and Practical Management of Real-World Valvular Heart Disease

 

Velocity (m/s)


Mean gradient (mmHg)


AVA (cm2)


LV thickness (mm)


2010


2.6


14


1.7


9


2012


2.8


18


1.6


9


2014


3.0


24


1.4


9


2015


3.2


28


1.3


10


2016


3.5


33


1.2


11


NOW


3.7


37


1.1


11.5




Physical Examination


BP 110/64; pulse 54


Neck: carotid upstrokes mildly delayed. CVP 5 cm H2O


Chest: clear


Cor: 3/6 Mid-late peaking SEM


Ext: no edema


  1. Q16.

    The following are reasonable except:


    1. (A)

      Continue running until data indicate “severe” AS


       

    2. (B)

      No therapy but stop running


       

    3. (C)

      Standard SAVR


       

    4. (D)

      The Ross procedure


       

     

She indicates that cessation of marathon running is unacceptable to her and she wishes to proceed with valve replacement therapy . She wishes advice on the risks and benefits of various valve replacement strategies.


  1. Q17.

    For mechanical vs. heterograft bioprostheses valves you advise that:


    1. (A)

      Survival is better for mechanical valves compared to bioprostheses.


       

    2. (B)

      Bleeding risk is higher for mechanical valves


       

    3. (C)

      Valve deterioration is more likely for bioprostheses


       

    4. (D)

      TAVR valve in valve will prolong life if the bioprosthesis fails


       

    5. (E)

      A, B, and C


       

    6. (F)

      All the above


       

     

  2. Q18.

    The patient requests more information regarding homograft valves and the Ross procedure as she does not want to pursue lifelong warfarin therapy . You advise that:


    1. (A)

      Homografts are more durable than heterografts


       

    2. (B)

      The Ross procedure is inferior to homograft implantation


       

    3. (C)

      Neither A or B


       

     

Case 8


The patient is a 50 y/o man who works in an office and has little time for exercise. He denies dyspnea on exertion, orthopnea, PND, angina, syncope, or edema. He was told of a heart murmur by his primary care giver and is referred for further evaluation. He denies hypertension, smoking, or diabetes.


Physical Examination


BP 110/76; pulse 80


Neck: carotid upstrokes normal; CVP 5 cm H2O


Chest: clear


Cor: PMI displaced downward and to the left; 3/6 holosystolic apical murmur. S3


Ext: no edema


Echocardiogram: Enlarged LV and LA. EF 60%; end systolic dimension 38 mm. est RV systolic pressure: 30 mmHg. There is a flail P2 mitral leaflet and severe mitral regurgitation (MR) with systolic pulmonary vein flow reversal.


  1. Q19.

    Sound management strategies include all except:


    1. (A)

      Referral for mitral repair to a center of repair excellence


       

    2. (B)

      Obtaining and BNP level and exercise test


       

    3. (C)

      Conservative “watchful waiting” with follow-up in 2 years


       

    4. (D)

      Referral for mitral valve replacement


       

    5. (E)

      C&D


       

     

Case 9


A 76 y/o man is seen for evaluation of heart failure. He suffered an anterior myocardial infarction 4 years previously for which he delayed seeking medical attention for several hours. An echocardiogram obtained 2 years ago found akinesis of the LV apex and anterior wall with an EF of 30%. He noted that over the past several weeks that he has become progressively more dyspneic, now unable to walk 30 ft to get the newspaper each morning. He now sleeps on 3 pillows instead of his usual 2. He denies chest pain or syncope but developed ankle edema about 2 weeks ago.


Current Medications


Furosemide 80 mg daily


Lisinopril 10 mg daily


Physical Examination


BP 130/72; pulse 80


Est CVP 12 cm H2O


Chest: bibasilar rales


Cor: S3; 1/6 holosystolic apical murmur


Ext: +2 ankle edema


BNP: 845 ng/mL


Creatinine: 1.1 mg/dL


Echocardiogram: Moderate LV and LA enlargement. Anterior and apical akinesis with wall thinning in those regions. EF 25%. Est RV systolic pressure: 55 mmHg. Severe MR with both leaflets tethered, a central jet and ERO 0.4 cm2.


  1. Q20.

    A true statement regarding this patient is


    1. (A)

      Mitral surgery will prolong his life.


       

    2. (B)

      Mitral repair is favored over mitral valve replacement


       

    3. (C)

      He should undergo exercise testing to further define his pulmonary hypertension


       

    4. (D)

      Surgery is preferred over medical therapy.


       

    5. (E)

      His medical therapy should be up-titrated.


       

     

Case 10


The patient is a 42 y/o man seen by his primary care provider for general malaise and back pain . He has known of a heart murmur for several years but was told it was an “innocent” murmur. His physical activity has never been limited by heart disease and he worked out at a local gym nearly daily without difficulty until recently. He underwent routine teeth cleaning about 2 months ago. Over the past month he has noted a gradual decline in his health. He has become fatigued and noted occasional night sweats, anorexia and a 10 lb. weight loss. He is unable to work out at the gym where his activity is limited both by fatigue and dyspnea. He denies orthopnea, PND, syncope, angina, or edema. He denies intravenous drug use.


Physical Examination


BP 130/80; pulse 100; T 100.8 °F. RR 16


Skin: petechiae anterior chest


HEENT: conjunctival petechiae


Chest: clear


Cor: S1, S2 normal; 2/6 SEM radiating to the neck


Abd: soft non-tender; no organomegaly


Back: no flank or spinal tenderness


Lab Exam


Hb: 10.9 g/dL


WBCs: 11,600/μL; 85% neutrophils


Creatinine: 1.0 mg/dL


Echocardiogram: LV volume normal. EF 65%. Bicuspid aortic valve with mild leaflet restriction. Mean gradient 10 mmHg; 5 × 7 mm vegetation, non-coronary cusp.


4 of 4 blood cultures are + for Viridans group Streptococcus.


  1. Q21.

    Which of the following is/are true?


    1. (A)

      He should have received antibiotic prophylaxis for his dental procedure.


       

    2. (B)

      He requires urgent aortic valve replacement .


       

    3. (C)

      Back pain is an uncommon presenting symptom in infective endocarditis IE).


       

    4. (D)

      Cardiac surgery and infectious disease should be consulted.


       

     

Case 11


A 28 y/o man presents to the emergency department with fever and malaise. He uses IV heroin regularly. Two weeks ago, he began noting chills and fever which he thought represented the “flu.” Persistence of the symptoms caused him to seek medical attention. He notes fatigue and poor appetite but denies dyspnea, orthopnea, PND, angina, or edema.


Physical Examination


Ill appearing man but in no acute distress


BP 100/60; pulse 110; T 102.0 °F


Skin: Hot to the touch; no petechiae


Neck: CVP: 8 cm H2O; pronounced v waves


Chest: scattered rales


Cor: S1 normal; 2/6 holosystolic murmur R lower sternal border; 1/6 diastolic blowing murmur, L upper sternal border


Abd: non-pulsatile liver


Lab Exam


Hb: 10 g/dL


WBC: 15,600/μL


Creatinine: 1.5 mg/dL


Blood cultures are drawn and are + for methicillin-resistant Staph aureus.


Echocardiogram: LV normal in size, EF 65%. 10 × 12 mm vegetation, aortic valve, mild aortic insufficiency; 8 × 8 mm vegetation tricuspid valve; moderate tricuspid insufficiency.


  1. Q22.

    Which of the following statements are true?


    1. (A)

      He is at moderate risk for vegetation embolization


       

    2. (B)

      The risk of embolization is mitigated by antibiotic therapy


       

    3. (C)

      He currently has a class I indication for surgery


       

    4. (D)

      Early surgical therapy will improve his chance of survival


       

    5. (E)

      All of the above


       

     

Antibiotic therapy with vancomycin is begun and his fever improves. On the third hospital day he notes difficulty in sleeping the night before due to orthopnea. Physical exam finds:


BP 90/60; pulse 110. RR 22; T 99.6 °F


CVP 8 cm H2O


Chest bibasilar rales


Cor: soft S1, 1/6 diastolic blowing murmur


  1. Q23.

    Which statement(s) is/are true


    1. (A)

      Stat TEE is indicated


       

    2. (B)

      A stat surgical consult is indicated


       

    3. (C)

      Valve replacement after just 2 days of antibiotics will lead to a high reinfection rate


       

    4. (D)

      The best pressor agent to use is norepinephrine


       

    5. (E)

      A and B


       

     

Case 12


A 60 y/o man is followed for management of aortic insufficiency . He suffered an episode of IE 8 years previously, resulting in an aortic leaflet perforation but was hemodynamically stable at the time and did not undergo surgery. He denies symptoms, leads an active lifestyle, and plays singles tennis two times per week.


Physical Examination


BP 140/60; pulse 71


Neck: bounding carotid pulse. CVP 5 cm H2O


Chest clear


COR: PMI prominently visible 3 cm L mid-clavicular line


2/6 diastolic rumble LUSB; Apical diastolic rumble


Ext: Quinke’s pulse present


Serial echocardiograms: (all show severe AR of tricuspid perforated aortic valve):






































 

EF (%)

End diastolic dimension (cm)

End systolic dimension (cm)

12/2010

60

6.0

4.0


11/2011

60

6.1

4.1


12/2013

58

6.4

4.3


12/2014

58

6.5

4.4


Now

55

7.0

4.9





  1. Q24.

    Reasonable options for the patient are


    1. (A)

      Begin an ACE inhibitor


       

    2. (B)

      Recommend AVR


       

    3. (C)

      Discuss TAVR options


       

    4. (D)

      Continue to observe his progress


       

    5. (E)

      B, C, and D


       

     

Case 13


The patient is a 55 y/o woman of Middle Eastern extraction seen for evaluation of dyspnea on exertion . As a child she was told she had had acute rheumatic fever and suffered from arthritis that kept her out of school for several weeks. Her symptoms eventually resolved and she was well until about 2 years ago when she noted progressive dyspnea while performing household chores. About 2 years ago she began sleeping on two pillows. She denies PND, syncope, hemoptysis, or angina. She complains about frequent palpitation. She notes the recent onset of peripheral edema. She has an 8-year history of insulin-controlled diabetes. She notes controlled hypertension. She suffered a stroke 5 years ago from which she has recovered completely. She was noted to be in sinus rhythm at the time of the stroke.


Physical Examination


BP 123/78; pulse 80 and regular


Neck: CVP 10 cm H2O


Chest: bilateral rales


Cor; Loud S1; Increased P2, S2 followed by and opening snap 80 ms later, followed by a diastolic rumble


Ext: +2 pitting edema


Lab Exam


Hb: 12.3 g/dL


Creatinine: 3.3 mg/dL


Hb: a1c 7.3%


Echocardiogram: LV EF 55%. Moderate LA enlargement. Mitral valve, thickened, calcified, poorly mobile with mild to moderate MR. Est RV systolic pressure 68 mmHg. Est Wilkins score 10.


  1. Q25.

    You would recommend:


    1. (A)

      A formal exercise tolerance test with echo estimation of RV pressure


       

    2. (B)

      Begin beta blockade


       

    3. (C)

      MVR


       

    4. (D)

      TEE; If no LAA clot, proceed to balloon mitral valvotomy


       

     

Case 14


A 45 y/o woman is evaluated for the acute onset of dyspnea . She has had similar self-limited episodes in the past but her current episode has persisted. Between acute episodes she is asymptomatic but lives a sedentary lifestyle and works as a bank teller.


Physical Examination


BP 110/80; pulse 177, irregularly, irregular


Neck: CVP 8 cm H2O


Chest: bibasilar rales


COR: loud S1; no murmur


Ext: no edema


EKG: AF with rapid ventricular response


Chest X-ray: Double density R heart border


  1. Q26.

    Proper management calls for:


    1. (A)

      Rate control. Anticoagulation with heparin


       

    2. (B)

      Rate control. Anticoagulation with apixaban


       

    3. (C)

      D/C cardioversion. Anticoagulation with dabigatran


       

    4. (D)

      Rate control followed by a loading dose of warfarin.


       

     

Case 15


A 60 y/o man is evaluated for dyspnea. He began noting difficulty in keeping pace with his wife on their evening walks about 6 months ago and his exercise tolerance has grown progressively worse since then. He has begun sleeping on two pillows. He denies angina, syncope or edema. He denies diabetes, smoking, or hypertension. An echocardiogram performed 3 years ago to evaluate a heart murmur found severe AR and a preserved EF. He was then lost to follow-up.


Physical Examination


BP: 120/60; pulse 79


Neck: CVP 9 cm H2O; bounding carotid pulse


Chest: clear


Cor: prominent PMI anterior axillary line; 2/6 long diastolic blowing murmur LUSB; 1/6 apical diastolic rumble


EXT: trace edema


Echocardiogram; Severe AR. End diastolic dimension, 8.0 cm; end systolic dimension 6.8 cm; EF 30%


  1. Q27.

    You would:


    1. (A)

      Begin workup for cardiac transplant


       

    2. (B)

      Recommend urgent AVR


       

    3. (C)

      Begin guideline-directed heart failure therapy


       

    4. (D)

      Begin heart failure therapy followed by AVR


       

     

Case 16


A 35 y/o man is seen for the recent onset of progressive dyspnea . Three years ago, he received a bileaflet mechanical heart valve for symptomatic unicuspid aortic stenosis . Surgery resulted in resolution of angina, his complaint at the time. Since then he received warfarin 8 mg/day with INR in therapeutic range 60% of the time. However, 3 weeks ago he ran out of his medications and has not had them refilled. His dyspnea has progressed so that he has dyspnea with minimal activity such as going to the bathroom.


Physical Examination


BP 90/70; pulse 102; RR 22


Neck: CVP 11 cm H2O. Carotid upstrokes weak


Chest: Bibasilar rales


Cor: S1 normal; prosthetic clicks muted. No murmur


EXT: bilateral ankle edema


Lab Exam


INR 1.0


Hb 14 g/dL


Creatinine 1.4 mg/dL


  1. Q28.

    The patient should undergo:


    1. (A)

      Transthoracic echocardiography


       

    2. (B)

      Transesophageal echocardiography


       

    3. (C)

      Fluoroscopy


       

    4. (D)

      Cardiac MRI


       

    5. (E)

      A and B


       

     

TEE finds a 6 × 8 mm thrombus limiting leaflet motion. LV EF 30%. Peak jet velocity: 5.2 m/s.


  1. Q29.

    Best management is:


    1. (A)

      Urgent surgery


       

    2. (B)

      Thrombolytic therapy


       

    3. (C)

      Administration of unfractionated heparin


       

    4. (D)

      Administration of low molecular weight heparin


       

     

Case 17


The patient is a 71 y/o woman evaluated for progressive dyspnea on exertion . She was told of heart murmur by her primary provider several years ago but was asymptomatic until 6 months ago. Since then she has noted becoming progressively short of breath performing routine housework. She denies syncope, orthopnea, PND, angina, or edema. She has never smoked and denies diabetes and hypertension.


Physical Examination


BP 110/70; Pulse 76 with occasional extra systoles. BMI 21


Neck: carotid upstrokes delayed; CVP 6 cm H2O


Chest: clear


COR: 2/6 SEM RUSB; Apical systolic murmur. Following the pause after her extra-systoles, both murmurs intensify and the carotid pulse is augmented.


Lab Exam


Hb 14 g/dL


Creatinine 1.8 mg/dL


  1. Q30.

    Her physical exam is most consistent with:


    1. (A)

      Obstructive hypertrophic cardiomyopathy


       

    2. (B)

      Aortic stenosis with Gallavardin’s Phenomenon


       

    3. (C)

      Aortic and pulmonic stenosis


       

    4. (D)

      Aortic stenosis and mitral regurgitation


       

    5. (E)

      Both B and D


       

     

Echocardiography finds: a severely calcified aortic, peak jet velocity 3.9 m/s; mean gradient 40 mmHg; AVA 0.9 cm2. There is mitral prolapse of P2 with moderate MR. LV and LA mildly enlarged.


  1. Q31.

    Best therapy would be:


    1. (A)

      TAVR


       

    2. (B)

      SAVR


       

    3. (C)

      SAVR + mitral repair


       

    4. (D)

      SAVR + MVR


       

     

Case 18


A 73 y/o man is evaluated for severe mitral regurgitation . The patient has known of a heart murmur for several years but was asymptomatic until 6 months ago when he began experiencing dyspnea playing golf. He carries his golf clubs and began noting dyspnea climbing to an uphill green that, in the past, had not caused him symptoms. He denies orthopnea, PND, angina, syncope, or edema. He is a lifelong nonsmoker and denies diabetes or hypertension.


Physical Examination


BP 118/82; pulse 76


Neck: carotid upstrokes normal; CVP 6 cm H2O without prominent v waves


Chest: clear


Cor; PMI displaced downward and to the left. 3/6 holosystolic apical murmur


Ext: no edema


Lab Exam


Hb 14.1 g/dL


Creatinine 0.9 mg/dL


Echocardiogram: LV and LA enlargement. EF 60%. LV end systolic dimension 4.0 cm. Severe MR with a flail P2 segment. ERO 0.4 cm2. Moderate tricuspid regurgitation. Est RV systolic pressure 30 mmHg. RV and RA slightly enlarged. Normal RV systolic function.


Mitral repair is planned.


  1. Q32.

    Regarding this patient’s tricuspid regurgitation :


    1. (A)

      Tricuspid surgery is not warranted since his TR will improve with successful mitral repair


       

    2. (B)

      Tricuspid repair will both reduce TR and prolong life


       

    3. (C)

      Tricuspid repair will reduce the risk of worsening TR later in life


       

    4. (D)

      The incidence of tricuspid repair during left- sided surgery has increased over the past decade


       

    5. (E)

      C and D


       

     

Case 19


The patient is a 30-year-old man referred for evaluation of a heart murmur . The murmur has been present since birth but he has not seen a health care professional since childhood. He now wishes to begin training for a marathon race and has begun running 4 miles/day. He runs an average 8 min mile without dyspnea. He denies angina, syncope, orthopnea, PND, or edema. Otherwise he is in excellent health and denies diabetes, hypertension, and other systemic illness.


Physical Examination


BP 100/60. Pulse 58


Neck: carotid upstrokes normal. CVP 4 cm H2O


Chest: clear


COR: LUSB ejection click followed by a 3/6 SEM; Click disappears with inspiration


Ext: no edema


Lab Exam


Echocardiogram: Normal LV, LA, aortic, mitral, and tricuspid valves. There is doming of the pulmonic valve and peak jet velocity of 4.2 m/s.


  1. Q33.

    You advise:


    1. (A)

      Proceed with his marathon training but to alert you if he notices symptoms


       

    2. (B)

      Undergo pulmonic balloon valvotomy


       

    3. (C)

      Undergo surgical pulmonary valve replacement


       

    4. (D)

      Undergo transcatheter pulmonary valve replacement


       

     

Case 20


A 40 y/o man is seen for his yearly follow-up visit after pulmonary balloon valvotomy as a child. He denies dyspnea on exertion and works out at a gym three times per week. He denies edema, ascites, orthopnea, PND, or angina. Five years ago he was noted to have moderate to severe pulmonic regurgitation and undergoes yearly cardiac MRI for quantification of RV volume and function.


Physical Examination


BP 110/70; pulse 72


Neck: CVP 8 cm H2O. Prominent v waves noted


Chest: clear


COR: RV sternal lift. 3/6 long diastolic murmur heard throughout the precordium


EXT: no edema


Lab Exam


Hb: 14.6 g/dL


Creatinine: 1.0 mg/dL























































 

Serial MRI results

 

RVEDVI

RVESDI

RVEF (%)

RVRF (%)

LVEF (%)

2010

110

50

55

35

60


2012

122

56

54

36

62


2014

145

70

52

36

60


2016

145

70

52

36

60


Now

160

81

49

41

58

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Apr 23, 2020 | Posted by in CARDIOLOGY | Comments Off on and Practical Management of Real-World Valvular Heart Disease

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