Valvular Heart Disease Management Flashcards

A 68-year-old woman with severe aortic stenosis (AVA 0.7 cm², mean gradient 52 mmHg) and an EF of 30% is evaluated for valve replacement. After dobutamine stress echocardiography, her AVA increases to 0.85 cm² and mean gradient increases to 48 mmHg. Which of the following best characterizes her condition and guides management?

Answer: True severe AS with contractile reserve — proceed with AVR given symptomatic low-flow, low-gradient physiology

This patient has low-flow, low-gradient severe AS with reduced EF. On dobutamine stress echo, the AVA remains 1.0 cm²) as gradient rises. Patients with true severe AS and contractile reserve have acceptable surgical risk and benefit from AVR (or TAVR). Those without contractile reserve (EF does not improve with dobutamine) carry higher procedural risk but may still benefit from TAVR on a case-by-case basis.

A 45-year-old man with known bicuspid aortic valve and moderate aortic regurgitation has an aortic root diameter of 4.8 cm and ascending aorta of 4.3 cm. He is asymptomatic with EF of 62% and LVESD of 42 mm. Which is the most appropriate management?

Answer: Refer for surgery now given aortic root ≥4.5 cm in a bicuspid aortic valve patient with additional risk modifier

In bicuspid aortic valve (BAV) disease, the threshold for prophylactic aortic surgery is lower than in tricuspid valves. Current AHA/ACC guidelines recommend surgery at ≥5.5 cm for tricuspid valves but ≥5.0 cm for BAV. However, surgery is reasonable at ≥4.5 cm in BAV patients who have an additional risk modifier — such as a family history of aortic dissection, a rapid growth rate (>0.5 cm/year), or planned cardiac surgery for another indication. At 4.8 cm root with BAV, the threshold is met if any risk modifier exists; this patient warrants surgical referral evaluation. Beta-blockers alone do not change the aortopathy trajectory sufficiently to defer needed intervention.

A 72-year-old man undergoes TAVR for severe calcific aortic stenosis. Post-procedure TEE shows a small, eccentric paravalvular leak (PVL) graded as mild-to-moderate. His 30-day echocardiogram shows the PVL is unchanged. He remains mildly symptomatic with dyspnea on exertion. Which statement about his prognosis and management is most accurate?

Answer: Mild-to-moderate PVL after TAVR is associated with increased mortality and warrants consideration of repeat intervention if symptoms persist

Even mild-to-moderate paravalvular leak (PVL) after TAVR is independently associated with increased short- and long-term mortality — a finding replicated across multiple large registries including PARTNER and CoreValve trials. Unlike surgical AVR PVL, transcatheter PVL may partially reduce with valve expansion, but moderate or greater PVL rarely resolves fully. Symptomatic patients with ≥mild-moderate PVL should be evaluated for re-dilation (post-dilatation), valve-in-valve TAVR, or surgical correction. Medical optimization alone does not abolish the mortality risk conferred by significant residual PVL.

A 58-year-old woman with rheumatic mitral stenosis (MVA 1.1 cm², mean gradient 14 mmHg) has moderate mitral regurgitation, a Wilkins score of 9, and no left atrial thrombus on TEE. She develops atrial fibrillation with rapid ventricular response. Which is the most appropriate next step in valve management?

Answer: Refer directly for surgical mitral valve replacement given the Wilkins score >8

A Wilkins score >8 predicts suboptimal outcomes and higher restenosis rates after PMBC. Additionally, this patient has moderate mitral regurgitation — moderate MR (≥2+) is a relative contraindication to PMBC because balloon inflation may worsen regurgitation acutely. With both an unfavorable valve morphology (Wilkins 9) and coexisting moderate MR, surgical mitral valve repair or replacement is the preferred intervention. PMBC is most appropriate when Wilkins ≤8, MR is absent or trivial, and the valve anatomy is pliable. Deferring intervention is inappropriate given symptomatic hemodynamically significant MS.

A 65-year-old man with severe primary mitral regurgitation (ERO 0.55 cm², regurgitant volume 68 mL) is asymptomatic with EF 58% and LVESD 38 mm. He is evaluated at a high-volume valve center where the surgical repair rate for isolated posterior leaflet prolapse exceeds 95%. What is the most appropriate recommendation?

Answer: Early mitral valve repair is reasonable (Class IIa) given high repair likelihood at an experienced center

Current AHA/ACC guidelines (2021 update) give a Class IIa recommendation for early mitral valve repair in asymptomatic patients with severe primary MR when: (1) the patient is at low surgical risk, (2) repair is highly likely (>95% probability) at a Heart Valve Center of Excellence, and (3) ERO ≥0.40 cm² or regurgitant volume ≥60 mL. This patient meets all three criteria. The traditional 'watchful waiting' until EF <60% or LVESD ≥40 mm represents Class I thresholds, but early surgery at experienced centers has been shown to prevent irreversible LV dysfunction and improves long-term outcomes. ACE inhibitors lack evidence in asymptomatic primary MR. MitraClip is indicated for high-surgical-risk or secondary MR — not primary MR in a low-risk surgical candidate.

A 55-year-old woman with hypertrophic obstructive cardiomyopathy (HOCM) and a resting LVOT gradient of 68 mmHg develops worsening exertional dyspnea despite maximally tolerated doses of metoprolol. Echocardiography reveals severe, posteriorly-directed mitral regurgitation due to systolic anterior motion (SAM) of the mitral valve. She has no significant septal perforator anatomy on coronary angiogram. Which intervention is most appropriate?

Answer: Surgical myectomy with concurrent mitral valve repair/replacement

In HOCM, SAM-related MR is secondary to the outflow tract obstruction — it is not a primary valve pathology. Correcting the obstruction (myectomy) typically eliminates SAM and the associated MR. This patient has failed maximal medical therapy and has no suitable septal perforator for alcohol ablation (a contraindication to ASA). Surgical septal myectomy is therefore the procedure of choice, and concurrent intraoperative assessment allows mitral valve repair/replacement if the MR does not resolve after myectomy. Disopyramide could be tried before surgery but is not appropriate as a next step when the patient has already failed maximally tolerated beta-blockade and has no suitable anatomy for ASA. MitraClip addresses the mitral valve without treating the underlying obstruction causing the SAM, making it inappropriate here.