LVOTO

Question 1

Different levels of LVOTO?

Answer 1

Valvular (75% of all LVOTO)
Subvalvular
Supravalvular

Question 2

Bicuspid aortic valve epidemiology

Answer 2

Prevalence 1-2% of general population

3M:1F

Question 3

What is a functional bicuspid valve?

Answer 3

2 leaflets fused

Question 4

What gene mutation has been related to BAV?

Answer 4

NOTCH I gene mutation

Question 5

Which bicuspid AV patients have a faster progression?

Answer 5

Those with greater closure line eccentricity and anteroposterior-oriented line of closure

Question 6

Prognosis in BAV

Answer 6

Good

SCD is rare in asymptomatic patients with good ET, even is AS is severe

Question 7

Symptoms of Valvular AS

Answer 7

Angina, dyspnoea, syncope

Question 8

Cardiac mortality in patients with BAV

Answer 8

0.3% per patient-year of follow-up

Question 9

Frequency of aortic dissection in patients with BAV

Answer 9

0.1%

Question 10

Frequency of endocarditis in patients with BAV

Answer 10

0.3%

Question 11

What is the Vmax (m/s), MPG (mmHg), AVA (cm2) and indexed AVA (cm2/m2 BSA) for patients with moderate AS?

Answer 11

Vmax: 3.0-3.9 m/s
MPG: 30-49 mmHg
AVA: 1.0-1.5 cm2
AVAi: 0.6 - 0.9 cm2/m2 BSA

Question 12

Clinical findings of AS

Answer 12

ESM over Aortic area, radiating to carotid arteries
Palpable thrill
Narrow pulse pressure
Slow rising pulse
LVH

Question 13

ECG findings in patients with AS

Answer 13

LVH with or without strain

Question 14

In what patients is exercise testing recommended?

Answer 14

asymptomatic, severe AS to confirm asymptomatic status and evaluate exercise tolerance, BP response and arrhythmias for risk stratification and timing of surgery

Question 15

In what patients is low-dose DSE useful?

Answer 15

AS with impaired LV (low flow, low gradient)

Question 16

What medical treatment options are available for patients with AS?

Answer 16

Medical treatment for HF is reserved for non-operable patients
Statins show no benefit in retarding progression of AS

Question 17

What treatment options are available?

Answer 17

BAV
Mechanical AVR
Tissue AVR
Ross procedure
Percutaneous valve implantation is an alternative for treating stenosis of PV homograft
TAVI currently has no role in treatment of congenital AS

Question 18

For which patients can the Ross procedure be considered?

Answer 18

Patients of child-bearing age wanting to avoid anticoagulation, but has significant re-operation rate after the first post-operative decade

Question 19

How often should patients with bicuspid aortic valve be followed-up?

Answer 19

Lifelong and regular follow-up is required, intervals depend upon degree of stenosis severity.
After valve intervention - annual follow-up

Question 20

What imaging modalities are recommended after valve surgery?

Answer 20

TTE; CMR of aorta in patients with BAV, even after surgery

Question 21

Exercise/sport recommendations in patients with valvular stenosis

Answer 21

Severe symptomatic and asymptomatic AS and those with moderate AS due to BAV and dilated aorta should avoid strenuous or isometric exercise and competitive sports. In mild and moderate AS sport is allowed. A prior exercise test for counselling is recommended

Question 22

Pregnancy recommendations in patients with AS

Answer 22

Contraindicated in severe symptomatic AS. Treatment by either balloon valvotomy or surgery should be performed before conception.
In asymptomatic patients with severe AS and normal exercise test, pregnancy may be possible but is controversial.
BAV-related aortic dilatation may be induced and progress during pregnancy with a risk of dissection

Question 23

What is the rate of recurrence of CHD?

Answer 23

> 5%

Question 24

IE prophylaxis in patients with AS

Answer 24

Only for high risk patients

Question 25

What patients should undergo valve surgery?

Answer 25

• Severe symptomatic AS
• Asymptomatic patients with severe AS, symptomatic on exercise testing
• Severe AS with LVEF<50% (even if asymptomatic)
• Severe AS undergoing any other open heart surgery

Question 26

What patients should be considered for surgery?

Answer 26

• If ascending aorta >50mm anon other indications for cardiac surgery (regardless of symptoms)
• Asymptomatic with severe AS with drop in BP during ET
• Asymptomatic patients with severe AS and moderate-severe calcification and rate of peak velocity progression >/= 0.3m/s/year
• Moderate AS undergoing any other open heart surgery
• Severe AS with low gradient (<40mmHg) and LVSD with or without contractile reserve
• Asymptomatic patients with severe AS and LVH (>/= 15mm) unless due to HTN