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Delta Med - Cardiology > Cardiology 2 - Valve Disease > Flashcards

Cardiology 2 - Valve Disease Flashcards

1
Q

By what criteria is AS or MS severe?

A

In AS, valve area 4.0, Transvalvular gradent >=40mmHg.

In MS, valve area

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2
Q

What are recommendations for combined CABG/Valve surgery?

A

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)

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3
Q

What are features of aortic stenosis in the population?

A

Calcific AS in ~5% of the population >65

Bicuspid more common in

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4
Q

What is the relationship between mortality and asymptomatic AS?

A 
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.
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5
Q

What is the mortality rate for valve surgery for AS?

A

~1% for patients

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6
Q

What is the role of balloon valvuloplasty for AS?

A

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)

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7
Q

What are class I indications for AS?

A

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

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8
Q

What are complications of TAVI?

A

Access site mainly - rupture, bleeding, thrombosis.

30 day mortality is 10% - not a benign or low risk procedure.

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9
Q

When is medical therapy indicated for severe AS?

A

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.

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10
Q

What are indications for TAVI?

A

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)

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11
Q

What are absolute C/I to TAVI?

A 
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
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12
Q

What are relative contraindications for TAVI?

A

Bicuspid or non-calcified valves
Untreated CAD req revasc
Haemodynamic instability
LVEF

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13
Q

What are causes of acute, severe AR?

A

Endocarditis

Dissection

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14
Q

What are causes of chronic AR?

A 
Hypertension
Degenerative (w AS)
Previous endocarditis
bicuspid
marfan's
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15
Q

What is the mortality of symptomatic AR?

A

10-20% per year with symptoms, and nil intervention

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16
Q

What is the mortality of asymptomatic AR with LV dysfucntion?

A

20% per year with end diastolic diameter >50mm = 20% per annum

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17
Q

What are indications for chronic severe AR?

A

Severe symptomatic AR (1B)

Asymptomatic AR with LVEF

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18
Q

When is aortic root/ascending aorta surgery indicated, regardless of AR?

A

Ascending arota >50mm with marfans snydrome
Consider in marfans >45 with risk factors (FHx rupture)
Consider bicuspid >50mm with RFs
Consider all others >55mm

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19
Q

What are medical therapy options in marfan’s disease?

A

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

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20
Q

What is the primary cause of severe MS?

A

rheumatic disease - ongoing decrease in prevalence

Valve area

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21
Q

What are indications for intervention in MS?

A

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

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22
Q

What is the scoring system for MV split score? (wilkins)

A

Grade 1-4 for mobililty, thickening, calcification, subvavlular thickening - score

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23
Q

What are C/I to Mitral valvuloplasty?

A 
Mitral valve area >1.5cm^2
Left atrial thrombus
More than mild MR
Severe or bicommisural calcification
Absence of commisural fusion
Severe concomitant AV disease, or severe TS and TR
Concomitant CAD requiring CABG
24
Q

What is used for anticoagulation in MS?

A

MS + AF = warfarin (NOACS C/I, as is ASA)
MS + SR + previous embolus = warfarin
MS + SR + LA thrombus on toe - WARFARIN
Mechanical MVR - warfarin
Bioprosthetic MVR - only if low risk for AF, otherwise warfarin
When in doubt - warfarin with INR 2.5-3.5

25
Q

What are features of MR?

A

acute severe MR = papillary muscle rupture post infarct, endocarditis, trauma.
Clinical signs unreliable - TTE can miss jet.
NEED TOE and right heart cath.

Chronic severe MR - repair valve when possible, otherwise replace.

Symptomatic severe chronic MR - surgery in all patients who are surgical candidates - LV dysfunction preop - indicates poor outcomes

26
Q

What are features of primary and secondary MR?

A

primary is due to intrinsic issue with leaflets or chordae
Secondary MR is functional - valve ok but subvalvular apparartus is distorted.

Surgical outcomes are worse in secondary MR

27
Q

When is treatment of asymptomatic MR deemed approrpiate?

A

Generally if LV dysfunction thought to be due to MR, and high likelihood of durable repair, or large flail leaflet or pulmonary hypertension on exercise.

28
Q

What features generally herald development of symptomatic MR?

A

when new AF or pulmonary hypertension at rest develop.

29
Q

What is the class I indication for surgery in chronic secondary MR?

A

Indicated in patients with severe MR, undergoing CABG and LVEF >30%

30
Q

What are features of tricuspid regurgitation?

A

almost always due to other pathology (eg. pulm HTN)
Generally no point in repair if underlying pathology remains.
BUT if severe MR causing pHTN and then TR, concomitant TR surgery indicated if repairing MR

31
Q

What are features of TS?

A

rare!
rheumatic, carcinoid (5HIAA) - incidence may increase with radiotherapy survivors
Poorly tolerated - present with RHF signs - mean gradient of 5mmHg is severe (compared to 10mmHg for MS)

32
Q

What are indications for TS?

A

Symptomatic patients with severe TS (IC)
Severe TS undergoing left sided valve intervention (IC)
Severe primary or secondary TR undergoing left sided surgery (IC)
Surgery indicated in symptomatic patients w severe isolated primary TR without severe RV dysfunction (IC)

33
Q

When are mechanical prostheses indicated?

A

Patient desire and no c/I to anticoag (IC)
Patients at risk of accelerated valve deterioration (IC)
Patients already on A/C due to other mechanical valve (IC)

34
Q

When are bioprosthetic valves indicated?

A

Informed patient preference (IC)
Good quality anticoagulation is unlikely (IC)
Mechanical valve thrombosis despite good quality anticoagulation (IC)

35
Q

What are recommendations for prophylaxis post rheumatic fever?

A

Daily penicillin for at least 10 years or until age 40, whichever is longest.

36
Q

Which procedures generally require endocarditis prophylaxis?

A

Any prosthetic valve/any prothestic material in repair
Previous IE
cyanotic CHD
Any CHD repaired with prosthetic material (6 months) or lifelong if residual shunt/regurg remains

37
Q

What medications are recommended for prophylaxis?

A

amoxicillin 2g orally or iv

clindamycin 600mg orally or iv

38
Q

When is a TTE acceptable in excluding IE?

A

If negative and there is a low clinical suspicion for IE.

39
Q

What are major duke criteria for IE?

A

Culture appropriate organisms on >=2 separate cultures/continuous cultures
Single positive culture for coxiella
Imaging showing vegetation, abscess, perforation, or abnormal PET/SPECT for valve >3 months since implantation

40
Q

What are minor duke criteria for IE?

A 
Predisposition (heart disease, IVDU)
Fever >38
Embolic phenomena
Immunologic phenomena
Microbiology not meeting major critera
41
Q

What are Dx criteria for IE?

A

2 major, 1 major 3 minor or 5 minor = definite IE

1 major, 1 minor or 3 minor = possible IE

42
Q

What are predictors of poor outcome in IE?

A

Old age, prosthetic valve, diabetes, comorbidities
Heart failure, renal failure, shock, stroke
S. aureus, fungal, non HACEK gram -ve
Imaging: several, large vegetations, periannular complications (abscess/fistula), LVEF down, severe prosthetic valve dysfunction

43
Q

What is a reasonable empiric regime for endocarditis in the unwell patient?

A

Gentamicin, flucloxacillin and benzyl penicillin (change to vanc if MRSA suspected or if there is a prosthetic valve/lead)

44
Q

What are indications for surgery in IE?

A

heart failure - if refractory pulmonary oedema/shock

uncontrolled infection - local complications - abscess/fistula/enlarging vegetation, fungi, persisting BC+ despite appropriate therapy

prevention of embolism - vegetation >10mm after embolic event despite appropriate therapy

IIb evidence for >30mm vegetation and for vegetation >10mm associated with severe stenosis or severe regurg

Embolism rare after 2 weeks of appropriate therapy

45
Q

What are features of right sided endocarditis surgery?

A

usually not indicated
issues with compliance, recurrent given IVDU
consider if difficult organisms/>7days culture positive
persistent vegetation >20mm after PE
Refractory HF due to severe TR

46
Q

What are guidelines for valve replacement anticoagulation?

A

With minor surgeries - continue warfarin (cataracts, dental)

Major generally require INR

47
Q

What are principles of management of thrombotic valve obstruction?

A

Dx with TTE, TOE, Fluoroscopy
almost always due to subtherapeutic anticoagulation
if obstructive and patient critical - for surgery and thrombolyse elsewhere
if obstructive and stable with recent low INR - consider heparin, aspriin and observe

48
Q

What is the rationale of management of non-obstructive valve thrombosis?

A

optimisation of anticoagulation is the goal - surgery if patient has had embolic event and still has large thrombus
- if progression, recurrent embolism or failure or resolution - surgery

49
Q

What is the rationale of managing AS and non-cardiac surgery?

A

in symptomatic severe AS - AVR first unless emergency surgery, or high risk AVR (consider TAVI, plasty)
Asymptomatic severe AS with low/moderate risk surgery - no AVR, proceed
Asymptomatic severe AS and high risk non-cardiac surgery (e.g. open AAA, major thoracic) - AVR first unless patient high risk for AVR

50
Q

What are features of valve disease and pregnancy?

A

Severe MS often becomes symptomatic - bed rest, beta blocker, consider plasty post 20/40

Severe AS - uncommon - if truly asymptomatic then usually ok during pregnancy - if deterioration - for valvuloplasty

Chronic AR and MR - usually ok provided LV function is ok

Caardiopulmonary bypass during pregnancy has 20-30% foetal loss rate.

51
Q

What are features of PFO?

A

10-20% adults - nonsignificant shunt size
no indication for closure on haemodynamic grounds
little evidence of closure in cryptogenic stroke - given >40% are due to unrecognised AF.

52
Q

What are features of ASD?

A

ASD larger, bidirectional shunt of haemodynamic significance
can be closed percutaneously, or by surgery
Indications for closure = >10mm ASD, shunt ratio 1.5.
ASD = loading of the Right heart - RV dilatation, and dysfunction, pulmonary hypertension

53
Q

What are the features of VSD?

A

shunt (L->R) between LV and RV. volume loads the left heart.
intervene for haemodynamic grounds (ventricular dysfunction, not pressure gradient), endocarditis or post infarct.
Small sized VSD = large pressure gradient - >80mmHg = loud murmur, not for intervention.
most only require conservative management

54
Q

What are indications for management of coarctation of the aorta?

A

if hypertension and >moderate gradient across lesion - usually near site of ductus arteriosus.

Leads to htn above lesion, and hypotension below.

55
Q

What are features of PDA?

A

persistence of foetal circulation with shunt from aorta to pulmonary artery
very high risk for endocarditis
often closed percutaneously in adults
indicated for closure in all patients due to endocarditis risk

Delta Med - Cardiology (4 decks)

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