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Valvular Disease Flashcards

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1
Q

What are the indications for PMBC?

A
  • Progressive MS (MVA > 1.5 cm2, T1/2 < 150 ms)
    • PMBC at CVC (Class IIb)
      • Exertional symptoms →
      • Stress test with hemodynamically significant MS →
      • Pliable valve, no clot, < 2+ MR →
  • Severe MS (MVA « 1.5 cm2, T1/2 « 150 ms)
    • PMBC at CVC (Class I)
      • Symptomatic +
      • Pliable valve, no clot, < 2+ MR
    • PMBC at CVC (Class IIb)
      • Symptomatic +
      • Pliable valve, no clot, < 2+ MR (does not meet) +
      • Severe symptoms, NYHA III-IV
      • NOT Surgical candidate
    • PMBC at CVC (Class IIa)
      • Asymptomatic
      • Pliable valve, no clot, > 2+ MR​
      • PASP > 50 mmHg
    • PMBC at CVC (Class IIb)
      • Asymptomatic
      • Pliable valve, no clot, > 2+ MR
      • New onset A-fib
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2
Q

What are the indications for MVR in MS?

A
  • Severe MS (MVA « 1.5 cm2 and T 1/2 ► 150 ms)
    • Symptomatic –>
    • No Favorable valve morphology, No LAA clot, < Mild MR
    • Severe symptoms - NYHA Class III-IV symptoms
    • Surgical candidate

***Class I recommendation

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3
Q

What are the contraindications to PMBV?

A
  • Persistent LA or LAA thrombus
  • Obstruction of IVC
    • tumor, thrombus, therapeutic ligation, filter placement
  • Bleeding diatheses
  • Anatomic deformity resulting in rotation of the heart
    • severe kyphoscoliosis
    • previous pneumonectomy
  • > Moderate MR
  • Massive or bicommisural calcification
  • Severe concomitant aortic valve disease
  • Severe TS
  • Severe functional TR with enlarged annulus
  • Severe concomitant CAD requiring CABG
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4
Q

What is the recommended duration of Rheumatic Fever Prophylaxis?

  • Rheumatic fever with carditis
  • Residual heart disease (persistent valvular disease)
A

10 years

or

Until 40 years of age

  • whichever is longer
  • sometimes lifelong prophylaxis
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5
Q

What is the recommended duration of Rheumatic Fever Prophylaxis?

  • Rheumatic fever with carditis
  • No residual heart disease
A

10 years

or

until 21 years of age

  • whichever is longer
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6
Q

What is the recommended duration of Rheumatic Fever Prophylaxis?

  • Rheumatic fever without carditis
A

5 years

or

until 21 years of age

  • whichever is longer
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7
Q

What are the medical treatment options for rheumatic fever prophylaxis?

A
  • Benzathine PCN G
  • PCN VK
  • Sulfadizine
  • Macrolide or Azalide
    • only if allergic to PCN and Sulfadiazine
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8
Q

What is the medical therapy for chronic, primary MR?

A

no pharmacologic agent has been shown to slow progression toward surgical intervention

  • ACE/ARBs –> decreased Regurgitant volume but no difference in clinical event rates
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9
Q

Why is MV repair recommended over MVR in primary MR?

A
  • preservation of LV function
  • lower operative mortality rate
  • lower rate of long term complications associated with prosthetic valves
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10
Q

What subgroups of patients with primary MR have been found to have higher event rates or clinical deterioration?

A
  • EROA ► 0.40 cm2 or
  • Flail leaflets
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11
Q

What is the recommended medical therapy?

  • chronic, primary MR
  • LVEF < 60%
  • surgery is not planned
A
  • ACE/ARBs
  • Vasodilator agents

****Class IIa recommendation

*****not indicated for normotensive, asymptomatic, LVEF ► 60%

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12
Q

Describe the management of chronic, severe MR

  • Primary, Severe MR
  • Asymptomatic
A
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13
Q

Describe the management of chronic, severe MR

  • Primary, Severe MR
  • Symptomatic
A
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14
Q

Describe the management of chronic, severe MR

  • Primary, Severe MR
  • Asymptomatic
A
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15
Q

What factors are required to proceed with TEER in primary severe MR?

A
  • High or prohibitive surgical risk
  • Anatomy favorable for transcatheter approach
  • Life expectancy > 1 year
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16
Q

Describe the management of severe secondary MR

A
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17
Q

Describe the management of chronic, severe MR prior to proceeding with any surgical/procedural intervention

A
  • Treat comorbidities:
    • CAD Rx
    • HF Rx
    • AFib Rx
    • Consider CRT
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18
Q

What is the treatment for acute, severe MR?

A
  • Afterload reduction (may improve hemodynamic status by)
    • reducing RV
    • increasing LV forward SV
    • increasing CO
  • Sodium nitrorpusside
  • Hypotension –> IABP
  • Emergent Surgery = definitive therapy
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19
Q

What is the preferred treatment for chronic, secondary MR prior to surgical intervention?

A
  • Medical therapy
    • ACE, BB, Aldosterone antagonists –> treat LV systolic dyfunction and/or CAD
    • reduces preload, afterload and reduces adverse LV remodeling –> secondary MR
  • CRT
    • to improve severe LV dysfunction with mechanical dyssynchrony
    • may reduce MR severity
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20
Q

When is transcatheter (edge-to-edge) MV repair considered in chronic, severe, secondary MR?

A
  • LV dysfunction (LVEF < 50%)
  • NYHA class III-IV symptoms
    • despite optimal therapy for CHF
    • including Bi-V pacing
  • Anatomy (favorable)
    • LVEF 20-50%
    • LVESD < 70 mm
    • PASP < 70 mm

****Class IIa

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21
Q

EKG definition:

  • Pacemaker malfunction, not constantly capturing (atrium or ventricle) “failure to capture”
A
  • Pacemaker stimulus without appropriate depolarization
    • at a time when the myocardium refractory
  • May be caused by:
    • lead fracture
    • increased pacing threshold secondary to myocardial scar
    • medications (flecainide, amiodarone)
    • perforation
    • electrolyte abnormalities
    • displacement
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22
Q

What are causes of “failure to capture” in pacemaker malfunction?

A
  • lead fracture
  • increased pacing threshold secondary to myocardial scar
  • medications (flecainide, amiodarone)
  • perforation
  • electrolyte abnormalities
  • displacement
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23
Q

What are the age cutoff’s for mechanical over bioprosthetic valve replacement?

A
  • Aortic
    • < 50 years –> mechanical
    • 50-65 years –> either
    • > 65 years –> bioprosthetic
  • Mitral
    • < 65 years –> mechanical
    • > 65 years –> bioprosthetic
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24
Q

What are risk factors for poor outcomes in severe AR?

A
  • Symptoms
  • Increased LVEDD
    • > 65 mm
  • Increased LVESD
    • > 50 mm
  • Reduced exercise EF
    • < 50%
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25
What test should be ordered in a patient with incidental finding of dilated aortic root (4.2 cm)? Why?
* **TTE** * **Bicuspid aortic valve**
26
Describe the risk categories in selection of TAVR vs. SAVR
27
What mechanical prosthetic valves require bridging anticoagulation?
* Bileaflet aortic valve with increased thromboembolic risk factors * Caged ball or tilting disc prosthesis * Mitral valve prosthesis * Recent CVA/TIA
28
What mechanical prosthetic valves do not require bridging anticoagulation?
Bileaflet AV without other risk factors of thromboembolism
29
What are risk factors for thromboembolism in the setting a mechanical valve?
* Hypercoaguable condition * A-Fib * LV dysfunction * Thromboembolism (previous)
30
When is a target INR 3.0 (2.5-3.5) recommended in regards to mechanical prosthesis?
* Mechanical AVR + risk factors for TE * Older generation mechanical AVR * ball in cage * Mechanical MVR
31
What are the INR recommendations for On-X valve in the aortic position?
**VKA + ASA** * First 3 months --\> INR 2.5 * \> 3 months --\> INR 2.0
32
What are the recommended anticoagulation strategies in pregnancy and prosthetic valves?
* Continued VKA * 1st Trimester UFH or LMWH --\> VKA (sequential therapy) * UFH/LMWH (entire pregnancy) \*\*\*\*\*\*\*UFH prior to delivery
33
What is the first step in assessment of prosthetic valve (AV or MV) with high gradients after surgery?
Calculate Indexed EOA * Indicate Patient-Prosthesis mismatch: * Aortic = **EOA \< 0.85 cm2 / m**2 (severe = \< 0.65 )​ * Mitral = **EOA \< 1.2 cm2 / m2 **(severe = \< 0.9 )
34
What is the second step in assessment of prosthetic valve (AV or MV) with high gradients after surgery?
TTE, TEE, Cinefluor --\> to identify * Gradient increased during follow-up * Aortic \> 10 mmHg * Mitral \> 5 mmHg * abnormal leaflet morphology / mobility * DVI: * Aortic \< 0.30 * Mitral \> 2.2 * Difference between measured EOA and reference EOA \> 0.30 - 0.4 cm2 * EOA and DVI decreased during follow up YES --\> consider prosthesis stenosis NO --\> consider * High flow state * Technical error * Localized high gradient (bileaflet valve)
35
Describe the risk/benefits in anticoagulation strategies used in pregnancy with prosthetic valves?
* VKA * Lowest likelihood of maternal complications * Highest likelihood of fetal complications (1st trimester (particularly) + dose \> 5 mg) --\> * miscarriage * fetal death * congenital abnormalities * Reduced dose \< 5mg/day --\> decreased (not eliminated) fetal complications * Reduced thromboembolic complications (compared to UFH/LMWH) * UFH/LMWH * increased maternal complications * greatest number of successful live births
36
What are the anticoagulation recommendations following bioprosthetic valve placement?
* ASA daily * **indefinitely** if no contraindication * SAVR * VKA --\> **3-6 months (Class IIb)** * TAVR * VKA --\> **3 months (Class IIb) or** * DAPT --\> **3-6 months (Class IIb)**
37
What is the recommended anticoagulation strategy in patients receiving TAVR who are unable to be anticoagulated?
**DAPT x 6 months** * dc Clopidogrel after 6 months and continue ASA indefinitely
38
What is the recommendation regarding ASA in patients with valve replacement?
**ASA daily (indefinitely)** + VKA * decreases incidence of: * major embolism or death (**1.9% vs. 8.5%** per year; p \< 0.001) * stroke rate (**1.3% vs. 4.2%** per year) * overall mortality (**2.8% vs. 7.4%** per year) * Increased bleeding (not statistically significant)
39
What findings on exercise stress testing, in a patient with asymptomatic, severe AS, would merit intervention?
Symptoms or Inability to augment BP by 20mmHg or Decrease in BP at peak exercise
40
What murmur is related to the Gallavardian phenomenon? Describe the murmur
* AS (degenerative or age-related) * harsh murmur at the base + musical murmur at the apex * due to the high-frequency components of the AS murmur radiating to the LV apex * often confused with MR
41
How can these murmurs be differentiated? * AS (age-related or degenerative) * MR
* AS (age-related or degenerative) * ​Systolic ejection murmur​ * harsh at base * musical at apex * **increases with bradycardia or after a pause (PVC)** * MR * holosystolic * not affected by HR, PVC
42
Describe the valvular lesion associated with these hemodynamic findings * Large LV to aorta pressure gradient
AS
43
Calculate posthetic valve EOA
CSA LVOT x VTI LVOT ----------------------------------- VTI jet
44
Describe the valvular lesion associated with these hemodynamic findings * large V wave on PCWP
MR
45
Describe the valvular lesion associated with these hemodynamic findings * large V wave on the RA
TR
46
Describe the valvular lesion associated with these hemodynamic findings * increased PA O2 saturation
Left-to-right shunt / VSD
47
Describe the valvular lesion associated with these hemodynamic findings * large RVOT to PA pressure gradient
PS
48
Describe the effects on cardiac auscultation and murmur as AS worsens
* diminished ejection sound/intensity of A2 * murmur peaks later in systole \*\*\*\*\*PVC --\> murmur increases
49
What can cause the murmur of AS to intensify or worsen?
PVC
50
Describe key differences between the murmurs: * Acute AR * Chronic AR
* Acute AR * diastolic murmur may be short * mitral valve might close prematurely (S1 softens) and * mid-diastolic rumble of relative mitral stenosis (**Austin-Flint murmur**) may occur * Chronic AR * holodiastolic murmur
51
Describe the effects of cardiac auscultation/murmur with worsening MS
* A2-opening snap interval in MS shortens --\> * as LA pressure rises and * approaches that of the aortic early diastolic pressure
52
What is one finding of bicuspid aortic valve fusion that carries prognostic implications?
Right-Noncoronary cusp fusion --\> higher incidence of aortic dilation
53
What is the monitoring recommendation for BAV?
**Annually (if)** * significant aortic dilatation **\> 4.5 cm** * rapid rate of change in aortic diameter **\> 0.5 cm/year** * **FH of aortic dissection**
54
What is the cutoff for aortic imaging with Echo?
visualization of the aorta up to **4 cm** distal to the valve
55
What are the indications for surgical intervention in regards to aortic abnormalities in BAV?
* **Class I** * aortic diameter **\> 5.5 cm** * **Class IIa** * **​**aortic diameter **5.1 - 5.5 cm** + rapid growth ( **\> 0.5 cm/year**) or FH aortic **dissection** * aortic diameter **4.5 cm** + valve surgery (severe AS or AR)
56
What is recommendation regarding Warfarin use throughout pregnancy?
Continued throughout pregnancy if dose **« 5 mg/day** * embryopathy from warfarin appears to be dose dependent * switch to UFH just prior to delivery * **Class IIa recommendation**
57
What equation can be used to obtain MVA during cardiac catheterization?
* Hakki equation * MVA = CO (L/min) / √mean pressure gradient (mm Hg)
58
What are common errors / problems when obtaining MVA during cardiac catheterizaton (Hakki equation)?
* subject to errors in estimation of CO * failure to simultaneously measure left atrial (LA) and LV pressure * Concomitant regurgitation
59
What is the problem when utilizing PCWP in place of LA pressure to determine MVA during cardiac catheterization (Hakki equation)?
measurement of PCWP in place of LA pressure may * overestimate gradient and * underestimate MVA
60
Define patient prosthesis mismatch (PPM)
effective orifice area (EOA) of a prosthesis is too small relative to the patients body size --\> resulting in **abnormally high postoperative gradients**
61
What are two situations in which bioprosthetic valves are utilized over mechanical valves?
* Pregnancy (anticipating) * History of IVDA
62
What are 3 priniciples that must be understood by both sonographer and interpreting echocardiographer in the assessment of prosthetic vavles?
* All prosthetic valves have some **inherent obstruction** (which varies based on valve type and size), which can make differentiating between normal and pathologic gradients challenging. * Prosthetic valves have **inherent transprosthetic regurgitation** that must not be confused with pathologic regurgitation. * **Acoustic shadowing** and other **artifacts** such as **reverberations** can make evaluation of the structure of the valve and presence/degree of regurgitation difficult
63
What is the EOA (indexed) cutoff in regards to PPM for a prosthesis in the aortic position?
**EOA indexed ≤ 0.85 cm2 / m2** * smaller areas --\> rapid increase in transvalvular gradients
64
What is the EOA (indexed) cutoff for severe PPM for a prosthesis in the aortic position?
**EOA indexed ≤ 0.65 cm2 / m2**
65
What are the major adverse outcomes associated with PPM?
short-term and long-term survival * particularly if associated with LV dysfunction
66
What peak velocity should prompt further evaluation in assessment of aortic prosthetic valves?
**\> 3 m/s**
67
What is the severity scale for aortic prosthetic valves? * Peak velocity
* Normal \< 3 m/s * Possible stenosis 3-4 m/s * Significant stenosis \> 4 m/s
68
Assessment of peak and mean gradients across the mitral/tricuspid valve prostheses are greatly dependent upon this?
**Heart rate** * gradients across mitral and tricuspid prostheses are very HR dependent
69
What is the severity scale for mitral prosthetic valves? * Peak velocity
* Normal \< 1.9 m/s * Possible stenosis 1.9-2.5 m/s * Significant stenosis \> 2.5 m/s
70
What is the severity scale for mitral prosthetic valves? * Mean gradient
* Normal ≤ 5 mmHg * Possible stenosis 6-10 mmHg * Significant stenosis \> 10 mmHg
71
What is the severity scale for aortic prosthetic valves? * Mean gradient
* Normal \< 20 mmHg * Possible stenosis 20-35 mmHg * Significant stenosis \> 35 mmHg
72
What is the severity scale for aortic prosthetic valves? * DVI
* Normal ≥ 0.30 * Possible stenosis 0.29 - 0.25 * Significant stenosis ≤ 0.25
73
What is the severity scale for mitral prosthetic valves? * VTIPrMV / VTILVOT
* Normal \< 2.2 * Possible stenosis 2.2 - 2.5 * Significant stenosis \> 2.5
74
What is the severity scale for mitral prosthetic valves? * EOA
* Normal ≥ 2cm2 * Possible stenosis 1-2 cm2 * Significant stenosis \< 1 cm2
75
What is the severity scale for aortic prosthetic valves? * EOA
* Normal \> 1.2 cm2 * Possible stenosis 1.2 - 0.8 cm2 * Significant stenosis \< 0.8 cm2
76
What is the severity scale for mitral prosthetic valves? * PHT
* Normal \< 130 ms * Possible stenosis 130 - 200 ms * Significant stenosis \> 200 ms
77
What is the severity scale for aortic prosthetic valves? * Acceleration time (AT)
* Normal \< 80 ms * Possible stenosis 80 - 100 ms * Significant stenosis \> 100 ms
78
What are findings suggestive of prosthetic TS?
* PV ≥ 1.7 m/s * MG ≥ 6 mmHg * PHT ≥ 230 ms
79
What is the severity scale for aortic prosthetic valves? * jet velocity contour
* Normal - triangular, early peaking * Possible stenosis - triangular to indeterminate * Significant stenosis - rounded, symmetrical contour
80
What do microcavitations (in harmonic imaging) indicate in prosthetic valve assessment?
**normal prosthetic valve**
81
What prosthetic valves demonstrate the greatest degree of pressure recovery?
**Bileaflet (small)** and **Ball and cage**
82
Define Ejection clicks
* high-pitched sounds that occur at the moment of maximal opening of the aortic or pulmonary valves * heard just after the first heart sound * sounds occur in the presence of: * a dilated aorta or pulmonary artery of in the presence of * a bicuspid or flexible stenotic aortic or pulmonary valve
83
What are the recommendations in regards to PHT in assessment of prosthetic valves?
**Should not be used** / **Inaccurate**
84
In which mitral valve prosthesis is the largest degree of physiologic regurgitation seen?
**Bileaflet valves** * central and peripheral jets
85
Describe EKG findings in hyperkalemia (K 6.5 - 7.5)
* 1st degree AV block * flattening and widening of the P wave * ST-depression * **QRS widening**
86
What is recommended whenever paravalvular regurgitation is suspected?
**TEE** * essential to the evaluation of paravavular regurgitation
87
What are mimickers of constriction?
* Restrictive cardiomyopathy * Severe TR * Ventricular interdependence (other causes)
88
Describe the algorithm in evaluating aortic prosthesis with PV \> 3 m/s
89
Describe the timing of heart sounds
90
In which mitral valve prosthesis is a large central jet most consistent with normal valve function?
**Medtronic-Hall single disc valve**
91
What is the diagnosis and next best step? * 52 year old man with prior Type A aortic dissection s/p mAVR and root repair presents with 1 week of progressive dyspnea and orthopnea * HR 92 bpm, BP 148/92, RR 22, O2 90% on RA * PE: elevated JVP, rales and scattered wheezing, distant heart sounds, 1+ LE edema * EKG: NSR with lateral ST depressions * Labs: Cr 1.2, INR 2.2, BNP 1200, Troponin 0.40 * TTE: Normal LVEF with poor windows * CXR: bilateral, patchy infiltrates
* **TEE** * ​TTE (class I) indication --\> TEE utilized due to poor windows * TEE more sensitive for the detection of valve dysfunction and thrombosis * CCTA (Class IIa) can also be utilized * **Valve thrombosis** * **​**suspect in patients with interrupted anticoagulation or subtherapeutic INR
92
What is the most helpful distinguishing feature of a pulmonary ejection sound?
**Inspiration --\> decreased intensity / dissappearnce** * **inspiration** --\> increased venous return --\> partial opening of the pulmonary valve prior to systole --\> lack of a sharp opening movement of the pulmonary valve * maximal intensity of the ejection sound * **expiration** --\> valve opens rapidly from its fully closed position --\> sudden "halting" of this rapid opening --\> maximal intensity of ejection sound *
93
What are four criteria used to identify constrictive pericarditis?
* Ventricular inderdependence (septal motion abnormality) * Mitral inflow velocity ≥ Grade 2 * Mitral annulus medial e' ≥ 8 cm/s * Hepatic vein diastolic expiratory flow reversal
94
Why is severe AS associated with a single S2 heart sound?
A2 component of the second heart sound (due to AV closure) is delayed --\> occurs simultaneously with the pulmonic component (P2)
95
When does S2 become paradoxically split in AS?
severe AS + LV dysfunction
96
Describe the frequency of monitoring in AR
* Progressive (stage B) * Mild --\> **every 3-5 years** * Moderate --\> **every 1-2 years** * Severe (stage C) * Severe --\> **every 6-12 months** * Dilating LV --\> **more frequently**
97
Describe the frequency of monitoring in MS
* Progressive (stage B) * MVA \> 1.5 cm2 --\> **every 3-5 years** * Severe (stage C) * MVA 1 - 1.5 cm2 --\> **every 1-2 years** * Very severe * MVA \< 1.0 cm2 --\> **every 1 year**
98
Describe the frequency of monitoring in MR
* Progressive (stage B) * Mild --\> **every 3-5 years** * Moderate --\> **every 1-2 years** * Severe (stage C) * Severe --\> **every 6-12 months** * Dilating LV --\> **more frequently**
99
Describe the findings
**Parachute mitral valve** * mitral valve attached to a single papillary muscle with * redundant leaflet tissue
100
Describe the findings
Severe AR on M-Mode --\> **early surgical intervention** * rapidly rising LV diastolic pressure --\> * premature closure of the mitral valve * soft S1 heart sound
101
Describe the valvular abnormality: * Prominent carotid pulsations * apical impulse is slightly enlarged and laterally displaced to the anterior axillary line * S1, S2 are normal * S3 present * early systolic click that does not change with inspiration * left sternal border * soft (grade 2/6) crescendo-decrescendo systolic murmur * soft (grade 2/4) decrescendo diastolic murmur
**Bicuspid aortic valve with regurgitation** * sudden cessation of valve opening --\> ejection click * findings of AR / volume overload * enlarged and laterally displaced apical impulse * wide aortic pulse pressure * S3 gallop
102
What test should be performed prior to AVR in S. Bovis endocarditis? Why?
* **Colonoscopy** * Colon cancer screening
103
What is the next best step? * 30 year old female with progressive SOB worsening over 2 years * PE: opening snap with low-frequency murmur * Echo: * thickening of mitral valve leaflets with doming * MG 5 mmHg (HR 60 bpm)
**Exercise Stress Echo** * helpful when discrepancy between: * symptoms * Doppler echo findings * Positive test findings: increased * MG * PASP
104
What is the next best step? * Aysmptomatic, BAV s/p repair 20 years ago * Echo: * LVEF 57% * LVEDD 6.5 cm * LVESD 4.2 cm * Severe AR (RV 70 mL, RF 60%, AR diameter 4.2 cm)
**Serial monitoring - TTE in 6-12 months** * Asymptomatic, severe AR --\> surgery only if: * **LVEF \< 50% (class I)** * **Other cardiac surgery (class I)** * LVESD \> 50 mm (class IIa) * Progressive decline on 3 consecutive studies: * LVEF \< 55-60% or * LVEDD \> 65 mm * + low surgical risk (class IIb)
105
What accounts for the majority of cases of severe TR?
**80% are functional (secondary) due to RV remodeling** * Result of pressure and/or volume overload --\> * leaflet tethering * annular dilation
106
Describe EKG findings in hyperkalemia (K 5.5 - 6.5)
* Tall, peaked, narrow-based **T waves** * QT interval **shortening** * Reversible LAFB or LPFB
107
What are findings consistent with severe TR secondary to Carcinoid syndrome?
* 5-HIAA --\> unique characteristic findings of the RV * **short, thick, retracted leaflets** (posterior and septal) with systolic and diastolic restriction
108
What are common causes of TR
**80% are secondary (functional)**
109
What leads to increased S1?
* maximal opening of the MV and TV leaflets at the onset of ventricular systole * Loud closure sound requires a mobile valve and at least moderate excursion
110
What are causes of increased S1?
* MS * MVP * Short cycles in A-Fib * Short PR interval * Rapid HR (anemia, thyrotoxicosis)
111
What is the only right-sided ausculatory event that diminishes with inspiration?
**Pulmonary ejection click - associated with PS**
112
What is the "sail sound?" When is it seen?
* **midsystolic click in Ebstein's anomaly** * sound emanating from the **broad anterior TV leaflet**
113
Describe EKG findings in hyperkalemia (K \> 7.5 )
* Dissappearance of P-waves * LBBB, RBBB, or markedly widened and diffuse IVCD resembling a **sine wave pattern** * Arrhytyhmias and conduction disturbances * VT, VF, Idioventricular rhythm, Asystole
114
What leads to decreased S1?
reduced mobility of the MV or TV or early partial closure
115
What are causes of decreased S1?
* worsening MS * Acute AR with preclosure of the MV * Long P-R interval * LBBB * Body habitus issues (obesity, large breasts)
116
What leads to early systolic sounds?
* generally from the semilunar valves (aortic or pulmonary) * due to sudden abrupt cessation of a doming valve
117
What are causes of early systolic sounds?
* BAV * PS * Dilated aorta * Abnormal (or stiff) AV from systemic hypertension * Abnormal (or stiff) PV from pulmonary hypertension
118
What causes mid-late systolic sounds?
* emanate from the **MV (most commonly)** or TV * clicks coincide with the maximal MV excursion into the LA * thought to be due to a**brupt tensing of the redundant leaflets or chordae** * at times, multiple clicks are audible
119
What are causes of mid-late systolic sounds?
* MVP * Ebstein's anomaly * Pericardial rub
120
What is the indication and recommendation for PMBV in pregnant patients?
* Severe MS (MVA \< 1.5 cm2, PHT \> 150 ms) * favorable valve morphology * NYHA Class III or IV HF symptoms + despite medical therapy * PMBV - (**Class IIa)** if: * \< Mild MR * Favorable Wilkins score « 8
121
Describe the findings:
A. - A4C vies B. - Color-flow display C. - Measure of PISA D. - CW doppler of TR jet allowing calculation of EROA and RVol
122
Describe the findings:
**Hepatic vein flow reversal in Severe TR** * A and B * Color Doppler demonstrating systolic flow reversal into the vena cava ad hepatic vein * C * spectral doppler recording from the hepatic vein * also showing the systolic retrograde flow
123
Describe the findings
Diastolic gradient RA-RV should be noticed (associated TR) and absence of A wave due to A-fib
124
When is the Dobutamine infusion stopped in LF-LG, reduced EF, AS evaluation?
* Maximum dose of Dobutamine reached * Positive result obtained * HR rises 10-20 bpm over baseline or exceeds 110 bpm * Symptoms, BP drop or concerning arrhythmias
125
Describe the mumur: * Heart murmur since childhood * Normal JVP and contour * high-pitched sound just after S1, followed by a murmur * auscultation along left sternal border
**Pulmonary stenosis** * Right-sided ejection click and ejection murmur
126
What are considered positive results for Dobutamine stress echo in LF-LG, reduced EF, AS evaluation?
* **Pseudostenosis** * Increase in effective AVA \> 1.0 cm2 * **True stenosis** * PV \> 4.0 m/s or MG \> 40 mmHg + * AVA \< 1.0 cm2 (at any flow rate) * **Absence of contractile reserve** * failure to **exceed stroke volume by \> 20%** * predicts poor surgical outcomes
127
What are causes of a single S2?
* Congenital absence of the pulmonic valve * Transposition of the great vessels * Inaccurate auscultation * body habitus, emphysema, pericardial effusion * Pulmonary HTN * PS * Severe AS
128
When should TTE monitoring be performed following valve implantation? Why?
* **6 weeks - 3 months** * establish baseline for comparison should complications or deterioration occur later
129
What is the only right-sided ausculatory event that diminishes with inspiration?
**Pulmonary stenosis**
130
What is the recommendation regarding perioperative anticoagulation management? * mechanical (bileaflet) AVR * no TE risk factors * Surgery: nephrectomy
* discontinue VKA 3-4 days prior to surgery * **continue ASA 81mg daily**
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What is the differential? * paced P-wave is not followed by either a paced or native QRS complex * Dual-chamber PPM programmed to DDD mode
* failure of ventricular output * sensing is appropriate but the pacemaker is not able to deliver a packemaker spike owing to a problem internal to the pacemaker * oversensing * the pacemaker senses something in the AV interval that it misidentifies as ventricular activity, such as a T wave or external artifact * failue to capture * pacemaker spike is generated at the appropriate time but fails to capture the ventricle
132
Why do transvalvular gradients increase during pregnancy?
* increased HR * increased plasma volume * increased stroke volume
133
Describe the treatment algorithm for: * Severe AS * Asymptomatic
134
Describe the treatment algorithm for: * Severe AS * Symptomatic
135
Describe the treatment algorithm for: * Abnormal aortic valve with reduced systolic opening * Moderate AS * Asymptomatic
136
What is the rate of progression of aortic stenosis? * PV * MG
* PV * 0.1 - 0.4 m/sec/year * MG * 3-7 mmHg / year
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Describe the stepwise approach for AS Severity
138
Describe stepwise approach for diagnosing severe AS: * Low Gradient * Normal LVEF
139
Describe the treatment algorithm: * Moderate AR
140
Describe the treatment algorithm: * Severe AR
141
Describe imaging interval for BAV
142
Describe TR treatment algorithm: * Progressive TR
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Describe the treatment algorithm * Severe TR * Asymptomatic
144
Describe the prosthetic valve treatment algorithm: * Valve thrombosis/suspected thrombosis or * TE event
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Describe the treatment algorithm * Severe TR * Symptomatic
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Describe the treatment algorithm * Progressive TR
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Describe the treatment algorithm * Severe TR * Right Heart Failure
148
Describe Echo criteria for severe TR
* VC ≥ 0.7 cm * RVol ≥ 45 mL * EROA ≥ 0.4 cm2
149
Surgical correction of which valvular abnormality would result in the following change in the PV loop?
**Mitral Regurgitation** * decrease preload * fixing the valvular abnormality * decreased SV * increased afterload after removing low pressure atrial offloading *
150
What is the major pathophysiologic abnormality?
Increased afterload, normal preload * severe AS
151
Describe the findings and effect on LV filling pressure? * Valsalva maneuver performed
**High Filling Pressures - Square wave response** * Valsalva initiated (normal filling pressured) * Preload drops (beats 4, 5, 6, 7) → SV drops → PP drops → BP drops * Valsalva initiated (elevated filling pressure) = **flat starling curve** * Preload drops ( beats 4, 5, 6, 7) → * negligible drop in SV, PP, BP
152
Describe the phases of the Valsalva maneuver
* Phase I - Early phase - Bearing down * increase in intrathoracic pressure * Preload to LV not affected * Pressure increases * Phase 2 - Strain phase * continuous decrease in preload to the LV → * SV and PP decreases * **Reflex tachycardia** * Phase 3 - Release phase * intrathoracic pressure drops * LV pressure drops * Phase 4 * Overshoot * Preload returns to LV - SV, PP returns to normal
153
Describe the management: * Prosthetic heart valve * Thromboembolic event
154
Describe the management: * Prosthetic heart valve * Suspected mechanical valve thrombosis
* **Urgent TTE, TEE, Fluoro and/or CT imaging** * Left-sided mechanical obstruction * **TPA** * urgent slow-infusion * **Emergency surgery**
155
Describe the management: * Prosthetic heart valve * Suspected bioprosthetic valve thrombosis
* 3D TEE or 4D CT imaging * VKA treatment \*\*\*\*2a recommendations
156
Differentia factors favoring each in prosthetic valve thrombosis * TPA * Surgery

Medical (69 decks)

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