guidelines for the management of patients with aortic valve disease dr sajeer k t senior resident,...
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Guidelines for the Management ofPatients With Aortic Valve Disease
Dr sajeer K TSenior Resident,
Dept. of Cardiology, MCH, Calicut
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2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease
2012 ACCF/AATS/SCAI/STS Expert Consensus Document onTranscatheter Aortic Valve Replacement
Guidelines on the management of valvular heart disease - ESC guidelines 2007
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Aortic Stenosis
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Aortic stenosis Severity
Mild Moderate Severe
1. Jet velocity (m/sec) <3.0 3.0-4.0 >4.0
2. Mean gradient (mm Hg) <25 25-40 >40
3. Valve area (cm2) 1.5 1.0-1.5 <1.0
4. Valve area index (cm2/m2) <0.6
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III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
Role of Echocardiography in Aortic Stenosis
Diagnosis and assessment of AS severity
Assessment of LV wall thickness, size, and function
Re-evaluation of asymptomatic patients: Severe AS : every year Moderate AS : every 1 to 2 years Mild AS : every 3 to 5 years
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Exercise Testing
Poor diagnostic accuracy for evaluation of concurrent CAD - abnormal baseline ECG - LV hypertrophy - limited coronary flow reserve
ST depression during exercise occurs in 80% of adults with asymptomatic AS - No prognostic significance
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Exercise Testing
To elicit exercise-induced symptoms and abnormal blood pressure responses
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Exercise testing should not be performed in symptomatic patients with AS.
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
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Indications for Cardiac Catheterization
- Before AVR in patients with AS at risk for CAD
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
- Before AVR in patients with AS for whom a pulmonary auto graft (Ross procedure) is contemplated ( If the origin of the coronary arteries was not identified by noninvasive technique)
Coronary angiography :
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Cardiac catheterization for hemodynamic measurements : - assessment of severity of AS in symptomatic patients when noninvasive tests are inconclusive or - when there is a discrepancy between noninvasive tests and clinical findings regarding severity of AS
Indications for Cardiac CatheterizationIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
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Cardiac Catheterization in AS
Not recommended for the assessment of severity of AS before AVR when noninvasive tests are adequate and concordant with clinical findings
III IIa IIb IIIIIIIIIIIIIII
Not recommended for the assessment of LV function and severity of AS in asymptomatic patients
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Definition - Valve area smaller than 1.0 cm2
- LV ejection fraction less than 40% - Mean gradient less than 30 to 40 mm Hg
Low-Flow/Low-Gradient Aortic Stenosis
After Dobutamine:
Severe AS : - increase in aortic velocity to at least 4 m/sec at any flow rate - with a valve area less than 1.0 cm2
AS is not severe :- valve area is increased to more than 1.0 cm2
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Low-Flow/Low-Gradient Aortic StenosisIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
Dobutamine stress echocardiography : - reasonable to evaluate patients with low-flow/low-gradient AS and LV dysfunction
Cardiac catheterization for hemodynamic measurements with infusion of Dobutamine - useful for evaluation of patients with low-flow/low-gradient AS and LV dysfunction
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Dobutamine infusion:
Increment in SV Increase in AVA greater than 0.2 cm2 little change in gradient
Increase in SV Fixed valve areaIncrease in gradient
Baseline evaluation overestimated the severity of stenosis
Respond favorably tosurgery
Patients who fail to show an increase in stroke volume with Dobutamine (less than 20%) - “lack of contractile reserve” - Appear to have a very poor prognosis with either medical or surgical therapy
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Indications for Aortic Valve Replacement
1. Symptomatic patients with severe AS
2. Severe AS undergoing CABG
3. Severe AS undergoing surgery on the aorta or other heart valves
4. Severe AS and LV systolic dysfunction
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III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
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AVR is reasonable for patients with Moderate AS undergoing CABG or surgery on the aorta or other heart valves
Indications for Aortic Valve Replacement contd..
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AVR is not useful for the prevention of sudden death in asymptomatic patients with AS
III IIa IIb IIIIIIIIIIIIIII
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Management Strategy for Patients With Severe AS
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Aortic Balloon Valvotomy
As a bridge to surgery in hemodynmically unstable adult patients with AS who are at high risk for AVR
For palliation in adult patients with AS in whom AVR cannot be performed because of serious co-morbid conditions
III IIa
IIb IIIIIIIIIIIIIII
Not recommended as an alternative to AVR in adult patients with ASException : younger adults with AS without valve calcification
III IIa
IIb IIIIIIIIIIIIIII
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Medical Therapy
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Medical Therapy contd……
Antibiotic prophylaxis is indicated in all patients with AS For prevention of IERheumatic AS : for prevention of recurrent RF
Patients with associated systemic HTN - treated cautiously with appropriate antihypertensive agents
Role of statins: Prospective, randomized, placebo-controlled trial in patients with calcific aortic valve disease failed to demonstrate a benefit of atorvastatin in reducing the progression of aortic valve stenosis over a 3-year period
Intensive lipid-lowering therapy in calcific aortic stenosis. N Engl J Med 2005;352:2389 –97.
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Medical Therapy for the Inoperable AS patients
-There is no therapy available that prolongs life
- AS patients with evidence of pulmonary congestion: - can benefit from cautious treatment with digitalis, diuretics, and ACE inhibitors- AS with acute Pulmonary edema: - Nitroprusside infusion (reduces congestion and improve LV performance) - Digitalis - reserved for AS with depressed systolic function or AF
If angina is the predominant symptom: - cautious use of nitrates and beta blockers can provide relief.
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Special Considerations in the Elderly
- AVR must be considered in all elderly patients who have symptoms caused by AS - Valve replacement is technically possible at any age - Older patients with symptoms due to severe AS, normal coronary arteries, and preserved LV function can expect a better outcome than those with CAD or LV dysfunction
- Elderly women→ a narrow LV OT and a small aortic annulus - require enlargement of the annulus
- Heavy calcification of the valve, annulus, and aortic root may require debridement
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2012 ACCF/AATS/SCAI/STS Expert Consensus Document onTranscatheter Aortic Valve Replacement
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Aortic Regurgitation
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Aortic Regurgitation
Mild Moderate Severe
Angiographic grade 1+ 2+ 3-4+
Color Doppler jet width Central jet, width < 25% of LVOT
> Mild but no signs of severe AR
Central jet, width>65% LVOT
Doppler VC width (cm) <0.3 0.3-0.6 >0.6
Regurgitant volume (mL/beat) <30 30-59 ≥60
Regurgitant fraction (% ) <30 30-49 ≥50
Regurgitant orifice area (cm2) <0.10 0.10-0.29 ≥0.30
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DIAGNOSIS AND INITIAL EVALUATION
Role of Echocardiography:- severity of acute or chronic AR- Valve morphology and aortic root size and morphology - LV hypertrophy, dimension (or vol.), and systolic function
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Radionuclide angiography or magnetic resonance imaging : - initial and serial assessment of LV volume and function at rest in patients with AR and suboptimal echocardiograms.
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Role of Exercise stress testing in chronic MR
- for assessment of functional capacity and symptomatic response in patients with a history of equivocal symptoms
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INDICATIONS FOR CARDIAC CATHETERIZATION
- Cardiac catheterization with aortic root angiography and measurement of LV pressure : - for assessment of severity of regurgitation - LV function - Aortic root size ( when non-invasive tests are inconclusive or discordant with clinical findings in patients with AR)
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- Coronary angiography is indicated before AVR in patients at risk for CAD
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INDICATIONS FOR AORTIC VALVE REPLACEMENT OR AORTIC VALVE REPAIR
“AVR” applies to both aortic valve replacement and aortic valve repair
Aortic valve repair should be considered only in those surgical centres' that have developed the appropriate technical expertise, gained experience in patient selection, and demonstrated outcomesequivalent to those of valve replacement
The indications for valve replacement and repair do not differ
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INDICATIONS FOR AORTIC VALVE REPLACEMENT OR AORTIC VALVE REPAIR
1. Symptomatic patients with severe AR irrespective of LV systolic function.2. Asymptomatic patients with chronic severe AR and LV systolic dysfunction (ejection fraction 0.50 or less) at rest
3. AVR is indicated for patients with chronic severe AR while undergoing CABG or surgery on the aorta or other heart valves. (level of evidence C)
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- Asymptomatic patients with severe AR with normal LV systolic function (EF> 0.50) but with severe LV dilatation (EDD > 75 mm or ESD> 55 mm)
INDICATIONS FOR AORTIC VALVE REPLACEMENT OR AORTIC VALVE REPAIR
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
- Moderate AR while undergoing surgery on the ascending aorta - Moderate AR while undergoing CABG
- Asymptomatic severe AR and normal LV systolic function at rest (EF> 0.50), - when the degree of LV dilatation exceeds an EDD of 70 mm or ESD of 50 mm - when there is evidence of progressive LV dilatation, declining exercise tolerance, or abnormal hemodynamic responses to exercise
III IIa
IIbIIIIIIIIIIIIIII
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AVR is not indicated
1. Asymptomatic patients with mild, moderate, or severe AR and normal LV systolic function at rest ( EF> 0.50) when degree of
dilatation is not mod. or severe ( EDD< 70 mm, ESD< 50 mm)
III IIa IIb IIIIIIIIIIIIIII
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Indications for surgery in aortic regurgitation
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Guideline for Medical therapy
Vasodilator therapy:
- Chronic therapy is indicated in patients with severe AR who have symptoms or LV dysfunction when surgery is not recommended because of additional cardiac or non-cardiac factors.
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- As a short-term therapy to improve the hemodynamic profile of patients with severe heart failure symptoms and severe LV dysfunction before proceeding with AVR
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Vasodilator therapy not indicated (Class III)
1. Asymptomatic patients with mild to moderate AR and normal LV systolic function
2. Asymptomatic patients with LV systolic dysfunction who are otherwise candidates for AVR
3. Symptomatic patients with either normal LV function or mild to moderate LV systolic dysfunction who are otherwise
candidates for AVR.
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Concomitant Aortic Root Disease
Dilatation of the ascending aorta is among the most common causes of isolated AR
In addition to causing acute AR, diseases of the proximal aorta may also contribute to chronic AR
- Marfan syndrome- Dissection- Chronic dilatation of the aortic root related to HTN or a BAV
AVR and aortic root reconstruction are indicated in patients with disease of the aortic root or proximal aorta and AR of any severity when the degree of dilatation of the aorta or aortic root reaches or exceeds 5.0 cm by echocardiography
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Evaluation of Patients After Aortic Valve Replacement
An echocardiogram should be performed soon after surgery to assess the results of surgery on LV size and function
A better predictor of LV systolic function following AVR is the reduction in LV end-diastolic dimension(LVEDD), which declines significantly within the first week or 2 after AVR
This is an excellent marker of the functional success of valvereplacement(because 80% of the overall reduction in EDD observed during the long-term postoperative course occurs within the first 10 to 14 daysafter AVR)
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Bicuspid Aortic Valve With Dilated Ascending Aorta class I- Initial TTE to assess the diameters of the aortic root and Asc.Ao
- CMR or CT indicated when morphology cannot be assessed accurately by TTE- Diameter > 4.0 cm should undergo serial evaluation of aortic root /ascending aorta size and morphology by echo, CMR, or CT on a yearly basis
Surgery to repair the aortic root or replace the ascending aorta is indicated: - if the diameter of the aortic root or ascending aorta is > 5.0 cm or if the rate of increase in diam. is 0.5 cm per year or more
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Bicuspid Aortic Valve With Dilated Ascending Aorta class IIaBeta-adrenergic blocking agents- (diameter > 4.0 cm): - who are not candidates for surgical correction and who do not have moderate to severe AR.
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MCQs
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1. True about severe AS except?a) Aortic jet velocity- 4.5 m/secb) Mean gradient- 42 mmHgc) Valve area index- 0.7 (cm2/m2)d) Valve area – 1 cm2
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2. True about low-flow/low-gradient AS except?a) Valve area - 0.8 cm2 b) LV ejection fraction - 46% c) Mean gradient - 30 mm Hgd) AVR is reasonable
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3. All are indications of AVR in except?a) Severe AS - NYHA class IIb) Severe AS with EF 40%c) Severe AS with TVDd) Asymptomatic AS with positive TMTe) Asymptomatic AS with family history of SCD
![Page 46: Guidelines for the Management of Patients With Aortic Valve Disease Dr sajeer K T Senior Resident, Dept. of Cardiology, MCH, Calicut](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649db95503460f94aa912a/html5/thumbnails/46.jpg)
4. All are true about medical therapy of AS except?
a) ACEI should be used with cautionb) Metoprolol is the only Beta blocker that can
be given in AS patientsc) No definite role for atorvastatind) Digitalis is useful in AS with LV dysfunction
![Page 47: Guidelines for the Management of Patients With Aortic Valve Disease Dr sajeer K T Senior Resident, Dept. of Cardiology, MCH, Calicut](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649db95503460f94aa912a/html5/thumbnails/47.jpg)
5.All are true about AS in elderly?a) AVR is technically possible at 80 years of ageb) Elderly men usually require enlargement of
aortic annuls at the time of AVRc) TAVI indicated when predicted survival- 15
monthsd) TAVI is reasonable alternative to surgical AVR
in patients with high surgical risk
![Page 48: Guidelines for the Management of Patients With Aortic Valve Disease Dr sajeer K T Senior Resident, Dept. of Cardiology, MCH, Calicut](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649db95503460f94aa912a/html5/thumbnails/48.jpg)
6.All are indications of AVR in AR except?a) Severe AR NYHA class IIb) Severe AR with EF 35%c) Asymptomatic severe AR with EF 50%d) Asymptomatic severe AR with EF 55%, LV
EDD-75mm, LVESD-55mm
![Page 49: Guidelines for the Management of Patients With Aortic Valve Disease Dr sajeer K T Senior Resident, Dept. of Cardiology, MCH, Calicut](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649db95503460f94aa912a/html5/thumbnails/49.jpg)
7. Severe AR true except?a) Doppler VC width 0.28cmb) Regurgitant volume- 70 (mL/beat)c) Regurgitant fraction 56 % d) Regurgitant orifice area 0.4 cm2
![Page 50: Guidelines for the Management of Patients With Aortic Valve Disease Dr sajeer K T Senior Resident, Dept. of Cardiology, MCH, Calicut](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649db95503460f94aa912a/html5/thumbnails/50.jpg)
8. True about Indication of surgery in AR with aortic root disease?
a) Aortic root diameter>45mm in patients with Marfan syndrome
b) Aortic root diameter>50 mm in patients with BAV
c) Diameter increase more than 0.5 cm/yeard) All of the above
![Page 51: Guidelines for the Management of Patients With Aortic Valve Disease Dr sajeer K T Senior Resident, Dept. of Cardiology, MCH, Calicut](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649db95503460f94aa912a/html5/thumbnails/51.jpg)
Answers
![Page 52: Guidelines for the Management of Patients With Aortic Valve Disease Dr sajeer K T Senior Resident, Dept. of Cardiology, MCH, Calicut](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649db95503460f94aa912a/html5/thumbnails/52.jpg)
1. True about severe AS except?a) Aortic jet velocity- 4.5 m/secb) Mean gradient- 42 mmHgc) Valve area index- 0.7 (cm2/m2)d) Valve area – 1 cm2
![Page 53: Guidelines for the Management of Patients With Aortic Valve Disease Dr sajeer K T Senior Resident, Dept. of Cardiology, MCH, Calicut](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649db95503460f94aa912a/html5/thumbnails/53.jpg)
2. True about low-flow/low-gradient AS except?a) Valve area - 0.8 cm2 b) LV ejection fraction - 46% c) Mean gradient - 30 mm Hgd) AVR is reasonable
![Page 54: Guidelines for the Management of Patients With Aortic Valve Disease Dr sajeer K T Senior Resident, Dept. of Cardiology, MCH, Calicut](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649db95503460f94aa912a/html5/thumbnails/54.jpg)
3. All are indications of AVR in except?a) Severe AS - NYHA class IIb) Severe AS with EF 40%c) Severe AS with TVDd) Asymptomatic AS with positive TMTe) Asymptomatic AS with family history of SCD
![Page 55: Guidelines for the Management of Patients With Aortic Valve Disease Dr sajeer K T Senior Resident, Dept. of Cardiology, MCH, Calicut](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649db95503460f94aa912a/html5/thumbnails/55.jpg)
4. All are true about medical therapy of AS except?
a) ACEI should be used with cautionb) Metoprolol is the only Beta blocker that can
be given in AS patientsc) No definite role for atorvastatind) Digitalis is useful in AS with LV dysfunction
![Page 56: Guidelines for the Management of Patients With Aortic Valve Disease Dr sajeer K T Senior Resident, Dept. of Cardiology, MCH, Calicut](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649db95503460f94aa912a/html5/thumbnails/56.jpg)
5.All are true about AS in elderly?a) AVR is technically possible at 80 years of ageb) Elderly men usually require enlargement of
aortic annuls at the time of AVRc) TAVI indicated when predicted survival- 15
monthsd) TAVI is reasonable alternative to surgical AVR
in patients with high surgical risk
![Page 57: Guidelines for the Management of Patients With Aortic Valve Disease Dr sajeer K T Senior Resident, Dept. of Cardiology, MCH, Calicut](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649db95503460f94aa912a/html5/thumbnails/57.jpg)
6.All are indications of AVR in severe AR except?a) Severe AR NYHA class IIb) Severe AR with EF 35%c) Asymptomatic severe AR with EF 50%d) Asymptomatic severe AR with EF 55%, LV
EDD-75mm, LVESD-55mm
![Page 58: Guidelines for the Management of Patients With Aortic Valve Disease Dr sajeer K T Senior Resident, Dept. of Cardiology, MCH, Calicut](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649db95503460f94aa912a/html5/thumbnails/58.jpg)
7. Severe AR true except?a) Doppler VC width - 0.28cmb) Regurgitant volume- 70 (mL/beat)c) Regurgitant fraction 56 % d) Regurgitant orifice area 0.4 cm2
![Page 59: Guidelines for the Management of Patients With Aortic Valve Disease Dr sajeer K T Senior Resident, Dept. of Cardiology, MCH, Calicut](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649db95503460f94aa912a/html5/thumbnails/59.jpg)
8. True about Indication of surgery in AR with aortic root disease?
a) Aortic root diameter>45mm in patients with Marfan syndrome
b) Aortic root diameter>50 mm in patients with BAV
c) Diameter increase more than 0.5 cm/yeard) All of the above
![Page 60: Guidelines for the Management of Patients With Aortic Valve Disease Dr sajeer K T Senior Resident, Dept. of Cardiology, MCH, Calicut](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649db95503460f94aa912a/html5/thumbnails/60.jpg)
Thank you