How can we rely on EF from echo, when it is considered not to be the most specific modality of assessing LV function and quite frequently we see discrepancy between TTE and (MUGA) for example!?
Thank you for your questions!! We will respond to the last few and post Dr. Nishimura's sketches in the next few days. If interested in registering for the course, go to cecourses.mayo.edu/cvboardreview
In patients with AS, if there is Peak/Mean Gradient and AVA mismatch, what parameter do we pick to grade stenosis?
More of an emphasis has been placed on use of the peak velocity and mean gradient in the new Valve guidelines. If the velocity is > 4m/s, then the patient should be considered to have severe AS. In those patients with velocity < 4, If there is a discrepancy between the two measures, attempts should be made to explain why this is the case (for example, low flow, low gradient severe aortic stenosis). Use of the dimensionless index (ratio of LVOT TVI to AV TVI) can also be used to further evaluate severity.
From Dr. Nishimura:
How can we rely on EF from echo, when it is considered not to be the most specific modality of assessing LV function and quite frequently we see discrepancy between TTE and (MUGA) for example!?
Echocardiographic ejection fraction is not a perfect parameter, and volumetric assessment by axial modalities (MRI, CT) may be more accurate. With 3D ejection fraction assessment there has been a stronger correlation with axial measures. Regardless, 2D echocardiographic ejection fraction derived from 2D guideded LVEDD and LVESD has been well correlated with outcomes and remains a parameter of clinical significance.
From Dr. Nishimura:
For Severe MR with Low EF what is the EF cut off for not intervening?
A reduced ejection fraction in severe mitral regurgitation portends increased surgical risk, as post-operatively the ventricle will have reduced preload and increased afterload relative to the preoperative state. There is currently not a cutoff for an EF that is "too low to operate", however reduced ejection fraction should be considered when risk stratifying patients. An experienced surgeon and center should be considered in such cases. If there is truly severe MR due to a primary leaflet abnormality and the patient has severe symptoms, operation should be considered
From Dr. Nishimura:
Will the new guidelines be fair game in this year's boards?
The ABIM boards typically lag 2-3 years behind published guidelines. However, boards will not ask questions where recommendations have changed with new guidelines. I would recommend learning the new guidelines so that you can incorporate them into your practice. Then you can answer questions on the Boards the way you clinically practice.
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How can we rely on EF from echo, when it is considered not to be the most specific modality of assessing LV function and quite frequently we see discrepancy between TTE and (MUGA) for example!?
Thanks for the great talk
thanks so much Drs. Nish and Ommen. awesome session on VHD
For Severe MR with Low EF what is the EF cut off for not intervening?
Will the new guidelines be fair game in this year's boards?
Thank you for your questions!! We will respond to the last few and post Dr. Nishimura's sketches in the next few days. If interested in registering for the course, go to cecourses.mayo.edu/cvboardreview
Thank you for this easy to understand discussion on Valvular guidelines.
From Dr. Nishimura:
In patients with AS, if there is Peak/Mean Gradient and AVA mismatch, what parameter do we pick to grade stenosis?
More of an emphasis has been placed on use of the peak velocity and mean gradient in the new Valve guidelines. If the velocity is > 4m/s, then the patient should be considered to have severe AS. In those patients with velocity < 4, If there is a discrepancy between the two measures, attempts should be made to explain why this is the case (for example, low flow, low gradient severe aortic stenosis). Use of the dimensionless index (ratio of LVOT TVI to AV TVI) can also be used to further evaluate severity.
From Dr. Nishimura:
How can we rely on EF from echo, when it is considered not to be the most specific modality of assessing LV function and quite frequently we see discrepancy between TTE and (MUGA) for example!?
Echocardiographic ejection fraction is not a perfect parameter, and volumetric assessment by axial modalities (MRI, CT) may be more accurate. With 3D ejection fraction assessment there has been a stronger correlation with axial measures. Regardless, 2D echocardiographic ejection fraction derived from 2D guideded LVEDD and LVESD has been well correlated with outcomes and remains a parameter of clinical significance.
From Dr. Nishimura:
For Severe MR with Low EF what is the EF cut off for not intervening?
A reduced ejection fraction in severe mitral regurgitation portends increased surgical risk, as post-operatively the ventricle will have reduced preload and increased afterload relative to the preoperative state. There is currently not a cutoff for an EF that is "too low to operate", however reduced ejection fraction should be considered when risk stratifying patients. An experienced surgeon and center should be considered in such cases. If there is truly severe MR due to a primary leaflet abnormality and the patient has severe symptoms, operation should be considered
From Dr. Nishimura:
Will the new guidelines be fair game in this year's boards?
The ABIM boards typically lag 2-3 years behind published guidelines. However, boards will not ask questions where recommendations have changed with new guidelines. I would recommend learning the new guidelines so that you can incorporate them into your practice. Then you can answer questions on the Boards the way you clinically practice.