The Signs And Symptoms Of Significant MS

The Signs And Symptoms Of Significant MS
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The Signs And Symptoms Of Significant MS
1. A 90-year-old former congressman is referred to you
for possible aortic valvuloplasty. He has significant
chronic obstructive lung disease and has had a prior
biventricular pacer with implantable defibrillator
placed owing to congestive heart failure and an
LV ejection fraction of 28%. The biventricular
pacemaker has not improved his symptoms. He
had been a heavy alcohol user in the past. Over
the last few years he has developed progressive
symptoms of dyspnea and chest pressure. A cardiac
catheterization in his local community revealed a
2. mm Hg mean aortic gradient with no aortic
insufficiency and an aortic valve area of 0.8 cm2.
He has no coronary artery disease. He is referred
for a second cardiac catheterization during which
time he is given intravenous dobutamine while
simultaneously determining his cardiac output and
valve gradient. His valve gradient rises to a mean
of 30 mm Hg and his aortic valve area increases to
1.2 cm2. Which of the following statements is true?
(A) He should be considered for immediate aortic
valve replacement (AVR), though at high risk
due to his pulmonary status. A bioprosthetic
valve should be used
(B) He should undergo elective AVR with an aortic
(C) He should undergo percutaneous aortic valvuloplasty as a trial to see if he gets better. If he
does, then he should go to surgical AVR in the
The Signs And Symptoms Of Significant MS
(D) He is not a candidate for either surgical or
percutaneous valvuloplasty
(E) He should be referred to a center that has access
to a percutaneous aortic valve stent
11 A 22-year-old college student is referred because of a
murmur. On examination and by echocardiography
she has a classic doming pulmonary valve with a
peak pulmonary valve gradient by echocardiography
of 80 mm Hg. She is minimally symptomatic, but
the decision is made to proceed with pulmonary
valvuloplasty based on the hemodynamics. The procedure goes smoothly, but she becomes hypotensive
immediately after the balloons are removed. The preprocedure and postprocedural right ventriculograms
are shown in the following figure. What is the most
likely cause for hypotension in this setting?
(A) The pulmonary valve has ruptured and there is
severe pulmonary regurgitation
(B) A ventricular septal defect has been caused by
the procedure
(C) Relief of the pulmonary valve stenosis has resulted in severe subpulmonic dynamic stenosis
with low output
(D) There is obvious tamponade due to rupture of
the PA
12 Pulmonary hypertension associated with mitral valve
(A) Completely resolves following surgical valve
correction, but not with percutaneous treatment
(B) Is associated with a soft P2 on physical examination
(C) Is an absolute contraindication to percutaneous
(D) May lead to a falsely elevated cardiac output by
the Fick calculation
(E) Can lead to significant concomitant tricuspid
regurgitation (TR)
236 900 Questions: An Interventional Cardiology Board Review
13 Dr. Y has just performed his second inflation across
a congenitally stenotic pulmonary valve using a single balloon technique. The pre- and postprocedural
pressure curves are obtained. The next most appropriate action would be to:
Preprocedure Postprocedure
(A) Conclude that the procedure is a success
(B) Upsize to a larger balloon to improve the valvular
(C) Place an intra-aortic balloon pump and call for
emergent pulmonary valve replacement
(D) Perform an emergent TEE to assess whether
there is severe pulmonary regurgitation
(E) Add low dose dobutamine for support given the
drop in the RV pressure
14 A 14-year-old white boy, a member of his high
school basketball team, sees you for consultation
regarding a murmur. He had been followed up for
the murmur by his local pediatric cardiologist but
he has recently moved to your town and he thought
he would check in. He has been feeling fine, except
he notes some increased fatigue lately after an hour
or so of pickup basketball with his friends. He denies
any chest pressure or presyncope. On examination
he has the murmur of aortic stenosis. You obtain
an echocardiogram and his LV function is normal.
The Doppler gradient across his aortic valve reveals a
4.0 m per second maximal velocity and a calculated
valve area of 0.7 cm2. What should be your next
course of action?
(A) He is doing well enough clinically, and he needs
no further studies
(B) He should be referred to an invasive pediatric
cardiologist for consideration of a percutaneous
aortic valvuloplasty procedure
(C) He should undergo a cardiac catheterization
to confirm the aortic stenosis and evaluate his
coronary arteries
(D) He should be started on β-blockers and followed
up with an echocardiogram every 6 months
(E) He should be referred for surgical valve replacement
15 The signs and symptoms of significant MS include
all of the following, except:
(A) Hemoptysis
(B) Pulmonary hypertension
(C) Platypnea-orthodeoxia
(D) Hepatic congestion
(E) Atrial fibrillation with systemic embolism
16 You are asked to see a 25-year-old woman who
is 27 weeks pregnant. She has had little prenatal
care. She has no known heart condition but is
getting progressively short of breath as the pregnancy
continues. She finally saw an internist and obtained
an echocardiogram revealing significant MS with
trivial MR. When you see her, she is clearly in
congestive heart failure but still has normal sinus
rhythm. What is the best option?
(A) Aggressive therapy for her heart failure using
diuretics, angiotensin-converting enzyme (ACE)
inhibitors, β-blockers and digoxin
(B) Put her on complete bed rest until she delivers
the baby
(C) Consult cardiac surgery for mitral valve commissurotomy or replacement now
(D) Consider percutaneous balloon valvuloplasty
now if the valvular anatomy is suitable
(E) Consider abortion of the pregnancy
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