Valvular disease

Question 1

most common mechanism of TR.
leaflet restriction and eccentric regurgitation.
redundant tissue

Answer 1

annular dilatation.
leaflet restriction and eccentric regurgitation.
myxomatous degeneration

Question 2

Endocarditis early surgery for:

Answer 2

HF
Persistent bacteremia or fevers lasting >5 days after onset of appropriate antimicrobial therapy;
Heart block, annular or aortic abscess, or destructive penetrating lesions;
Highly resistant organisms (e.g., Staphylococcus aureus, fungal, Pseudomonas aeruginosa, Brucella, enterococci, and other gram-positive cocci)
Recurrent emboli.

Question 3

Severe AI.
Intervene (SAVR only) if

Answer 3

vena contracta >0.6 cm, RF >50%, and RVol >60 mL.
LVESD >50 mm/ LVESDi >25/ LVEF <55% or symptomatic

Question 4

Mechanical mitral valve AC

Answer 4

Warfarin only with goal INR of 3. Can add aspirin if atrial fibrillation, previous thromboembolism, LV dysfunction, hypercoagulable state

Question 5

greatest likelihood of successful mitral valve repair

Answer 5

localized prolapse of P2 and A2

Question 6

low likelihood of successful mitral valve repair

Answer 6

prolapse involving three or more scallops, extensive annular/leaflet calcification, destructive lesions of the leaflets, and mitral annulus diameters >50 mm

Question 7

MVP MR assessment

Answer 7

CMR

Question 8

Acute hemorrhagic stroke

Answer 8

no anticoagulation at all

Question 9

Marfan characteristics

Answer 9

mitral valve prolapse, pectus carinatum, pneumothorax, scoliosis, skin striae, severe myopia, retrognathia, malar hypoplasia, enophthalmos, aortic disease (main cause of M&M).
Decreased preload (sitting, standing)-> earlier click, louder. Increased afterload (squatting)-> later click, decreased murmur.
Louder on valsalva.
Other MR murmurs do the opposite.

Question 10

Most common cause of aortic valve pathology in elderly

Answer 10

Degenerative (sclerocalcific) disease

Question 11

PDA echo

Answer 11

diastolic flow reversal in the aorta

Question 12

Vasodilators for AI

Answer 12

Asymptomatic + SBP > 140

Question 13

Severe MR.
Intervene if.
Chronic primary MR meds

Answer 13

EROA >0.4, RF >50%, Rvol > 60 ml
Symptomatic/ LVEF ≤60% or LVESD ≥40 mm/ pulmonary hypertension/ afib.
None, can treat htn.

Question 14

Provoke symptoms in valvular disease with

Answer 14

exercise, not dobutamine

Question 15

Impact of TAVR paravalvular leak.
TAVR vs SAVR advantages

Answer 15

increased mortality.
lower transvalvular gradients, larger effective orifice areas, and less patient–prosthetic mismatch

Question 16

diastolic decrescendo murmur along the LSB, systolic murmur at the right USB and an Austin Flint murmur (apical diastolic murmur due to the AR jet restricting opening of the anterior mitral leaflet).

Answer 16

AI

Question 17

Severe primary MR treatment

Answer 17

surgical repair. If high or prohibitive surgical risk and suitable anatomy for the procedure-> mitraclip.

Question 18

Severe MS
Incongruent symptoms vs echo

Answer 18

MVA < 1.5
Exercise echo/RHC: PA wedge pressure >25 mm Hg or mean MV gradient >15 mm Hg

Question 19

prolonged AT (>100 msec)

Answer 19

intrinsic abnormality of valve. Degeneration is chronic, thrombus is acute

Question 20

severe PPM aortic.

severe PPM mitral

Answer 20

indexed EOA <0.65 cm2/m2. associated with a lack of regression of LVH following valve replacement.
<.9,

Question 21

capillary nail bed pulsations (known as Quincke’s sign), retinal arteriolar pulsations (Becker’s sign), water hammer pulses (Corrigan’s pulse), head bobbing (De Musset’s sign), and uvula pulsations (Muller’s sign).

Answer 21

AI

Question 22

Duroziez sign elicited by

Answer 22

compressing the femoral artery with the diaphragm of the stethoscope, If severe aortic regurgitation is present, a diastolic murmur from retrograde flow will then be heard.

Question 23

Surgical Bioprothestic mitral valve med

Answer 23

3-6 mos: warfarin, INR goal of 2.5
lifelong aspirin

Question 24

TAVR AC

Answer 24

DAPT for 6 months

Question 25

TMVR

Answer 25

high or prohibitive surgical risk and/or secondary MR

Question 26

No benefit of mitraclip

Answer 26

left ventricular end-diastolic dimension (LVEDD) 75 mm, PASP >70

Question 27

Pre mitral balloon valvuloplasty

Answer 27

Get TEE to look for LA thrombus and quantify MR

Question 28

EOA prosthetic valve elevated velocity for aortic bioprosthetic valve

Answer 28

LVOT area * DVI >3 m/s

Question 29

valve stenosis

Answer 29

DVI < 0.25

Question 30

AS replacement if

Answer 30

severe AS in symptomatic patients, asymptomatic patients with a reduced ejection fraction (<50%), and patients requiring other cardiac surgery.

Question 31

Severe secondary MR treatment

Answer 31

Optimize GDMT (optimize treatment of underlying LV dysfunction-cath/CRT if needed), then consider mitraclip. If anatomy is not favorable-> surgical repair

Question 32

Antibiotic ppx

Answer 32

Prior history of endocarditis, prosthetic valves or material, congenital heart disease, transplanted heart with primary valvular disease. Use amoxicillin or IV ampicillin

Question 33

endocarditis first step

Answer 33

blood cultures, then antibiotics and TTE

Question 34

most likely endocarditis patient to derive benefit from urgent surgery

Answer 34

heart failure (HF)

Question 35

normal LVOT VTI

Answer 35

20 cm

Question 36

prosthetic aortic valve high velocity (3 m/s)

Answer 36

start with DVI >0.25= PPM (iEOA < 0.85), high flow state (LVOT VTI high) <0.25= thrombus (more acute) or pannus (AT will be more than 100 for both) >0.25 + AT > 100= subvalvular narrowing or improper measurement

Question 37

most important risk factor for development of calcific aortic stenosis

Answer 37

age

Question 38

very severe AS

Answer 38

peak aortic valve (AoV) velocity of 5 m/sec. Intervene regardless of symptoms

Question 39

most common congenital valvular lesion

Answer 39

bicuspid aortic valve

Question 40

endocarditis with device involvement/ presence?

Answer 40

extraction

Question 41

Valvular afib

Answer 41

Warfarin, not DOAC. Same if prior embolic event/LAA thrombus.

Question 42

severe TR

Answer 42

VC 0.7, EROA 0.4, Systolic hepatic vein flow reversal prominent descent of the V wave, venous systolic thrill, and tender hepatomegaly

Question 43

strep bovis endocarditis

Answer 43

also get colonoscopy, repeat in 4-6 months

Question 44

pulmonary stenosis intervention

Answer 44

valvuloplasty first line if there's no PR, surgical repair if needed surgical replacement if marked valvular dysplasia or hypoplasia of the annulus

Question 45

warfarin reversal dabigatran reversal other DOACS

Answer 45

prothrombin complex concentrate (PCC) Idarucizumab Andexanet alpha

Question 46

Lambl's excresence management

Answer 46

no further testing, observation

Question 47

fibrosis and fusion of the mitral chordae, calcified leaflet tips. calc of annulus and the base of the mitral leaflets. Congenital absence of a papillary muscle.

Answer 47

rheumatic MS. calcific MS. parachute mitral valve.

Question 48

TAVR preprocedural planning

Answer 48

Cardiac and aortic CT angiography (TEE if CT would be harmful) invasive or CT coronary angiography, dental examination to rule out potential infection sources

Question 49

most common etiology of TS [tricuspid stenosis]. severe TS.

Answer 49

rheumatic disease, associated with mitral disease. mean pressure gradient >5 mm Hg, [PHT] ≥190 [msec], valve area ≤1.0 cm2 (continuity equation)

Question 50

asymptomatic moderate AS/AI/MR surveillance

Answer 50

1-2 years 6-12 mos for severe disease

Question 51

severe MS auscultation.

Answer 51

narrowing of the A2–opening snap interval, <80 msec. bring out the MS rumble by having the patient perform sit-ups

Question 52

Bicuspid risk of associated disease

Answer 52

AI is highest, then AS, then ascending aortic aneurysm, then coarctation, then dissection

Question 53

end-stage renal disease on dialysis substantially increases surgical mortality risk.

Question 54

prosthetic mitral valve high velocity (E velocity >2), mean gradient > 5

Answer 54

iEOA < 0.9= severe PPM PHT > 200 = stenosis

Question 55

most likely defect in Turner syndrome

Answer 55

bicuspid aortic, then coarctation

Question 56

Fungal (candida, aspergillus) endocarditis

Answer 56

surgery

Question 57

Valvular surgery follow up

Answer 57

TTE at 6-12 weeks

Question 58

most common cause of a flail leaflet

Answer 58

myxomatous disease

Question 59

MR poor prognosis

Answer 59

elevated BNP

Question 60

Avoid SAVR

Answer 60

STS> 8%, highly calcified aorta, prior chest radiation, severe lung, liver, or renal disease.

Question 60

Hill's sign

Answer 60

systolic BP in the leg >40 mm Hg higher than in the arm: severe AI

Question 61

Aortic root repair in bicuspids

Answer 61

root >5.5 cm OR root >5 cm if additional risk factors are present (family history of dissection, growth >0.5 cm in 1 year, coarctation) OR root >4.5 cm if performing AVR anyway.

Question 62

staph UTI

Answer 62

think staph bacteremia despite no other signs of infection, could be subacute