 % in STS database (2.4% in partner trial)

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19
Q

What is thought to be the cause of Aortic valve replacement (AVR) stroke risk

A

Aortic cross-clamping

20
Q

High stroke risk factors for Aortic valve replacement (AVR)

A 
STS Risk > 10%
Age > 80 
Presence of aortic calcifications
Addition of CABG or other procedures
Ejection fraction <40%
21
Q

Most common Bicuspid Aortic Valve configuration

A

Right-left cusp fusion: 2 commissures located in AP direction, giving right and left cusp. Associated with root dilation. In contrast, the left and non-coronary fusion is the rarest.

22
Q

Bicuspid aortic valve with right-non coronary fusion configuration

A

Has 2 commissures on the right and left sides of the annulus, which creates anterior and posterior cusps
Associated with ascending and arch dilation.

23
Q

In patients with bicuspid valve and has a valve-related indication for surgery, what aortic size should warrant an aortic replacement?

A

> 4.5 cm

24
Q

In patients with bicuspid valve and has no valve-related indication for surgery, what aortic size should warrant an aortic replacement?

A

aortic diameter > 5 cm, or change in diameter >0.5 cm in 1 year

25
Q

Incidence of need for a permanent pacemaker after AVR

A

3-6%

26
Q

Incidence of transient postop AV block of some magnitude

A

45%

27
Q

Peak incidence of post op AV block (in days)

A

2-5 days

28
Q

Generally how long should you wait before placing a permanent pacemaker after AVR

A

Wait 7 days after conventional AVR

29
Q

Risk factors of a permanent pacemaker after AVR

A

1) Pre-existing conducting system disease

Stentless prostheses
Smaller sized valves (<21 mm)
AVR in children/women (possibly due to smaller size?)
Reoperations
Combined: (MVR or CABG plus AV surgery) 
Aortic regurgitation > aortic stenosis.
30
Q

Patient prosthesis mismatch definition

A

Effective orifice index area (EOIA) of a prosthetic valve

31
Q

Criteria for mild, moderate and severe patient prosthesis mismatch (PPM)

A

Mild if >0.85 cm2/m2
Moderate at 0.65-0.85 cm2/m2
Severe if <0.65 cm2/m2

32
Q

<p>Pathophysiology of Aortic Stenosis?</p>

A

<p>In AS, gradual obstruction of the left ventricular outflow leads to an increased left ventricular afterload and left ventricular wall stress, elevated left ventricular systolic and diastolic pressures, decreased aortic pressure, and prolonged left ventricular ejection time. Over time, this results in compensatory concentric left ventricular hypertrophy (LVH) to maintain ejection fraction. In patients with chronic severe AS, this compensatory mechanism may become insufficient, leading to gradual dilation and thinning of the left ventricle, and result in a decrease in ejection fraction and in congestive heart failure.</p>

33
Q

What is the predicted 15 year risk for needing reoperation because of structural deterioration for aortic valve bioprosthesis in patients aged, 20, 40, 50, >65?

A

Overall, the predicted
15-year risk of needing reoperation because of
structural deterioration is 10% for patients over 65, 22% for patients 50
years of age, 30% for patients 40 years of age,
and 50% for patients 20 years of age

34
Q

What are the indications for SAVR in Aortic Stenosis?

A

ACC/AHA 2020

Severe symptomatic aortic stenosis (MG >40 or Vmax >4m/s) Class 1 A

Severe symptomatic low flow low gradient aortic stenosis (AVA <1cm2) with reduced EF and + dobutamine stress testing, the Vmax should rise >4m/s with a AVA of <1cm2 and dobutamine no more than 20mcg/kg/minute Class 1 B. If it doesn’t and the AVA increases, then pseudosevere AS and no surgery. If indeterminate consider MDCT to look at calcium score >2000 men or >1200 women (not in guidelines).

Severe symptomatic low flow low gradient stenosis (AVA <1cm2) with preserved EF, should have LV SVI <35 mL/m2 and AVAi <0.6cm2 along some sign of small LV or LVH. Class 1B

Severe asymptomatic aortic stenosis if:

Exercise stress testing promotes the development of symptoms, a drop in sBP >10mmHg or greatly reduced exercise tolerance. Class 1B

Other concomitant cardiac surgery Class 1C

Severe asymptomatic aortic stenosis and low surgical risk if:

BNP >3x the normal limit Class IIa B

Very severe aortic stenosis Vmax >5.0m/s or MH >60mmHg Class IIa B

Progressively worsening AS >0.3cm/yr Class IIa B

Progressive decrease in LVEF x 3 studies to below 60% Class IIb B

Moderate aortic stenosis if:

Undergoing surgery for other reasons Class IIb C

35
Q

What are the indications for valve decision making (mechanical vs bioprosthetic vs Ross?)

A

In depth individualized discussion about the pros and cons of each valve type for each patient with decision taking into account patient’s preferences and values Class 1 C

Contraindication to anticoagulation, patient refusal or perceived challenge with complying with life long anticoagulation is a indication for bioprosthetic valve l AVR Class 1 C

Age <50 - Mechanical valve Class IIa B

Age 50-65 - Valve type based on individualized discussion and patient’s preferences/values Class IIa B

Age >65 - Bioprosthetic valve Class IIa B

Age <50 and patient prefers bioprosthetic valve, Ross procedure at a specialized center may be recommended Class IIb B

36
Q

If the patient is for bioprosthetic aortic valve, what are the indications for SAVR vs TAVR?

A

In patients with asymptomatic or symptomatic severe AS, and are age <65 or have life expectancy >20 years, SAVR > TAVR Class I A

In patients with symptomatic severe AS, and are age 65-80 or have life expectancy 10-20 years, SAVR vs TAVR should be discussed based on the estimated life-expectancy and valve durability for the patient Class I A

In patients with symptomatic severe AS and age >80 or life expectancy <10 years, TAVR > SAVR Class I A

In asymptomatic patients with severe AS, <80 age, LVEF <50% and no contraindication to TF-TAVR, decision should be based on algorithm above Class I B

In asymptomatic severe AS patients with an indication for AVR and recommendation for bioprosthetic valve but LVEF >50% and low-moderate risk for surgery they should get SAVR Class I B

In patients with an indication for bioprosthetic AVR and there are contraindications for TAVR based on valve or vascular anatomy, SAVR is indicated Class I A

For symptomatic severe AS with a high risk (>8% STS risk) or prohibitive risk of mortality, TAVR is recommended Class I A

For symptomatic severe AS with life expectancy <12 months or expected minimal improvement in life expectancy palliative care is recommended after shared decision making

In critically ill patients were symptomatic severe AS, percutaneous aortic balloon dilation may be considered as a bridge to SAVR or TAVR Class IIb C

37
Q

What is the definition of high, moderate or low risk of mortality in AS according to the STS?

A

High >8%, Moderate 3-8%, Low <3%

38
Q

What are the echo parameters of mild AI aka stage B AI

A 
Jet width <25% of LVOT
Vena contracta <0.3 cm
 Regurgitant volume <30 mL/
beat
Regurgitant fraction <30%
ERO <0.10 cm2
 Angiography grade 1
39
Q

What are the echo parameters of moderate AI aka stage B AI

A 
Jet width 25%–64% of LVOT
Vena contracta 0.3–0.6 cm
 Regurgitant volume 30–59 mL/
beat
 Regurgitant fraction 30% to
49%
ERO 0.10–0.29 cm2
Angiography grade 2
40
Q

What are the echo parameters of severe AI aka stage C/D AI

A 
Jet width ≥65% of LVOT
Vena contracta >0.6 cm
Holodiastolic flow reversal in
the proximal abdominal aorta
 Regurgitant volume ≥60 mL/
beat
Regurgitant fraction ≥50%
ERO ≥0.3 cm2
Angiography grade 3 to 4
 In addition, diagnosis of chronic
severe AR requires evidence of
LV dilation
41
Q

What are the indications for surgery in AI?

A

Symptomatic severe AI Class I A I B

Asymptomatic severe AI with LVEF <55% I B

Asymptomatic severe AI with concomitant cardiac surgery I C

Asymptomatic severe AI with normal LVEF >55% and LVESD >50mm or LVESDi >25mm/m2 IIa B

Asymptomatic severe AI and low risk of surgery with progressive increasing LVEDD to > 65mm or EF dropping under 60% in 3 serial studies IIb B

Moderate AI with concomitant cardiac surgery IIa C

TAVI is not recommended if patient is surgical candidate III B

42
Q

What are the prevalences of moderate AS, AI and aortopathy in biscuspid AV?

A

13-30% for mod+ AS, 12-37% for mod+ AI and 20-40% for aortopathy

43
Q

What is the normal size of the AAo, STJ, sinus of valsalva and aortic annulus?

A

22-36mm for the AAo and STJ, 29-45mm for sinus of valsalva, 20-31 for the aortic annulus.

44
Q

What are the indications to replace the ascending aorta or aortic sinuses in bicuspid aortic valve? What is the indication for valve sparing procedure in bicuspid valve?

A
  1. 5cm Class 1 B
  2. 0cm with risk factors if family hx of aortic dissection, aortic coarctation or aortic growth rate >0.5cm/year when performed at a comprehensive valve center IIa B
  3. 0cm in low risk asymptomatic patients without risk factors when performed at a comprehensive valve center IIb B
  4. 5cm if concomitant AVR when performed at a comprehensive valve center IIa B

In patients with biscuspid valve with aortic sinuses dilation, valve-sparing root replacement may be indicated if performed at a comprehensive valve center IIb C

45
Q

What are the indications for aortic valve repair in bicuspid valve?

A

In patients with severe AI and meet criteria for AVR, bicuspid valve repair can be performed in select patients if performed at a comprehensive valve center - IIb C

46
Q

What are the indications for TAVR in bicuspid valve?

A

In patients with BAV and severe symptomatic AS, TAVR can be considered as an alternative to SAVR if patient risk factors taken into account - IIb B

47
Q

What does the literature show regarding TAVR in bicuspid valve?

A

No difference in paravalvular leak or mortality but higher rate of stroke in bicuspid valve.

AA - Cardiac surgery COPY (29 decks)

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