Cardiology 2 - Valve Disease Flashcards
By what criteria is AS or MS severe?
In AS, valve area 4.0, Transvalvular gradent >=40mmHg.
In MS, valve area
What are recommendations for combined CABG/Valve surgery?
Almost all requiring valve Dz should have angiogram prior (1C)
Angiogram for all with 2ndary MR, due to ischaemic aetiology likely (1C)
CABG for lesion >70% at time of valve surgery (1C)
CABG for moderate stenosis at time of valve surgery (50-70%) (IIa C)
What are features of aortic stenosis in the population?
Calcific AS in ~5% of the population >65
Bicuspid more common in
What is the relationship between mortality and asymptomatic AS?
if nil symptoms and SEVERE, death rate is only 1% Once symptomatic (angina, dysponea, syncope) - 5 year survival drops to 50%, and intervention is indicated.
What is the mortality rate for valve surgery for AS?
~1% for patients
What is the role of balloon valvuloplasty for AS?
Good for children, only short term benefit in adults (weeks to months)
Buy time - i.e. pregnant woman with AS/reduction in surgical anaesthetic risk.
An also use to determine if valve is reason for Sx in determining indication for surgery (i.e. COPD and AS)
What are class I indications for AS?
Severe AS with ANY symptoms.
Indicated in patients with severe AS undergoing CABG, aortic or other valve surgery.
Indicated in asymptomatic patients with severe AS and LVEF due to AS
Severe AS in patient with no sx and abnormal stress test
What are complications of TAVI?
Access site mainly - rupture, bleeding, thrombosis.
30 day mortality is 10% - not a benign or low risk procedure.
When is medical therapy indicated for severe AS?
Only in those with such poor LE outside AS that they are unlikely to benefit (given recovery time) - Medical Rx = palliation.
TAVI for patients with high surgical risk (>10% mortality) and who have suitable anatomy.
Durability not yet determined, not for young patients.
What are indications for TAVI?
Performed after heart team assessment (surgeons/cardiologists) (1C)
On site CTS (1C)
Severe AS where surgical AVR is too high risk, Life exp >1y and likely to have symptomatic benefit (1B)
Consider for high risk patients who are surgical candidates but where TAVI is lesser of two evils (IIa B)
What are absolute C/I to TAVI?
Absence of heart team Appropriateness not confirmed by heart team Life expectancy 29mm^2 Thrombus in LV Active endocarditis Elevated risk of ostium obstruction Mobile thrombi in ascending aorta or arch Inadequate vascular access
What are relative contraindications for TAVI?
Bicuspid or non-calcified valves
Untreated CAD req revasc
Haemodynamic instability
LVEF
What are causes of acute, severe AR?
Endocarditis
Dissection
What are causes of chronic AR?
Hypertension Degenerative (w AS) Previous endocarditis bicuspid marfan's
What is the mortality of symptomatic AR?
10-20% per year with symptoms, and nil intervention
What is the mortality of asymptomatic AR with LV dysfucntion?
20% per year with end diastolic diameter >50mm = 20% per annum
What are indications for chronic severe AR?
Severe symptomatic AR (1B)
Asymptomatic AR with LVEF
When is aortic root/ascending aorta surgery indicated, regardless of AR?
Ascending arota >50mm with marfans snydrome
Consider in marfans >45 with risk factors (FHx rupture)
Consider bicuspid >50mm with RFs
Consider all others >55mm
What are medical therapy options in marfan’s disease?
Slower rate of aortic dilatation using beta blockers pre and post surgery
Some ARBs preseve elastin
Screen TTE all 1st degree relatives of marfans, and any bicuspid patient with dilated aortic root
What is the primary cause of severe MS?
rheumatic disease - ongoing decrease in prevalence
Valve area
What are indications for intervention in MS?
If truly asymptomatic, clinically stable and exercise without symptoms - can watch and wait
If symptomatic, or possibility of rapid deterioration - balloon valvuloplasty if suitable, MVR if not suitable
What is the scoring system for MV split score? (wilkins)
Grade 1-4 for mobililty, thickening, calcification, subvavlular thickening - score