valvular diseases questions

When patient with aortic stenosis develops symptoms?

Symptoms do not usually develop until the area is < 1 cm2 (the normal valve area is 3–4 cm2), jet velocity is > 4 m/sec, and the pressure gradient is > 40 mmHg

What is the classical clinical presentation of aortic stenosis?

Clinical Presentation: Exertional dyspnea, ↓ exercise tolerance, angina pectoris, syncope, congestive heart failure, sudden death.

What is management of asymptomatic AS ?

There is no effective pharmacologic therapy for aortic stenosis.

Asymptomatic AS management includes close clinical follow-up to monitor aortic valve area (normal is 3 to 4 cm2).

In addition, patients require endocarditis antibiotic prophylaxis and avoidance of medication that could result in hypotension.

Symptoms occur late in the course of disease and are an ominous sign. Onset of symptoms triggers the need for surgical evaluation

When AVR indicated?

indicated if the patient becomes symptomatic, if there is evidence of left ventricular dysfunction, or if the patient has an expanding poststenotic aortic root

Valve replacement is associated with ↓ symptoms and improved mortality

What is preferable surgery in children and young adults with congenital, noncalcific AS ?

Percutaneous balloon aortic valvuloplasty

What is management of asymptomatic mitral stenosis?

An annual history and physical examination, as well as a chest x-ray and ECG, are recommended in asymptomatic patients. Endocarditis prophylaxis in indicated in patients with MS; however, no further medical therapy is indicated.

When mild symptoms develop, diuretic may be helpful in reducing left atrial pressure and decreasing symptoms.

If symptoms are more than mild or if there is evidence of pulmonary hypertension, mechanical intervention is warranted and delaying intervention worsens prognosis

When surgery is indicated in case of mitral stenosis?

Indicated in symptomatic patients with isolated MS whose valve orifice is <1.7 cm

Enumerate types of mitral stenosis surgeries?

Percutaneous Mitral balloon valvotomy

surgical (“open”) valvotomy

What is mainstay medical treatment of aortic regurgitation?

The mainstays of medical management in symptomatic patients are after load reduction (ACE AND OTHER vasodilator), which reduces the amount of aortic regurgitations. Long-acting nefidipin has been shown to delay the need for valve surgery

When surgery indicated for patient with aortic regurgitation?

Aortic valve replacement should also be performed with progressive left ventricular dysfunction and a left ventricular ejection fraction <55% or left ventricular end-systolic volume >55%—“55/55 Rule” (even if asymptomatic).

WHAT ARE  Valvular Lesions Increasing Maternal and Fetal Risk?

æ Severe AS with or without symptoms

æ MR or AR with NYHA functional Class III to IV symptoms

æ MS with NYHA functional Class II to IV symptoms

æ Valve disease resulting in severe pulmonary hypertension (pulmonary pressure > 75% of systemic pressures)

æ Valve disease with severe left ventricular dysfunction (EF <0.40)

æ Mechanical prosthetic valves requiring anticoagulation

æ AR in Marfan syndrome

Prosthetic valve:

Bioprosthetic valves are preferable to mechanical valves for older patients with a life expectancy of < 10 years and for those who are unable to take long-term anticoagulants.

Anticoagulation

æ Bioprosthetic valves: Give three months of warfarin after placement; then consider aspirin in high-risk patients.

æ Mechanical valves: All patients should be anticoagulated in light of the higher risk of thrombus formation. The target INR depends on the type and location of the valve.

Complications

1. Thrombosis is the most common problem. Risk is ↑ with the mitral valve, AF, previous emboli, left atrial thrombus, and LV dysfunction.

iSummary EBC INTERNAL MEDICINE

æ The highest risk occurs with the mitral valve and inadequate anticoagulation.

æ Can present with heart failure, poor perfusion, and hemodynamic instability.

æ Diagnosed by echocardiogram.

æ Larger thrombi (> 5 mm) require fibrinolysis or valve replacement.

æ Heparin may be used with smaller thrombi.

2. Endocarditis:

æ With invasive procedures, patients should receive antibiotic prophylaxis.

æ Early: Occurs during the first 60 days after placement. Often fulminant with high mortality.

æ Late: A higher risk is associated with multiple valves or bioprosthetic valves.

3. Other problems include hemolysis, perivalvular leak, valve failure, and dysrhythmias