B P8 C72 Aortic Valve Stenosis

Question 1

Causes/etiology of AS
1.
2.
3.

Answer 1

A congenital bicuspid valve with superimposed calcification
Calcification of a normal trileaflet valve
Rheumatic disease

Question 2

The most prevalent anatomy for a bicuspid valve is two cusps with a right-left systolic opening, consistent with congenital fusion of the____________________, seen in 70% to 80% of patients

Answer 2

Right and left coronary cusps

Question 3

AVA ≤1.0 cm2 with resting aortic Vmax <4 m/s or mean ∆P <40 mm Hg

Dobutamine stress echocardiography shows AVA <1.0 cm2 with V max ≥4 m/s at any flow rate

Answer 3

Stage D2

Question 4

ACC AHA Class 1 indications for treatment of AS

Answer 4

In adults with severe high-gradient AS (Stage D1) and symptoms of exertional dyspnea, HF, angina, syncope, or presyncope by history or on exercise testing, AVR is indicated

In asymptomatic patients with severe AS and an LVEF <50% (Stage C2), AVR is indicated

In asymptomatic patients with severe AS (Stage C1) who are undergoing cardiac surgery for other indications, AVR is indicated

In symptomatic patients with low-flow, lowgradient severe AS with reduced LVEF (Stage D2), AVR is recommended

In symptomatic patients with low-flow, lowgradient severe AS with normal LVEF (Stage D3), AVR is recommended if AS is the most likely cause of symptoms

Question 5

Recommendations for Choice of SAVR Versus TAVI for Patients for Whom a Bioprosthetic AVR Is Appropriate

Recommendations for severe AS >80 years old

Answer 5

TAVR is Class 1

Question 6

The most common clinical presentation in patients with a known diagnosis of AS who are followed prospectively is a _____.

Answer 6

Gradual decrease in exercise tolerance, fatigue,or dyspnea on exertion

Question 7

The mechanism of exertional dyspnea may be _____, with an excessive rise in end-diastolic pressure leading to pulmonary congestion.

Answer 7

LV diastolic dysfunction

Question 8

In patients without CAD, angina results from the combination of _____, which reduce the coronary perfusion pressure gradient and impair myocardial flow reserve.

Answer 8

(1) the increased O2 needs of hypertrophied myocardium and reduction of O2 delivery due to decreased myocardial capillary density

(2) endothelial cell loss

(3) increased LVEDP

Question 9

Syncope most often is caused by the ______ that occurs during exertion when arterial pressure declines because of systemic vasodilation and an inadequate increase in cardiac out- put related to valvular stenosis

Answer 9

Reduced cerebral perfusion

Question 10

Syncope also has been attributed to malfunction of the baroreceptor mechanism in severe AS, as well as to a _____ to a greatly elevated LV systolic pressure during exercise.

Answer 10

Vasodepressor response

Question 11

Syncope at rest may be caused by _____ with loss of the atrial contribution to LV filling, which causes a precipitous decline in cardiac output, or to _____ caused by extension of the calcification of the valve into the conduction system.

Answer 11

Transient AF

Transient AV block

Question 12

The prevalence of _____ without stenosis, defined as irregular thickening or calcification of the aortic valve leaflets, increases with age and ranges from 9% in populations with a mean age of 54 years to 42% in populations with a mean age of 81 years.

Answer 12

Aortic valve sclerosis

Question 13

In population-based echocardiographic studies, _____% of persons aged 65 or older and _____% of persons 75 or older had calcific aortic stenosis (AS)

Answer 13

> 65 years: 1-2%

> 75 years: 12%

Question 14

The rate of progression from aortic sclerosis to stenosis is _____% per year.

Answer 14

1.8-1.9%

Question 15

Valvular AS has three principal causes:

Answer 15

(1) Congenital bicuspid valve with superimposed calcification
(2) Calcification of a normal trileaflet valve
(3) Rheumatic disease

Question 16

Rarely, AS is caused by severe atherosclerosis of the aorta and aortic valve; this form of AS occurs most frequently in patients with severe hypercholesterolemia and is observed in children with _____.

Answer 16

Homozygous type II hyperlipoproteinemia

Question 17

Rheumatoid involvement of the valve is a rare cause of AS and results in _____ of the valve leaflets and involvement of the _____.

Answer 17

Nodula thickening

Proximal portion of the aorta

Question 18

_____ affecting a congenital bicuspid or normal trileaflet valve is now the most common cause of AS in adults

Answer 18

Calcific (formerly “senile” or “degenerative”) aortic valve disease

Question 19

Aortic sclerosis, identified by either echocardiography or computed tomography (CT), is the initial stage of calcific valve disease and, even in the absence of valve obstruction or known cardiovascular disease, is associated with an increased risk of _____.

Answer 19

Myocardial infarction (MI)
Cardiovascular and all-cause mortality

Question 20

_____ valves typically produce severe obstruction in infancy and are the most common malformations found in fatal valvular AS in children younger than 1 year but also may be seen in young adults with an anatomy that mimics bicuspid valve disease.

Answer 20

Unicuspid

Question 21

A congenital bicuspid aortic valve (BAV) is present in approximately 1% to 2% of the population, with a male predominance of approximately _____.

Answer 21

3:1

Question 22

A BAV may be an isolated abnormality (approximately 50% of the time) or occur in the context of a genetic syndrome (e.g.,Turner syndrome), alongside other congenital heart defects (e.g., hypoplastic left heart, coarctation of the aorta), or with a _____ (most common nonvalvular manifestation).

Answer 22

Thoracic aortic aneurysm

Question 23

The most prevalent anatomy for a bicuspid valve is two cusps with a right-left systolic opening, consistent with congenital fusion of the _____, seen in 70% to 80% of patients

Answer 23

Right and left coronary cusps

An anterior-posterior orientation, with fusion of the right and noncoronary cusps, is less common, seen in approximately 20% to 30% of patients. Fusion of the left and noncoronary cusps is rarely seen.

A prominent ridge of tissue or raphe may be present in the larger of the two cusps so that the closed valve in diastole may mimic a trileaflet valve.

Question 24

Unicuspid valves are distinguished from a bicuspid valve by having only ___ aortic commissure.

Answer 24

One

Question 25

The risk of aortic dissection in patients with BAV is _____ times higher than in the general population

Patients with BAV also are at increased risk for endocarditis (0.4 per 100,000) accounting for approximately 1200 deaths per year, however, the most common cardiac event is need for ______, and most patients with BAV develop calcific valve stenosis later in life, typically presenting with severe AS _______

Answer 25

5-9x

AVR
After the age of 50 years

Although the histopathologic features of calcific stenosis of a BAV are no different from those of a trileaflet valve, the turbulent flow and increased leaflet stress caused by the abnormal architecture are postulated to result in accelerated valve changes,

Question 26

Rheumatic AS results from _____, leading to retraction and stiffening of the free borders of the cusps

Answer 26

(1) Adhesions and fusions of the commissures and cusps
(2) Vascularization of the leaflets of the valve ring

Question 27

Normal valve leaflets comprise the fibrosa (facing the aorta), ventricu- laris (facing the ventricle), and spongiosa (located between the fibrosa and ventricularis). _____ are the most predominant cell type; endothelial and smooth muscle cells are also present.

Answer 27

Valve interstitial cells (VICs)

Question 28

The most consistently observed genetic association is for _____.

Heritable forms of calcific aortic valve disease have been linked to ________

Answer 28

Lipoprotein(a) (Lp(a))

NOTCH1 mutation

Question 29

Progressive valve obstruction imposes a _____overload state that leads to numerous changes in the structure and function of the left ventricle and accompanying changes in the pulmonary and systemic vasculature.

Answer 29

Chronic pressure overload

Question 30

LV responses to AS

Answer 30

Hypertrophic myocardial remodeling
Myocardial fibrosis
Myocardial ischemia
Left ventricular diastolic dysfunction
left ventricular systolic dysfunction

Question 31

The hypertrophied and pressure-overloaded left ventricle transmits increased pressure to the pulmonary vasculature, which leads to pulmonary hypertension in many patients with AS, becoming severe in _____%

Answer 31

15-20%

Question 32

Maintenance of cardiac output in the face of an obstructed aortic valve imposes a chronic increase in LV pressure. In response, the ventricle typically undergoes hypertrophic remodeling characterized by _______ and ________

Answer 32

Myocyte hypertrophy and increased wall thickness

Question 33

LV remodeling may manifest as concentric remodeling, ________ or ________

Answer 33

Concentric hypertrophy, or eccentric hypertrophy

LV remodeling reduces wall stress (afterload) and is considered one of the important compensatory mechanisms to maintain LV ejection performance,

Question 34

In patients with AS, several studies have now documented that increased LV hypertrophic remodeling is associated with more _________ and ________, as well as higher mortality.

Answer 34

Severe ventricular dysfunction and heart failure (HF) symptoms

Question 35

As a part of the hypertrophic remodeling process, _____ and _______ (not fibrosis from prior MI) may develop, although the incidence and extent of fibrosis are variable and unpredictable and the underlying biologic mechanisms not yet clarified

Answer 35

Diffuse and replacement myocardial fibrosis

Question 36

What type of fibrosis tend to regress after AVR?

Answer 36

Diffuse fibrosis tends to regress after AVR, whereas replacement fibrosis does not.

Question 37

In patients with AS, the _____, ______ and _____ all elevate myocardial oxygen (O2) consumption.

Answer 37

Hypertrophied left ventricle, increased systolic pressure, and prolongation of ejection

Question 38

At the same time, even in the absence of epicardial coronary artery disease (CAD), _______ in the hypertrophied ventricle, ______, _______, ________ all serve to decrease the coronary perfusion pressure gradient and myocardial blood flow

Answer 38

Decreased myocardial capillary density
Endothelial cell loss
Increased LV end-diastolic pressure (LVEDP)
Shortened diastole

Question 39

_____ underlies symptoms of angina in patients with AS that is often indistinguishable from that caused by epicardial coronary obstruction

Answer 39

Impaired myocardial flow reserve

Myocardial flow reserve is independently associated with aerobic exercise capacity and HF functional class in severe AS and appears to be influenced by the extent of LV hypertrophic remodeling and fibrosis, endothelial cell loss, and severity of valve obstruction.

Question 40

_________ or ________ may exacerbate this ischemic imbalance and provoke angina that may not be experienced at rest.

Answer 40

Exercise or other states of increased O2 demand

Question 41

______ each contribute to increased chamber stiffness and higher end diastolic pressures.

Answer 41

Higher cardiomyocyte stiffness, increased myocardial fibrosis, advanced-glycation end products, and metabolic abnormalities

Question 42

Atrial contraction plays a particularly important role in filling of the left ventricle in AS because it _____ without causing a concomitant elevation of mean left atrial pressure.

Answer 42

Increases LVEDP

This “booster pump” function of the left atrium prevents the pulmonary venous and capillary pressures from rising to levels that would produce pulmonary congestion, while maintaining LVEDP at the elevated level necessary for effective contraction of the hypertrophied left ventricle.

Question 43

Loss of appropriately timed, vigorous atrial contraction, as occurs in _____ or _____, may result in rapid clinical deterioration in patients with severe AS.

Answer 43

Atrial fibrillation (AF) or atrioventricular (AV) dissociation

Question 44

Before a reduction in EF occurs, more subtle systolic dysfunction can be detected as _____, which is associated with worse outcomes in patients with severe AS

Answer 44

Reduced longitudinal systolic strain

Question 45

The development and severity of systolic dysfunction results from a complex interplay of factors, including the

Answer 45

Severity of valve obstruction, metabolic abnormalities, vascular load, maladaptive hypertrophy (resulting in impaired contractility), ischemia, and fibrosis

Question 46

In these patients, systolic function usually improves after the ventricle is unloaded by ______; the amount of recovery depends on many factors, including the degree to which systolic dysfunction was affected by afterload mismatch versus myocardial fibrosis and altered contractility.

Answer 46

AVR

Question 47

The hypertrophied and pressure-overloaded left ventricle transmits increased pressure to the pulmonary vasculature, which leads to pulmonary hypertension in many patients with AS, becoming severe in __________.

Answer 47

15% to 20%

Question 48

Among asymptomatic patients, exercise-induced pulmonary hypertension is associated with decreased event-free survival, and among patients undergoing TAVR or surgical AVR (SAVR), the ________ is associated with increased postoperative mortality.

Answer 48

Presence and severity of pulmonary hypertension

Question 49

Generally, repeat imaging/monitoring:

Mild AS
Moderate AS
Severe AS

Answer 49

Mild AS - every 3 to 5 years for mild AS, unless a change in signs or symptoms prompts repeat imaging sooner
Moderate AS - every 1 to 2 years
Severe AS - every 6 to 12 months

Question 50

The cardinal manifestations of acquired AS are

Answer 50

Exertional dyspnea
Angina,
Sncope
Heart Failure

Question 51

Symptoms can develop at any age but typically begin at _______ with BAV stenosis and in those ______ with calcific stenosis of a trileaflet valve, although even in this age group approximately 40% of patients with AS have a congenital BAV

Answer 51

BAV - 50 to 70 years
Calcific AS - older than 70 years

Question 52

The most common clinical presentation in patients with a known diagnosis of AS who are followed prospectively is a _________

Answer 52

Gradual decrease in exercise tolerance, fatigue, or dyspnea on exertion

Question 53

The mechanism of exertional dyspnea may be ______, with an excessive rise in end-diastolic pressure leading to pulmonary congestion. Alternatively, exertional symptoms may be a result of the _____ with exercise

Answer 53

LV diastolic dysfunction

Limited ability to increase cardiac output

Question 54

The mechanism of exertional dyspnea may be ______, with an excessive rise in end-diastolic pressure leading to pulmonary congestion. Alternatively, exertional symptoms may be a result of the _____ with exercise

Answer 54

LV diastolic dysfunction

Limited ability to increase cardiac output

Question 55

Angina is a frequent symptom of patients with severe AS, indicates _____

Answer 55

Myocardial ischemia

Question 56

In patients without CAD, angina results from the combination of the increased O2 needs of hypertrophied myocardium and reduction of O2 delivery due to _______ and ______, and increased LVEDP, which reduce the _____ and impair myocardial flow reserve.

Answer 56

Decreased myocardial capillary density, endothelial cell loss

Coronary perfusion pressure gradient

Question 57

In patients with CAD, angina is caused by a combination of ____ and ____ characteristic of AS.

Very rarely, angina results from ______ to the coronary vascular bed.

Answer 57

Epicardial coronary artery obstruction and the O2 imbalance

Calcific emboli

Question 58

Causes of Syncope in AS

Answer 58

Reduced cerebral perfusion that occurs during exertion when arterial pressure declines because of systemic vasodilation

Inadequate increase in cardiac output related to valvular stenosis

Malfunction of the baroreceptor mechanism

Vasodepressor response to a greatly elevated LV systolic pressure during exercise

Question 59

Syncope at rest may be caused by _____ with loss of the atrial contribution to LV filling, which causes a precipitous decline in cardiac output, or to _____ caused by extension of the calcification of the valve into the conduction system.

Answer 59

Transient AF

Transient AV Block

Question 60

Gastrointestinal bleeding may develop in patients with severe AS, often associated with ______ (most frequently of the _____) or other vascular malformations.

This complication arises from shear stress–induced platelet aggregation with a reduction in highmolecular-weight multimers of _________ and increases in proteolytic subunit fragments.

These abnormalities correlate with the severity of AS and are correctable by _____.

Answer 60

Angiodysplasia - right colon

von Willebrand factor

AVR

Question 61

The carotid upstroke directly reflects the arterial pressure waveform.

The expected finding with severe AS is a _________, the parvus and tardus carotid impulse.

Answer 61

Slow-rising, late-peaking, low amplitude carotid pulse

When present, this finding is specific for severe AS.

Question 62

In addition, with severe AS, radiation of the murmur to the carotid arteries may result in a _____.

Answer 62

Palpable thrill or carotid shudder

Question 63

The ejection systolic murmur of AS typically is ______ and heard best at the ______ of the heart, with radiation to the carotids.

Answer 63

Late-peaking

Base

Question 64

Cessation of the murmur _____ is helpful in differentiation from a pansystolic mitral murmur.

Answer 64

Before A2

Question 65

In patients with calcified aortic valves, the systolic murmur is loudest at the base of the heart, but high-frequency components may radiate to the apex the so-called _________, in which the murmur may be so prominent that it is mistaken for the murmur of mitral regurgitation (MR).

Answer 65

Gallavardin phenomenon

Question 66

In general, a _____ and _______ murmur indicates more severe stenosis.

Answer 66

Louder and later-peaking

Question 67

When the _____ and _______, the systolic murmur of AS becomes; rarely, it disappears altogether.

Answer 67

Left ventricle fails and stroke volume falls

Question 68

________ is helpful in excluding the diagnosis of severe AS, because normal splitting implies the aortic valve leaflets are flexible enough to create an audible closing sound (A2)

Answer 68

Splitting of S2

Question 69

With severe AS, S2 may be single because

Answer 69

(1) calcification and immobility of the aortic valve make A2 inaudible
(2) closure of the pulmonic valve (P2 ) is buried in the prolonged aortic ejection murmur
(3) prolongation of LV systole makes A2 coincide with P2

Question 70

The intensity of the systolic murmur varies from beat to beat when the _____ varies, as in AF or after a premature contraction.

This characteristic is helpful in differentiating AS from MR, in which the murmur usually is unaffected.

Answer 70

Duration of diastolic filling

Question 71

Effects on the murmur of AS:

Squatting
Standing/Strain of Valsalva

Answer 71

The murmur of valvular AS is augmented by squatting which increases stroke volume.

It is reduced in intensity during the strain of the Valsalva maneuver and on standing, both of which reduce transvalvular flow.

Question 72

This may be helpful in apparently a asymptomatic patients or when symptoms are vague (e.g., fatigue) to unmask symptoms or demonstrate limited exercise capacity or an abnormal blood pressure response.

Answer 72

Exercise testing

Question 73

Use of Cardiac CT Tomography in AS

Answer 73

Evaluating aortic dilation in patients with evidence or s picion of aortic root disease on echocardiography or chest radiography, particularly those with a bicuspid valve.

Measurement of aortic dimensions at several levels, including the sinuses of Valsalva, sinotubular junction, and ascending aorta,

Question 74

CT is increasingly used to assess ____ to predict the rate of disease progression or, more often, when the severity of the stenosis is in doubt, particularly in those with ____

Answer 74

Valve calcification

Low-flow, low-gradient AS

It is complementary to e ography in assessing valve morphology and provides valuable information on the location and extent of calcification

Question 75

CT is also a routine part of the preprocedural evaluation of patients undergoing SAVR or TAVR, principally to look for a _______, as well as determine appropriate _____ and assess _______ and _______ for a potential transcatheter approach

Answer 75

Porcelain aorta

Valve sizing

Aortic and peripheral arterial anatomy

Question 76

This is recommended only when noninvasive tests are inconclusive, when clinical and echocardiographic findings are discrepant, and for coronary angiography before AVR

Answer 76

Cardiac catheterization

Question 77

CMR is useful in assessing LV volume, function, and mass, especially in settings in which this information cannot be obtained readily from echocardiograph

CMR is not recommended for assessment of stenosis severity because of ______ of transvalvular velocities

Answer 77

Underestimation

CMR with T1 mapping and late gadolinium enhancement (LGE) may be used to risk stratify patients with AS

Question 78

This is increasingly recognized as a coexistent disease process in individuals with AS, particularly those with low-flow or low-gradient AS.

Answer 78

Transthyretin cardiac amyloidosis (ATTR-CA)

Question 79

Markers of more rapid symptom onset in AS include

Answer 79

Greater valve calcification
Higher transvalvular gradient
More rapid increase in transvalvular gradient
Higher B-type natriuretic peptide, among others

Question 80

Factors associated with more rapid hemodynamic progression include

Answer 80

Older age
More severe leaflet calcification
Renal insufficiency
Hypertension
Obesity
Metabolic syndrome
Smoking
Hyperlipidemia
Eevated circulating levels of Lp(a)
Increased activity of Lp-PLA2

Question 81

Normal AV area ___

Cut offs?

Severe
Moderate
Mild

Answer 81

Normal AVA - 3-4cm2

Severe AS
Aortic jet velocity of >/= 4.0 m/sec
Mean transvalvular pressure gradient of >/= 40 mm Hg
AVA of < 1.0 cm2

Moderate AS
Aortic jet velocity of 3.0 to 3.9 m/sec
Mean transvalvular pressure gradient of 20 to 39 mm Hg
AVA of 1.0 to 1.5 cm2

Mild AS
Aortic jet velocity of 2.0 to 2.9 m/sec
Mean transvalvular pressure gradient less than 20 mm Hg
Aortic orifice of 1.5 to 2.0 cm2

Question 82

The most specific definition for severe AS is a peak jet velocity of ___ m/sec or greater or mean gradient of ____ mm Hg or greater, usually accompanied by an AVA of ___

Answer 82

> /= 4 m/sec
/= 40 mm Hg
< 1.0 cm2

Question 83

This apparent discordance in indices of AS severity occurs because at a normal flow rate, an AVA of 1.0 corresponds to a mean gradient of ______

Answer 83

30 mm Hg

Question 84

The strongest predictor of AS progression to symptoms is the ______

Answer 84

Doppler aortic jet velocity

Question 85

This stage is defined as high-gradient severe AS with no symptoms but overt LV systolic dysfunction with an LVEF <50%

Answer 85

Stage C2

Question 86

This is defined as AVA of 1.0 cm 2or less with an aortic velocity less than 4.0 m/sec or mean gradient less than 40 mm Hg and LVEF less than 50%

Answer 86

Classic low-flow, low-gradient AS

Question 87

True severe AS based on Dobu echo is defined as

Answer 87

Severe AS is present if there is an increase in aortic velocity to at least 4 m/sec at any flow rate, with AVA that remains less than 1.0 cm2

Question 88

Dobutamine echocardiography also provides evidence of myocardial contractile reserve (increase in _____ from baseline), which historically has been an important predictor of operative risk and survival after SAVR in these patients.

Answer 88

Increase in stroke volume >20%

Question 89

This stage in AS can occur with a normal LVEF (≥50%) typically in elderly patients with a small, hypertrophied left ventricle or those with concurrent hypertension.

Answer 89

Low-flow, low-gradient AS also can occur with a normal LVEF (≥50%)

Question 90

This is often referred to as “paradoxical” low-flow, low-gradient AS because despite a normal EF, transaortic flow is low (_______).

Answer 90

Stroke volume index <35 mL/ m2

Question 91

________ has been used to augment flow to distinguish truly severe AS from pseudosevere AS, but is less preferred in these patients with a small, hypertrophied ventricle and marked diastolic dysfunction.

Answer 91

Dobutamine

Question 92

Medical therapy has thus far been shown to have ______ on disease progression in patients with AS

Answer 92

No effect

Question 93

There is no one class of medicines established as the preferred treatment of hypertension in patients with AS, but because the renin- angiotensin system is upregulated in the valve and ventricle of patients with AS, ______ or ______ may be preferentially considered

Answer 93

Angiotensin-converting-enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs)

Question 94

Concomitant CAD is common in middle-aged and elderly patients with AS. _______, and the decision of whether to prescribe a statin medication should not be influenced by the presence of AS.

Answer 94

Primary and secondary prevention guidelines should be followed

Question 95

AF or atrial flutter develop in up to one third of older patients with AS, perhaps exacerbated by _____ related to diastolic dysfunction.

Answer 95

Left atrial enlargement

Question 96

When such an arrhythmia is observed in a patient with AS, the possibility of associated _____ should be considered.

Answer 96

Mitral valvular disease

Question 97

New-onset AF in a previously asymptomatic patient with severe AS may be a marker of impending symptom onset.

For those with AF and native valve AS, as well as those treated with a bioprosthetic valve more than 3 months ago, anticoagulation with a ______ is an effective alternative to warfarin.

Answer 97

Non–vitamin K oral anticoagulant

Question 98

This is the procedure of choice for relief of outflow obstruction in adults with valvular AS.

Answer 98

AVR

Question 99

______ has only a modest hemodynamic effect in patients with calcific AS. It can provide short-term improvement in survival and quality of life, but these benefits are not sustained.

Answer 99

Balloon aortic valvuloplasty

Balloon aortic valvuloplasty is not recommended as an alternative to valve replacement for calcific AS.

In selected cases, it might be reasonable as a bridge to definitive treatment with AVR in unstable patients or as a palliative procedure in patients who are not candidates for AVR.

Question 100

ACC AHA Class 1 Indications for AVR in AS

Answer 100

In adults with severe high-gradient AS (Stage D1) and symptoms of exertional dyspnea, HF, angina, syncope, or presyncope by history or on exercise testing, AVR is indicated

In asymptomatic patients with severe AS and an LVEF <50% (Stage C2), AVR is indicated

In asymptomatic patients with severe AS (Stage C1) who are undergoing cardiac surgery for other indications, AVR is indicated

In symptomatic patients with low-flow, lowgradient severe AS with reduced LVEF (Stage D2), AVR is recommended

In symptomatic patients with low-flow, lowgradient severe AS with normal LVEF (Stage D3), AVR is recommended if AS is the most likely cause of symptoms

Question 101

For patients with life expectancy less than 1 year or anticipated poor quality of life not related to their AS, AVR is likely futile and ____ is recommended

Answer 101

Palliative care

Question 102

_______ leads to an improvement in symptoms, quality of life, and functional capacity and lower rates of hospitalization and death; accompanied by reverse remodeling in the heart and improvements in LV function

Answer 102

AVR

Question 103

Class 1 indications for TAVR in AS

Answer 103

For symptomatic patients with severe AS who are older than 80 years of age or for younger patients with a life expectancy <10 years and no anatomic contraindication to transfemoral TAVI, transfemoral TAVI is recommended in preference to SAVR.

For symptomatic patients with severe AS who are 65 to 80 years of age and have no anatomic contraindication to transfemoral TAVI, either SAVR or transfemoral TAVI is recommended after shared decision making about the balance between expected patient longevity and valve durability.

For symptomatic patients of any age with severe AS and a high or prohibitive surgical risk, TAVI is recommended if predicted postTAVI survival is >12 months with an acceptable quality of life

Question 104

Factors to Consider for Patient Selection for Transcatheter Versus Surgical Aortic Valve Replacement

Answer 104

Age
Bicuspid versus tricuspid valve
Valve calcification (amount, location)
Aortic size
Annulus size
Concomitant severe mitral or tricuspid valve disease
Extent, location, and complexity of coronary disease
Severity of left ventricular dysfunction
Transfemoral vascular acces