ITE Valvular Heart Disease Management 5 — Questions and Answers
Question 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?
- Mitral valve replacement with a mechanical prosthesis
- MitraClip (transcatheter edge-to-edge repair) (Correct answer)
- Surgical mitral annuloplasty
- Cardiac resynchronization therapy alone
Correct 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.
Question 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?
- Proceed with PMBC with careful technique
- Perform immediate surgical mitral valve replacement
- Continue anticoagulation for another 3 months and repeat TEE (Correct answer)
- Aspirate thrombus percutaneously under fluoroscopic guidance
Correct 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.
Question 3: Which of the following is the strongest independent predictor of poor outcomes after TAVR?
- Age >75 years
- Severe frailty and functional dependence (Correct answer)
- Bicuspid aortic valve anatomy
- STS score 5-8%
Correct 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.
Question 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?
- Streptococcus viridans
- Staphylococcus aureus (Correct answer)
- Enterococcus faecalis
- HACEK organisms
Correct answer: Staphylococcus aureus
Staphylococcus aureus is the most common cause of right-sided infective endocarditis in IV drug users, particularly affecting the tricuspid valve.
Question 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?
- Pseudo-severe AS—aortic valve is not truly stenotic
- True severe AS with contractile reserve—AVR is likely beneficial (Correct answer)
- Absence of contractile reserve—AVR is contraindicated
- Low-gradient AS due to measurement error
Correct 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.
Question 6: Which class of medications should be AVOIDED in patients with severe aortic stenosis presenting with systemic hypertension?
- ACE inhibitors
- Dihydropyridine calcium channel blockers
- Nitrates and systemic vasodilators (Correct answer)
- Low-dose beta-blockers
Correct 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.
Question 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?
- Watchful waiting until LVEF falls below 60%
- Mitral valve repair is reasonable (Class IIa indication) (Correct answer)
- Mitral valve replacement with a mechanical prosthesis
- Annual surveillance echocardiography only
Correct 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.
ITE Valvular Heart Disease Management 5
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?