Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

AA - Cardiac surgery COPY > Mitral Valve > Flashcards

Mitral Valve Flashcards

1
Q

Symptoms of acute ischemic mitral regurgitation

A

Shock; pulm edema

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Etiology of acute ischemic mitral regurgitation

A

Involvement of papillary muscle during MI (40% of STEMI); posteromedial papillary muscle is affected in 3/4 of cases, as its blood supply is from a single source (either right or distal circumflex)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Temporizing measures for acute ischemic mitral regurgitation

A

IABP or ECLS. Usually requires emergent mitral valve replacements (rare repair) +/- CABG

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is the Wilkins score

A

Assessment of mitral valve anatomy for mitral valve stenosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What characteristics included in Wilkins score

A

Mobility
Subvalvular thickening
Leaflet thickening
Calcification

The Score is the sum of severity number (1-4) to 4 valve characteristics

Wilkins score <9 and less than moderate mitral regurgitation has the best outcomes.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Contraindication to balloon valvuloplasty

A

Mild mitral stenosis
Moderate or severe regurgitation
Left atrial thrombus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is considered a successful Balloon Mitral Valvotomy (BMV)>

A

Post-procedure mitral valve area >1.5 cm2with no more than moderate mitral regurg

Approximately 65% percent of patients are free of restenosis after 10 years.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Criteria for severe Mitral valve insufficiency (5)

A 
Vena contracta > 0.7 cm
Regurgitant volume > 60 mL
Regurgitant fraction > 50 %
Left ventricular dilation > 4 cm
Effective regurg orifice > 0.4 cm
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Which trial studied the surgical management of ischemic mitral regurgitation?

What are the findings of the trial?

A

CTSnet trial

Studied repair vs replacement

No significant difference in 2 year survival (although not powered to study survival)

No difference in LVESV

Risk of recurrence significantly more for MV repair than replacement (58.8% vs 3.8%). More readmission for CV and heart failure symptoms.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Operation for ischemic mitral regurg

A

The best operation for ischemic MR is controversial.

a) Mitral valve REPAIR with a somewhat downsized annuloplasty ring can be performed with low mortality.
b) Mitral valve REPLACEMENT: higher operative mortality but a stable resolution of regurgitation. Unfortunately, this operation also fails to yield a survival benefit over continued medical therapy.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Diagnosis of hemolysis after MV repair/replace

A

1) Persistent anemia (hgb <10 g/dL, hct< 33%)
2) LDH > 440 U/L
3) Haptoglobin <37 mg/dL
4) Presence of schistocytes, fragmented cells, and polychromasia on peripheral blood smear.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Which type of surgical mitral valve cause more hemolysis?

A

More common with mechanical

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What is AV groove separation?

A

Separation between LA and ventricle

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What causes AV groove separation?

A

This can occur when the LV is elevated following mitral valve replacement

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Risk factors for AV groove separation?

A

Mitral annular calcification
Women
Elderly

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What to do after an AV groove separation?

A

Reinstitute CPB, cardioplegic arrest, remove the valve, then internal repair using a patch, followed by low profile mechanical prosthesis implantation. Other approaches:

  • Placement of adhesive patch material and glue externally
  • Removal of the heart, “bench” repair, and autotransplantation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Dressler’s

A

Pericarditis following injury to heart or pericardium. AKA post-pericardiotomy syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Incidence of dressler’s

A

15-20%; colchicine post-op day 3 can reduce the incidence by 58%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Rx for Dressler’s syndrome

A

NSAIDS (ibuprofen or indomethacin) 90% effective for resolving fever, chest pain or friction rubs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Constrictive pericarditis is distinctive from restrictive cardiomyopathy because of what cardiac cath finding?

A

Diastolic equalization of pressures, ventricular interdependence (discordance with resp cycle), and square root sign. RVEDP and LVEDP are almost equal in constrictive pericarditis. Subsequently causes diastolic heart failure. In contrast, LVEDP is higher than RVEDP in restrictive

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Square root sign

A

A hemodynamic sign of dip (the rapid ‘y’-descent in the jugular venous pressure) and plateau during right heart catheterization

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Classification for mitral valve regurgitation

A

Carpentier’s mitral classification

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Management of chronic ischemic mitral regurg in the setting of multivessel CAD?

Prognosis?

Goal of surgery?

A

Indication for CABG + Mitral Replacement (Repair is prone to more re-op)

Less CHF symptoms when MVR is combined with CABG

Goal is symptom control. No change in survival

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Management of isolated severe, chronic secondary MR ?

A

Not an indication for MVR, may consider TMVR

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Patient with pulm edema and shock, with new systolic murmur that developed 7 days after an MI. Diagnosis?

Diagnostic test?

What would you see on right heart cath (RHC)

A

Acute massive mitral regurgitation may occur 4-7 days after MI

TEE > TTE

RHC: V waves

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What are factors that suggest mitral valve repair for moderate MR during CABG is beneficial compared to CABG alone?

A

LVESVI >60
LVEDD >50
Presence and extent of LV scar tissue or basal aneurysm of inferior-posterior LV dyskinesia
Small LCX and RCA circulations

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

What are Carpentier’s principles of reconstructive valve surgery?

A
  1. Preserve or restore full range of leaflet motion
  2. Create a large surface area of coaptation
  3. Remodel and stabilize the entire annulus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What position do you place a mechanical mitral valve in?

A

Anti-anatomic, because placing it in the anatomic position could result in preferential flow through the anterior leaflet and thrombus formation on the posterior leaflet.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What percentage of mechanical mitral valve patients complain about the “ticking” sound at 1 month and 1 year?

A

20% and 10% respectively

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

What percentage of patients can hear the “ticking” sound of a mechanical valve?

A

Approximately 70-80% can hear it, 50% can hear it clearly

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

What are the indications for MV repair/replacement?

A

Severe symptomatic and LVEF >30% I B
Severe symptomatic and LVEF <30% IIb C
Severe and severely symptomatic (NYHA 3-4), suitable for clip and prohibitive risk of surgery IIb C for MitraClip
Severe asymptomatic if:
LVESD >40mm I B
LVEF <60% I B
new onset A-fib or PASP >50mmHg IIa B
Likelihood of successful repair over 95% and mortality <1% IIa B
progressive increase in LV size or decrease in LVF on serial imaging studies IIa C
Moderate if:
concomitant cardiac surgery IIa B

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

What are the incisions for mitral valve access?

A
  1. Sondergaard’s (Waterston’s) groove
  2. Transseptal
  3. Superior septal
  4. Left atrial dome (superior approach)
  5. Transection of the SVC and LA atriotomy
  6. Dubost approach (transverse right atriotomy extending into the RSPV and then incise through the septum into the left atrium and mitral valve)
  7. Transaortic approach (standard aortotomy, for AVR+MVR)
  8. LV approach
  9. Right Thoracotomy approach
  10. Left Thoracotomy approach
  11. Cardiac autotransplantation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

What are the echo criteria for mitral stenosis?

A

Mitral valve area <1.5cm2
Mitral valve pressure half time <150ms
(Mitral valve mean gradient >10mmHg (high heart rate will overestimate stenosis))

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

What are the hemodynamic criteria for mitral stenosis?

A

PASP >50mmHg

severe LA dilation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

What are the medical therapies in rheumatic MS?

A

beta-blockers and ivabradine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

What are the four major causes of MS?

A

Rheumatic, calcific and radiation induced and iatrogenic (mitral valve repair with small ring)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

What are the guideline recommendations for intervention in mitral stenosis?

A

Class 1 A - Symptomatic (NYHA 2-4) severe rheumatic MS with favourable valve morphology and less than 2+ MR in the absence of LA thrombus should get PMBC if done at a comprehensive valve center

Class 1 B - Symptomatic (NYHA 3-4) severe rheumatic MS not a candidate for PMBC, previous failed PMBC, require other cardiac operations or no access to PMBC should get mitral valve repair/comissurotomy/replacement

Class IIa B - Asymptomatic severe rheumatic MS with favourable valve morphology and less than 2+ MR in the absence of LA thrombus but have elevated PASP >50mmHg, should get PMBC if done at a comprehensive valve center

Class IIb C Asymptomatic severe rheumatic MS with favourable valve morphology and less than 2+ MR in the absence of LA thrombus with new onset AFib, should get PMBC if done at a comprehensive valve center

Class IIb C In symptomatic patients (NYHA class II, III,
or IV) with rheumatic MS and an mitral valve area >1.5 cm2, if there is evidence of hemodynamically significant rheumatic MS on the basis of a pulmonary artery wedge
pressure >25 mmHg or a mean mitral valve gradient >15 mmHg during exercise, PMBC may be considered if it can be performed at a Comprehensive Valve Center

Class IIb C In severely symptomatic patients (NYHA class III or IV) with severe rheumatic MS (mitral valve
area ≤1.5 cm2 , Stage D) who have a suboptimal
valve anatomy and who are not candidates for
surgery or are at high risk for surgery, PMBC
may be considered if it can be performed at a
Comprehensive Valve Center

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

What are the long term outcomes of successful PMBC?

A

Long-term follow-up has shown 70% to 80% of patients
with an initial good result after PMBC to be free of
recurrent symptoms at 10 years, and 30% to 40%
are free of recurrent symptoms at 20 years

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

What do the guidelines say regarding calcific MS?

A

Intervention should only be considered if patients are severely symptomatic and refractory to medical therapy. PMBC and surgical commissurotomy are not options in these patients.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

What are the three major causes of acute MR?

A

Infective endocarditis - leaflet perforation or chordal rupture
Spontaneous chordal rupture - myxomatous MV disease
Acute papillary muscle rupture - MI (usually inferior)

41
Q

What are the medical/non-surgical therapies in acute MR?

A

vasodilator therapies (sodium nitroprusside, nicardipine), IABP - both reduce afterload

42
Q

What is the difference between primary MR and secondary MR?

A

Primary MR is a disease of the mitral valve apparatus

Secondary MR is a disease of the ventricles or atria

43
Q

What are the echo criteria for severe MR?

A 
Central jet MR >40% LA or
holosystolic eccentric jet MR
Vena contracta ≥0.7 cm
Regurgitant volume ≥60 mL
Regurgitant fraction ≥50%
ERO ≥0.40 cm2
Angiographic grade 3+ to 4+
44
Q

What is the effect of anesthesia on MR?

A

Anesthesia lessens afterload, preload and mitral valve closing force, reducing MR, so decisions about severity of MR should be evaluated prior to the OR

45
Q

What is global longitudinal strain and how is it used in timing of intervention in MR?

A

Global longitudinal strain is an echo measurement that assess change in longitudinal length as a percentage of baseline. It has been shown to be more predictive of LV dysfunction than LVEF.

46
Q

What are the indications for surgery in primary MR?

A

Class 1 B - Symptomatic severe MR
Class 1 B - Asymptomatic severe MR with LVEF <60% or LVESD >40mm
Class 1 B - Mitral valve repair > replacement if anatomically possible in primary degenerative MR
Class 2a B - Asymptomatic severe MR with LVEF >60% and LVESD >40mm, mitral valve repair should be performed if likelihood of repair is >95% and <1% risk of mortality
Class 2b B - Asymptomatic severe MR with LVEF >60% and LVESD >40mm and increasing LV size or reduced LVEF on 3 or more serial imaging studies, mitral valve surgery may be performed

47
Q

What are the indications for transcatheter MV repair?

A

Class 2a B - . In severely symptomatic patients (NYHA class III or IV) with primary severe MR and high or
prohibitive surgical risk, transcatheter edge-toedge repair (TEER) is reasonable if mitral valve
anatomy is favorable for the repair procedure
and patient life expectancy is at least 1 year.

Class 2a B - In patients with chronic severe secondary MR related to LV systolic dysfunction (LVEF <50%)
who have persistent symptoms (NYHA class
II, III, or IV) while on optimal GDMT for HF
(Stage D), TEER is reasonable in patients with
appropriate anatomy as defined on TEE and
with LVEF between 20% and 50%, LVESD ≤70
mm, and pulmonary artery systolic pressure
≤70 mmHg

48
Q

What are the indications for rheumatic mitral valve repair for MR?

A

Class 2a B - In symptomatic patients with severe primary MR attributable to rheumatic valve disease,
mitral valve repair may be considered at a
Comprehensive Valve Center by an experienced
team when surgical treatment is indicated, if a
durable and successful repair is likely.

49
Q

What is the class III indication in mitral valve surgery?

A

Class III - In patients with less than half of posterior leaflet prolapse, MVR should not be performed before a MV repair has been attempted at a comprehensive valve center

50
Q

What is the indication for surgery in secondary MR?

A

Class IIa B - In secondary severe MR, patients undergoing CABG for myocardial ischemia should receive mitral valve surgery

Class IIb B - In patients with chronic severe secondary MR
from atrial annular dilation with preserved
LV systolic function (LVEF ≥50%) who have
severe persistent symptoms (NYHA class III
or IV) despite therapy for HF and therapy for
associated AF or other comorbidities (Stage D),
mitral valve surgery may be considered

Class IIb B - In patients with chronic severe secondary
MR related to LV systolic dysfunction (LVEF
<50%) who have persistent severe symptoms
(NYHA class III or IV) while on optimal GDMT
for HF (Stage D), mitral valve surgery may be
considered

Class IIb B - In patients with CAD and chronic severe
secondary MR related to LV systolic
dysfunction (LVEF <50%) (Stage D) who are
undergoing mitral valve surgery because of
severe symptoms (NYHA class III or IV) that
persist despite GDMT for HF, chordal-sparing
mitral valve replacement may be reasonable
to choose over downsized annuloplasty
repair

51
Q

<p><strong>NIH</strong> Trial on <strong>MVRepair</strong> vs. <strong>MVR</strong> for severe Ischemic MR - <strong>Primary endpoint</strong></p>

A

<p><strong>LVESVI</strong> at <strong>12months</strong></p>

<p>(Acker MA - NEJM 2014)</p>

52
Q

<p><strong>NIH </strong>Trial <strong>CABG</strong> vs. <strong>CABG+MVRepair</strong> for Ischemic MR - Percentage of moderate or severe <strong>MR at 1yr</strong></p>

A

<p><strong>30%</strong> CABG alone</p>

<p><strong>10%</strong> CABG+MVRepair</p>

<p>(Smith PK - NEJM 2014)</p>

53
Q

<p>Wilkins Score</p>

A

<p>Feasibility for balloon valvuloplasty for MS</p>

<p>Feasible < <strong>8 - 9</strong> > Not Feasible</p>

<p>Determinants:</p>

<ol>
<li>Leaflet <strong>Mobility</strong></li>
<li>Leaflet <strong>Thickening</strong></li>
<li>Leaflet <strong>Calcification </strong></li>
<li><strong>Subvalvular</strong> Thickening</li>
</ol>

54
Q

<p><strong>SAM</strong> - Medical Treatment</p>

A

<ol>
<li><strong>Beta-blockers</strong></li>
<li>Increase <strong>Volume</strong>/Preload</li>
<li>Increase <strong>Afterload</strong></li>
<li><strong>Decrease Inotropes</strong>/Contractility</li>
<li>AV Synchrony/<strong>Pacing</strong></li>
</ol>

55
Q

<p><strong>COAPT</strong> Trial - Primary <strong>effectiveness</strong> endpoint</p>

A

<p>All <strong>hospitalizations for CHF</strong> in <strong>24-months</strong></p>

<p><strong>35%</strong> per-patient-year <strong>Device</strong> Group</p>

<p><strong>65%</strong> per-patient-year <strong>Control</strong> Group</p>

56
Q

<p><strong>COAPT</strong> Trial - <strong>Death</strong> from any cause rate</p>

A

<p>In <strong>24months</strong></p>

<p><strong>30%</strong> <strong>Device</strong> Group</p>

<p><strong>45% Control</strong> Group</p>

<p>*Statistically significant</p>

57
Q

<p><strong>MitraFR</strong> Trial - Primary endpoint</p>

A

<p><strong>Composite</strong> at <strong>12-months</strong></p>

<ol>
<li>Death from any cause</li>
<li>Unplanned hospitalization for CHF</li>
</ol>

<p></p>

<p><strong>55% Device</strong> Group</p>

<p><strong>50% Control</strong> Group</p>

<p>NOTstatistically significant</p>

58
Q

<p><strong>MitraFR</strong> Trial - Common criticisms</p>

A

<p>Definition of severe MR</p>

<p><strong>ROA > 20mm2</strong>(AHA Guidelines > 40mm2)</p>

<p>Regurg <strong>Volume > 30mL/beat</strong> (AHA Guidelines > 60mL/beat)</p>

59
Q

<p>Mechanisms of <strong>posteriorly directed MR</strong></p>

A

<ol>
<li><strong>Prolapse</strong> of the <strong>anterior</strong> mitral leaflet</li>
<li><strong>Restriction</strong> of the <strong>posterior</strong> mitral leaflet</li>
</ol>

60
Q

<p>MR Etiology</p>

A 
<ul>
	<li>Rheumatic</li>
	<li>Degenerative</li>
	<li>Ischemic</li>
</ul>
61
Q

<p>MR Mechanisms</p>

A

<ul>
<li>Leaflet retraction (fibrosis or calcification)</li>
<li>MV annular dilation</li>
<li>Chordal changes (rupture, elongation, shortening or tethering)</li>
<li>LV dysfunction +/- papillary muscle involvement</li>
</ul>

62
Q

<p>MR Presentation of Sx</p>

A 
<ul>
	<li>Asymptomatic</li>
	<li>DOE</li>
	<li>CHF</li>
</ul>
63
Q

<p>Classic PE finding of MR</p>

A

<p>Holosystoic murmur heard at apex, radiating to axilla</p>

64
Q

<p>Characteristics of Myxomatous MR</p>

A

<ul>
<li>Acquired: fibroelastic <u>deficiency</u> in older patients</li>
<li>Congenital: <u>excessive</u>, <u>weak</u> fibroelastic connective tissue</li>
</ul>

<p></p>

<ul>
<li>Leaflets: thickened and spongy</li>
<li>Annulus: thickented and dilated</li>
</ul>

<p></p>

<ul>
<li>Changes more pronounced in younger patients (Barlow syndrome)
<ul>
<li>Less obvious is older patients</li>
</ul>
</li>
<li>Chordal rupture likely due to:
<ul>
<li>Defective collagen</li>
<li>Underlying papillary muscle fibrosis and dysfunction</li>
<li>Posterior chorde most likely to rupture</li>
</ul>
</li>
</ul>

65
Q

<p>MR and Echocardiography</p>

A 
<ul>
	<li>Best overall diagnostic modality, can visulaize mechanism</li>
	<li>Quantitate regurgitation</li>
	<li>MV prolapse</li>
	<li>Directon of jet:
	<ul>
		<li>Anterior (septal): posterior leaflet prolapse</li>
	</ul>
	</li>
</ul>

<p></p>

66
Q

<p>MR and Cardiac Catheterization</p>

A 
<ul>
	<li>Quantitate regurgitation</li>
	<li>Assess function of pulmonary hypertension</li>
	<li>Assess coronaries for CAD</li>
</ul>
67
Q

<p>MCC of MR</p>

A

<p>MV prolapse</p>

<p>(2-6% of poplulation)</p>

68
Q

<p>Natural History of MR</p>

A 
<ul>
	<li>Prolonged asymptomatic phase</li>
	<li>Accelerated phase</li>
	<li>Ruptured chordae tendinae</li>
</ul>

<p></p>

<ul>
<li>Men age > 45 subject to complications</li>
<li>Sudden death rate: <1%/year</li>
</ul>

69
Q

<p>Annual sudden death rate for MR</p>

A

<p><1% per year</p>

70
Q

<p>MR indications for operation</p>

A

<ul>
<li><strong>Acute symptomatic MR</strong></li>
<li>Symptomatic or Asymptomatic MR with <strong>LV dysfunction</strong>
<ul>
<li>Mild (EF 50-60%, Systoic Dimension 45-50 mm)</li>
<li>Moderate (EF 30-50%, Systolic Dimension 50-55 mm)</li>
<li>Severe (EF < 30%, Systolic Dimension > 55 mm)</li>
</ul>
</li>
<li>Asymptomatic with <strong>AFib or Pulmonary Hypertension</strong>
<ul>
<li>PA > 50 (rest) or >60 (with exercise)</li>
</ul>
</li>
</ul>

71
Q

<p>Surgical Approaches to MV</p>

A 
<ul>
	<li>Left thoracotomy (rare, mostly historical)</li>
	<li>Right thoracotomy
	<ul>
		<li>Redo MVR or TV repair</li>
	</ul>
	</li>
	<li>Median sternotomy
	<ul>
		<li>Interatrial groove</li>
		<li>Interatrial groove + SVC detachment</li>
		<li>Superior via dome of LA</li>
		<li>Trans-septal
		<ul>
			<li>Associated TV repair, Afib</li>
		</ul>
		</li>
	</ul>
	</li>
	<li>Partial sternotomy</li>
</ul>
72
Q

<p>Techniques of MV Repair</p>

A 
<ul>
	<li>Reduction annuloplasty</li>
	<li>Triangular resection</li>
	<li>Quadrangular resection</li>
	<li>Sliding posterior leaflet repair</li>
	<li>Artificial chordae</li>
	<li>Posterior leaflet transfer</li>
	<li>Combined anterior leaflet augmentation and posterior reduction</li>
	<li>Anterior leaflet augmentation</li>
</ul>
73
Q

<p>Operations for MR</p>

A 
<ul>
	<li>MV Repair
	<ul>
		<li>Likely with posterior leaflet prolapase or ruptured chordae</li>
		<li>Less likely with anteiror leaflet prolapse</li>
	</ul>
	</li>
	<li>Choradal Sparing MVR
	<ul>
		<li>Bioprosthesis</li>
		<li>Mechanical</li>
		<li>Mitral homograft</li>
	</ul>
	</li>
</ul>
74
Q

<p>MV Repair Outcomes</p>

A

<ul>
<li>Hospital mortality (non-ischemic MR): 0-1%</li>
<li>Mortality for IMR:
<ul>
<li>Low-risk patients have improved hospital mortality with Repair over replacement</li>
<li>No surival benefit for repair over replacement</li>
<li>Survival after MVR/Repair + CABG worse for IMR compared to rheumatic or degenerative MR</li>
</ul>
</li>
</ul>

75
Q

<p>3 key factors to consider for chronic, IMR</p>

A 
<ol>
	<li>Presence/severity of CAD</li>
	<li>Severity of MR</li>
	<li>Presence of LV dysfunction</li>
</ol>
76
Q

<p>Treatment principles of chronic IMR</p>

A

<ul>
<li>Mild (1+) MR: can be left alone</li>
<li>Modeate (2+) MR: surgical tx controversial
<ul>
<li>If CHF, will benefit most form CABG+MV Repair</li>
</ul>
</li>
<li>Severe (3-4+) MR: needs surgery</li>
</ul>

77
Q

<p>Outcome after MV Repair</p>

A

<ul>
<li>Freedom form reoperation: 80-95% at 10-15 years</li>
<li>Repair more effective for myxomatous (rather than rheumatic) disease</li>
<li>Residual MR is usually immediately present after repair (rather than developing later)</li>
<li>Recurrent regurgitation after repair:
<ul>
<li>Inadequate operation</li>
<li>Progression of disease</li>
</ul>
</li>
</ul>

78
Q

<p>Factors that may increase ris of late reopeation after MV Repair</p>

A

<ul>
<li>Rheumatic diease</li>
<li>Anterior leaflet degenerative changes</li>
<li>Residual MR after initial operation</li>
</ul>

79
Q

<p>MC Etiology of MS</p>

A

<p>Rheumatic fever</p>

80
Q

<p>Clinical presentation of MS</p>

A 
<ul>
	<li>Dyspnea</li>
	<li>Fatigue</li>
	<li>Palpitations</li>
	<li>Hemoptysis</li>
	<li>Afib</li>
</ul>
81
Q

<p>Physical Exam findings characterstic of MS</p>

A 
<ul>
	<li>Loud 1st heart sound</li>
	<li>Diastolic rumble</li>
	<li>Opening snap</li>
</ul>
82
Q

<p>Modality used for definitive diagnosis of MS</p>

A

<p>Echocardiogram</p>

<ul>
<li>Valve area</li>
<li>Valve morphology</li>
</ul>

83
Q

<p>Normal and abnormal MVA</p>

A 
<ul>
	<li>Normal:4.0-5.0 cm2</li>
	<li>Symptomatic MS: <2.5 cm2 (<1.5 cm2 at rest)</li>
	<li>Critical MS: < 1.0 cm2</li>
</ul>
84
Q

<p>Natural History of MS</p>

A 
<ul>
	<li>Continuous progressive lifelong disease</li>
	<li>Slow, stable early course
	<ul>
		<li>latent period of 20-40 years after Rheumatic fever to onset of sx.</li>
	</ul>
	</li>
	<li>Onset of symptoms to disability : ~ 10 years</li>
	<li>Atrial fibrillatin (30-40%)
	<ul>
		<li>MC in older pts (50-60%)</li>
		<li>Often paroxysmal at first</li>
		<li>Indicated relatively advanced MS</li>
	</ul>
	</li>
</ul>
85
Q

<p>Characteristics of Atrial Fibrillation with MS</p>

A

<p>MC in older pts (50-60%)</p>

<p>Often paroxysmal at first</p>

<p>Indicated relatively advanced MS</p>

86
Q

<p>% of MS patients asymptomatic on presentation</p>

A

<p>>80%</p>

<p>(60% with no progression of symptoms)</p>

87
Q

<p>% of MS patients in NSR</p>

A

<p>45-50% (46%)</p>

88
Q

<p>% of MS patients that are symptomatic on presentation</p>

A

<p>0-15%</p>

89
Q

<p>% of MS patients with severe pulmonary hypertension</p>

A

<p><3%</p>

90
Q

<p>MCC of death in MS patients</p>

A 
<ul>
	<li>CHF (60-65%)</li>
	<li>Systemic embolism (20-30%)</li>
	<li>Pulmonary embolism (10%)</li>
	<li>Infection (1-5%)</li>
</ul>
91
Q

<p>Characteristics of Pulmonary Hypertension in MS</p>

A

<ul>
<li>Elevated at rest and can become near systemic pressures with exercise</li>
<li>PA systolic > 60 mmHg significantly affects RV performance</li>
<li>LA pressure > 30 mmHG results in reduced lung compliance and pul edema</li>
</ul>

92
Q

<p>MS characteristics ammenable to MV repair</p>

A 
<ul>
	<li>Prominant opening snap</li>
	<li>No calcification</li>
	<li>Pliable leaflets</li>
	<li>Commissural fusion</li>
	<li>Normal Chordae and papillary muscles</li>
</ul>
93
Q

<p>Balloon vs. Open Commissurotomy</p>

A

<ul>
<li>Based upon surgeon experience</li>
<li>LA thrombus or MR = NO BALLOON</li>
<li>MR occurs in 2-5% of patients after open commissurootomy
<ul>
<li>Mild postocommissurotomy MR has little effect on long-term surival or need for MVR</li>
</ul>
</li>
<li>50% of commissurotomy patients witll require addittional operation (i.e. MVR) within 20 years</li>
</ul>

94
Q

<p>Indictions for Surgical Intervention for MS</p>

A 
<ul>
	<li>Symptomatic patients (i.e.NHYA III or IV)
	<ul>
		<li>MVA < 1.5 cm2</li>
		<li>PA pressures > 50 (rest) or > 60 (with exercise)</li>
	</ul>
	</li>
	<li>Asymptomatic patients:
	<ul>
		<li>New onset Atrial Fibrillation</li>
		<li>LA thrombus or embolism after anticoagulation</li>
		<li>PA pressure > 60 at rest</li>
	</ul>
	</li>
</ul>
95
Q

<p>Surgical Procedures of MS</p>

A 
<ul>
	<li>Closed mitral commissurotomy</li>
	<li>Open mitral commissurotomy +/- anterior leaflet augmentation</li>
	<li>MVR
	<ul>
		<li>Thick anterior leaflet</li>
		<li>Calficication</li>
		<li>Mitral regurgitation</li>
		<li>Thick, short chordae</li>
	</ul>
	</li>
</ul>
96
Q

<p>MVR Surgical Options</p>

A 
<ul>
	<li>Bioprosthesis</li>
	<li>Mechanical prosthesis</li>
	<li>MV homograft</li>
</ul>
97
Q

<p>Risks associated withMVR</p>

A 
<ul>
	<li>Type of prosthesis <strong><u>not</u></strong> a factor</li>
	<li>Previous valvotomy or commissurotomy <strong><u>not</u></strong> a factor</li>
	<li>NHYA class</li>
	<li>MR</li>
	<li>LV size</li>
	<li>LA size</li>
	<li>Age</li>
	<li>Concomitant TV disease</li>
	<li>CAD (3x risk)</li>
	<li>Subvalvular apparatus (preservation of chordae reduces risk)</li>
</ul>
98
Q

<p>Outcomes after MVR</p>

A

<ul>
<li>Hospital mortality (non-ischemic valve disease): 2-7%</li>
<li>Hospital mortality higher for MVR+CAB</li>
<li>10 year survival: 55%</li>
<li>70% of MVR patients alive without compications at 5 years</li>
</ul>

AA - Cardiac surgery COPY (29 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions