Track 7: Prosthetic Valve

Question 1

Takes native pulmonary valve and replaces it in the aortic position
Take homograft or heterograft and put this in the pulmonary position

Answer 1

Ross procedure

Question 2

Cons of mechanical valve

Answer 2

• Lifelong anticoagulation with warfarin

Question 3

Pros of mechanical valve

Answer 3

• Lasts forever

Question 4

Pros of bioprosthesis

Answer 4

• Only requires anticoagulation for 3 months (unless with concomitant AF)
• Option for transcatheter approach

Question 5

Cons of bioprosthesis valve

Answer 5

• Breakdown/early degeneration (especially true in younger patients
• Ie 40 yo will like see degeneration in 8-10 years
• Older patient 70s-80s, might see slower degeneration. maybe 15-20 years

Question 6

Pros and cons of Ross procedure

Answer 6

Pros
- Valve holds up well with time

Cons
- When valve does degenerate, not only do you have an aortic valve issue you may have pulmonary problems as well
- Traded in one valve problem for 2 valve problems

Question 7

Aortic valve replacement
Age < 50
Patient can tolerate OAC
Valve?

Answer 7

• Mechanical valve (likely has survival benefit)
• Ross procedure

Question 8

Aortic valve replacement
Age > 65
Valve?

Answer 8

• Bioprosthetic (degeneration will be slower in older patients)
• Won’t require lifelong OAC

Question 9

At what age is a bioprosthetic aortic valve preferred over mechanical

Answer 9

> 65
if < 50 and can tolerate OAC then mechanical preferred

Question 10

Aortic valve replacement
Age 50-65
Valve?

Answer 10

Shared decision making process

Question 11

Mitral valve replacement
Age < 65
Valve?

Answer 11

Mechanical

Question 12

Mitral valve replacement
Age > 65
Valve?

Answer 12

Bioprosthetic

Question 13

“closing click” during closure

Answer 13

Mechanical prosthesis

Question 14

no click
mild stenosis

Answer 14

Bioprosthetic valve

Question 15

S1 normal
S2 crisp closing click

Answer 15

Mechanical aortic valve

Question 16

S1 crisp closing click
S2 normal

Answer 16

Mechanical mitral valve

Question 17

Normal S1, S2
Slight systolic ejection murmur

Answer 17

Bioprosthetic aortic valve
*Each replacement valve has small degree of intrinsic obstruction

Question 18

Normal S2, S2
Slight early diastolic rumble

Answer 18

Bioprosthetic mitral valve

Question 19

Mechanical valve
Lose closing click

Answer 19

Bad sign
Usually indicates thrombosis or something else is inhibiting valve closure

Question 20

In a mechanical valve you always want to hear what?

Answer 20

closing click
bad sign if not hearing this

Question 21

Mechanical aortic position
Loud systolic ejection murmur ≥ 3/6, extending to second heart sound

Answer 21

Bad sign
Usually indicates obstruction

Question 22

Mechanical mitral position
Loud diastolic murmur

Answer 22

*Not should not hear a murmur with mechanical mitral
Indicates significant stenosis

Question 23

Bioprosthesis aortic position
Very loud systolic murmur extending to S2
OR
Bioprosthesis mitral position
Very loud diastolic rumble

Answer 23

Bad sign
Suggests stenosis of bioprosthesis

Question 24

You suspect something is wrong with the aortic prosthesis, what is your next line test?

You suspect something is wrong with the mitral prosthesis, what is your next line test?

Mechanical prosthesis you suspect is malfunctioning, next test?

Answer 24

TTE

TEE
- Because of acoustic shadowing, need to get TEE to clearly evaluate mitral prosthesis

Fluoroscopy or 3D CT scan

Question 25

Mechanical OR bioprosthetic aortic prosthesis Diastolic decrescendo murmur

Answer 25

Bad sign Suspect regurgitation

Question 26

Mechanical bioprosthetic mitral prosthesis Holosytolic murmur present

Answer 26

Bad sign Suspect regurgitation

Question 27

Bioprosthetic aortic valve What next test to evaluate if malfunction suspected?

Answer 27

TTE

Question 28

Bioprosthetic mitral valve What next test to evaluate if malfunction suspected?

Answer 28

TEE (d/t acoustic shadowing, TTE will be nondiagnostic)

Question 29

Mechanical mitral or aortic valve What next test to evaluate if malfunction suspected?

Answer 29

Fluoroscopy or 3D CT scan

Question 30

Low risk anticoagulation criteria for prosthetic valve INR goal? Bridging?

Answer 30

AVR New generation (St judes, on-x) No prior embolic event NSR Normal EF Target INR 2.5 No longer require ASA unless indicated for other cause Stop warfarin Let INR drift Once sub-therapeutic, surgery Ideally restart the night of the surgery

Question 31

High risk anticoagulation criteria for prosthetic valve INR goal

Answer 31

MVR Prior embolic event AF Decreased EF Target 3.0

Question 32

Low risk anticoagulation patient INR goal

Answer 32

Target 2.5

Question 33

High risk anticoagulation patient INR goal

Answer 33

Target 3.0

Question 34

On-X aortic valve Trials have shown you can go as low as what INR?

Answer 34

1.5-2.0

Question 35

Warfarin bridging in patient with low risk anticoagulation prosthetic valve (AVR New generation (St judes, on-x) No prior embolic event NSR Normal EF)

Answer 35

Stop warfarin Let INR drift Once sub-therapeutic, surgery Ideally restart the night of the surgery

Question 36

Warfarin bridging in patient with high risk anticoagulation prosthetic valve (MVR Prior embolic event AF Decreased EF)

Answer 36

Stop warfarin Once INR < 2.0 bridge with LMWH (outpatient) or UFH (inpatient) At least 6 hours prior to operation stop UFH At least 12 hours prior to operation stop LMWH (if spinal surgery stop LMWH at least 24 hours) Restart warfarin as soon as possible post surgery

Question 37

For patient with AF and native valve heart disease (except rheumatic mitral stenosis) or who received a bioprosthetic valve > 3 months prior, what is the recommended anticoagulation?

Answer 37

DOAC is an effective alternative to VKA Should be administered on the basis of the pt's CHADS2-VASc **Class I**

Question 38

For patients with AF and rheumatic MS, what anticoagulation is recommended

Answer 38

Longterm VKA **Class I**

Question 39

For patients with new onset AF ≤ 3 months after surgical or transcatheter bioprosthetic valve replacement, anticoagulation with?

Answer 39

VKA **Class 2a (Moderate)**

Question 40

In patients with mechanical heart valves with or without AF who require long term anticoagulation, which anticoagulation is recommended and which is not recommended

Answer 40

VKA recommended DOAC not recommended **Class III (Harm)**

Question 41

Under what circumstances should pt with VHD and AF be treated with VKA (DOAC unsafe)

Answer 41

Mechanical valve Rheumatic mitral stensosis

Question 42

DOAC is a reasonable option in patients with AF and native VHD with the exception of:

Answer 42

Rheumatic MS (then VKA indicated)

Question 43

Patients with postoperative AF in the first 3 months after surgical or trancatheter bioprosthetic valve implantation should be anticoagulated with?

Answer 43

VKA May be some evidence that DOACs are safe, but data still being compiled

Question 44

Outline the OAC plan Pt with VHD (rheumatic MS) and AF

Answer 44

VKA

Question 45

Outline the OAC plan Pt with VHD (native valve disease, NOT rheumatic MS) and AF

Answer 45

DOAC or VKA based on CHADS2VASc

Question 46

Outline the OAC plan 1. Pt with VHD (bioprosthetic valve) > 3 months after procedure and AF 2. Pt with VHD (bioprosthetic valve) < 3 months after procedure and AF

Answer 46

1. DOAC or VKA based on CHADs2VASC 2. VKA

Question 47

Pt with mechanical bileaflet or current-generation single-tilting disk AVR AND NO risk factors for thromboembolism OAC plan?

Answer 47

VKA w/ INR of 2.5 **(Class I)**

Question 48

Mechanical AVR and additional risk factors for thromboembolism (ie AF, previous thromboembolism, LV dysfunction, hypercoaguable state) or an older generation prosthesis (ie ball in cage) OAC plan?

Answer 48

VKA w/ INR of 3.0 **(Class I)**

Question 49

Mechanical mitral valve OAC plan?

Answer 49

VKA w/ INR of 3.0 **(Class I)**

Question 50

Bioprosthetic TAVI (3+ months out) No other indications for anticoagulation Plan?

Answer 50

ASA 75-100 mg **(Class 2a)**

Question 51

Bioprosthetic SAVR or mitral valve replacement and no other indications for anticoagulation Plan?

Answer 51

ASA 75-100 mg **(Class 2a)**

Question 52

Bioprosthetic SAVR or mitral valve replacement and low risk for bleeding Short term OAC plan?

Answer 52

VKA to achieve INR of 2.5 for at least 3 months and for as long as 6 months after surgical replacement **(Class 2a)**

Question 53

Mechanical SAVR or mitral valve replacement who are managed with VKA and have an indication for antiplatelet therapy Plan?

Answer 53

Addition of ASA 75-100 mg so long as bleeding risk is low **Class 2b**

Question 54

Mechanical On-X AVR and no thromboembolic risk factors OAC plan?

Answer 54

VKA w/ targeted lower INR (1.5-2.0) starting ≥ 3 months after surgery with continuation of ASA 75-100 mg **Class 2b**

Question 55

Bioprosthetic TAVI, low risk of bleeding Plan? Alternative plan?

Answer 55

DAPT w/ ASA 75-100 mg and clopidogrel 75 mg for 3-6 months after valve implantation **Class 2b** Anticoagulation with VKA w/ INR of 2.5 may be reasonable for 3 months after implantation **Class 2b**

Question 56

Mechanical valve prosthesis, anticoagulation with direct thrombin inhibitor, dabigitran?

Answer 56

Contraindicated **Class 3, Harm**

Question 57

Mechanical valve prosthesis, anticoagulation with anti-Xa direct oral anticoagulant?

Answer 57

**Class 3, Harm** Has not been assessed yet and is not currently recommended