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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2669_Библиотеки_им_академика_М_И_Перельмана
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MCQ #2 2024
A 79 year old woman with a history of hypertension is re-evaluated in clinic regarding 3 months of
exertional dyspnea. She has NYHA II-III symptoms. She has no orthopnea, PND or peripheral edema. She
has no angina. Her exam is significant for a 3/6 mid to late peaking systolic murmur best heard at the right
upper sternal border. Her ECG shows normal sinus rhythm with LVH and associated repolarization changes.
Pulmonary function testing and chest imaging are within normal limits. Her NT-pro BNP is mildly elevated
at 1000. A coronary angiogram performed last month did not show any obstructive coronary artery disease.
A transthoracic echocardiogram commented on hyperdynamic systolic function, with an LVEF of 65%,
severe LVH and a small LV cavity. The aortic valve is calcified, though the mean gradients are only mildly
elevated at 25 mmHg. The interpreting cardiologist notes possible paroxysmal low-flow-low-gradient aortic
stenosis, as the stroke volume index is low at 25 mL/m2 (reference cut off 35 mL/m2). What is your next
test of choice to better evaluate her aortic valve severity?
A. Exercise stress echocardiogram
B. Dobutamine stress echocardiogram
C. Persantine myocardial perfusion scan
D. Cardiac CT aortic valve calcium score
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Valve Disease - Guiding Principles
Valves disease is a complicated topic
– Know the physical exam findings (JAMA RCE/physical exam) – more resources at the
end of this section
– Know WHEN TO REFER for CONSIDERATION of intervention (Class I guidelines). Class
II recommendations have been added for completeness, knowing the principles
around these recommendations is helpful but it is unlikely you will need to know the
specific numbers for Class II recommendations.
– *Canadian guidelines are old (2004); ACC/AHA 2020 Valvular Heart Disease Guidelines
more up to date and testable
– Don’t need to know PV disease or much about TV intervention
Valves management involves:
Surveillance à duration changes based on risk and severity of pathology
Pharmacotherapy à temporizes a mechanical problem, treats symptoms
- NB. indications for endocarditis prophylaxis
Surgery à effective, durable, generally more carries risk
Catheter-based interventions à less durable, less data, usually less risk
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Valve Disease - Guiding Principles
Transthoracic echocardiography is the initial diagnostic test for all valvular disease
General AHA staging system similar for all valve disease
• Stage A à “at risk”
• Stage B à “progressive”
• Stage C à ”severe disease, but asymptomatic”
• Stage D à “severe disease, with symptoms”
Severe disease matters most (and usually guides intervention)
• Symptoms: angina, dyspnea, heart failure, syncope
• Surrogate markers of impending badness (e.g. LV dilatation, pulmonary HTN, new Afib)
• Repeat assessment (e.g. echo) q6-12m for severe valvular disease
Valve type (bioprosthetic vs. mechanical)
• For any patient whom VKA is contraindicated à bioprosthetic
• Younger patients (<50y) à mechanical
• Older patients (>65y) à bioprosthetic
• Patients 50-65y à individualized decision making
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Pharmacotherapy for VHD
Very few recommendations for medical therapy in valve disease
(primarily an interventional disease)
• Aortic stenosis à Treat HTN as per standard guidelines; treat lipids per
guidelines for prevention of atherosclerosis
(not to prevent hemodynamic progression
of AS – no evidence for this);
use ACEI/ARBs post-TAVI
• Aortic regurgitation
à
Treat HTN (preferably with ACE/ARB); symptomatic
AR and/or LV systolic dysfunction + prohibitive surgical risk à GDMT with
ACE/ARB or ARNI
• Mitral stenosis
à
Anticoagulation (VKA) indicated if à prior embolic event
OR LA thrombus OR AF; control tachycardia can help symptoms (AF or sinus
tachycardia)
• MR, TR
à
Treat HF as per standard guidelines; vasodilator therapy is NOT
recommended for asymptomatic primary MR and normal LV function
ACC/AHA 2020 Valve
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Aortic Stenosis
• Etiology: bicuspid
(
young )
, rheumatic (
developing
countries
), calcific (
old
)
– Bicuspid AV associated with aortopathy ***
• Prolonged asymptomatic period, then rapid
deterioration with onset of symptoms (angina,
syncope, HF)
• Patients with severe AS are often afterload
dependent (caution with vasodilators/afterload
reducers, e.g. ACEi)
• Severe AS Criteria (mostly from echo now):
– Mean Gradient ≥40 mmHg
– Max jet velocity ≥4 m/s
– AVA <1.0 cm
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“Classic” low-flow, low-gradient AS
DON’T PANIC!!
Bottom Line: if the ventricle is weak (LV systolic dysfunction) à will not be able to
mount gradients / velocities in the severe range, even if valve is anatomically severe
• Be suspicious when à AVA < 1.0 (looks severe) with non-severe gradients/Vmax
• Check the LVEF and SV!
• Correct answer is usually à do a dobutamine stress echo (allows the LV to squeeze better to see
if the gradients increase) or calcium score of the valve.
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“Paradoxical” low-flow, low-gradient AS
The paradox is that the stroke volume is low, but the LVEF is
normal. How can this happen?
Typically this occurs in a patient who has a small LV cavity with concentric LVH.
Therefore, the stroke volume is low because the LV cavity is small, and the
ejection fraction is normal (>55%) and often hyperdynamic (>65%) to maintain
cardiac output. These patients will have a LOW stroke (SV index <35 mL/m2)
despite a normal LVEF.
To further evaluate these patients if you are unsure if the valve is severe, obtain a
cardiac CT for calcium scoring of the valve (>2000 in men, >1300 in women
indicates severe). Dobutamine stress echo will NOT be helpful here as the ventricle
is already squeezing well (LVEF is normal).
Diastole
Systole
Paradoxical LFLG AS Classic LFLG AS
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Aortic Stenosis - Intervention
Class I indications for replacement*:
• Severe, symptomatic AS
• Severe, asymptomatic AS with LV dysfunction (LVEF <50%)
• Severe, asymptomatic AS undergoing other CV surgery
• Symptomatic low-flow, low gradient AS with LV dysfunction (LVEF<50%)
• Symptomatic low-flow, low gradient AS with LVEF >50% (“paradoxical” low-flow, low-gradient aortic stenosis)
– if AS most likely cause of symptoms
*Options include surgical AVR (SAVR) or transcatheter aortic valve implantation (TAVI)
– For SAVR, mechanical valve is recommended is age <50 and no contraindications for VKA, bioprosthetic valve recommended if
age >65 or if contraindication to VKA; ages 50-65 engage in shared decision making
– TAV I (/ TAVR) – expanding indications in 2020 guidelines:
• for intermediate, high, prohibitive surgical risk patients
• age >80 or younger patients with life expectancy <10y
• consider for patients ages 65-80* vs. SAVR
– TAV I CONTRAINDICATED if comorbidities preclude benefit (palliative care recommended instead if life expectancy with
reasonable QOL <1y)
– All TAVI valves are bioprosthetic (and need endocarditis prophylaxis)
*TAVI vs Surgical AVR decision making made with expert team after shared decision making, accounting for patient values and
preferences + expected longevity, valve durability, amenable anatomy etc.
AVATAR trial (Circulation 2021) showed ↓ all cause
death/MI/stroke/HHF with an early surgery strategy in pts
w severe ASYMPTOMATIC AS vs conservative strategy.
Small trial published AFTER latest guideline iteration:
take home for GIM = earlier referral if progressive
asympt. AS
AHA 2020 Valve
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Aortic Stenosis - Intervention
Class IIa indications for replacement:
• Asymptomatic, severe AS with low surgical risk when exercise testing
shows decreased exercise tolerance for age/sex or drop in SBP <10 mmHg
at peak from rest
• Asymptomatic, very severe aortic stenosis (aortic velocity >5m/s) with low
surgical risk
• Asymptomatic, severe AS with low surgical risk and elevated BNP 3x upper
limit of normal
• Asymptomatic, severe AS with low surgical risk and increase in aortic
velocity 0.3m/s or more per year
Class IIb indications for replacement:
• Asymptomatic, severe AS with progressive decrease in LVEF to less than
60% in at least 3 serial studies
• Moderate AS undergoing surgery for other indications
AHA 2020 Valve
“Critical” aortic stenosis with
a aortic velocity >5m/s is
helpful to know to intervene
even if the patient is
asymptomatic (recall severe
AS is >4m/s).
To know someone with
severe AS is truly
asymptomatic can be a
challenge. Stress testing or
BNP can be helpful.
Progressive increases in
aortic velocity, or decreases
in LVEF while still in the
normal range, signal a
higher risk patient, hence
these class II
recommendations.
BONUS
Read on own
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Aortic Regurgitation
– Dissection
– Endocarditis
– Trauma
– Prosthetic valve dysfunction
– Primary aorta problems: dilatation (associated with autoimmune conditions,
syphilis, Marfan, bicuspid, HTN, others …), dissection, trauma
– Primary valve problems
: degenerative (calcific), bicuspid, rheumatic,
endocarditis, VSD
you should not need to know
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