Podcast
Questions and Answers
What is the purpose of performing a dental examination before valve intervention?
What is the purpose of performing a dental examination before valve intervention?
- To rule out potential infection sources (correct)
- To determine cardiac function
- To assess coronary anatomy
- To evaluate recovery chances
Which test provides prognostic markers for further risk stratification in patients with known or suspected VHD?
Which test provides prognostic markers for further risk stratification in patients with known or suspected VHD?
- CMR imaging
- Frality score assessment
- Stress testing (correct)
- Dental examination
What does the frailty score assess in patients undergoing valve procedures?
What does the frailty score assess in patients undergoing valve procedures?
- Quality of life pre-procedure
- Future risk of valve disease
- Procedure recovery chances and risks (correct)
- Coronary anatomy assessment
Which imaging technique is used to assess suitability for TAVI?
Which imaging technique is used to assess suitability for TAVI?
What is the role of the STS score in evaluating patients with VHD?
What is the role of the STS score in evaluating patients with VHD?
What does the CT: peripheral test specifically assess in the context of transcatheter procedures?
What does the CT: peripheral test specifically assess in the context of transcatheter procedures?
Why might a CMR indicate cardiac magnetic resonance imaging be ordered for a patient with suspected VHD?
Why might a CMR indicate cardiac magnetic resonance imaging be ordered for a patient with suspected VHD?
Which test is essential for providing an assessment of coronary anatomy before valve intervention?
Which test is essential for providing an assessment of coronary anatomy before valve intervention?
What defines a Low-Risk Surgical Aortic Valve Replacement (SAVR)?
What defines a Low-Risk Surgical Aortic Valve Replacement (SAVR)?
Which criterion indicates a High Surgical Risk for surgical valve procedures?
Which criterion indicates a High Surgical Risk for surgical valve procedures?
What is a requirement for Low-Risk Surgical Mitral Valve Repair for Primary MR?
What is a requirement for Low-Risk Surgical Mitral Valve Repair for Primary MR?
What characterizes the Prohibitive Surgical Risk category?
What characterizes the Prohibitive Surgical Risk category?
Which statement about the STS-predicted risk of mortality is TRUE for low-risk assessments?
Which statement about the STS-predicted risk of mortality is TRUE for low-risk assessments?
What is a necessary consideration if using the EUROSCORE II risk calculator?
What is a necessary consideration if using the EUROSCORE II risk calculator?
In which scenario would a patient be classified as Low-Risk?
In which scenario would a patient be classified as Low-Risk?
What is an example of a criterion for High Surgical Risk?
What is an example of a criterion for High Surgical Risk?
What characterizes Stage A of valve heart disease (VHD)?
What characterizes Stage A of valve heart disease (VHD)?
In which stage do patients exhibit symptoms due to severe valve heart disease?
In which stage do patients exhibit symptoms due to severe valve heart disease?
How often should an asymptomatic patient with mild aortic stenosis be followed up with an echocardiogram?
How often should an asymptomatic patient with mild aortic stenosis be followed up with an echocardiogram?
What does Stage C1 indicate in patients with valve heart disease?
What does Stage C1 indicate in patients with valve heart disease?
For patients with moderate mitral regurgitation, how frequent should echocardiographic evaluations be conducted?
For patients with moderate mitral regurgitation, how frequent should echocardiographic evaluations be conducted?
What condition falls under the description of Stage B in valve heart disease?
What condition falls under the description of Stage B in valve heart disease?
Which of these statements about mixed valve disease is true?
Which of these statements about mixed valve disease is true?
What defines Stage C2 in the classification of valve heart disease?
What defines Stage C2 in the classification of valve heart disease?
What is a key consideration when choosing an intervention for a patient with severe aortic stenosis?
What is a key consideration when choosing an intervention for a patient with severe aortic stenosis?
What is the primary indication for intervention in cases of valvular regurgitation?
What is the primary indication for intervention in cases of valvular regurgitation?
Who benefits most from a percutaneous edge-to-edge mitral repair?
Who benefits most from a percutaneous edge-to-edge mitral repair?
What is an important factor to consider for patients with severe symptomatic isolated tricuspid regurgitation?
What is an important factor to consider for patients with severe symptomatic isolated tricuspid regurgitation?
What causes bioprosthetic valve dysfunction?
What causes bioprosthetic valve dysfunction?
Which of the following statements is true about catheter-based treatment for prosthetic valve dysfunction?
Which of the following statements is true about catheter-based treatment for prosthetic valve dysfunction?
Why have the thresholds for intervention in valvular regurgitation lowered?
Why have the thresholds for intervention in valvular regurgitation lowered?
What risk factors are commonly associated with severe symptomatic isolated tricuspid regurgitation?
What risk factors are commonly associated with severe symptomatic isolated tricuspid regurgitation?
What factors are used to classify disease stages in patients with valvular heart disease?
What factors are used to classify disease stages in patients with valvular heart disease?
When should further noninvasive or invasive testing be considered for valvular heart disease patients?
When should further noninvasive or invasive testing be considered for valvular heart disease patients?
Which patients with atrial fibrillation and valvular heart disease should receive a vitamin K antagonist for anticoagulation?
Which patients with atrial fibrillation and valvular heart disease should receive a vitamin K antagonist for anticoagulation?
What is the recommended approach for patients with severe valvular heart disease regarding valve intervention?
What is the recommended approach for patients with severe valvular heart disease regarding valve intervention?
What should primarily guide the treatment of severe aortic stenosis?
What should primarily guide the treatment of severe aortic stenosis?
Which approach is suggested for the decision-making process regarding anticoagulation in patients with atrial fibrillation?
Which approach is suggested for the decision-making process regarding anticoagulation in patients with atrial fibrillation?
In light of recent trials, what is true about transcatheter aortic valve implantation?
In light of recent trials, what is true about transcatheter aortic valve implantation?
Which of the following is NOT a recommended evaluation for patients with valvular heart disease?
Which of the following is NOT a recommended evaluation for patients with valvular heart disease?
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Study Notes
Surgical Valve Procedures Risk Assessment
- Low-Risk SAVR (Surgical Aortic Valve Replacement): Must meet all criteria in this column.
- STS (Society of Thoracic Surgeons)-predicted risk of mortality: 50% at 1 year.
- Frailty: None
- Cardiac or other major organ system compromise: None.
- Low-Risk Surgical Mitral Valve Repair for Primary MR: Must meet all criteria in this column.
- STS-predicted risk of mortality: 50% at 1 year.
- Frailty: None
- Cardiac or other major organ system compromise: None.
- High Surgical Risk: Any one criterion in this column.
- STS-predicted risk of mortality: 50% at 1 year.
- Frailty: ≥ 2 Indices (moderate to severe)
- Cardiac or other major organ system compromise: 1 to 2 organ systems
- Procedure-specific impediment: Possible procedure-specific impediment.
- Prohibitive Surgical Risk: Any one criterion in this column.
- Frailty: ≥ 2 Indices (moderate to severe)
- Cardiac or other major organ system compromise: ≥ 3 organ systems.
- Procedure-specific impediment: Severe procedure-specific impediment.
Evaluation of Patients with Known or Suspected VHD
- Further risk stratification:
- Stress testing: Provides prognostic markers, information on future risk of valve disease, and important for determining timing of intervention.
- Procedural risk: Quantified by STS (Predicted Risk of Mortality) and TAVI scores.
- Frailty score: Provides assessment of risk of procedure and chance of recovering quality of life.
- Preprocedural Testing:
- Dental examination: Rules out potential infection sources.
- CT coronary angiogram or invasive coronary angiogram: Provides an assessment of coronary anatomy.
- CT (Computed Tomography): Peripheral - Assess femoral access for TAVI (Transcatheter Aortic Valve Implantation) and other transcatheter procedures.
- CT (Computed Tomography): Cardiac - Assesses suitability for TAVI and other transcatheter procedures.
Stages of VHD (Valvular Heart Disease)
- Stage A: At risk: Patients with risk factors for developing VHD.
- Stage B: Progressive: Patients with progressive VHD, mild to moderate severity, and asymptomatic.
- Stage C: Asymptomatic severe: Asymptomatic patients who have severe VHD.
- C1: Asymptomatic patients with severe VHD where the LV (Left Ventricular) or RV (Right Ventricular) remains compensated.
- C2: Asymptomatic patients with severe VHD with decompensation of LV or RV.
- Stage D: Symptomatic severe: Patients who have developed symptoms as a result of VHD.
Diagnostic Testing and Follow-Up:
- Frequency of Echocardiograms in Asymptomatic Patients with VHD and Normal LV Function:
- Aortic Stenosis:
- Every 3–5 years for mild severity (Vmax 2.0–2.9 m/s)
- Every 1–2 years for moderate severity (Vmax 3.0–3.9 m/s)
- Aortic Regurgitation:
- Every 3–5 years for mild severity
- Every 1–2 years for moderate severity.
- Mitral Stenosis:
- Every 3–5 years (MV area >1.5 cm2)
- Mitral Regurgitation:
- Every 3–5 years for mild severity
- Every 1–2 years for moderate severity.
- Aortic Stenosis:
Top 10 Take Home Messages:
- Evaluating a patient with valvular heart disease should involve a correlation of history and physical examination with results of noninvasive testing. If findings are discordant, consider additional noninvasive or invasive testing to determine the optimal treatment strategy.
- For patients with valvular heart disease and atrial fibrillation (except for patients with rheumatic mitral stenosis or a mechanical prosthesis), the decision to use oral anticoagulation to prevent thromboembolic events should be made with a shared decision-making process based on the CHA2DS2-VASc score.
- All patients with severe valvular heart disease considering valve intervention should be evaluated by a multidisciplinary team.
- Treatment of severe aortic stenosis should be based primarily on symptoms or reduced ventricular systolic function.
- Indications for transcatheter aortic valve implantation are expanding, and the choice of intervention should be a shared decision-making process considering the benefits and risks.
- Indications for intervention for valvular regurgitation are relief of symptoms and prevention of long-term consequences of left ventricular overload.
- A percutaneous edge-to-edge mitral repair benefits patients with severely symptomatic primary mitral regurgitation who are at high or prohibitive risk for surgery.
- Patients with severe symptomatic isolated tricuspid regurgitation may benefit from surgical intervention to reduce symptoms and recurrent hospitalizations.
- Bioprosthetic valve dysfunction may occur due to degeneration of the valve leaflets or valve thrombosis. Catheter-based treatment is reasonable for bioprosthetic leaflet degeneration or paravalvular leak in the absence of active infection.
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