ITE Valvular Heart Disease Management 4 — Questions and Answers
Question 1: A 35-year-old woman with mitral valve prolapse presents with palpitations. Echo shows classic MVP with bileaflet prolapse and mild MR. Her resting ECG shows no pre-excitation. What is the most appropriate management?
- Prophylactic antiarrhythmic therapy
- Mitral valve repair
- Reassurance and follow-up with periodic echocardiography (Correct answer)
- Implantable cardioverter-defibrillator
Correct answer: Reassurance and follow-up with periodic echocardiography
Most patients with MVP and palpitations without high-risk features (severe MR, LV dysfunction, complex ventricular ectopy, T-wave changes in inferolateral leads) require only reassurance and surveillance.
Question 2: Which of the following patients with severe aortic stenosis requires concurrent coronary artery bypass grafting (CABG) at the time of surgical AVR?
- Patient with coronary stenosis of 30% in RCA
- Patient with coronary stenosis of 70% in the LAD (Correct answer)
- Patient with prior PCI with drug-eluting stent 2 months ago
- Patient with coronary calcium score of 300
Correct answer: Patient with coronary stenosis of 70% in the LAD
Concomitant CABG is recommended for significant CAD (≥70% stenosis in major coronary arteries) at the time of AVR to reduce perioperative MI risk.
Question 3: Which anticoagulation regimen is recommended for a patient with a bileaflet mechanical aortic valve prosthesis with no additional risk factors?
- Warfarin with INR target 2.0-3.0 (Correct answer)
- Warfarin with INR target 2.5-3.5
- Dabigatran 150 mg twice daily
- Aspirin 325 mg daily alone
Correct answer: Warfarin with INR target 2.0-3.0
For a bileaflet mechanical AVR with no additional thromboembolic risk factors, warfarin with INR target 2.0-3.0 is recommended; higher targets are needed for additional risk factors.
Question 4: A 58-year-old with severe mitral stenosis develops atrial fibrillation. Her resting ventricular rate is 110 bpm. Which is the most appropriate initial rate control agent?
- Digoxin alone
- Metoprolol or diltiazem (Correct answer)
- Amiodarone
- Flecainide
Correct answer: Metoprolol or diltiazem
Beta-blockers (metoprolol) or non-dihydropyridine calcium channel blockers (diltiazem, verapamil) are preferred for ventricular rate control in AF with mitral stenosis.
Question 5: What is the most common cause of acquired mitral stenosis in adults in the United States?
- Rheumatic heart disease (Correct answer)
- Calcific mitral annular stenosis in the elderly
- Congenital mitral stenosis
- Infective endocarditis
Correct answer: Rheumatic heart disease
Rheumatic heart disease remains the most common cause of mitral stenosis worldwide and in the US, though calcific annular MS is increasing in the elderly population.
Question 6: A 77-year-old with symptomatic severe tricuspid regurgitation secondary to RV pacing lead has LVEF 65% and no significant left-sided disease. He is high surgical risk. What is the appropriate next step?
- Medical management with diuretics alone indefinitely
- Tricuspid valve repair with pacing lead extraction
- Transcatheter tricuspid valve intervention (Correct answer)
- Liver transplant evaluation given hepatic congestion
Correct answer: Transcatheter tricuspid valve intervention
Transcatheter tricuspid valve interventions (e.g., TRILUMINATE, CLASP) are emerging as options for high-surgical-risk patients with severe symptomatic TR.
Question 7: Which physical exam finding is most characteristic of severe aortic regurgitation?
- Slow-rising carotid pulse (pulsus parvus et tardus)
- Wide pulse pressure with bounding/water-hammer pulse (Correct answer)
- Fixed split S2
- Middiastolic rumble at the apex
Correct answer: Wide pulse pressure with bounding/water-hammer pulse
Severe AR causes volume overload of the LV, producing a wide pulse pressure (elevated systolic, low diastolic) and a bounding, collapsing (water-hammer) pulse.
ITE Valvular Heart Disease Management 4
A 35-year-old woman with mitral valve prolapse presents with palpitations.
Echo shows classic MVP with bileaflet prolapse and mild MR.
Her resting ECG shows no pre-excitation.
What is the most appropriate management?