ITE Valvular Heart Disease Management 2 — Questions and Answers
Question 1: A 68-year-old man with severe aortic stenosis (AVA 0.7 cm², mean gradient 55 mmHg) is asymptomatic with preserved LVEF of 60%. Which management is most appropriate?
- Immediate surgical AVR
- Watchful waiting with close follow-up every 6-12 months (Correct answer)
- Balloon aortic valvuloplasty
- TAVR within 3 months
Correct answer: Watchful waiting with close follow-up every 6-12 months
Asymptomatic severe AS with preserved LVEF is managed with close surveillance (every 6-12 months) as intervention is deferred until symptoms develop or LVEF falls below 50%.
Question 2: A 55-year-old woman with severe mitral regurgitation has progressive LV enlargement (LVESD 47 mm) but remains asymptomatic with LVEF 60%. What is the next step?
- Continue medical management with ACE inhibitors
- Mitral valve repair or replacement (Correct answer)
- Cardiac resynchronization therapy
- Diuretics and reassess in 6 months
Correct answer: Mitral valve repair or replacement
In chronic severe MR, surgery is indicated when LVESD reaches ≥40 mm (Class IIa) or ≥45 mm (Class I) even without symptoms, as irreversible LV dysfunction can develop.
Question 3: Which finding on echocardiography is most consistent with severe mitral stenosis?
- Mitral valve area of 1.8 cm²
- Mean transmitral gradient of 3 mmHg
- Mitral valve area of 1.0 cm² (Correct answer)
- Pressure half-time of 90 ms
Correct answer: Mitral valve area of 1.0 cm²
Severe mitral stenosis is defined by an MVA ≤1.5 cm², with very severe disease defined as MVA ≤1.0 cm².
Question 4: A 72-year-old with severe symptomatic aortic regurgitation and LVEF of 45% declines surgery. Which medication is most appropriate to reduce afterload?
- Metoprolol
- Nifedipine or ACE inhibitor (Correct answer)
- Digoxin
- Spironolactone
Correct answer: Nifedipine or ACE inhibitor
Vasodilators (long-acting nifedipine, ACE inhibitors, or ARBs) reduce afterload and are indicated in symptomatic severe AR when surgery is not an option or as a bridge.
Question 5: A 48-year-old woman with rheumatic mitral stenosis (MVA 1.2 cm²) develops symptomatic dyspnea. Echo shows pliable leaflets, no significant MR, and no left atrial thrombus. What is the preferred intervention?
- Mitral valve replacement with bioprosthesis
- Percutaneous mitral balloon commissurotomy (PMBC) (Correct answer)
- Open surgical commissurotomy
- Medical therapy with diuretics only
Correct answer: Percutaneous mitral balloon commissurotomy (PMBC)
PMBC is the procedure of choice for symptomatic moderate-severe MS with favorable valve morphology (pliable leaflets, minimal calcification, no significant MR, no LA thrombus).
Question 6: Which of the following valvular conditions most commonly causes a late-peaking systolic murmur heard best at the right upper sternal border that radiates to the carotids?
- Mitral valve prolapse
- Hypertrophic obstructive cardiomyopathy
- Aortic stenosis (Correct answer)
- Pulmonary stenosis
Correct answer: Aortic stenosis
Severe aortic stenosis produces a harsh, late-peaking crescendo-decrescendo systolic murmur at the right upper sternal border radiating to the carotids; the later the peak, the more severe the stenosis.
Question 7: A patient with a mechanical mitral valve prosthesis becomes pregnant. Which anticoagulation strategy is associated with the lowest risk of valve thrombosis?
- Low-molecular-weight heparin throughout pregnancy
- Warfarin throughout pregnancy (Correct answer)
- Aspirin monotherapy throughout pregnancy
- Unfractionated heparin throughout pregnancy
Correct answer: Warfarin throughout pregnancy
Warfarin throughout pregnancy offers the most reliable anticoagulation for mechanical valves and the lowest thrombosis risk, though it carries fetal risks (especially in the first trimester).
ITE Valvular Heart Disease Management 2
A 68-year-old man with severe aortic stenosis (AVA 0.7 cm², mean gradient 55 mmHg) is asymptomatic with preserved LVEF of 60%.
Which management is most appropriate?