ITE - Internal Medicine In-Training Valvular Heart Disease Management Questions and Answers

Question 1

A 72-year-old male with a history of hypertension presents for a routine evaluation. He denies chest pain, dyspnea, or syncope. On physical exam, you note a grade 3/6 late-peaking systolic ejection murmur at the right upper sternal border that radiates to the carotids. An echocardiogram reveals a calcified aortic valve with a peak velocity of 4.5 m/s, a mean gradient of 50 mm Hg, and an aortic valve area of 0.8 cm². His left ventricular ejection fraction (LVEF) is 65%. Which of the following is the most appropriate next step in management?

Accepted Answer

Perform an exercise stress test to confirm asymptomatic status.

Answer

According to the 2020 ACC/AHA guidelines, for asymptomatic patients with severe aortic stenosis, exercise testing is reasonable to confirm the absence of symptoms and to assess hemodynamic response. The development of symptoms during exercise would be an indication for intervention. Medical therapy with beta-blockers or ACE inhibitors has not been proven to alter the natural history of aortic stenosis and is not the primary treatment. While the patient has severe aortic stenosis based on echocardiographic criteria, intervention is primarily indicated for symptomatic patients or those with LV dysfunction. Therefore, confirming his asymptomatic status with objective testing is the most appropriate next step before considering valve replacement.

Question 2

A 65-year-old female is diagnosed with severe, symptomatic, degenerative mitral regurgitation (MR) and is referred for surgical evaluation. Her LVEF is 65% and left ventricular end-systolic dimension (LVESD) is 38 mm. Which of the following is the preferred surgical approach?

Accepted Answer

Mitral valve repair.

Answer

For patients with severe primary mitral regurgitation who are symptomatic and have preserved left ventricular function, mitral valve repair is the preferred surgical technique over replacement when it is feasible and likely to be durable. Repair is associated with lower operative mortality, better preservation of postoperative LV function, and improved long-term survival compared to mitral valve replacement. Mechanical and bioprosthetic replacements are typically reserved for cases where repair is not possible. TEER is generally considered for patients who are at high or prohibitive surgical risk.

Question 3

A 58-year-old male with a bicuspid aortic valve is found to have severe chronic aortic regurgitation (AR) on a routine echocardiogram. He is completely asymptomatic. His LVEF is 52% and his LV end-diastolic dimension is 72 mm. Blood pressure is 130/50 mmHg. According to the most recent guidelines, which of the following is the strongest indication for aortic valve replacement in this patient?

Accepted Answer

The left ventricular ejection fraction.

Answer

The 2020 ACC/AHA guidelines lowered the threshold for intervention in asymptomatic severe aortic regurgitation. Aortic valve replacement is recommended for asymptomatic patients with severe AR if the LVEF is 55% or less. This patient's LVEF is 52%, which is a clear indication for surgery to prevent irreversible left ventricular dysfunction. While the bicuspid valve is the etiology and the wide pulse pressure is a physical finding, the LVEF is the key parameter guiding the timing of intervention in this asymptomatic patient.

Question 4

A 45-year-old female immigrant from Southeast Asia presents with progressive exertional dyspnea. She has a history of rheumatic fever in childhood. On exam, she has an opening snap and a low-pitched diastolic rumble at the apex. She is found to be in atrial fibrillation with a rapid ventricular response. Echocardiography confirms severe rheumatic mitral stenosis (valve area 0.9 cm²). Which of the following medications is contraindicated for anticoagulation in this patient?

Accepted Answer

Dabigatran.

Answer

In patients with atrial fibrillation and moderate-to-severe rheumatic mitral stenosis, anticoagulation with a vitamin K antagonist (VKA) like warfarin is recommended. Non-vitamin K antagonist oral anticoagulants (NOACs), such as dabigatran, are not recommended and are considered contraindicated in this specific patient population due to a lack of evidence and potential for harm. Heparin and enoxaparin can be used for bridging or acute anticoagulation.

Question 5

Which of the following is an established indication for intervention in a patient with asymptomatic severe primary mitral regurgitation?

Accepted Answer

Pulmonary artery systolic pressure (PASP) at rest of 55 mmHg.

Answer

For asymptomatic patients with severe primary mitral regurgitation and preserved LV function (LVEF >60% and LVESD <40 mm), surgery is indicated if new-onset atrial fibrillation or pulmonary hypertension (pulmonary artery systolic pressure >50 mmHg at rest) develops. An LVEF of 65% and LVESD of 38 mm are within the normal range and would not trigger intervention on their own. Advanced age is a factor in risk assessment but not a primary indication for surgery.

ITE - Internal Medicine In-Training Exam Practice Test

ITE - Internal Medicine In-Training Exam Practice Test

ITE - Internal Medicine In-Training Valvular Heart Disease Management Questions and Answers