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Chapter 51: Tricuspid and Pulmonary Valve Disease

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A 15-year-old boy with a prior medical history of childhood murmur presented to the emergency department after a series of presyncopal episodes. The physical examination revealed a systolic ejection click, a loud systolic murmur peaking in late systole as well as a soft P2. Initial ECG and chest radiography showed evidence of right heart chamber enlargement. An echocardiogram was obtained and showed doming and restricted opening of the pulmonary valve. In addition, spectral and color-flow Doppler revealed high-velocity turbulent flow in the main pulmonary artery consistent with pulmonary stenosis. The patient underwent cardiac catheterization, which revealed an RV–to–pulmonary artery peak-to-peak gradient of 37 mm Hg. Which of the following would be the best step in the management of this patient?

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A. Medical therapy with follow-up

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B. Surgical valvotomy

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C. Percutaneous balloon valvotomy

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D. Bioprosthetic valve replacement

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E. Mechanical valve replacement

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The answer is C. (Hurst’s The Heart, 14th Edition, Chap. 51) According to the American College of Cardiology/American Heart Association Guidelines for the Management of Patients with Valvular Heart Disease,1 balloon valvotomy is recommended in adolescent and young adult patients with pulmonic stenosis who have exertional dyspnea, angina, syncope, or presyncope and an RV-to-pulmonary artery peak-to-peak gradient greater than 30 mm Hg at catheterization (Class I and Level of Evidence: C). Moderately severe and severe pulmonary valve stenosis is currently treated by percutaneous balloon valvotomy (option C). Surgical valvotomy or replacement is rarely needed (options B, D, E). There is no effective medical therapy for this structural condition (option A).

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In which of the following settings is surgical correction of tricuspid valve regurgitation (TR) most commonly performed?

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A. Isolated procedure for primary TR

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B. Isolated procedure for secondary TR

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C. Concomitant procedure during mitral valve surgery

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D. Concomitant procedure during aortic valve surgery

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E. Concomitant procedure during coronary artery bypass grafting

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The answer is C. (Hurst’s The Heart, 14th Edition, Chap. 51) Surgical correction of tricuspid valve disease is most commonly performed at the time of mitral valve surgery (option C).2 Significant TR is less frequently observed in patients with aortic valve or ischemic heart disease, and therefore tricuspid valve surgery is less often needed at the time of these surgeries (options D, E). Furthermore, the majority of patients with TR, whether primary or secondary, are effectively managed medically with diuretics, such that tricuspid valve surgery is not often performed as an isolated ...

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