Evidenced-Based and Practical Management of Real-World Valvular Heart Disease Flashcards
1
Q
What is the age and gender of the patient in Case 1?
A
76 y/o white male
2
Q
What physical activity does the patient in Case 1 engage in?
A
Gardening
3
Q
What is the patient’s blood pressure in Case 1?
A
130/76
4
Q
What is the significance of a sustained PMI in the physical examination?
A
Indicates possible left ventricular hypertrophy or volume overload
5
Q
What type of murmur is noted in the patient from Case 1?
A
2/6 late peaking SEM at RUSB
6
Q
What is the patient’s echocardiogram finding regarding the aortic valve in Case 1?
A
Heavily calcified aortic valve
7
Q
What is the peak aortic jet velocity found in Case 1?
A
4.2 m/s
8
Q
According to current guidelines, what is the degree of aortic stenosis (AS) for the patient in Case 1?
A
Severe
9
Q
What is the appropriate management option for the patient in Case 1 after 6 months?
A
Refer for AVR
10
Q
What is the age and gender of the patient in Case 2?
A
85 y/o white female
11
Q
What symptom progression does the patient in Case 2 experience?
A
Dyspnea on exertion
12
Q
What is the physical examination finding related to the patient’s edema in Case 2?
A
+1 edema
13
Q
What is the echocardiogram finding related to EF in Case 2?
A
EF 55%
14
Q
What is the STS mortality risk percentage for the patient in Case 2?
A
11%
15
Q
What treatment options does the Heart Team recommend for the patient in Case 2?
A
B, C, or D (TAVR, Hospice, Balloon valvotomy as a bridge to TAVR)
16
Q
What is the patient’s diagnosis in Case 6?
A
Severe aortic stenosis
17
Q
What is the appropriate next step in management for the patient in Case 6?
A
Consideration for hospice
18
Q
What does a peak jet velocity of 4.1 m/s indicate during dobutamine infusion in Case 6?
A
Worsening aortic stenosis
19
Q
What is the patient’s age and gender in Case 7?
A
39 y/o woman
20
Q
What was the patient’s best marathon time mentioned in Case 7?
A
3:56:23
21
Q
What trend is observed in the patient’s echocardiogram findings from 2010 to the present in Case 7?
A
Progressive worsening of aortic stenosis
22
Q
What procedure does the patient in Case 7 wish to pursue?
A
Valve replacement therapy
23
Q
What is the general advice regarding mechanical vs. heterograft bioprostheses valves?
A
A, B, and C (Survival is better for mechanical valves, bleeding risk is higher for mechanical valves, valve deterioration is more likely for bioprostheses)
24
Q
What is true regarding homograft valves and the Ross procedure in Case 7?
A
Neither A or B
25
What is the patient's peak jet velocity in Case 6?
4.7 m/s
26
What is the mean gradient of the aortic valve found in Case 6?
50 mmHg
27
What is the patient's hemoglobin level in Case 6?
5 g/dL
28
What is the probable cause of the patient's anemia in Case 6?
Occult blood in stools
29
What is a likely complication of aortic insufficiency noted in Case 6?
Overestimation of AVA by jet velocity
30
What is the main concern for a patient who does not want to pursue lifelong warfarin therapy?
Durability of valve options
## Footnote
Homografts are generally considered more durable than heterografts.
31
What defines a flail P2 mitral leaflet?
Severe mitral regurgitation (MR) with systolic pulmonary vein flow reversal
32
What are the management strategies for a patient with severe mitral regurgitation?
* Referral for mitral repair to a center of repair excellence
* Obtaining a BNP level and exercise test
* Referral for mitral valve replacement
33
What is a true statement regarding a 76-year-old man with a history of anterior myocardial infarction?
Mitral repair is favored over mitral valve replacement
34
What symptoms did the 42-year-old man with a heart murmur experience?
* Fatigue
* Night sweats
* Anorexia
* Weight loss
35
Which statement regarding antibiotic prophylaxis for dental procedures is true?
He should have received antibiotic prophylaxis for his dental procedure
36
What is the risk associated with a patient using IV heroin and presenting with fever and malaise?
Moderate risk for embolization due to vegetations
37
What is indicated for a patient with difficulty in sleeping due to orthopnea after starting antibiotics?
Stat TEE is indicated
38
What is the significance of a bounding carotid pulse in a patient with aortic insufficiency?
It indicates high stroke volume and low diastolic pressure
39
What reasonable options exist for managing a 60-year-old man with aortic insufficiency?
* Begin an ACE inhibitor
* Recommend AVR
* Discuss TAVR options
* Continue to observe his progress
40
What findings are consistent with a diagnosis of infective endocarditis?
* Vegetation on echocardiogram
* Positive blood cultures
* Symptoms like fever and malaise
41
What does a 100.8°F temperature indicate in a patient with suspected endocarditis?
Possible infection
42
In the context of aortic stenosis, what does a peak jet velocity of 3.9 m/s indicate?
Severe aortic stenosis
43
What are common symptoms of mitral stenosis?
* Dyspnea on exertion
* Orthopnea
* Palpitations
44
What is the appropriate management for a patient in atrial fibrillation with rapid ventricular response?
* Rate control
* Anticoagulation
45
What findings are associated with severe mitral regurgitation?
* S3 heart sound
* Enlarged left atrium
* Flail mitral leaflet
46
What is the expected echocardiogram finding in a patient with aortic stenosis?
Severely calcified aortic valve
47
What does a high Wilkins score indicate?
Severe mitral valve disease
48
What are the consequences of untreated severe aortic regurgitation?
* Left ventricular dilation
* Heart failure
49
What is a hallmark sign of infective endocarditis on physical examination?
Petechiae
50
What is the first-line antibiotic therapy for suspected infective endocarditis?
Vancomycin
51
What are the clinical features of aortic insufficiency?
* Diastolic murmur
* Bounding pulses
* Wide pulse pressure
52
What is the importance of BNP levels in heart failure management?
BNP levels help assess the severity of heart failure
53
What does a diastolic blowing murmur at the left upper sternal border suggest?
Aortic regurgitation
54
What is the peak jet velocity indicating severe aortic stenosis?
≥4.0 m/s
## Footnote
This is one of the criteria for classifying severe aortic stenosis.
55
What does an AVA of ≤1.0 cm2 indicate?
Severe aortic stenosis
## Footnote
AVA stands for Aortic Valve Area.
56
What is the mean gradient that indicates severe aortic stenosis?
40 mmHg
## Footnote
This is another criterion for severe aortic stenosis classification.
57
What is the best therapy for a patient with severe aortic stenosis and mitral regurgitation?
SAVR + mitral repair
## Footnote
SAVR stands for Surgical Aortic Valve Replacement.
58
True or False: Tricuspid surgery is warranted in patients with tricuspid regurgitation if mitral repair is successful.
False
## Footnote
Tricuspid surgery may not be needed as TR can improve with mitral repair.
59
What is the condition of a 73 y/o man with severe mitral regurgitation and dyspnea?
Severe MR with a flail P2 segment
## Footnote
MR stands for Mitral Regurgitation.
60
What findings are indicative of severe mitral regurgitation on echocardiogram?
LV and LA enlargement, EF 60%
## Footnote
LV stands for Left Ventricle, LA for Left Atrium, and EF for Ejection Fraction.
61
What is the recommended action for a 30-year-old man with a heart murmur training for a marathon?
Proceed with his marathon training but alert if symptoms arise
## Footnote
Monitoring is essential for patients with known heart murmurs.
62
What is the significance of a flail P2 segment in mitral regurgitation?
Indicates severe mitral regurgitation
## Footnote
A flail segment suggests loss of normal valve function.
63
What is the estimated RV systolic pressure in a patient with severe mitral regurgitation?
30 mmHg
## Footnote
RV stands for Right Ventricle.
64
What does the term 'doming of the pulmonic valve' indicate?
Pulmonic stenosis
## Footnote
This is often seen on echocardiography in patients with congenital heart defects.
65
What is the significance of a sustained PMI in physical examination?
Indicates LV involvement
## Footnote
PMI stands for Point of Maximal Impulse.
66
What is one of the criteria for severe aortic stenosis based on echocardiography?
Peak jet velocity of ≥4.0 m/s
## Footnote
This is used to assess the severity of the condition.
67
Fill in the blank: The best therapy for the patient with severe aortic stenosis is _______.
TAVR
## Footnote
TAVR stands for Transcatheter Aortic Valve Replacement.
68
What does a regurgitant fraction of 40% indicate?
Less than severe pulmonic regurgitation
## Footnote
Regurgitant fraction is a measure of the severity of regurgitation.
69
What are the two options for managing severe aortic stenosis?
SAVR or TAVR
## Footnote
Both are surgical options for replacing the aortic valve.
70
What is the role of inotropic stress testing in aortic stenosis?
To differentiate true aortic stenosis from aortic pseudo-stenosis
## Footnote
Inotropic agents help assess the severity of stenosis under increased flow conditions.
71
What is the common treatment for leaflet thrombosis after TAVR?
Anticoagulation
## Footnote
Anticoagulation has shown to reduce the incidence of leaflet thrombosis.
72
True or False: Gastrointestinal bleeding in aortic stenosis is often caused by shear stress at the stenotic valve.
True
## Footnote
Shear stress can degrade von Willebrand factor, leading to bleeding.
73
What is the significance of valve calcium scoring?
Correlates well with valve area
## Footnote
It helps confirm the severity of aortic stenosis.
74
What does severe aortic insufficiency (AI) affect in the context of aortic stenosis (AS)?
It affects the total stroke volume and increases the gradient
## Footnote
The total pressure load on the left ventricle (LV) directs the natural history of the disease, not simply the valve area.
75
What causes gastrointestinal bleeding in aortic stenosis (AS)?
Shear stress at the stenotic valve that degrades von Willebrand factor (vwf)
## Footnote
This degradation can worsen bleeding in patients with AS.
76
What are the two surgical options that substantially reduce gastrointestinal bleeding in patients with AS?
SAVR and TAVR
## Footnote
These options restore relatively normal valve architecture.
77
What is the calculated STS risk in the given scenario?
1.5
## Footnote
This risk assessment is used to guide surgical intervention decisions.
78
What is the most logical choice for correcting symptoms in a patient with severe symptomatic AS?
Arterial bypass + SAVR
## Footnote
This approach is favored over medical therapy which is deemed inappropriate.
79
In patients with moderate aortic stenosis, what do recent guidelines counsel against?
Long distance running for competitive athletes
## Footnote
The definition of 'competitive' can be controversial.
80
What is the natural history of mixed aortic valve disease (MAVD) compared to severe aortic stenosis (AS)?
Mixed disease has the same natural history as severe aortic stenosis
## Footnote
This finding underscores the seriousness of mixed valve conditions.
81
What factors predict the progression of aortic stenosis (AS) in patients?
Longitudinal data indicating steady and predictable progression
## Footnote
This makes patients candidates for valve replacement.
82
What are the risks associated with mechanical valves compared to heterografts in older patients?
Higher risk of bleeding with mechanical valves
## Footnote
Despite this, existing data suggests significantly longer survival with mechanical valves.
83
Fill in the blank: The likelihood of structural valve deterioration with a bioprosthesis increases inversely with the age of the patient at _______.
implantation
## Footnote
Patients under 50 years at implantation have a >50% chance of requiring valve re-replacement.
