Valve Disease

Question 1

Aetiology of AS

Answer 1

<70yrs = bicuspid and rheumatic
>70yrs = degenerative and bicuspid

Question 2

Grading of severity of AS

Answer 2

ECG: LVH

TTE: Severe = valve area <1 or mean gradient >40

Concern with low flow severe AS where poor LV function –> low valve gradient due to poor output. Low dose dobutamine challenge or balloon valvuloplasty can be used to assess

Question 3

Sign of poor prognosis with AS

Answer 3

HEART FAILURE +++

2nd = syncope
3rd = angina

Question 4

Prognosis for AS

Answer 4

If asymptomatic SCD = <1% annually. BUT must do exercise assessment to determine if really asymptomatic

If symptomatic then 5yr survival is <50% = intervention is required

Question 5

Surgical mortality for AS

Answer 5

1% for patients under 70yrs

4-8% for patients > 80yrs

Question 6

What about balloon valvuloplasty?

Answer 6

Children = benefit

Adults = buy time or to assess symptom benefit for high risk surgical patients

Question 7

Indications for AS surgery

Answer 7

Symptomatic severe AS

Severe AS and having other cardiac surgery

Question 8

Surgical Vs TAVI replacement

Answer 8

Surgical = mainstay of treatment

TAVI = high surgical risk (>10% mortality) but have suitable anatomy and life expectancy >1yr and likely to have symptomatic benefit

Medical management = poor life expectancy due to comorbidities

Question 9

Complications of TAVI?

Answer 9

BLEEDING +++
Vascular injury

30 day mortality = 10%

Question 10

Causes of AR?

Answer 10

Acute severe = dissection or endocarditis –> emergent surgery

Chronic = HTN, Degeneration due to AS, previous endocarditis, bicuspid and Marfans

Question 11

Mortality from AR?

Answer 11

Chronic severe symptomatic AR - mortality = 10-20%/yr

Chronic severe Asymptomatic AR + LV dysfunction = 20%/yr

Question 12

Clinical signs of AS?

Answer 12

Low diastolic BP, high SBP
Duration of murmur = severity
S3
LVF

Question 13

What surgery for AR?

Answer 13

Valve replacement usually

May have valve repair but expect to reoperate

Question 14

Surgical indications for AR?

Answer 14

Severe symptomatic AR
Asymptomatic with LVEF<50%
Having other heart surgery
Asymptomatic with normal EF but dilated LV

Question 15

What about aortic root surgery?

Answer 15

Marfans with root >50
Bicuspid >50 with risk factors
Everything else at >55

Question 16

Medical therapy in aortic disease?

Answer 16

Beta blockers to reduce rate of aortic dilation
?ARBs
Screening of relatives with Marfans and bicuspid valves with dilated aortic roots

Question 17

Causes of Mitral stenosis?

Answer 17

Severe = RHEUMATIC HD

Calcific rarely becomes severe

Question 18

Clinical signs of MS?

Answer 18

Loud S1 - opening snap and diastolic rumble
DURATION OF MURMUR = Severity
Pulmonary HTN and RV failure

ECG = AF
CXR = LA enlargement

Question 19

Indications for intervention for MS

Answer 19

Severe symptomatic MS
Severe MS + pulmonary HTN
Asymptomatic patient who them become symptomatic when in AF

Question 20

Surgical options for MS?

Answer 20

Percutaneous mitral balloon commisurotomy = usually for younger patients

Surgical replacement = elderly due to concomitant MR

Question 21

Indications for Surgery for MS

Answer 21

Symptomatic MS

If MR = surgical, if not = PMC

Question 22

Signs of MR?

Answer 22

LV dysfunction - displaced apex beat, S3, LV failure
Early short murmur = acute MR
Late murmur in MVP

SEVERE = RHF

Question 23

Causes of MR?

Answer 23

Acute severe = papillary muscle rupture post MI, endocarditis or trauma

Chronic severe MR =

• Primary = intrinsic problem with the leaflets or chordae
• Secondary = functional due to distortion of subvalvular apparatus = WORSE OUTCOMES

Question 24

Treatment of MR?

Answer 24

Chronic severe MR without symptoms = valve repair

Symptomatic severe chronic MR = surgery

Question 25

Causes of TR?

Answer 25

Almost always secondary to other pathology Fix underlying path = fix TR

Question 26

Causes of TS? Presentation? Treatment?

Answer 26

RARE Rheumatic HD Carcinoid Poorly tolerated --> RHF Treatment = Surgery for severe

Question 27

Mechanical Vs Bioprosthetic valve

Answer 27

``` Mechanical = lasts longer BUT needs anticoagulation Bioprosthetic = shorter life ``` ``` AR = bioprosthetic if >60yrs MR = bioprosthetic if >65yrs ``` If needs anticoagulation anyway = mechanical valve

Question 28

Anticoagulation bridging?

Answer 28

INR must be <1.5 for most major surgery = stop warfarin and bridge with unfractionated heparin

Question 29

Management of valve obstruction?

Answer 29

Diagnosis = TTE/TOE/Fluoroscopy Check INR - usually always subtherapeutic = optimise If obstructive and patient critical = surgery or thrombolyse and transfer for surgery If obstructive and stable = heparin and aspirin and close surveillance

Question 30

Severe AS and non-cardiac surgery?

Answer 30

Symptomatic severe AS = AVR first unless emergency surgery Asymptomatic severe AS and low risk surgery = proceed with surgery Asymptomatic severe AS and high risk surgery = AVR first

Question 31

Valve disease and pregnancy

Answer 31

Severe MS --> worse --> symptoms Treatment = bed rest, beta blocker and vavuloplasty at 20 weeks Severe AS = rare. Valvuloplasty if deteriorates Chronic AR and MR are usually okay in pregnancy as long as LV function is okay C-P bypass = 20-30% fetal loss rate