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1

2017 Recomendation of severe secondary vs primairy MR - 

  • ERO 
  • Regurgitant volume 

Some data has suggested that with severe secondary MR, a smaller ERO should be used 

(? weakend ventricle, correlates with regurg volume) 

Recs unchanged: 

ERO: >0.4cm2 (more specific),  ERO 0.2cm2 (more sensitive) 

Regurg volume > 60ml 

2

reccomendataion for patient with : 

Decreased exercise tolerance

Exertional dyspnea

ERO = 0.5cm2 

LVEF > 30 

1B evidence for Surgery 

Standing 2014 guideline -

Mitral valve surgery is recommended for symptomatic

patients with chronic severe primary MR (stage D) and

LVEF greater than 30%

3

reccomendation for patient with: 

no symptoms 

Chronic severe MR 

LVEF 45% 

LVESD 40mm 

 

 

1B recomendation is surgery. 

The 2014 recs stand: 

Mitral valve surgery is recommended for asymptomatic

patients with chronic severe primary MR and LV dysfunction

(LVEF 30% to 60% and/or left ventricular end-systolic

diameter [LVESD] ‡40 mm,

4

Recomendation for a patient with: 

no symptoms 

Chronic severe primairy MR 

LVEF: 65% 

LVESD 35mm 

Surgery:

  • if the liklihood of a successful repair is >95% and expected mortality is <1% at a heart valve center of excellece: 

IIa B recomendation is for mitral valve repair 

5

From a Mitral data perspective, what does an LVEF of 60% and a LVESD > 40 indicate 

The presence of systolic LV dysfunction 

6

Mitral regurgitation: 

Other than LVEF (<60) and LVESD > 40mm, what data can push a patient with primairy MR to surgery ?

  1. New onset atrial fibrillation 
  2. Pulmonary artery systolic pressure > 50mmHg 

IIa B recomendation: 

Mitral valve repair is reasonable for asymptomatic patients

with chronic severe nonrheumatic primary MR (stage C1) and preserved LV function (LVEF >60% and LVESD <40 mm) in whom there is a high likelihood of a successful and durable repair with 1) new onset of AF or 2) resting pulmonary hypertension (pulmonary artery systolic arterial pressure >50 mm Hg

7

Anticoagulation for patients with rheumatic mitral stenosis and atrial fibrillation 

Anticoagulation with vitamin K antagonist 

8

Reccomendatioins for antibotic prophylaxis with dental procedures  IE prophylaxis ? 

Prophylaxis against IE is reasonable before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or

perforation of the oral mucosa in patients with the

following (13,15,23–29):

1. Prosthetic cardiac valves, including transcatheterimplanted

prostheses and homografts.

2. Prosthetic material used for cardiac valve repair,

such as annuloplasty rings and chords.

3. Previous IE.

4. Unrepaired cyanotic congenital heart disease or

repaired congenital heart disease, with residual

shunts or valvular regurgitation at the site of or

adjacent to the site of a prosthetic patch or

prosthetic device.

5. Cardiac transplant with valve regurgitation due to a

structurally abnormal valve.

9

DOAC 

DOAC= Direct oral anticoagulants- 

 Apixaban (Eliquis®) 

Dabigatran (Pradaxa®)

Rivaroxaban (Xarelto®)

10

class IA reccomendations for TAVR 

Class IA Recs 

 

TAVR is recommended for symptomatic patients with severe AS (Stage D) and a prohibitive risk for surgical AVR who have a predicted post-TAVR survival greaterthan 12 months

11

​Valve hemodynamic criteria for Symptomatic severe high-gradient AS? 

​Valve hemodynamic criteria for Symptomatic severe high-gradient AS

  1. valve hemodynamics:
    1. aortic velocity  4.0 m/s or higher,
    2. corresponding to a mean trans-aortic gradient of 40 mm Hg or higher.
    3. valve area is <1.0 cm2 with an indexed aortic valve area of  < 0.6 cm2/m2
    4. but it may be larger, with mixed stenosis and regurgitation.

12

​Valve hemodynamic criteria for Symptomatic severe high-gradient AS

valve hemodynamics:

velocity? 

​Valve hemodynamic criteria for Symptomatic severe high-gradient AS

valve hemodynamics:

aortic velocity  4.0 m/s or higher

 

13

​Valve hemodynamic criteria for Symptomatic severe high-gradient AS

valve hemodynamics:

mean transaortic gradient:

40 mm Hg or higher.

 

14

​Valve hemodynamic criteria for Symptomatic severe high-gradient AS

valve hemodynamics:

valve area: .

  • valve area is <1.0 cm2
  • indexed aortic valve area of  < 0.6 cm2/m2

but it may be larger, with mixed stenosis and regurgitation.

15

TAVI

Severe symptomatic low-flow low-gradient With low EF:

 

TAVI

Severe symptomatic low-flow low-gradient With low EF:

  1. severe AS with a low left ventricular (LV) ejection fraction (EF) (<50%)
  2. defined by a severely calcified valve with:
    1. reduced systolic opening and an aortic valve area <1.0 cm2.
    2. Aortic velocity is ≤4.0 m/s at rest but increases ≥4.0 m/s on low-dose dobutamine stress echocardiography.

16

TAVI

Severe symptomatic low-flow low-gradient severe AS with a normal LVEF

ECHO CRITERIA 

Severe symptomatic low-flow low-gradient severe AS with a normal LVEF

  1. aortic valve area <1.0 cm2 with a
  2. aortic velocity <4.0 m/s
  3. mean gradient <40 mm Hg.
  4. indexed aortic valve area  <0.6 cm2/m2  
  5. stroke volume index <35 ml/m2

17

TAVI 

 

Patient specific factors important to evaluating TAVI candidacy 

Per 2014 Guidelines:

integrated assessment combining

  1. the Society of Thoracic Surgeons (STS) Predicted Risk of Mortality score
    • the STS score: <4% (low risk),

    • 4% to 8% (intermediate risk),

    • >8% (high risk).

  2. frailty
  3. main organ system dysfunction

18

TAVI Evaluation 

Major CV comorbidities assessed? 

Major CV Comorbidities assessed:

  1. Coronary artery disease
  2. LV systolic dysfunction
  3. Concurrent valve disease (MR/MS)
  4. Pulmonary hypertension
  5. Aortic disease (porcelain aorta)
  6. Peripheral Vascular disease
  7. Hostile chest / prohibitive previous open heart surgery

19

TAVI Evaluation 

Major non-CV comorbidities 

  1. Malignancy (remote, active, impact on life expectancy)
  2. GI and liver Disease
  3. GIB, IBD, Cirrhosis,
  4. GFR < 30cc/min/1.73m2
  5. HD
  6. O2 requirement
  7. FEV1 < 50% predicted
  8. DLCO < 50% predicted
  9. Neurologic disorders
    1. Movement disorders, dementia

20

TGA 

 

what are the two major anatomic variants? 

And their relative frequency 

  1. Two major subdivisions
    1. “Simple TGA” – 60- 70%
    2. “VSD”  30-50%

21

TGA 

frequency of VSD + Pulmonary stenosis 

 

  1. VSD and pulmonary stenosis : 10%

22

TGA 

frequency of a subaortic conus 

Subaortic conus : 90%

 

23

TGA 

 

frequency of PFO 

PFO in nearly all

24

TGA 

if left uncorrected, when does the LV thickness begin to decrease 

1 month 

25

TGA 

what form of TGA presents with severe cyanosis after birth? 

TGA + IVS 

 

Cyanosis depends on the level of mixing -- 

no mixing 

26

TGA 

What form presents with mild cyanosis and heart failrue in the first month ? 

Why? 

TGA with a large PDA/VSD  (and no LVOTO) 

Cyanosis depends on mixing - large PDA or VSD permit mixing 

LVTOTO would prevent the ammount of pulmonary over flow (pulmonary vascular bed has low resistance) 

 

27

TGA Presentation of: 

TGA / Large VSD / LVOTO? 

Why? 

severe cyanosis without heart failure 

 

Cyanosis depends on the mixing 

LVOTO controlls the over circulation through the pulmonary bed, which is controlled by the LVOTO

28

TGA Presentation of: 

TGA / large VSD or PDA / NO LVOTO ? 

Why? 

Heart failure within the first month, mild cyanosis 

 

cyanosis depends on mixing - provided by VSD/PDA 

 

no LVOTO to inhibit the inhibit the overcirculation through the vascular bed. 

29

TGA Presentation of: 

TGA with IVS 

 

Why? 

Cyanosis 

No mixing 

30

TGA is what % of all CHD ? 

7.8%