1. Answer: D. Meta-analyses have shown that all of the risk factors listed are predictors of significant paravalvular regurgitation. Low or high implantation, low cover index, and greater degrees of calcium were in most studies, associated with greater severity of paravalvular regurgitation. Not on the list, but also considered a likely risk factor for paravalvular regurgitation is valve type. In the only randomized comparison of balloon-expandable and self-expanding valve implantation, the self-expanding valve also had a higher incidence of significant paravalvular regurgitation.

2. Answer: D. According to the systematic review of cases of coronary obstruction by Ribeiro et al. the possible risk factors for coronary obstruction include:

3. Answer: B. Calcium in the LVOT is a risk factor for paravalvular regurgitation for either balloonexpandable or self-expanding valves. Thus surgical AVR, which has the lowest paravalvular regurgitation rate, might be a better option in lower-risk surgical patients. Patients with small annulus and female sex have been shown to benefit from TAVR compared to surgical AVR. Although some studies suggest severe MR at baseline has worse outcomes only for surgical AVR compared to TAVR, other studies have suggested poor outcomes also may be seen in the TAVR patients. Thus the differential effect of significant MR on outcomes for surgical versus TAVR is still not well defined.

4. Answer: C. Key anatomic inclusion criteria for the EVEREST trial included a regurgitant jet origin associated with the A2 to P2 segments of the mitral valve. For patients with functional MR, a coaptation length of at least 2 mm and a coaptation depth of no more than 11 mm were required. For patients with leaflet flail, a flail gap <10 mm and a flail width <15 mm were required. Thus C would be an exclusion (not inclusion) criterion.

5. Answer: D. Prior to release of the MitraClip, the echocardiographer must demonstrate adequate clip capture of the anterior and posterior leaflet, absence of a high (typically >6 mm Hg) gradient and an adequate mitral valve area (>2.0 cm²). In addition, the clip should reduce the severity of MR. If any adverse features are seen, the clip can be removed and repositioned.

6. Answer: D. All steps of the transcatheter mitral valve repair procedure are guided by echocardiographic imaging prior to and after the release of the MitraClip. However, once anterior and posterior leaflet grasp is ensured with documentation of residual MR, transmitral gradients, and planimetry of the mitral valve area—release of the clip does not require guidance by echocardiography.

7. Answer: B. To date no studies have examined LAA closure in valvular AF and therefore this is a contraindication not an indication. See the answer to Question 8 for a definition of the CHADS₂ score.

8. Answer: D. The CHADS₂ score is a clinical prediction rule for estimating the risk of stroke in patients with nonrheumatic AF with the acronym standing for: C, congestive heart failure (1 point); H, hypertension (1 point); A, age >75 years (1 point); D, diabetes (1 point); S, prior stroke, TIA or thromboembolism (2 points). The treatment algorithm using this score:

9. Answer: C. In the PROTECT AF trial, 707 patients were randomized to LAA closure with the Watchman device and subsequent discontinuation of warfarin, or warfarin standard therapy. The most frequent primary safety event in the intervention group was serious pericardial effusion (defined as the need for percutaneous or surgical drainage), which occurred in 22 (4·8%) of patients. Fifteen of these patients were treated with pericardiocentesis and seven underwent surgical intervention. Other complications included major bleeding in 3.5%, procedure-related ischemic stroke in 1.1%, and device embolization in 0.6%.

10. Answer: D. In the recent multicenter report of 89 patients undergoing the LARIAT device LAA closure there were 3 access-related complications (during pericardial access, n = 2; and transseptal catheterization, n = 1). Additional adverse events included severe pericarditis postoperatively (n = 2), late pericardial effusion (n = 1), unexplained sudden death (n = 2), and late strokes thought to be nonembolic (n = 2).

11. Answer: B. Patients with prosthetic paravalvular regurgitation may be asymptomatic or present with heart failure or hemolysis. Symptomatic patients are candidates for either percutaneous or surgical closure. Percutaneous repair is contraindicated in patients with active endocarditis or significant dehiscence involving more than one-fourth of the valve ring. Prior endocarditis is not a contraindication to percutaneous closure.

12. Answer: D. The surgical or anatomic view is suggested by the American Society of Echocardiography guidelines on three-dimensional echocardiography places the aortic valve anterior (or at 12 o’clock) with the left atrial appendage identifying the lateral sewing ring and the interatrial septum the medial sewing ring (Fig. 21-16).

13. Answer: C. The transseptal approach can be challenging for the medial defect which requires acute angulation reducing catheter manipulation. This defect may be best approached through a transapical puncture. For some operators, the approach can be more systematically determined by the location of the defect: the transseptal antegrade technique for leaks located between 6 o’clock and 9 o’clock; the retrograde (retroaortic) technique for leaks located between 10 o’clock and 2 o’clock; the transapical approach for the majority of mitral paravalvular leaks, especially if located between 10 o’clock and 6 o’clock.

14. Answer: C. Congestive heart failure is treated more effectively than hemolysis. Studies have shown that 33% of patients requiring transfusions had worsening hemolysis after the procedure, and there was newly developed hemolysis in 10% of patients. Importantly, acute technical success is a determinant of long-term outcome where patients with moderate or severe residual mitral regurgitation had worse 3-year survival. Reported procedural success rates = 86%-89% with complication rates of 9%-13%.

15. Answer: B. The definition of LVOT obstruction refers to a peak instantaneous LV outflow gradient of ≥30 mm Hg. LVOT gradients of ≥50 mm Hg, either at rest or with provocation, meet the conventional threshold for surgical or percutaneous intervention assuming symptoms cannot be controlled with medications. If the resting outflow gradient is <50 mm Hg, provocative measures may be used to elicit higher gradients. However, dobutamine is no longer recommended as a provocative test as per the ACCF/AHA guidelines. Provocation of a higher gradient may be accomplished with exercise, the strain phase of the Valsalva maneuver and isoproterenol in the cardiac catheterization laboratory.

16. Answer: C. The effectiveness of ASA is uncertain with marked HCM (>30 mm) and is generally discouraged in these patients. Successful ASA is defined by a reduction of the LVOT gradient by at least 50%. Myocardial contrast echocardiography has become an important addition to the ASA procedure to identify the vascular distribution of the individual perforator branches, shorten intervention time, reduce infarct size, reduce the likelihood of heart block, and improve the likelihood of success. Following injection of alcohol, the septum thins and has reduced excursion.

17. Answer: B. Excluding high-grade atrioventricular block, nonfatal complications occur in 2%-3% of cases (in experienced centers). Ventricular septal defect is more likely with a septal thickness of <15 mm. Approximately 5% of patients have sustained ventricular tachyarrhythmias during hospitalization for septal ablation with an inhospital mortality rate of upto 2%. Complete heart block occurs in approximately half of patients undergoing alcohol septal ablation. Persistent complete heart block prompting implantation of a permanent pacemaker occurs in 10%-20% depending on baseline conduction. Although atrial arrhythmias are common with obstructive HCM, they are not a result of ASA.

18. Answer: C. Appropriate sizing of TAVR valves reduces the rate of paravalvular regurgitation (see Question 1). The risk for annular rupture with balloon-expandable valve increases with area oversizing of >20% as well as calcium burden. The percent oversizing is determined by the formula: ([nominal THV area/cross-sectional area] – 1) × 100. The manufacturer’s recommended sizing algorithms are shown for the balloon-expandable valve (Table 21-1) and the self-expanding valve (Table 21-2). The self-expanding valve requires a perimeter oversizing of typically 10%-20% (but upto 50%), thus the appropriate size device would be 29 mm. The 26-mm balloon-expandable valve nominal area is 5.31 cm² which would be 26% oversized for this annular area and a higher risk for annular rupture. Left bundle branch block rate and pacemaker rates are higher with the self-expanding valve compared to the balloon-expandable valve. Coronary obstruction is associated with small aortic root diameters and female sex. Panel C shows a root diameter of only 2.7 cm which may put this patient at risk for coronary obstruction (see Question 2).

19. Answer: B. The morphology exclusion criteria used by the MitraClip trials were:

Although these criteria have been used as a guideline for the commercial use of this device, complex mitral valve disease can be successfully treated. Multiple ruptured chordae (patient A) resulting in what appears to be prolapse in different regions of the posterior leaflet would be less likely to be successful with a single clip and multiple clips placed far apart would likely cause significant mitral stenosis. Because the reduction in valve area with a single MitraClip is approximately 40%, a valve area of <4.0 cm² (patient C) remains an exclusion criteria for the clip. The incomplete mitral ring seen in patient C, as well as the severe degenerative mitral annular calcium seen in patient D, both result in small baseline valve areas and thus are not good candidates for MitraClip. Patient B has the typical P2 flail with an acceptable flail width and valve area.

20. Answer: B. The images shown are: (A) The single lobe/windsock type LAA is an anatomy in which one dominant lobe of sufficient length is the primary structure. (B) The C-shape/chickenwing type LAA is an anatomy whose main feature is a sharp bend in the dominant lobe of the LAA anatomy at some distance from the perceived LAA ostium. (C) The fanshaped/cauliflower type LAA is an anatomy whose main feature is an LAA that has limited overall length with more complex internal characteristics. (D) The cactus/multi-lobed LAA is an anatomy whose main feature is an LAA with multiple distinct protrusions. The LARIAT device cannot be maneuvered around the C-shaped/chicken wing.

21. Answer: B. Posterior para-aortic regurgitant jets are better imaged on TEE (panel A) whereas anterior para-aortic jets are easiest to see on transthoracic imaging. Para-aortic defects are typically smaller than paramitral defects and can usually be closed with a single device as in the example shown. For para-aortic defects the lower pressure difference between the aorta and left ventricle (compared to the difference between the left ventricle and left atrium for paramitral defects) makes hemolysis less likely.

22. Answer: B. Panel A is a continuous-wave Doppler across the tricuspid valve. Panel C is the continuous-wave Doppler across the mitral valve of a patient with obstructive HCM; note the relatively delayed systolic flow pattern since regurgitation occurs secondary to malcoaptation of the leaflets with systolic anterior motion. Panel D is the continuous-wave Doppler across the aortic valve in the setting of a valvular aortic stenosis with rapid generation of a pressure gradient. The concave-to-the-left contour of panel B is the key to making the diagnosis of a dynamic outflow obstruction.

23. Answer: C. Contrast injection is used to identify the myocardium supplied by the septal perforator. The larger the volume of muscle supplied, the larger the controlled infarction. Figure 21-6C shows the largest region of myocardium supplied by the septal perforator and thus the greatest myocardium at risk for infarction following alcohol injection; this patient also developed a bundle branch block during the procedure. It is important to document the absence of perfusion of myocardial segments remote from the targeted areas for ablation, including the left ventricular anterior wall, right ventricular (RV) free wall, and papillary muscles. Perfusion of these regions may result in cessation of the procedure.

24. Answer: D. The only class I indication for intervention is “Symptomatic mitral stenosis (MVA ≤1.5 cm²) and favorable valve morphology in the absence of contraindication.” This patient fulfills this criterion. The reference measurement for MVA is two-dimensional echocardiography planimetry since pressure halftime method may not accurately estimate valve area in the setting of acute increase in left atrial compliance following balloon valvuloplasty. Three-dimensional echocardiography has replaced two-dimensional imaging for planimetry of the mitral orifice since it allows an accurate localization of the tips of the leaflets. These compliance changes normalize 24-48 hours after the procedure, when pressure halftime can again be used to assess MVA. Procedural success is defined as an increase of ≥50% of MVA or a final area of ≥1.5 cm², with no more than 1 grade increment in MR severity assessed by echocardiography 24 hours after the procedure. This is usually accompanied by a >50% reduction in mean gradient, however, mean gradient change in not typically used as a criteria for success since it is dependent on multiple hemodynamic parameters (including heart rate).