286.2 🩺 國考版

286.2.1 高頻考點

286.2.1.1 MS

  • Mostly rheumatic (Asia, South America)
  • Wilkins score ≀ 8 → PMBV
  • Warfarin (not DOAC) for rheumatic MS-AF (INVICTUS 2022)
  • Severe: MVA ≀ 1.0 cm²

286.2.1.2 MR Primary vs Secondary

  • Primary: leaflet/chordal/annular pathology (degenerative > rheumatic > IE)
  • Secondary: ventricular/atrial dysfunction
  • Treatment paradigm differs significantly

286.2.1.3 Primary MR Surgery Indications

  • Symptoms with severe MR
  • Asymptomatic with EF 30-60%, LVESD ≥ 40 mm
  • Repair >> replacement (better outcomes)

286.2.1.4 Secondary MR

  • GDMT first (HF therapy)
  • COAPT trial: TEER beneficial in EROA > 30 mm² + smaller LV
  • MITRA-FR: same disease, different selection — neg result
  • RESHAPE-HF2 (2024): confirms TEER benefit

286.2.1.5 TR Treatment

  • Functional > primary (RV dilation from PH/LH disease)
  • Diuretics, treat underlying
  • TRILUMINATE Pivotal (2023): TEER (TriClip) effective for symptomatic severe TR
  • TRICVALVE / EVOQUE: orthotopic TV replacement emerging

286.2.1.6 TPVR (Pulmonary Valve)

  • For post-TOF, adult congenital
  • Melody, Harmony, Sapien valves

286.2.2 易混淆比范

Valve Most Common Cause Severe Criterion Key Treatment
MS Rheumatic MVA ≀ 1.0 cm² PMBV (Wilkins ≀ 8) or MVR
MR (primary) Degenerative EROA > 0.40, ERV > 60 mL Repair > MVR
MR (secondary) LV dysfunction Same as primary + GDMT first GDMT → TEER (COAPT)
TR Functional from PH VC > 7 mm Diuretics → TEER → surgery
Pulmonic Congenital, post-TOF Variable TPVR

286.2.2.1 Murmurs Cheat Sheet

  • MS: opening snap + diastolic rumble at apex (L decubitus)
  • MR: holosystolic at apex → axilla
  • TS: similar diastolic at L sternal border (with inspiration)
  • TR: holosystolic at LSB (Carvallo: ↑ inspiration)
  • PS: systolic at L upper border, ↑ inspiration
  • PR (functional, Graham Steell): diastolic at LSB

286.2.2.2 COAPT vs MITRA-FR

  • Same indication (functional MR + HFrEF) but opposite results
  • COAPT: severe MR (EROA > 30) + smaller LV (LVEDV indexed < 96) + GDMT optimized → TEER beneficial
  • MITRA-FR: moderate MR + larger LV → no benefit
  • Take-home: select patients for TEER carefully