Valvular Heart Disease

Question 1

What are the echocardiographic indications for surgery in chronic AR?

Answer 1

EF <50%
LVESD >5cm
LVEDD >6.5cm
Rapid progression/deterioration

Question 2

What is the Wilkins Score and what is its use?

Answer 2

Predicts procedural success for mitral valvuloplasty based on valve structure. <8 predicts favourable result.

Question 3

What are the scores used to predict outcomes after valve surgery?

Answer 3

Euroscore 2

STS score

Question 4

At what aortic diameter in a female with marfans or bicuspid Aortic valve would you recommend against pregnancy?

Answer 4

> 50mm

Question 5

What is the medical therapy for chronic AR?

Answer 5

ACE/ARB

Beta Blocker

Question 6

What is the progression of moderate AR without concurrent aortic dilation?

Answer 6

Slow

Question 7

What is the use of MSCT in the setting of AS?

Answer 7

Useful to characterise likelihood of severity in the setting of low flow, low gradient AS in patients with HFPEF

Question 8

What are the risk factors post cardiac valve surgery not considered in the ES2 and STS scores?

Answer 8

Porcelain aorta
Frailty
Sequelae of chest radiotherapy

Question 9

In what valve disease does exercise testing provide information on prognosis and management?

Answer 9

Aortic stenosis

Mitral regurgitation

Question 10

What is the Carpentier classification?

Answer 10

Used to characterise mitral valve anatomy in preparation for surgery

Question 11

Describe the types in the carpentier classification.

Answer 11

Type 1 - normal leaflet motion, jet directed centrally
Type 2 - excessive leaflet motion, jet eccentric and directed away from pathological leaflet
Type 3 - restricted leaflet motion
A - restricted in systole and diastole
B - restricted in diastole

Question 12

What are the most common causes of MR based on the Carpentier classification?

Answer 12

Type 1 - secondary MR, endocarditis with perforation
Type 2 - degenerative Disease
Type 3a - rheumatic heart disease
Type 3b - ischaemic MR

Question 13

What are the most common causes of MR?

Answer 13

Degenerative (60-70%)
Functional (25%)
Rheumatic (15%)

Question 14

What are the indications on echocardiography for surgery in the setting of asymptomatic severe primary mitral regurgitation?

Answer 14

EF - <60%
LVESD >45mm
SPAP >50mmhg
(new onset AF)

Question 15

What are the independent predictors of failed mitral valve repair?

Answer 15

Operative - Surgical inexperience
Pathological - Infective endocarditis
Mitral Valve Anatomy - Absence of annular dilation, Mitral stenosis/sclerosis, leaflet calcification, annular calcification

Question 16

What are the benefits of MV repair over replacement?

Answer 16

Reduced peri-operative mortality (ARR 3-4%)
Better 20 year survival (ARR 20%)
Reduced re-operation

Question 17

What is the medical therapy for acute mitral regurgitation?

Answer 17

Diuretics and Nitrates to reduce filling pressures

+/- inotropic agents and IABP

Question 18

When is a patient with severe MR considered to have a low EF and would warrant Href therapy?

Answer 18

<60%

Question 19

In asymptomatic patients with severe primary MR and EF >60% and LVESD 40-45, what are the Echo findings that should make one consider surgery?

Answer 19

Flail leaflet

LA dilatation >60ml/m2 in sinus rhythm

Question 20

What additional investigations can be useful in the assessment of secondary mitral regurgitation when it is unclear if surgery will be of benefit?

Answer 20

Stress echocardiography

Question 21

Why must a TOE be performed prior to mitral valve comissurotomy?

Answer 21

Exclude left atrial thrombus

Question 22

When is it appropriate to utilise stress echocardiography in the setting of MS?

Answer 22

Asymptomatic or symptoms discordant with severity of MS

Question 23

What are the contraindications to mitral valve commisurotomy?

Answer 23

Mitral Valve Area >1.5 
Left atrial thrombus
Moderate to severe MR 
Severe/bi commissural calcification 
Absence of commissural fusion 
Concomitant CAD requiring bypass
Severe aortic valve disease/severe TR and TS requiring surgery

Question 24

What is the medical therapy for mitral stenosis?

Answer 24

Diuretics
Beta Blockers
Consider digoxin/calcium channel blockers to control rate

Question 25

What are the echo criteria for significant prosthetic valve degeneration?

Answer 25

Mean Transvalvular gradient - >20mmhg EOA decrease - >0.6cm2 Doppler velocity index decrease - >0.15

Question 26

In patients with mitral stenosis in sinus rhythm, when would you consider anticoagulation?

Answer 26

Spontaneous echo contrast in LA | LA volume >60ml/m2

Question 27

When would you consider intervention on an asymptomatic patient with mitral stenosis with MVA <1.5?

Answer 27

High thromboembolism risk (previous stroke, LA SEC, new AF) High risk of haemodynamic decompensation - SPAP >50mmhg, desire for pregnancy, major non cardiac surgery Need to have favourable clinical and echo characteristics

Question 28

What is the rate of TV bioprosthetic valve dysfunction at 10 years?

Answer 28

42%

Question 29

What types of valve degeneration are seen with porcine and bovine valves?

Answer 29

Bovine - stenosis | Porcine - regurgitation

Question 30

What are the risk factors for structural valve degeneration?

Answer 30

``` PATIENT Higher BMI Lower Age DISEASE Smoking Diabetes Hyperparathyroidism Chronic kidney disease ANATOMY Prosthesis patient mismatch Incomplete expansion (Percutaneous valves) ```

Question 31

What are the patient related risk factors for thromboembolism in the setting of mechanical heart valve replacement?

Answer 31

``` Mitral replacement Tricuspid replacement Previous thromboembolism Atrial fibrillation Mitral stenosis of any degree EF <30% ```

Question 32

What are the potential management options for patients with prosthetic valve obstructive thrombus?

Answer 32

1. Surgery - severe symptoms, mobile veg >3mm or non mobile veg >10mm 2. Fibrinolytics - right sided 3. Anticoagulation - left sided no indication for surgery 3. Palliative care

Question 33

What is the investigative approach to prosthetic valve thrombus?

Answer 33

Transthoracic echo Transoesophageal echo 4D CT

Question 34

What are the echo criteria for prosthetic valve thrombosis?

Answer 34

BOTH 1. Impaired cusp mobility 2. Cusp thickness >2mm (soft echodensity on echo and hypoattenuation on CT) - more likely on downstream side of valve - valve calcification >mild more likely associated with degeneration

Question 35

What are the considerations that alter the management of a patient with obstructive valve thrombosis?

Answer 35

``` Age and comorbidities Symptoms Cause of obstruction Valve location Thrombus size Thrombus mobility ```

Question 36

What are the factors that favour fibrinolysis for management of obstructive prosthetic valve thrombosis?

Answer 36

``` High surgical risk No contraindication to fibrinolysis First episode valve thrombosis NYHA1-2 Non mobile clot <1cm Mobile clot <0.3cm No other indication for cardiac surgery Right sided valve involved ```

Question 37

What are the factors that favour surgical management of obstructive prosthetic valve thrombosis?

Answer 37

``` Imaging features with concurrent pannus Low surgical risk Large or mobile clot Other indication for cardiac surgery Contraindication to thrombolytics ```

Question 38

What are the indications for PMC in a pregnant female with MS and what is the timing?

Answer 38

Valve area <1.5cm2 Symptomatic NYHA3-4 SPAP >50mmhg Occur after 20 weeks gestation

Question 39

Valve prolapse is more common in which mitral valve? And why?

Answer 39

Posterior leaflet | Lax annulus with less fibrous tissue

Question 40

What is the difference between the primary secondary and tertiary cords?

Answer 40

Primary cords - mitral valve tip attachment Secondary cords - mitral valve body attachment Tertiary cords - mitral valve base attachment

Question 41

Which papillary muscle is more prone to ischaemia and prone to contribute to secondary MR?

Answer 41

Posterolateral pap muscle | Only one artery vs two arteries for anterolateral pap muscle

Question 42

In the setting of severe AS with functional MR, what tenting area is associated with improvement with Aortic replacement alone?

Answer 42

<2.5cm2