Valvuloplasty and TranscatheterValve Repair and Replacement

Question 1

What was the outcome of the PARTNER II trial regarding SAVR and TAVR?

Answer 1

There was no difference in all-cause death or disabling stroke between groups

The trial randomized patients with severe symptomatic aortic stenosis at intermediate surgical risk.

Question 2

What does the 2017 Update of the ACC/AHA Guidelines recommend for symptomatic patients with severe aortic stenosis and intermediate surgical risk?

Answer 2

TAVR is a reasonable alternative to SAVR

This recommendation is based on findings from studies like PARTNER II and SURTAVI.

Question 3

What is the current understanding of the long-term durability of transcatheter valves?

Answer 3

Long-term durability of transcatheter valves is not yet known

Short-term durability appears excellent and equivalent to surgical bioprosthesis.

Question 4

True or False: DAPT’s impact on stroke rates after TAVR has been evaluated.

Answer 4

False

Research indicates that while EPDs may decrease embolic events seen on imaging, no reduction in clinical stroke rates has been demonstrated.

Question 5

What is the definition of severe mitral regurgitation during mitral valvuloplasty?

Answer 5

Mitral regurgitation occurring in about 3% of patients

It is often due to rupture of a chord or a tear in the leaflet.

Question 6

What scoring system is used to evaluate mitral valve morphology?

Answer 6

The Wilkins score

It includes four characteristics: leaflet mobility, valvular thickening, subvalvular thickening, and valvular calcification.

Question 7

What is indicated by a total Wilkins score of ≤8?

Answer 7

A mobile valve readily amenable to percutaneous valvuloplasty

Higher scores result in less favorable outcomes after valvuloplasty.

Question 8

What are the indications for balloon mitral valvuloplasty?

Answer 8

Severe mitral stenosis (MVA ≤1.5 cm2), absence of LA appendage thrombus, and <2+ mitral insufficiency

Class I indications include symptomatic mitral stenosis with favorable anatomy.

Question 9

What is the normal tricuspid valve area and how is severe tricuspid stenosis defined?

Answer 9

Normal tricuspid valve area is about 10 cm2; severe tricuspid stenosis is diagnosed when mean gradient is >5 mm Hg

Severe tricuspid stenosis can lead to right heart failure.

Question 10

What does spontaneous echo contrast typically represent?

Answer 10

Slow atrial flow

It is often associated with a higher risk for embolization but does not indicate circulating thrombi.

Question 11

What is the latest guideline’s stance on endocarditis prophylaxis for patients with mitral valve stenosis?

Answer 11

Patients do not require endocarditis prophylaxis

The risk for endocarditis has not been shown to be reduced following mitral valvuloplasty.

Question 12

What defines low-gradient, low-output aortic stenosis?

Answer 12

Mean gradient <30 mm Hg and AVA <1.0 cm2

Distinguishing true stenosis from pseudostenosis is essential in this condition.

Question 13

What is the expected peak gradient reduction after a successful percutaneous balloon valvuloplasty of a classic domed pulmonary valve?

Answer 13

From about 90 mm Hg to about 29 mm Hg

The procedure has a low risk, generally in the range of 1% to 2%.

Question 14

What is VIV TAVR indicated for?

Answer 14

Treatment of degenerated aortic bioprosthesis with resultant aortic stenosis or regurgitation

Short-term outcomes are acceptable, but outcomes depend on the size of the surgical bioprosthesis.

Question 15

What is the definition of a successful pulmonary valvuloplasty procedure?

Answer 15

Gradient reduced to <20 mm Hg

The success rate is over 90% and complications are rare.

Question 16

What does TAVR stand for?

Answer 16

Transcatheter Aortic Valve Replacement

TAVR is a minimally invasive procedure for aortic valve replacement.

Question 17

What is the desired outcome of a successful TAVR procedure in terms of pressure gradient?

Answer 17

Gradient reduced to <20 mm Hg

This indicates a successful reduction in the obstruction caused by aortic stenosis.

Question 18

What is the success rate of pulmonary valvuloplasty?

Answer 18

Over 90%

Complications are rare in this procedure.

Question 19

What is the typical size to which the pulmonary artery is dilated during valvuloplasty?

Answer 19

1.2 to 1.4 times the measured anulus

This accounts for the elastic recoil of the pulmonary artery.

Question 20

What is the peak aortic velocity gradient that indicates a need for intervention based on symptoms?

Answer 20

4.5 m/s

This corresponds to a peak instantaneous aortic valve gradient of 81 mm Hg.

Question 21

What is the average reduction in aortic gradient achieved by balloon aortic valvuloplasty in adolescents?

Answer 21

About 60

The procedure has a high success rate of 90% with a procedural mortality of <2%.

Question 22

True or False: Balloon aortic valvuloplasty is effective in elderly patients.

Answer 22

False

It has not proven to be effective in elderly patients.

Question 23

What hemodynamic changes occur during pregnancy?

Answer 23

25% increase in red blood cell mass, 30% to 50% increase in blood volume

This leads to relative anemia and changes in vascular resistance.

Question 24

What is the mitral valve area threshold for intervention in pregnant patients with severe mitral stenosis?

Answer 24

≤1.5 cm2

This is accompanied by severe symptoms despite medical therapy.

Question 25

What was the 1-year survival rate for patients undergoing transcatheter mitral valve repair with MitraClip compared to a control group?

Answer 25

76% vs. 55% ## Footnote This was part of the EVEREST II High-Risk Registry.

Question 26

What is a common complication associated with aortic valvuloplasty?

Answer 26

57% of patients experienced complications ## Footnote Serious adverse events occurred in 15.6% of patients.

Question 27

What was the 1-year mortality rate for patients randomized to TAVR in the PARTNER trial?

Answer 27

30.7% ## Footnote Compared to 49.7% in medically treated patients.

Question 28

What access sites can be used for TAVR?

Answer 28

Iliofemoral vessels, ascending/descending aorta, subclavian, axillary, carotid arteries ## Footnote TAVR can also be performed via a transseptal approach or LV apical approach.

Question 29

What were the results of the EVEREST II trial comparing MitraClip to surgical repair?

Answer 29

Surgery favored with 73% vs. 55% freedom from mitral valve dysfunction ## Footnote However, MitraClip had a better procedural safety profile.

Question 30

What is the recommendation for transcatheter paravalvular leak closure according to the 2014 AHA/ACC guidelines?

Answer 30

Reasonable only for high-risk surgical patients with suitable anatomy ## Footnote This is for severe CHF symptoms or refractory hemolysis.

Question 31

What is the primary indication for MitraClip in patients?

Answer 31

Symptomatic patients with severe degenerative mitral regurgitation at prohibitive surgical risk ## Footnote Not approved for functional mitral regurgitation.

Question 32

What is the three-year survival rate following transcatheter paravalvular leak closure?

Answer 32

64.3% ## Footnote Among survivors, 72% showed freedom from CHF symptoms or reoperation.

Question 33

What is a significant risk factor associated with hemolytic anemia post-valve surgery?

Answer 33

Residual paravalvular leak ## Footnote Complete closure of the leak is necessary to resolve hemolytic anemia.

Question 34

What is the procedural mortality rate reported in aortic valvuloplasty?

Answer 34

1.6% ## Footnote This includes various complications such as vascular complications and bleeding.

Question 35

What is the impact of access site on outcomes following TAVR?

Answer 35

Transfemoral TAVR shows greater improvement in quality of life ## Footnote Access site choice can affect patient outcomes.

Question 36

Fill in the blank: The rate of paravalvular aortic insufficiency is approximately ______.

Answer 36

5% incidence of moderate or severe paravalvular AI ## Footnote This is consistent across balloon-expandable and self-expanding valves.

Question 37

What is the primary cause of hemolytic anemia in the context of a paravalvular leak?

Answer 37

Destruction of red blood cells due to turbulence created through the paravalvular leak ## Footnote Turbulence from the leak leads to hemolysis.

Question 38

What initial therapies may resolve mild hemolysis?

Answer 38

Folate, iron, and erythropoietin ## Footnote These treatments may help in cases of mild hemolysis but were ineffective in the discussed patient.

Question 39

What interventions may be required for definitive repair in severe cases?

Answer 39

Surgical or transcatheter intervention ## Footnote These should be considered for high-risk surgical patients with suitable anatomy.

Question 40

In what scenarios should surgical intervention for paravalvular leak be considered?

Answer 40

Severe CHF symptoms or refractory hemolysis ## Footnote Intervention is recommended at centers with expertise.

Question 41

What risk does withholding warfarin pose for patients with a mechanical prosthetic valve?

Answer 41

Risk for thrombosis of the mechanical prosthetic valve ## Footnote Withholding warfarin is not an appropriate strategy.

Question 42

What is the incidence of complications following transseptal puncture in experienced centers?

Answer 42

Less than 5% ## Footnote Complications are uncommon in skilled hands.

Question 43

What immediate differential diagnoses should be considered following transseptal puncture?

Answer 43

* Vagal reaction * Perforation of a cardiac structure with pericardial tamponade * Bleeding from the access site * Coronary embolus (either thrombus or air) ## Footnote These conditions should be evaluated if complications arise.

Question 44

What heart rate change would indicate a vagal reaction?

Answer 44

Lower heart rate ## Footnote A vagal reaction typically results in bradycardia.

Question 45

What heart rate change would suggest a retroperitoneal or access site bleed?

Answer 45

High heart rate ## Footnote Tachycardia may indicate significant blood loss.

Question 46

What should be done before proceeding with a procedure if hypotension is present?

Answer 46

Determine the cause of the hypotension ## Footnote It is crucial to identify the underlying issue before continuing.

Question 47

What does the ECG suggest in this instance?

Answer 47

Acute inferoposterior myocardial injury ## Footnote This finding necessitates further investigation.

Question 48

What would be the appropriate next step if acute inferoposterior myocardial injury is suggested on ECG?

Answer 48

Coronary angiography ## Footnote This procedure would help determine if there is a coronary embolus.