Prosthetic heart valves: management of usual and unusual complications January 14 th, h-15h30

What is the risk of thromboembolic events (per year) in patients with mechanical prosthetic heart valve? A) 0,05 to 0,5% B) 1 to 2% C) 3 to 4% D) 8%

What is the risk of thromboembolic events (per year) in patients with mechanical prosthetic heart valve? A) 0,05 to 0,5% B) 1 to 2% C) 3 to 4% D) 8%

What is the first exam to perform when you suspect a prosthetic valve thrombosis on TTE? A) Transoesophageal Echocardiography B) CT scan C) Fluoroscopy D) None, TTE is sufficient

What is the first exam to perform when you suspect a prosthetic valve thrombosis on TTE? A) Transoesophageal Echocardiography B) CT scan C) Fluoroscopy D) None, TTE is sufficient

Explanations Transoesophageal Echocardiography in emergency is the first option when suspicion of prosthetic valve thrombosis according to ESC 2012 and ACC/AHA 2014 guidelines. CT scan and Fluoroscopy may also be performed, but after TOE (class IIa C)

What is (are) the correct proposition(s) about pannus: A) Only appears on mechanical prosthesis B) Diagnosis can only be made after surgery C) More frequent on the ventricular side of prosthetic valves D) More frequent on aortic than mitral prosthetic valves

What is (are) the correct proposition(s) about pannus: A) Only appears on mechanical prosthesis B) Diagnosis can only be made after surgery C) More frequent on the ventricular side of prosthetic valves D) More frequent on aortic than mitral prosthetic valves

Explanations A) though very rare, pannus can also be found on bioprosthetic valves B) Pannus diagnosis can be made with CT scan C) More frequent on the ventricular side of prosthetic valves  only true for aortic prosthetic valves. Pannus are more often on the atrial side for mitral prosthesis.

Which of the following proposition(s) about prosthetic valve endocarditis is/are correct? A) Can benefit from ambulatory care with antibiotics administered through a picc-line B) The diagnosis may be difficult with non specific clinical signs and negative blood culture C) Trans-oesophageal echography (TOE) can show abcesses around the valve, periprosthetic leak or desinsertion of the prosthesis D) Staphylococcus is the most commonly found germ, in early and late endocarditis E) Cardiac surgeon especially like to operate on this kind of patients

Which of the following proposition(s) about prosthetic valve endocarditis is/are correct? A) Can benefit from ambulatory care with antibiotics administered through a picc-line B) The diagnosis may be difficult with non specific clinical signs and negative blood culture C) Trans-oesophageal echography (TOE) can show abcesses around the valve, periprosthetic leak or desinsertion of the prosthesis D) Staphylococcus is the most commonly found germ, in early and late endocarditis E) Cardiac surgeon especially like to operate on this kind of patients

A) Treament is initiated during the hospitalization and continued home with a picc-line B) Cardiac device-related infective endocarditis is one of the most difficult forms of IE to diagnose with misleading symptoms (IE Guidelines 2015) C) TOE show vegetation, abscess or pseudoaneurysm and new dehiscence of a prosthetic valve (IE Guidelines 2015) D) Staphylococci found in 31% of cases ( Murdoch DR et al Arch Intern Med 2009;169:463-73) Explanations

Which of the following proposition(s) about infective endocarditis (IE) on percutaneous pulmonary valve Melody® is/are correct? 1) The risk is the same as a surgically implanted homograft 2) The risk is higher than in case of TAVI (aortic position) 3) Long-term low-dose aspirin therapy seems to decrease this risk 4) May need an emergency intervention for acute valve obstruction

Which of the following proposition(s) about infective endocarditis (IE) on percutaneous pulmonary valve Melody® is/are correct? 1) The risk is the same as a surgically implanted homograft 2) The risk is higher than in case of TAVI (aortic position) 3) Long-term low-dose aspirin therapy seems to decrease this risk 4) May need an emergency intervention for acute valve obstruction

Which of the following proposition(s) is/are correct? A) Aortic bioprosthesis Mitroflow need more often a reintervention B) Sutureless valves stay in position due to the radial force of their stent C) Sutureless valves are implanted through a mini-thoracotomy D) The Lancelot S valve is a auto-expandable Sutureless aortic bioprosthesis E) The CoreValve is less responsible for conductive disorders after TAVI implantation than the Edward Sapien valves

Which of the following proposition(s) is/are correct? A) Aortic bioprosthesis Mitroflow need more often a reintervention B) Sutureless valves stay in position due to the radial force of their stent C) Sutureless valves are implanted through a mini-thoracotomy D) The Lancelot S valve is an auto-expandable Sutureless aortic bioprosthesis E) The CoreValve is less responsible for conductive disorders after TAVI implantation than the Edward Sapien valves

A) Early structural valve deterioration is frequent in Mitroflow bioprosthesis (models 12A/LX), especially for small sizes (19-21 mm), and reduces overall survival (Circulation, 2014) C) Mini-thoracotomy D) It’s Perceval !!! E) Placement of a new permanent pacemaker was less frequent in the balloon-expandable valve group (Edward Sapien XT) vs self- expandable valve (Medtronic Corevalve) (P = 0.001) Explanations (The CHOICE Randomized Clinical Trial FREE, M. Abdel-Wahab et al, JAMA 2014;31: )

Which of the following proposition(s) about IE affecting intracardiac prosthetic material is/are correct? A) At least 10 positive blood cultures are necessary before starting antibiotic treatment B) A TOE is recommended in case of high clinical suspicion whatever the results of TTE C) 18F-FDG PET/CT must be considered in case of clinical suspicion with positive blood culture and negative echocardiography D) In case of suspicion, the patient’s file must be evaluated by a multidisciplinary « Endocarditis Team » E) The Duke criteria are not valid

Which of the following proposition(s) about IE affecting intracardiac prosthetic material is/are correct? A) At least 10 positive blood cultures are necessary before starting antibiotic treatment B) A TOE is recommended in case of high clinical suspicion whatever the results of TTE C) 18F-FDG PET/CT must be considered in case of clinical suspicion with positive blood culture and negative echocardiography D) In case of suspicion, the patient’s file must be evaluated by a multidisciplinary « Endocarditis Team » E) The Duke criteria are not valid

A) 3 or more sets of blood cultures are recommended before prompt initiation of antimicrobial therapy for CIED infection IC B) TOE is recommended in patients with suspected CDRIE with positive or negative blood cultures, independant of the results of ETT IC C) 18 F-FDG PET/CT scanning may be considered in patients with suspected CDRIE, positive blood cultures, and negative echocardiography IIbC D) Patients with complicated IE should be evaluated and managed at an early stage in a reference centre, with immediate surgical facilities and the presence of multidisciplinary « Endocarditis Team » IIaB E) The Duke Criteria present with lower diagnostic accuracy in PVE.

Which of the following proposition(s) is/are correct? A) A TOE should be systematically performed for immediate post- operative care after mitral valve replacement B) The TTE performed at 8 days after valve surgery should be considered the reference examination C) Patients with a bioprosthesic valve should benefit from a close monitoring after the 6 th year following surgery D) The targeted mean transaortic gradient after aortic valve replacement with a mechanical prosthesis is 12±7 mmHg E) After valve replacement with a mechanical prosthesis, patients should have an hemogram every 3 months to check for hemolysis

Which of the following proposition(s) is/are correct? A) A TOE should be systematically performed for immediate post- operative care after mitral valve replacement B) The TTE performed at 8 days after valve surgery should be considered the reference examination C) Patients with a bioprosthesic valve should benefit from a close monitoring after the 6 th year following surgery D) The targeted mean transaortic gradient after aortic valve replacement with a mechanical prosthesis is 12±7 mmHg E) After valve replacement with a mechanical prosthesis, patients should have an hemogram every 3 months to check for hemolysis

Explanations A) TOE should not be systematically performed in post operative care, only in case of abnormal findings on TTE or if suspicion of complications. B) The 3-month TTE should be considered the reference echocardiography. C) True due to bioprosthesis alterations over time D) There are no overall targeted transvalvular gradient after surgery since the gradient depends on the prosthesis size and type. E) Only if suspicion of anemia, no systematical hemogram surveillance.