286.1 🎓 醫孞生版

286.1.0.1 📌 䞀頁重點

286.1.0.1.1 Mitral Stenosis (MS)
286.1.0.1.1.1 Etiology
  • Rheumatic (>90% globally): leaflet thickening, commissural fusion, chordal shortening
  • Calcific (mitral annular calcification): elderly, CKD; less amenable to PMBV
  • Congenital (parachute MV): rare
  • Carcinoid, SLE, RA
286.1.0.1.1.2 Pathophysiology
  • ↓ MV area → ↑ LA pressure → pulmonary HTN → RV failure
  • LA enlargement → AF + thromboembolism
  • Pulmonary congestion → dyspnea
  • Reduced LV preload → low CO
286.1.0.1.1.3 Symptoms
  • Dyspnea on exertion (most common, gradual onset)
  • Fatigue
  • Palpitations (often AF)
  • Hemoptysis (rupture of bronchial veins, pulmonary edema)
  • Hoarseness (Ortner’s: LA compresses recurrent laryngeal nerve)
  • Right HF (edema, ascites, hepatomegaly)
286.1.0.1.1.4 Examination
  • Loud S1 (early in disease)
  • Opening snap (after S2, before S3 area)
  • Diastolic rumble at apex, best in L lateral decubitus, with bell
  • Presystolic accentuation (sinus rhythm)
  • Long murmur = severe; OS-S2 interval shorter = severe
  • Soft S1 in late disease (immobile leaflets)
  • Loud P2 (PH)
286.1.0.1.1.5 Echocardiography
  • MV Area (MVA): planimetry, pressure half-time
    • Mild: > 1.5 cm²
    • Moderate: 1.0-1.5 cm²
    • Severe: ≀ 1.0 cm²
  • Mean gradient (severe ≥ 10 mmHg)
  • Pulmonary HTN (PASP)
  • LA size + thrombus (TEE)
286.1.0.1.1.6 Wilkins Score (for PMBV Suitability)
  • 4 components, each 1-4 points (max 16):
    • Leaflet mobility
    • Leaflet thickness
    • Subvalvular thickening
    • Valvular calcification
  • Score ≀ 8 = good PMBV candidate

  • 8: surgical MVR preferred

286.1.0.1.1.7 Treatment

Medical - HR control (β-blocker, non-DHP CCB, digoxin if AF) - Diuretics for congestion - Anticoagulation (warfarin) for: - AF (especially with MS) - Prior thromboembolism - LA thrombus - DOACs not recommended for rheumatic MS + AF (Class III by 2020 ACC/AHA) - INVICTUS 2022: rivaroxaban inferior to warfarin in rheumatic MS-AF (↑ thromboembolism + death) - Warfarin remains standard for rheumatic MS + AF

Percutaneous Mitral Balloon Valvuloplasty (PMBV) - For symptomatic severe MS with Wilkins score ≀ 8 - No moderate-severe MR - No LA thrombus (TEE) - Excellent long-term outcomes - Contraindications: severe calcification, mod-severe MR, LA thrombus, severe subvalvular disease

Surgical MVR - For Wilkins > 8 or PMBV failure - Mechanical (younger) or bioprosthetic (older or AC contraindication)

286.1.0.1.2 Mitral Regurgitation (MR)
286.1.0.1.2.1 Classification (CRUCIAL)

Primary (Organic / Degenerative) MR - Disease of valve leaflets, chordae, annulus, papillary muscle - Degenerative myxomatous (MV prolapse, Barlow’s, fibroelastic deficiency) — most common in developed countries - Rheumatic - Endocarditis (vegetation, leaflet perforation) - Ruptured chord (acute, dramatic) - Papillary muscle dysfunction or rupture (post-MI) - Congenital (cleft leaflet)

Secondary (Functional) MR - Normal valve, ventricular/atrial pathology - Ischemic (post-MI, regional dysfunction) - Non-ischemic dilated cardiomyopathy (annular dilation, leaflet tethering) - Atrial functional MR (LA dilation in AF + HFpEF) - Treatment paradigm different — guideline-directed HF therapy first

286.1.0.1.2.2 Carpentier Classification (Functional)
  • Type I: normal leaflet motion (annular dilation, perforation)
  • Type II: excessive leaflet motion (prolapse, flail)
  • Type IIIa: restricted leaflet motion in both phases (rheumatic)
  • Type IIIb: restricted in systole only (ischemic, DCM)
286.1.0.1.2.3 Symptoms
  • Chronic: dyspnea on exertion, fatigue, palpitations (AF)
  • Acute: pulmonary edema, shock
  • Asymptomatic for years in chronic disease
286.1.0.1.2.4 Examination
  • Holosystolic murmur at apex, radiating to axilla
  • Pansystolic, blowing
  • S3 (volume overload, often in moderate-severe MR)
  • Soft / absent S1
  • LV impulse displaced laterally, hyperdynamic
  • Acute MR: short systolic murmur, S4, pulmonary edema
286.1.0.1.2.5 Echo Severity
  • Regurgitant volume > 60 mL/beat (severe)
  • Regurgitant fraction > 50%
  • ERO > 0.40 cm²
  • Vena contracta > 7 mm
  • LA size, LV size + function
  • TEE for definitive assessment, especially pre-intervention
286.1.0.1.2.6 Treatment

Chronic Primary MR

Medical - ACEi/ARB controversial (may delay surgery) - Treat HF, AF - BP control

Surgical Indications - Symptoms with severe MR (Class I) - Asymptomatic severe primary MR with: - LV systolic dysfunction (EF 30-60% or LVESD ≥ 40 mm) — Class I - Other cardiac surgery - Repair feasible with low risk in experienced center — Class IIa - Pulmonary HTN (PASP > 50 mmHg) - AF (new-onset)

Repair > Replacement for primary degenerative MR (better outcomes, preserved subvalvular apparatus)

Chronic Secondary MR

Optimize Guideline-Directed Medical Therapy (GDMT) FIRST - Quadruple HF therapy (ARNI + β-blocker + MRA + SGLT2i) - CRT if indicated - Many patients improve with GDMT alone

MitraClip / TEER (Transcatheter Edge-to-Edge Repair) - EVEREST II (2010): feasible, less effective than surgery for primary MR (but reasonable for high-risk surgery candidates) - COAPT (2018): secondary MR; TEER + GDMT > GDMT alone — ↓ HF hosp 47%, ↓ mortality 38% - MITRA-FR (2018): secondary MR, similar trial but neg — different patient selection (less severe MR but larger LV) - EROA > 30 mm² + LVEDV indexed < 96 mL/m² = COAPT phenotype (TEER benefits) - RESHAPE-HF2 (2024): similar TEER benefit confirmed

Surgical Intervention for Secondary MR - Limited evidence of benefit; not first-line - Class IIb for patients on GDMT and CRT - TEER preferred over surgery in most secondary MR

286.1.0.1.2.7 Acute Severe MR
  • Causes: papillary muscle rupture (post-MI), endocarditis, ruptured chord
  • Pulmonary edema, shock
  • IABP, vasodilators, surgery
  • Urgent MV repair / replacement
286.1.0.1.3 Tricuspid Regurgitation (TR)
286.1.0.1.3.1 Etiology
  • Functional (secondary) (>80%): RV/annular dilation from LH disease, PH, AF, RV failure
  • Primary:
    • Endocarditis (IV drug use, indwelling lines)
    • Carcinoid syndrome
    • Ebstein’s anomaly
    • Rheumatic (uncommon, usually with MS)
    • Pacemaker / ICD lead (latrogenic)
    • Blunt trauma
    • Drugs (fenfluramine, ergotamine, methysergide)
286.1.0.1.3.2 Pathophysiology
  • RV volume overload → RV dilation → RV failure
  • Hepatic congestion, ascites
  • Pulmonary perfusion ↓ with reduced LV preload
  • Progressive AF, atrial dilation
286.1.0.1.3.3 Symptoms
  • Fatigue, dyspnea
  • Lower extremity edema, ascites
  • Right upper quadrant pain (hepatic congestion)
  • Pulsatile liver, JVD
  • Often underdiagnosed clinically
286.1.0.1.3.4 Examination
  • Holosystolic murmur at L sternal border, accentuates with inspiration (Carvallo’s sign)
  • JVD with prominent V wave, “CV wave”
  • Pulsatile liver, hepatomegaly
  • Lower extremity edema, ascites
286.1.0.1.3.5 Echo
  • Vena contracta > 7 mm (severe)
  • Regurgitant volume > 45 mL/beat
  • PISA radius > 9 mm
  • RV size, function
  • RA dilation
  • IVC dilation, plethora
286.1.0.1.3.6 Treatment

Medical - Diuretics - Treat LH disease, PH

Surgical - Indication: - Symptomatic with isolated primary TR - Combined with L-sided valve surgery - Severe TR + RV dilation - Tricuspid repair > replacement - Bioprosthetic if replacement needed

Transcatheter Therapies (2024 — EXPLODING) - TEER for TR: TriClip (Abbott), Pascal (Edwards) - TRILUMINATE Pivotal (2023): TEER vs medical therapy → ↓ TR severity, ↑ QOL, similar mortality - 2024 FDA approval for symptomatic severe TR + GDMT - Cardioband (annuloplasty): incremental adoption - TRICVALVE / EVOQUE (orthotopic transcatheter TV replacement): emerging - TRISCEND trial: TV replacement feasible - For high surgical risk patients

286.1.0.1.4 Pulmonic Valve Disease
286.1.0.1.4.1 Pulmonic Stenosis (PS)
  • Mostly congenital (rare adult new onset)
  • Balloon pulmonary valvuloplasty for symptomatic moderate-severe
  • Carcinoid (right-sided)
286.1.0.1.4.2 Pulmonic Regurgitation
  • Post-TOF repair (most common in adults)
  • PH (functional)
  • Carcinoid
  • Endocarditis (rare)
286.1.0.1.4.3 Treatment
  • TPVR (transcatheter pulmonary valve replacement): Melody, Harmony, Sapien
  • Used for post-TOF repair patients
  • Adult congenital heart disease populations
286.1.0.1.5 Carcinoid Heart Disease
  • Right-sided valves affected (TR + PS most common)
  • Serotonin-mediated fibrotic plaque
  • Treat carcinoid + valve surgery if severe
  • Plaque on R but not L due to lung MAO-A metabolism

286.1.0.2 🩺 床邊速查

  • MS Wilkins score ≀ 8 → PMBV good candidate
  • Rheumatic MS-AF: WARFARIN, NOT DOAC (INVICTUS 2022)
  • Primary MR: repair > replacement; surgery for symptoms or EF 30-60% or LVESD ≥ 40
  • Secondary MR: GDMT first; COAPT phenotype (EROA > 30, LVEDV indexed < 96) → TEER benefits
  • TR (TRILUMINATE 2023): TEER + GDMT → ↓ TR, ↑ QOL (FDA approval 2024)
  • TPVR for post-TOF and adult congenital