2020 Valvular heart disease

 

Assessment

         History

         Examination

         Non-invasive investigations: ECG, TTE, CXR

         Semi-invasive investigations: CT, MRI

         Invasive investigations: TOE, catheter

         MDT for every patient needing surgery

Severity

         Grades A, B, C, D

o    Symptoms

o    Valve anatomy

o    Valve dysfunction

o    Ventricular dysfunction

o    Upstream complications

  LV -> PHTN

  RV -> kidney, liver

Anticoagulation

         Non-valvular AF:

o    If CHADSVASC 2: warfarin or NOAC

o    If HASBLED score high: consider withholding

         Valvular AF: warfarin

         Metal mitral valve: warfarin INR 2.5-3.5

         Metal aortic valve: warfarin INR 2-3

Valve disease

         Aims:

o    Prevent irreversible damage to ventricles

o    Prevent pulmonary hypertension

o    Prevent irreversible damage to organs

o    Repair vs replacement

         Aortic stenosis:

o    Symptoms

o    Exercise-induced hypotension

o    LV systolic dysfunction (TTE, BNP)

o    Very severe stenosis

         Regurgitant valves:

o    Symptoms

o    LV dilation or dysfunction

o    If secondary to ventricular dysfunction: treat that first

         Miscellaneous

o    Mixed valve disease: attend to the worst lesion

o    Better treatments = lower threshold

o    i.e. expanding indications for percutaneous treatment

Infective endocarditis

         Blood cultures then antibiotics

         TTE TOE

         Multi-disciplinary team: surgeon + cardiologist + ID

         Early surgery if

o    Heart failure

o    Certain pathogens

o    Recurrent emboli or big vegetation

         Delay surgery >4/52 if

o    Terrible stroke

Pregnancy

         If severe MS or AS:

o    TAVR pre-conception is ideal

o    TAVR during pregnancy is possible

         If needing anticoagulation: LMWH with Xa levels

 

 

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