ITE Valvular Heart Disease Management 3 — Questions and Answers
Question 1: A 65-year-old man with bicuspid aortic valve has severe AR with LVEF 55% and LVESD 52 mm but no symptoms. What is the most appropriate management?
- Reassure and follow up in 2 years
- Start beta-blocker therapy
- Surgical aortic valve replacement (Correct answer)
- Percutaneous aortic valve replacement
Correct answer: Surgical aortic valve replacement
In severe AR, surgery is indicated when LVESD ≥50 mm (Class IIa) or ≥55 mm (Class I) even in asymptomatic patients to prevent irreversible LV dysfunction.
Question 2: Which echocardiographic parameter is most useful for determining surgical timing in asymptomatic chronic severe mitral regurgitation?
- Left atrial size
- Left ventricular end-diastolic diameter
- Left ventricular end-systolic diameter (LVESD) (Correct answer)
- Pulmonary artery systolic pressure alone
Correct answer: Left ventricular end-systolic diameter (LVESD)
LVESD ≥40-45 mm in severe chronic MR is the key echocardiographic threshold that prompts surgical intervention even in asymptomatic patients.
Question 3: A 70-year-old woman with known moderate aortic stenosis presents with new-onset syncope. Her echo shows AVA 0.85 cm² and mean gradient 48 mmHg. What is the most appropriate next step?
- Tilt-table testing
- Holter monitoring for 30 days
- Aortic valve replacement (Correct answer)
- Cardiac catheterization to exclude CAD first, then defer AVR
Correct answer: Aortic valve replacement
Syncope is one of the classic triad of symptoms in severe AS (along with angina and HF), and its onset marks a poor prognosis with ~3-year median survival if untreated—AVR is indicated.
Question 4: Which of the following is an absolute contraindication to percutaneous mitral balloon commissurotomy (PMBC)?
- Mild mitral regurgitation (MR grade 1+)
- Atrial fibrillation
- Left atrial thrombus (Correct answer)
- Mild aortic regurgitation
Correct answer: Left atrial thrombus
Left atrial thrombus is an absolute contraindication to PMBC because balloon inflation risks thrombus embolization and stroke.
Question 5: An 80-year-old man with severe AS is deemed high surgical risk (STS score 8%). He has no contraindications to TAVR. What is the recommended approach?
- Medical management with diuretics
- Balloon aortic valvuloplasty alone
- Transcatheter aortic valve replacement (TAVR) (Correct answer)
- Surgical AVR despite high risk
Correct answer: Transcatheter aortic valve replacement (TAVR)
TAVR is recommended for symptomatic severe AS in patients at high or prohibitive surgical risk (STS ≥8% or institutional agreement on high risk).
Question 6: Which murmur characteristic distinguishes hypertrophic obstructive cardiomyopathy (HOCM) from valvular aortic stenosis?
- HOCM murmur increases with standing; AS murmur does not (Correct answer)
- HOCM murmur radiates to the carotids; AS does not
- HOCM murmur decreases with Valsalva; AS increases
- HOCM murmur is diastolic; AS is systolic
Correct answer: HOCM murmur increases with standing; AS murmur does not
HOCM murmur increases with standing (decreased preload worsens obstruction) and Valsalva, whereas AS murmur decreases with maneuvers that reduce preload.
Question 7: A patient with a bioprosthetic aortic valve develops structural valve deterioration (SVD) 12 years postoperatively and is now symptomatic. She is a moderate surgical risk (STS 4%). What is the preferred intervention?
- Redo surgical AVR
- Valve-in-valve TAVR (Correct answer)
- Medical management
- Balloon valvuloplasty of the bioprosthesis
Correct answer: Valve-in-valve TAVR
Valve-in-valve TAVR within a failed bioprosthesis is preferred over redo surgery for patients with moderate-to-high surgical risk and appropriate bioprosthesis anatomy.
ITE Valvular Heart Disease Management 3
A 65-year-old man with bicuspid aortic valve has severe AR with LVEF 55% and LVESD 52 mm but no symptoms.
What is the most appropriate management?