Valvular Heart Disease Management Flashcards

A 58-year-old woman with severe aortic stenosis (AVA 0.7 cm², mean gradient 45 mmHg) is referred for valve replacement. Dobutamine stress echocardiography reveals a mean gradient that increases to 52 mmHg and AVA that increases to 0.95 cm² with dobutamine. LVEF is 35% at rest and increases to 48% with dobutamine. Which of the following best describes her hemodynamic pattern and guides management?

Answer: True severe AS with contractile reserve — proceed with AVR

This patient has true severe AS with contractile reserve (EF improves >10% and gradient rises with dobutamine, but AVA remains 1.0 cm² with dobutamine, indicating the low resting gradient was due to low flow rather than true severe stenosis.

A 72-year-old man with chronic severe aortic regurgitation has serial echocardiograms over 4 years. Current echo shows: LVEF 52%, LV end-systolic diameter (LVESD) 49 mm, LV end-diastolic diameter (LVEDD) 72 mm. He is asymptomatic and his exercise tolerance is excellent. What is the most appropriate next step?

Answer: Refer for aortic valve replacement surgery now

Per current ACC/AHA guidelines, AVR is indicated (Class I) for asymptomatic severe AR when LVESD ≥50 mm OR LVEDD >65 mm OR LVEF <55%. This patient's LVESD is 49 mm (borderline) but LVEDD is 72 mm, which exceeds the 65 mm threshold — meeting an independent surgical indication regardless of symptoms or EF. Waiting risks irreversible LV dysfunction. ACE inhibitors do not delay surgical timing in asymptomatic patients meeting size criteria. Exercise stress echo has no guideline-supported role in this scenario when structural thresholds are already met.

A 45-year-old woman with rheumatic mitral stenosis (MVA 1.1 cm², mean gradient 12 mmHg) presents 32 weeks pregnant with worsening dyspnea (NYHA Class III). Echo shows pliable leaflets, no significant MR, and Wilkins score 6. She has no left atrial thrombus on TEE. Which intervention is most appropriate?

Answer: Percutaneous mitral balloon commissurotomy (PMBC) under fluoroscopic guidance

Percutaneous mitral balloon commissurotomy (PMBC) is the procedure of choice for symptomatic mitral stenosis in pregnancy when valve anatomy is favorable (Wilkins score ≤8, pliable leaflets, no significant MR, no LA thrombus). At 32 weeks with NYHA Class III symptoms, medical therapy alone is unlikely to suffice until delivery, and waiting carries significant maternal and fetal risk. PMBC can be performed safely in the second and third trimester with abdominal shielding to minimize fetal radiation exposure. Surgical commissurotomy carries significant maternal and fetal mortality. Mitral valve replacement during pregnancy carries fetal mortality of 20–30% with mechanical valves and anticoagulation risks.

A 66-year-old man with bicuspid aortic valve and severe AS (TAVR candidate) is found to have a dilated ascending aorta measuring 4.6 cm on CT. He has no connective tissue disorder. His STS score is 3.2%. What is the most appropriate management of the aortic root at the time of valve replacement?

Answer: Surgical AVR with concomitant ascending aortic replacement given the bicuspid-specific threshold of 4.5 cm

Guidelines recommend concomitant ascending aortic replacement in patients with bicuspid aortic valve undergoing cardiac surgery when the aorta measures ≥4.5 cm (Class IIa recommendation), compared to the 5.5 cm threshold used for tricuspid valves. This lower threshold reflects the higher risk of aortic dissection and progressive dilatation associated with the bicuspid aortopathy phenotype, which is mediated by intrinsic smooth muscle cell abnormalities independent of hemodynamic stress. Because this patient's STS score is only 3.2%, surgical AVR with aortic repair is appropriate and TAVR alone would leave an at-risk aorta untreated. TAVR is generally contraindicated when concomitant aortic repair is needed.

A 55-year-old man with known HCM and LVOT obstruction (peak gradient 65 mmHg at rest) develops severe mitral regurgitation on surveillance echo. TEE shows systolic anterior motion (SAM) of the anterior mitral leaflet and elongated leaflets with no intrinsic leaflet pathology. He is on maximally tolerated disopyramide and metoprolol. Which statement best guides the approach to his MR?

Answer: Refer for septal reduction therapy (surgical myectomy preferred); the MR will likely resolve after relieving obstruction

In HCM, the majority of MR results directly from SAM-septal contact causing mitral leaflet malcoaptation — it is a secondary, flow-dependent phenomenon rather than intrinsic valve disease. After successful septal reduction (myectomy or alcohol septal ablation), LVOT gradient relief eliminates the forward drag that causes SAM, and MR resolves or improves significantly in >90% of cases. Surgical myectomy is preferred over alcohol septal ablation because it allows simultaneous direct inspection and repair of elongated leaflets if intrinsic pathology is found. Isolated valve repair would not address the root cause. ACE inhibitors are relatively contraindicated in obstructive HCM as afterload reduction can worsen obstruction. MitraClip would not address the underlying mechanism.

A 48-year-old woman with mechanical mitral valve replacement (St. Jude bileaflet, implanted 8 years ago) on warfarin (INR 2.8) presents to the ED with 6 hours of acute-onset respiratory distress, pulmonary edema, and a new harsh diastolic murmur. TEE confirms thrombus on the mechanical valve with restricted leaflet motion. She is hemodynamically unstable with BP 82/50 mmHg. Which is the most appropriate immediate management?

Answer: Emergency surgical thrombectomy/valve re-replacement — surgery is the treatment of choice for obstructive prosthetic valve thrombosis in the hemodynamically unstable patient

For obstructive prosthetic valve thrombosis (PVT) causing hemodynamic instability, current ACC/AHA/ESC guidelines recommend emergency surgery as the treatment of choice (Class I) rather than thrombolysis. While thrombolysis is an alternative for non-obstructive thrombus or when surgery is unavailable/prohibitively high risk, in an unstable patient with a left-sided obstructive mechanical valve thrombus, surgery offers definitive treatment with lower risk of systemic embolism (including stroke) and recurrence compared to fibrinolysis. Thrombolysis carries 10–15% major stroke risk in this setting. Heparin intensification alone is ineffective for acute obstructive thrombosis. Catheterization introduces unnecessary delay. The distinction between left-sided versus right-sided PVT is also critical — thrombolysis is more acceptable for right-sided (tricuspid) mechanical valve thrombosis.