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Valvular Heart Disease Management Flashcards

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  1. A 60-year-old woman with severe functional mitral regurgitation due to dilated cardiomyopathy (LVEF 30%) has persistent NYHA class III symptoms despite optimal GDMT. Which intervention has been shown to reduce HF hospitalizations in this population?

    Answer: MitraClip (transcatheter edge-to-edge repair)

    The COAPT trial demonstrated that MitraClip (transcatheter TEER) significantly reduced HF hospitalizations and mortality in patients with severe secondary MR on maximally tolerated GDMT.

  2. A patient with rheumatic mitral stenosis is started on anticoagulation for a new LAA thrombus. After 3 months of therapeutic anticoagulation, repeat TEE shows persistent thrombus. What is the next step?

    Answer: Continue anticoagulation for another 3 months and repeat TEE

    If LAA thrombus persists after 3 months of therapeutic anticoagulation, extending anticoagulation for another 3 months is reasonable before reassessing suitability for PMBC.

  3. Which of the following is the strongest independent predictor of poor outcomes after TAVR?

    Answer: Severe frailty and functional dependence

    Severe frailty and functional dependence are the strongest independent predictors of poor post-TAVR outcomes, as they reflect overall physiologic reserve independent of cardiac anatomy.

  4. A 45-year-old man with a history of IV drug use presents with fever, bacteremia, and a new holosystolic murmur at the left lower sternal border. Echo shows a large vegetation on the tricuspid valve with severe TR. Which organism is most likely responsible?

    Answer: Staphylococcus aureus

    Staphylococcus aureus is the most common cause of right-sided infective endocarditis in IV drug users, particularly affecting the tricuspid valve.

  5. A 55-year-old with severe aortic stenosis and LVEF 25% (low-flow, low-gradient AS) has a mean gradient of 28 mmHg and AVA 0.75 cm². Dobutamine stress echo shows mean gradient increases to 52 mmHg and AVA remains 0.75 cm². What does this indicate?

    Answer: True severe AS with contractile reserve—AVR is likely beneficial

    An increase in mean gradient >40 mmHg with stable low AVA on dobutamine stress echo confirms true severe AS with contractile reserve, indicating likely benefit from AVR despite low LVEF.

  6. Which class of medications should be AVOIDED in patients with severe aortic stenosis presenting with systemic hypertension?

    Answer: Nitrates and systemic vasodilators

    Potent vasodilators (nitrates, phosphodiesterase inhibitors, alpha-blockers) are dangerous in severe AS because fixed obstruction prevents cardiac output from increasing to compensate for the drop in SVR, causing severe hypotension.

  7. A 62-year-old woman with severe mitral regurgitation due to posterior leaflet flail has LVEF 65% and LVESD 38 mm and is asymptomatic. The surgical team estimates >95% likelihood of successful repair at a Mitral Valve Center of Excellence. What is the most appropriate recommendation?

    Answer: Mitral valve repair is reasonable (Class IIa indication)

    Current AHA/ACC guidelines allow early MV repair (Class IIa) for asymptomatic severe MR when repair is highly likely (>95% success rate) at an experienced center, even before guideline thresholds for LVESD or LVEF are met.