286.3 🏥 內科專科考前版

286.3.1 Mechanistic Deep Dive

286.3.1.1 Rheumatic MS Pathology

  • Group A Strep cross-reactivity → autoimmune valvulitis
  • Leaflet thickening, commissural fusion, chordal shortening
  • LA dilation, thrombus formation
  • Pulmonary HTN cascade
  • Right HF eventually

286.3.1.2 Functional MR Pathophysiology

  • LV dilation → papillary muscle displacement → leaflet tethering → incomplete coaptation
  • Annular dilation
  • Atrial functional MR (HFpEF + AF): annular dilation from LA
  • Different from primary disease — different treatment

286.3.2 Recent Trials & Updates

286.3.2.1 INVICTUS (2022) — Rheumatic MS-AF

  • Rivaroxaban vs warfarin in rheumatic MS-AF
  • Rivaroxaban inferior (↑ thromboembolism, death)
  • Warfarin remains standard for rheumatic MS-AF (Class I)

286.3.2.2 COAPT (2018)

  • N = 614 functional MR + HFrEF on optimal medical therapy
  • TEER (MitraClip) vs medical alone
  • ↓ HF hospitalization 47%, ↓ mortality 38%
  • 2-year RR for primary endpoint significant
  • Class IIa for secondary MR with severe symptoms

286.3.2.3 MITRA-FR (2018)

  • N = 304 similar population
  • No benefit of TEER vs medical
  • Differences: included less severe MR, larger LV
  • Highlighted importance of patient selection

286.3.2.4 RESHAPE-HF2 (2024)

  • Confirms COAPT findings
  • TEER + GDMT > GDMT alone in select functional MR
  • Wider patient selection accepted

286.3.2.5 TRILUMINATE Pivotal (2023)

  • N = 350 symptomatic severe TR
  • TriClip + medical vs medical alone
  • ↓ TR severity, ↑ QOL (KCCQ)
  • Mortality similar at 1 year
  • 2024 FDA approval

286.3.2.6 TRISCEND, CLASP-TR

  • Transcatheter tricuspid valve replacement (TTVR) feasibility
  • EVOQUE valve

286.3.2.7 TRANSFORM-TR (2024)

  • More data on transcatheter TR therapy benefits

286.3.2.8 EARLY-MR / EXPRESS-MR — Asymptomatic Primary Severe MR

  • Ongoing trials on early intervention in asymptomatic primary MR
  • Watch space for 2025-2026

286.3.3 High-Yield Specialist Points

286.3.3.1 MV Repair Techniques

  • Annuloplasty ring: rigid, semi-rigid, flexible
  • Quadrangular resection for posterior prolapse
  • Sliding plasty
  • Edge-to-edge repair (Alfieri): surgical equivalent of MitraClip
  • Neochordae with Gore-Tex
  • Long-term durability excellent in expert hands

286.3.3.2 MV Replacement Pearls

  • Subvalvular preservation important (reduces remodeling)
  • Mechanical vs bioprosthetic considerations
  • Patient prosthesis mismatch
  • AC required for mechanical valves
  • Reoperation in 10-15 years for bioprostheses

286.3.3.3 TEER Patient Selection

  • COAPT criteria for functional MR:
    • GDMT optimized (incl CRT if indicated)
    • Symptomatic NYHA II-IV
    • Severe MR (EROA ≥ 30, regurgitant volume ≥ 45 mL)
    • LVEF 20-50%
    • LVEDV indexed < 96 mL/m²
    • Tricuspid leaflets amenable

286.3.3.4 Transcatheter Mitral Valve Replacement (TMVR)

  • For native MV with severe MAC
  • Devices: SAPIEN (off-label), Tendyne, Intrepid, Sapien M3
  • Emerging field; trials ongoing

286.3.3.5 Tricuspid Transcatheter Therapies Update

  • TriClip / Pascal / Cardioband (annuloplasty): TEER and annuloplasty
  • EVOQUE / TRICVALVE: orthotopic TTVR
  • Lux-Valve: emerging
  • 2024 FDA TriClip approval, more in pipeline

286.3.3.6 Carcinoid Heart Disease

  • 50% of carcinoid syndrome patients
  • Right-sided valves (serotonin metabolism)
  • 5-HIAA urinary
  • Pre-treat with somatostatin analog
  • Valve surgery for severe (advanced disease)
  • Lutathera, peptide receptor radiotherapy

286.3.3.7 Ebstein’s Anomaly

  • Apical displacement of tricuspid valve
  • Septal + posterior leaflet attachment to RV
  • “Atrialization” of RV
  • TR variable; ECG: PR↑, RBBB, WPW
  • Cone reconstruction (newer surgical approach)
  • TV replacement if severe

286.3.3.8 Pulmonic Valve in Adult Congenital

  • Post-TOF: PR most common
  • TPVR (Melody, Harmony) for symptomatic PR
  • Future RV size and function key

286.3.3.9 Acute Functional MR — A Differential

  • Papillary muscle rupture post-MI → severe acute MR (rare with PCI)
  • Endocarditis → leaflet perforation
  • Chordal rupture (degenerative or traumatic)
  • All require urgent surgical evaluation

286.3.3.10 LV Reverse Remodeling

  • GDMT in HFrEF can ↓ functional MR
  • Important to optimize before TEER decision
  • Re-image after 3-6 months of optimized GDMT

286.3.4 Pearls

  • Rheumatic MS-AF: Warfarin, NOT DOAC (INVICTUS 2022)
  • PMBV: Wilkins ≀ 8, no LA thrombus, no mod-severe MR
  • Primary MR: repair > replacement; symptomatic / EF 30-60% / LVESD ≥ 40
  • Secondary MR: GDMT first; COAPT phenotype → TEER
  • TEER for TR: TriClip 2024 FDA approval (TRILUMINATE)
  • Carcinoid: right-sided valves; somatostatin pre-op
  • Ebstein: cone reconstruction; consider WPW workup