For a 62-year-old patient with mild aortic stenosis (AS; V2 2–3 m/s) who is asymptomatic, what is the recommendation for follow up echocardiogram?

1. Only when symptoms develop
   
2. Every 3–5 years
   
3. Every 1–2 years
   
4. Every 6–12 months

For a 72-year-old patient with AS with V2 of 4.2 m/s, aortic valve area (AVA) 0.8 cm², ejection fraction (EF) of 65% and normal pulmonary artery (PA) pressure and no symptoms, what would be your recommendation based on current guidelines?

1. Aortic valve replacement (AVR) as patient is likely to become symptomatic soon
   
2. Follow-up clinic and echo every 1–2 years
   
3. Follow-up clinic and echo every 6–12 months
   
4. No follow up till symptoms develop

A 22-year-old Asian woman presents with shortness of breath and has MS. What will you do about rheumatic fever prophylaxis?

1. Prophylaxis for the next 10 years
   
2. Prophylaxis till she turns 40 years
   
3. No prophylaxis as she is >21 years old
   
4. Prophylaxis for the next 5 years

Which of the following are acceptable for rheumatic heart disease prophylaxis?

1. Penicillin G benzathine 1.2 million units intramuscularly every 4 weeks
   
2. Penicillin V potassium 250 mg orally BID
   
3. Sulfadiazine 1 g orally once daily
   
4. Any of the above

Prophylaxis against infective endocarditis (IE) is reasonable for which of the following patients at highest risk for adverse outcomes from IE before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa?

1. Patients with prosthetic cardiac valves
   
2. Patients with previous IE
   
3. Cardiac transplant recipients with valve regurgitation due to a structurally abnormal valve
   
4. Patients with congenital heart disease with: (i) unrepaired cyanotic congenital heart disease, including palliative shunts and conduits; (ii) completely repaired congenital heart defect repaired with prosthetic material or device, whether placed by surgery or catheter intervention, during the first 6 months after the procedure; or (iii) repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device.
   
5. All of the above

Prophylaxis against IE is indicated in a patient with a prosthetic mitral valve (MV) undergoing which of the following procedures in the absence of local infection in the instrumented area?

1. Transesophageal echocardiogram (TEE)
   
2. Esophagogastroduodenoscopy
   
3. Colonoscopy
   
4. Cystoscopy
   
5. All of the above
   
6. None of the above

Definition of severe AS includes which of the following?

1. Aortic valve area <1.0 cm²
   
2. Transaortic velocity >4 m/s on echo
   
3. Transvalvular mean gradient >40 mmHg
   
4. Any of the above
   
5. Need all of the above

A 75-year-old man with no symptoms has severe aortic valve calcification, aortic valve velocity of 4.5 m/s and EF of 65%. What stage is he in?

1. Stage B
   
2. Stage C1
   
3. Stage C2
   
4. Stage D

A 72-year-old woman is found to have severe AS with V2 of 4.6 m/s and mean gradient of 47 mmHg. The EF is 60% and PA systolic pressure is normal by echo. She claims she has no symptoms, but the daughter thinks she has slowed down. It is reasonable to do which of the following?

1. An exercise stress test to confirm the asymptomatic status
   
2. Dobutamine echo to evaluate LV response to stress
   
3. Refer for cardiac catheterization and AVR
   
4. Follow up every 6–12 months

AVR is recommended in which of the following situations of severe AS?

1. For symptomatic patients with severe high-gradient AS who have symptoms (chest pain, shortness of breath, or syncope) by history or on exercise testing
   
2. For asymptomatic patients with severe AS (stage C2) and LVEF <50%
   
3. For patients with severe AS (stage C or D) when undergoing other cardiac surgery
   
4. All of the above

AVR is reasonable in which of the following situations of severe AS?

1. Asymptomatic patients with very severe AS (stage C1, aortic velocity >5.0 m/s) and low surgical risk
   
2. Asymptomatic patients (stage C1) with severe AS and decreased exercise tolerance or an exercise fall in blood pressure
   
3. Symptomatic patients with low-flow/low-gradient severe AS with reduced LVEF (stage D2) with a low-dose dobutamine stress study that shows an aortic velocity >4.0 m/s (or mean pressure gradient >40 mmHg) with a valve area >1.0 cm² at any dobutamine dose
   
4. Patients with moderate AS (stage B) (aortic velocity 3.0–3.9 m/s) who are undergoing other cardiac surgery
   
5. Symptomatic patients who have low-flow/low-gradient severe AS (stage D3) who are normotensive and have an LVEF >50% if clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms
   
6. All of the above

Transcatheter AVR (TAVR) is reasonable in which of the following situations?

1. Severe AS patients who meet an indication for AVR who have a prohibitive surgical risk and a predicted post-TAVR survival >12 months
   
2. As an alternative to surgical AVR in patients who meet an indication for AVR and who have high surgical risk
   
3. Neither A nor B
   
4. Both A and B

Which of the following statements is not true about balloon aortic valvuloplasty?

1. It is a good treatment for many forms of congenital AS
   
2. It is a good definitive treatment for calcific AS of the elderly
   
3. Percutaneous aortic balloon dilation may be considered as a bridge to surgical AVR or TAVR in severely symptomatic patients with severe AS
   
4. It is helpful to predilate the aortic valve just before TAVR

A 65-year-old woman with no prior cardiac history is short of breath on walking a flight of stairs and doing her daily activities for the last 6 months and is getting worse. Echocardiogram showed an EF of 65%, probable bicuspid aortic valve with V2 of 3.5 m/s, aortic mean gradient of 30 mmHg, V1 0.8 m/s and LV outflow tract diameter (LVOTd) of 20 mm. She walked 4 Mets and ramp II protocol on the treadmill. A TEE confirmed bicuspid aortic valve with a planimetered AVA of 0.7 cm² both on 2D and 3D. Normal coronaries on coronary angiography. PA pressure was normal. PFTs were normal. Hemoglobin 13.8 g/dL. What would be your recommendation?

1. Monitor the patient and repeat echo in 6 months
   
2. Do a dobutamine stress echo (DSE)
   
3. Enroll in an exercise program
   
4. Refer for AVR

A 72-year-old man with history of hypertension and diabetes is short of breath on walking a flight of stairs and doing his daily activities for the last 6 months and is getting worse. Echocardiogram showed an EF of 30%, calcific AS with V2 of 3.5 m/s, aortic mean gradient of 30 mmHg, V1 0.8 m/s, stroke volume index 32 mL/m², and LVOTd of 20 mm. Normal coronaries on coronary angiography. What would be your recommendation?

1. AS is not severe; treat with beta blockers and angiotensin-converting-enzyme inhibitor
   
2. Low-dose dobutamine echo for contractile reserve and hemodynamics
   
3. Refer for balloon valvotomy to see if the patient improves
   
4. Refer for TAVR

In the patient in Question 16.15, what is the approximate AVA by the continuity equation?

1. 0.7 cm²
   
2. 0.9 cm²
   
3. 1.2 cm²
   
4. Cannot calculate with the data given

In a patient with suspected AR, which is the preferred diagnostic modality?

1. Echocardiography
   
2. Contrast aortography
   
3. Cardiac magnetic resonance imaging
   
4. Radionuclide angiography

Severe AR is suggested by which of the following echocardiographic measures?

1. Doppler jet width ≥65% of LVOT
   
2. Vena contracta >0.6 cm
   
3. Holodiastolic flow reversal in the proximal abdominal aorta
   
4. Regurgitant volume ≥60 mL/beat, or regurgitant fraction ≥50%, or effective regurgitant orifice (ERO) area ≥0.3 cm²
   
5. All of the above

In a patient with chronic severe AR, which of the following constitute a definite indication for AVR?

1. Symptomatic patients with severe AR regardless of LV systolic function, even if EF is <30%
   
2. Asymptomatic patients with chronic severe AR and LV systolic dysfunction (LVEF <50%)
   
3. Patients with severe AR (stage C or D) while undergoing cardiac surgery for other indications
   
4. All of the above

In a patient with chronic severe AR, which of the following constitute a reasonable indication for AVR?

1. Asymptomatic patients with severe AR with normal LV systolic function (LVEF <50%) but with severe LV dilation (LV end-systolic dimension (LVESD) >50 mm, stage C2)
   
2. Moderate AR (stage B) patients who are undergoing other cardiac surgery
   
3. Asymptomatic patients with severe AR and normal LV systolic function (LVEF >50%, stage C1) but with progressive severe LV dilation (LV end-diastolic dimension (LVEDD) >65 mm) if surgical risk is low
   
4. All of the above

According to the AHA/ACC 2014 valve guidelines (Nishimura et al., 2014), when is MS considered severe?

1. MV area (MVA) <1.0 cm² and mean gradient >10 mmHg
   
2. MVA <1.0 cm²
   
3. MVA <1.5 cm²
   
4. MVA <1.5 cm² and mean gradient >10 mmHg

A 42-year-old patient is being followed up in valve clinic for rheumatic MS. She is asymptomatic and has no other comorbidities. Her echocardiogram shows an EF of 65%, severe left atrial enlargement, and a calculated MVA of 0.7 cm². PA systolic pressure is 40 mmHg, and Wilkins score is 6 out of 16 without commissural calcification. There was no MR. What would you recommend?

1. Follow up in 6 months
   
2. Refer for mitral balloon valvotomy
   
3. Refer for MV replacement and appendage ligation
   
4. Perform an exercise tolerance test

A 52-year-old man with rheumatic MS has been having progressive shortness of breath. His LVEF is normal, mean mitral gradient is 8 mmHg at a heart rate of 65 bpm, mitral pressure half-time is 180 ms. There is also moderate MR and the Wilkins score is 7. What would you recommend?

1. Continue to follow up as MS is not severe
   
2. Refer for mitral balloon valvotomy after coronary angiogram
   
3. Refer for MV replacement after coronary angiogram
   
4. Refer for MV repair after coronary angiogram

What are the echocardiographic indices of severe MR?

1. Central jet with the jet occupying >40% LA area
   
2. Holosystolic eccentric MR jet, which is wall hugging reaching posterior LA wall
   
3. Vena contracta >0.7 cm, or regurgitant volume >60 mL, or regurgitant fraction >50%
   
4. ERO area >0.40 cm²
   
5. Systolic flow reversal in pulmonary vein or veins
   
6. Any of the above

Which of the following are clear indications for surgical repair of primary severe MR?

1. Symptomatic patients with chronic severe primary MR (stage D) and LVEF >30%
   
2. Asymptomatic patients with chronic severe primary MR and LV dysfunction (LVEF 30–60% and/or LVESD >40 mm, stage C2)
   
3. Patients with chronic severe primary MR undergoing cardiac surgery for other indications
   
4. All of the above

In a patient undergoing MV surgery for severe MR, which type of anatomy is most suitable for successful repair?

1. Flail P2
   
2. Flail A2
   
3. Bileaflet MV prolapse
   
4. Barlow’s disease

A 62-year-old man with previous anterior myocardial infarction has an EF of 30%, LV dilation, and bileaflet tethering causing MR. The MR jet area is 4 cm², vena contracta 5 mm, and the ERO area is 0.25 cm². Which of the following describes the state of MR?

1. Mild
   
2. Moderate
   
3. Severe
   
4. Need more data

Criteria for severe tricuspid regurgitation (TR) include which of the following?

1. Central jet area >10 cm²
   
2. Vena contracta width >0.70 cm
   
3. Continuous-wave (CW) jet density and contour: dense, triangular with early peak
   
4. Hepatic vein flow: systolic reversal
   
5. All of the above

Reasonable indications for tricuspid valve (TV) surgery include which of the following?

1. Patients with severe TR (stages C and D) undergoing left-sided valve surgery
   
2. Patients with symptoms due to severe primary TR that are unresponsive to medical therapy
   
3. Asymptomatic or minimally symptomatic patients with severe primary TR (stage C) and progressive degrees of moderate or greater right ventricle dilation and/or systolic dysfunction
   
4. All of the above

Indicators of severe tricuspid stenosis include which of the following?

1. Mean diastolic gradient >5 mmHg
   
2. PHT >190 ms
   
3. Valve area by continuity equation <1.0 cm²
   
4. All of the above

Indicators of severe pulmonary stenosis include which of the following?

1. Transvalvular velocity >4 m/s
   
2. Peak gradient >40 mmHg
   
3. V2 >5 m/s
   
4. None of the above

For a 52-year-old man with bileaflet mitral mechanical valve without atrial fibrillation, LV dysfunction, prior thromboemboli, or hypercoagulable state, what is the preferred anticoagulation regimen?

1. Warfarin to an international normalized ratio (INR) goal of 3.0 and aspirin 81 mg daily
   
2. Warfarin to an INR goal of 3.0 only
   
3. Warfarin to an INR goal of 3.5
   
4. Warfarin to an INR goal of 2.5 and aspirin 81 mg daily

For a 52-year-old man with bileaflet aortic mechanical valve without atrial fibrillation, LV dysfunction, prior thromboemboli, or hypercoagulable state, what is the preferred anticoagulation regimen?

1. Warfarin to an INR goal of 3.0 and aspirin 81 mg daily
   
2. Warfarin to an INR goal of 3.0 only
   
3. Warfarin to an INR goal of 3.5
   
4. Warfarin to an INR goal of 2.5 and aspirin 81 mg daily

For a 52-year-old man with bileaflet aortic mechanical valve with one of the risk factors such as atrial fibrillation, LV dysfunction, prior thromboemboli,or hypercoagulable state, what is the preferred anticoagulation regimen?

1. Warfarin to an INR goal of 3.0 and aspirin 81 mg daily
   
2. Warfarin to an INR goal of 3.0 only
   
3. Warfarin to an INR goal of 3.5
   
4. Warfarin to an INR goal of 2.5 and aspirin 81 mg daily

For a patient with mechanical MV undergoing noncardiac surgery needing interruption of anticoagulation, what would you recommend?

1. Minimize nonanticoagulated period; bridge with heparin or LMWH
   
2. No bridging needed
   
3. Bridge with novel anticoagulant
   
4. Use fresh frozen plasma to cover surgery

For a patient with mechanical aortic valve undergoing noncardiac surgery needing interruption of anticoagulation, what would you recommend? Patient has no risk factors for higher embolic risk.

1. Minimize nonanticoagulated period; bridge with heparin or LMWH
   
2. Minimize nonanticoagulated period; no bridging needed
   
3. Bridge with novel anticoagulant
   
4. Use fresh frozen plasma to cover surgery

In patients with risk factors for IE presenting with fever of >48 h duration, which of the following guidelines for blood cultures are recommended?

1. At least two sets of blood cultures should be obtained, which may give positive culture rate of about 90%.
   
2. In patients with a chronic (or subacute) presentation, three sets of blood cultures should be drawn >6 h apart at peripheral sites before initiation of antimicrobial therapy
   
3. If option B is not feasible or safe in patients with severe sepsis or septic shock, two or more cultures at separate times are acceptable
   
4. All of the above

Based on the Duke criteria, a diagnosis of IE can be definitely made with which of the following present?

1. Two major criteria
   
2. One major and three minor criteria
   
3. Five major criteria
   
4. All of the above.

In a patient with risk factors for IE presenting with persistent fever, a TEE would be appropriate in which of the following situations after obtaining blood cultures and a transthoracic echocardiogram (TTE)?

1. Nondiagnostic TTE
   
2. Presence of intracardiac lead
   
3. IE complication is suspected
   
4. All of the above.

In a patient with proven endocarditis who also has a pacemaker device, device and lead removal is indicated or reasonable under which of the following situations?

1. Infection of lead or device pocket
   
2. Needs valve surgery for IE, but leads and pocket look normal
   
3. IE due to resistant organism such as S. aureus or fungi
   
4. All of the above.

In a pregnant patient with mechanical valve prosthesis, which of the following anticoagulation regimens are acceptable during the first trimester of pregnancy?

1. Warfarin if therapeutic INR can be achieved with a dose of 5 mg or less
   
2. Intravenous (IV) UFH to achieve partial thromboplastin time (PTT) twice the control
   
3. LMWH twice a day to achieve anti-Xa level 0.8–1.2 units/mL 4–6 h after the dose
   
4. All of the above