AHA: MR

Question 1

bp v mech

class 1 recommendation(s) for mitral valve choice

Answer 1

• shared decision-making (1)
• bp if warfarin contraindicated (1)

“For patients who require heart valve replacement, the choice of prosthetic valve should be based on a shared decision-making process that accounts for the patient’s values and preferences and includes discussion of the indications for and risks of anticoagulant therapy and the potential need for and risks associated with valve reintervention.”
“For patients of any age requiring valve replacement for whom anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired, a bioprosthetic valve is recommended.”

Question 2

bp v mech

class 1 recommendation(s) for mitral valve choice

(2)

Answer 2

• shared decision-making (1)
• bp if warfarin contraindicated (1)

“For patients who require heart valve replacement, the choice of prosthetic valve should be based on a shared decision-making process that accounts for the patient’s values and preferences and includes discussion of the indications for and risks of anticoagulant therapy and the potential need for and risks associated with valve reintervention.”
“For patients of any age requiring valve replacement for whom anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired, a bioprosthetic valve is recommended.”

Question 3

bp v mech

age-based recommendation(s) for mitral valve choice

Answer 3

• <65yo = mech (2a)
• ≥65yo = bp (2a)

assuming no contraindication to warfarin

“For patients <65 years of age who have an indication for MVR, do not have a contraindication to anticoagulation, and are unable to undergo MVRx, it is reasonable to choose a mechanical prosthesis over a bioprosthetic valve.”
“For patients ≥65 years of age who require MVR and are unable to undergo MVRx, it is reasonable to choose a bioprosthesis over a mechanical valve.”

Question 4

bp v mech

mitral valve choice if warfarin contraindicated

Answer 4

bp (1)

“For patients who require heart valve replacement, the choice of prosthetic valve should be based on a shared decision-making process that accounts for the patient’s values and preferences and includes discussion of the indications for and risks of anticoagulant therapy and the potential need for and risks associated with valve reintervention.”
“For patients of any age requiring valve replacement for whom anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired, a bioprosthetic valve is recommended.”

Question 5

bp v mech

mitral valve choice in <65yo

assuming no contraindication to warfarin

Answer 5

mech
(2a)

“For patients <65 years of age who have an indication for MVR, do not have a contraindication to anticoagulation, and are unable to undergo MVRx, it is reasonable to choose a mechanical prosthesis over a bioprosthetic valve.”
“For patients ≥65 years of age who require MVR and are unable to undergo MVRx, it is reasonable to choose a bioprosthesis over a mechanical valve.”

Question 6

bp v mech

mitral valve choice in ≥65yo

assuming no contraindication to warfarin

Answer 6

bp
(2a)

“For patients <65 years of age who have an indication for MVR, do not have a contraindication to anticoagulation, and are unable to undergo MVRx, it is reasonable to choose a mechanical prosthesis over a bioprosthetic valve.”
“For patients ≥65 years of age who require MVR and are unable to undergo MVRx, it is reasonable to choose a bioprosthesis over a mechanical valve.”

Question 7

regurgitant jet width (% of LA) in mild MR

Answer 7

<20

%

Question 8

vena contracta in mild MR

Answer 8

<0.3

cm

Question 9

RVol/V_regurg in mild MR

regurgitant volume

Answer 9

<30

mL/beat

Question 10

RF in mild MR

regurgitant fraction

Answer 10

<30

%

Question 11

EROA in mild MR

effective regurgitant orifice area

Answer 11

<0.2

cm²

Question 12

grade in mild MR

Answer 12

1+

Question 13

PV flow reversal in mild MR

Answer 13

systolic dominance

only specified in ASE

Question 14

regurgitant jet width (% of LA) in moderate MR

Answer 14

20-40

%

Question 15

vena contracta in moderate MR

Answer 15

0.3-0.7

cm

Question 16

RVol/V_regurg in moderate MR

regurgitant volume

Answer 16

30-60

mL/beat

Question 17

RF in moderate MR

regurgitant fraction

Answer 17

30-50

%

Question 18

EROA in moderate MR

effective regurgitant orifice area

Answer 18

0.2-0.4

cm²

Question 19

grade in moderate MR

Answer 19

2+

Question 20

PV flow reversal in moderate MR

Answer 20

systolic blunting

only specified in ASE

Question 21

regurgitant jet width (% of LA) in severe MR

Answer 21

>40

%

Question 22

vena contracta in severe MR

Answer 22

≥0.7

cm

Question 23

RVol/V_regurg in severe MR

regurgitant volume

Answer 23

≥60

mL/beat

Question 24

RF in severe MR

regurgitant fraction

Answer 24

≥50

%

Question 25

EROA in severe MR | effective regurgitant orifice area

Answer 25

≥0.4 | cm²

Question 26

grade in severe MR

Answer 26

3-4+

Question 27

PV flow reversal in severe MR

Answer 27

holosystolic | only specified in ASE

Question 28

# mitral valve regurgitant jet width (% of LA) \<20 %

Answer 28

mild MR

Question 29

# mitral valve vena contracta \<0.3 cm

Answer 29

mild MR

Question 30

# mitral valve RVol/V_regurg \<30 mL/beat | regurgitant volume

Answer 30

mild MR

Question 31

# mitral valve RF \<30 % | regurgitant fraction

Answer 31

mild MR

Question 32

# mitral valve EROA \<0.2 cm² | effective regurgitant orifice area

Answer 32

mild MR

Question 33

# mitral valve 1+ grade regurg

Answer 33

mild MR

Question 34

# mitral valve regurgitant jet width (% of LA) = 20-40 %

Answer 34

moderate MR

Question 35

# mitral valve vena contracta = 0.3-0.7 cm

Answer 35

moderate MR

Question 36

# mitral valve RVol/V_regurg = 30-60 mL/beat | regurgitant volume

Answer 36

moderate MR

Question 37

# mitral valve RF = 30-50 % | regurgitant fraction

Answer 37

moderate MR

Question 38

# mitral valve EROA = 0.2-0.4 cm² | effective regurgitant orifice area

Answer 38

moderate MR

Question 39

# mitral valve 2+ grade regurg

Answer 39

moderate MR

Question 40

# mitral valve regurgitant jet width (% of LA) \>40 %

Answer 40

severe MR

Question 41

# mitral valve vena contracta ≥0.7 cm

Answer 41

severe MR

Question 42

# mitral valve RVol/V_regurg ≥60 mL/beat | regurgitant volume

Answer 42

severe MR

Question 43

# mitral valve RF ≥50 % | regurgitant fraction

Answer 43

severe MR

Question 44

# mitral valve EROA ≥0.4 cm² | effective regurgitant orifice area

Answer 44

severe MR

Question 45

# mitral valve 3-4+ grade regurg

Answer 45

severe MR

Question 46

indication(s) for intervention in moderate 1° MR

Answer 46

NONE *regardless of sx status*

Question 47

indication(s) for intervention in moderate 2° MR

Answer 47

NONE *regardless of sx status*

Question 48

indication(s) for intervention in moderate MR

Answer 48

NONE *regardless of sx status* | neither 1° nor 2°

Question 49

indication(s) for intervention in severe 2° MR

Answer 49

- concomitant CABG ⇒ MVR/x (2a) *regardless of sx status* - sx (NYHA ≥II) ⊕GDMT + MR r/t LVEF<50% AND EF>20% + LVESD≤70mm + PASP≤70mmHg ⇒ TEER (2a) - v sx (NYHA ≥III) ⊕GDMT + MR r/t LVEF<50% ⇒ MVR/x (2b) - v sx (NYHA ≥III) ⊕GDMT + MR r/t LA annular dil + LVEF≥50% ⇒ MVR/x (2b)

Question 50

indication(s) for intervention in sx severe 2° MR

Answer 50

- concomitant CABG ⇒ MVR/x (2a) *regardless of sx status* - sx (NYHA ≥II) ⊕GDMT + MR r/t LVEF<50% AND EF>20% + LVESD≤70mm + PASP≤70mmHg ⇒ TEER (2a) - v sx (NYHA ≥III) ⊕GDMT + MR r/t LVEF<50% ⇒ MVR/x (2b) - v sx (NYHA ≥III) ⊕GDMT + MR r/t LA annular dil + LVEF≥50% ⇒ MVR/x (2b)

Question 51

indication(s) for intervention in sx severe 2° MR | (4)

Answer 51

- concomitant CABG ⇒ MVR/x (2a) *regardless of sx status* - sx (NYHA ≥II) ⊕GDMT + MR r/t LVEF<50% AND EF>20% + LVESD≤70mm + PASP≤70mmHg ⇒ TEER (2a) - v sx (NYHA ≥III) ⊕GDMT + MR r/t LVEF<50% ⇒ MVR/x (2b) - v sx (NYHA ≥III) ⊕GDMT + MR r/t LA annular dil + LVEF≥50% ⇒ MVR/x (2b)

Question 52

indication(s) for intervention in asx severe 2° MR

Answer 52

- concomitant CABG ⇒ MVR/x (2a) *regardless of sx status*

Question 53

ONLY indication for intervention in asx severe 2° MR

Answer 53

- concomitant CABG ⇒ MVR/x (2a) *regardless of sx status*

Question 54

indication(s) for *surgical* intervention in sx severe 2° MR

Answer 54

- concomitant CABG ⇒ MVR/x (2a) *regardless of sx status* - v sx (NYHA ≥III) ⊕GDMT + MR r/t LVEF<50% ⇒ MVR/x (2b) - v sx (NYHA ≥III) ⊕GDMT + MR r/t LA annular dil + LVEF≥50% ⇒ MVR/x (2b)

Question 55

indication(s) for *surgical* intervention in sx severe 2° MR | (3)

Answer 55

- concomitant CABG ⇒ MVR/x (2a) *regardless of sx status* - v sx (NYHA ≥III) ⊕GDMT + MR r/t LVEF<50% ⇒ MVR/x (2b) - v sx (NYHA ≥III) ⊕GDMT + MR r/t LA annular dil + LVEF≥50% ⇒ MVR/x (2b)

Question 56

indication(s) for *transcatheter* intervention in sx severe 2° MR

Answer 56

- sx (NYHA ≥II) ⊕GDMT + MR r/t LVEF<50% AND EF>20% + LVESD≤70mm + PASP≤70mmHg ⇒ TEER (2a)

Question 57

indication(s) for *transcatheter* intervention in sx severe 2° MR | (1)

Answer 57

- sx (NYHA ≥II) ⊕GDMT + MR r/t LVEF<50% AND EF>20% + LVESD≤70mm + PASP≤70mmHg ⇒ TEER (2a)

Question 58

preferred surgical intervention in 2° MR

Answer 58

chordal-sparing MVR (>MVRx) (2b)

Question 59

preferred surgical intervention in 1° MR

Answer 59

MVRx (>MVR) in degen dz (1)

Question 60

indication(s) for intervention in severe 1° MR

Answer 60

- sx (regardless of EF) (1) - v sx (NYHA ≥III) + high/prohib-risk ⇒ TEER (2a) - rheumatic etio & rx likely @ CVC ⇒ MVR/x (2b) - asx + LV dysfxn (EF≤60% OR LVESD≥40mm) (1) - asx + EF=WNL AND \>95% rx & \<1% mort @ CVC (2a) - asx + EF=WNL BUT progressive ￬ EF OR ↑ LVESD on 3 studies (2b)

Question 61

CTSNet severe ischemic MR trial: primary endpoint

Answer 61

LVESD volume index (i.e. LV remodeling) ⇒∅

Question 62

CTSNet severe ischemic MR trial: outcomes

Answer 62

￬HF SAEs (incl re-adm) & ￬mod+MR with replacement

Question 63

2° severe MR feature/anatomy most predictive of recurrent MR after MVRx

Answer 63

basal inferior dyskinesis (in post-hoc analysis of CTSNet severe MR trial; SESATS)

Question 64

preferred ring/band choice for a MVRx for 2° MR

Answer 64

complete (slightly undersized) ring (still semi-rigid?)

Question 65

pulmonary edema laterality 2/2 mitral dz

Answer 65

R 2/2 flow reversal into PVs during systole, with relative obstr to R-sided pulm venous return, with retrograde increase in hydrostatic pressure

Question 66

mgmt of acute MR 2/2 chordal rupture

Answer 66

emergent MVRx (usu not 2/2 MI)

Question 67

unilateral R pulm edema, fever, leukocytosis, acute onset, +systolic murmur

Answer 67

acute MR 2/2 chordal rupture

Question 68

Where & what structures are at risk around the mitral annulus?

Answer 68

1. LCx @ P1 \> anterolat commissure 2. NCC @ anterior leaflet (A3) ^(\>>LCC@A1) 3. coronary sinus @ posterior leaflet P3\>P2 - ± bundle of His @ A3/posteromed commissure (next to R trigone in membranous septum)

Question 69

What are the 2 papillary muscles and their blood supply?

Answer 69

1. anterolateral = LAD + LCx 2. posteromedial = RCA (PDA)