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AHA: MS Flashcards

1
Q

bp v mech

class 1 recommendation(s) for mitral valve choice

A
  • 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.”

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2
Q

bp v mech

class 1 recommendation(s) for mitral valve choice

(2)

A
  • 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.”

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3
Q

bp v mech

age-based guideline recommendation(s) for mitral valve choice

A
  • <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.”

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4
Q

bp v mech

mitral valve choice if warfarin contraindicated

A

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.”

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5
Q

bp v mech

mitral valve choice in <65yo

assuming no contraindication to warfarin

A

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.”

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6
Q

bp v mech

mitral valve choice in ≥65yo

assuming no contraindication to warfarin

A

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.”

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7
Q

bp v mech

mitral valve choice in 50-65yo

assuming no contraindication to warfarin

A

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.”

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8
Q

vmax in mild MS

A

<5†

m/s

†AHA classifies >5-10 as severe & ≤5 as not

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9
Q

vmax in mod MS

A

5-10†

m/s

†AHA classifies >5-10 as severe & ≤5 as not

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10
Q

vmax in sev MS

A

>10†

m/s

†AHA classifies >5-10 as severe & ≤5 as not

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11
Q

AVA in mild MS

A

> 1.5†

cm2

†AHA classifies ≤1.5 as severe & <1.5 as not

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12
Q

AVA in mod MS

A

1.0-1.5†

cm2

†AHA classifies ≤1.5 as severe & <1.5 as not

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13
Q

AVA in sev MS

A

<1.0†

cm2

†AHA classifies ≤1.5 as severe & <1.5 as not

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14
Q

mean gradient in mild MS

A

<5†

mmHg

†AHA classifies >5-10 as severe & ≤5 as not

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15
Q

mean gradient in mod MS

A

5-10†

mmHg

†AHA classifies >5-10 as severe & ≤5 as not

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16
Q

mean gradient in sev MS

A

> 10†

mmHg

†AHA classifies >5-10 as severe & ≤5 as not

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17
Q

mitral valve

vmax <5 m/s

A

mild MS†

†not included in AHA

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18
Q

mitral valve

vmax = 5-10 m/s

A

mod MS†

†not included in AHA

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19
Q

mitral valve

vmax >10 m/s

A

sev MS†

†not included in AHA

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20
Q

MVA >1.5 cm2

<3.0

A

mild MS†

†AHA classifies ≤1.5 as severe & <1.5 as not

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21
Q

MVA = 1.0-1.5 cm2

A

mod MS†

†AHA classifies ≤1.5 as severe & <1.5 as not

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22
Q

MVA = <1.0 cm2

A

sev MS†

†AHA classifies ≤1.5 as severe & <1.5 as not

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23
Q

mitral valve

mean gradient <5 mmHg

A

mild MS†

†AHA classifies >5-10 as severe & ≤5 as not

24
Q

mitral valve

mean gradient = 5-10 mmHg

A

mod MS†

†AHA classifies >5-10 as severe & ≤5 as not

25
# mitral valve mean gradient \>10 mmHg
sev MS† ## Footnote †AHA classifies >5-10 as severe & ≤5 as not
26
Is degenerative or rheumatic MS more common?
rheumatic
27
PLA ⇒ pulm edema
≥30mmHg
28
PASP in mild MS | PA systolic pressure
\<30† | mmHg ## Footnote †AHA classifies "WNL @ rest" as up to mild - mod & does not specify values for sev
29
PASP in mod MS | PA systolic pressure
30-50† | mmHg ## Footnote †AHA classifies "WNL @ rest" as up to mild - mod & does not specify values for sev
30
PASP in sev MS | PA systolic pressure
\>50† | mmHg ## Footnote †AHA classifies "WNL @ rest" as up to mild - mod & does not specify values for sev
31
# mitral valve dPt1/2 \<150 ms | diastolic PHT (pressure half-time)
mild MS† ## Footnote †AHA classifies ≥150 as severe & \<150 as not
32
# mitral valve dPt1/2 = 150-200 ms | diastolic PHT (pressure half-time)
mod MS† ## Footnote †AHA classifies ≥150 as severe & \<150 as not
33
# mitral valve dPt1/2 > 200 ms | diastolic PHT (pressure half-time)
sev MS† ## Footnote †AHA classifies ≥150 as severe & \<150 as not
34
PASP \<30 mmHg | PA systolic pressure
mild MS† ## Footnote †AHA classifies "WNL @ rest" as up to mild - mod & does not specify values for sev
35
PASP = 30-50 mmHg | PA systolic pressure
mod MS† ## Footnote †AHA classifies "WNL @ rest" as up to mild - mod & does not specify values for sev
36
PASP \>50 mmHg | PA systolic pressure
sev MS† ## Footnote †AHA classifies "WNL @ rest" as up to mild - mod & does not specify values for sev
37
dPt1/2 in mild MS | diastolic PHT (pressure half-time)
# mitral valve \<150† | ms ## Footnote †AHA classifies ≥150 as severe & \<150 as not
38
dPt1/2 in mod MS† | diastolic PHT (pressure half-time)
# mitral valve 150-200† | ms ## Footnote †AHA classifies ≥150 as severe & \<150 as not
39
dPt1/2 in sev MS | diastolic PHT (pressure half-time)
# mitral valve >200† | ms ## Footnote †AHA classifies ≥150 as severe & \<150 as not
40
indication(s) for intervention in severely sx, severe *non-rheumatic calcific* MS
MVI "may be considered only after" discussing high procedural risks (2b) | MVI = mitral valve intervention (NOS) ## Footnote "In severely symptomatic patients (NYHA class III or IV) with severe MS (MVA≤1.5cm2, Stage D) attributable to extnesive mitral annual calcification, valve intervention may be considered only after discussion of the high procedural risk and the individual patient's preferences and values." (2b)
41
indication(s) for intervention in *non-rheumatic calcific* MS
**basically none**, only: severely sx (NYHA III-IV), severe MS ⇒ MVI "may be considered only after" discussing high procedural risks (2b) | MVI = mitral valve intervention (NOS) ## Footnote "In severely symptomatic patients (NYHA class III or IV) with severe MS (MVA≤1.5cm2, Stage D) attributable to extnesive mitral annual calcification, valve intervention may be considered only after discussion of the high procedural risk and the individual patient's preferences and values." (2b)
42
Wilkins score indicating favorable mitral valve morphology
≤8 ## Footnote https://drive.google.com/file/d/1-UrIQilWndc3quVWMxYzq96wsuuprNXQ/view
43
Wilkins score components
leaflet: mobility, thickening, calcification + subvalvular thickening (graded 1-4 x4 = range 4-16) ## Footnote https://drive.google.com/file/d/1-UrIQilWndc3quVWMxYzq96wsuuprNXQ/view
44
indication(s) for intervention in asx moderate rheumatic MS
NONE
45
indication(s) for intervention in asx severe rheumatic MS
- PASP>50 ⇒ PMBC (2a) - new afib ⇒ PMBC (2b) | at a CVC
46
indication(s) for intervention in sx moderate rheumatic MS
MVA>1.5 (i.e. mod MS) + NYHA ≥II + "hemodynamically significant" during exercise, i.e. PAWP>25 OR mean grad>15 ⇒ PMBC (2b) | at a CVC ## Footnote "In symptomatic patients (NYHA class II, III, or IV) with rheumatic MS and an mitral valve area >1.5 cm2, if there is evidence of hemodynamically significant rheumatic MS on the basis of a pulmonary artery wedge pressure >25 mmHg or a mean mitral valve gradient >15 mmHg during exercise, PMBC may be considered if it can be performed at a Comprehensive Valve Center."
47
indication(s) for intervention in sx severe rheumatic MS
- NYHA ≥II + \
48
mgmt of asx severe rheumatic MS with PASP>50 | \+ \
PMBC (2a) | at a CVC
49
mgmt of asx severe rheumatic MS with new afib | \+ \
PMBC (2b) | at a CVC
50
mgmt of moderate rheumatic MS (MVA>1.5) + NYHA ≥II + "hemodynamically significant" during exercise, i.e. PAWP>25 OR mean grad>15
PMBC (2b) | at a CVC ## Footnote "In symptomatic patients (NYHA class II, III, or IV) with rheumatic MS and an mitral valve area >1.5 cm2, if there is evidence of hemodynamically significant rheumatic MS on the basis of a pulmonary artery wedge pressure >25 mmHg or a mean mitral valve gradient >15 mmHg during exercise, PMBC may be considered if it can be performed at a Comprehensive Valve Center."
51
mgmt of severe rheumatic MS + NYHA ≥II + \
PMBC (1) | at a CVC ## Footnote "1. In symptomatic patients (NYHA class II, III, or IV) with severe rheumatic MS (mitral valve area ≤1.5 cm2, Stage D) and favorable valve morphology with less than moderate (2+) MR in the absence of LA thrombus, PMBC is recommended if it can be performed at a Comprehensive Valve Center." (1)
52
mgmt of severe rheumatic MS + NYHA ≥III + concomitant \<3 surg OR PMBC not an option (d/t already failed, not an anatomic candidate, or not available)
MVR/x (1) ## Footnote "2. In severely symptomatic patients (NYHA class III or IV) with severe rheumatic MS (mitral valve area ≤1.5 cm2, Stage D) who 1) are not candidates for PMBC, 2) have failed a previous PMBC, 3) require other cardiac procedures, or 4) do not have access to PMBC, **mitral valve surgery (repair, commissurotomy, or valve replacement)** is indicated." (1)
53
mgmt of severe rheumatic MS + NYHA ≥III + not candidates or high-risk for surgery
PMBC (2b) | at a CVC ## Footnote "6. In severely symptomatic patients (NYHA class III or IV) with severe rheumatic MS (mitral valve area ≤1.5 cm2, Stage D) who have a suboptimal valve anatomy and who are not candidates for surgery or are at high risk for surgery, PMBC may be considered if it can be performed at a Comprehensive Valve Center."
54
What does PMBC mean?
percutaneous mitral balloon commissurotomy
55
further testing/evaluation of moderate MS with exertional sxs
exercise testing (1) | to measure MV gradient and/or PAWP ## Footnote "1. In patients with rheumatic MS and a discrepancy between resting echocardiographic findings and clinical symptoms, exercise testing with Doppler or invasive hemodynamic assessment is recommended to evaluate symptomatic response, exercise capacity, and the response of the mean mitral gradient and pulmonary artery pressure."

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