#7 Prosthetic Heart Valves

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All you need to do to sign up is go to pacesahead.com and I advertise for these two sponsors because I genuinely believe that combined they essentially guarantee you'll get that all important parts in Paces. So use the discount code Pre Paces 15 at quesimed.com and sign up today. Welcome along to another episode of the Pre Paces podcast. I am your host Dr Sam Williams and this week we secured an absolute Titan of the cardiology world to discuss one of the most common stations in Paces and that is prosthetic heart valves. Dr Ben Oishar is president of the British Heart valve Society and he joined me to discuss the examination findings of a patient with a prosthetic heart valve. We also discussed what you should include in your case presentation as well as the answers to the most common examiner questions. The Pre Paces podcast reached a mini milestone this week as we had our 1000th download of the show and honestly a few months back I never would have dreamed that the podcast will be listened to over a thousand times so thank you so much to everyone who has listened so far it really does mean a lot and if you really enjoy listening please do like and follow us on Twitter and Instagram it's at Pre Paces podcast and subscribe to the show wherever you get your podcasts. Welcome to the Pre Paces podcast. The podcast that prepares you as well for the MRCP as taking the batteries out of your bleep prepares you for a restful evening on call. The subject of today's episode is a cardiovascular classic in Paces and something that comes up so frequently in the exam and in your clinical practice. Now you may have heard murmurs that we are on the cusp of something special because a big name in the valve world is joining us on the podcast today. I'm delighted to say that those murmurs are graded at 6 out of 6 because we're delighted to welcome Dr Benoit Shart and the podcast. Benoit is a consultant cardiologist, subspecialising in cardiac imaging at University Hospital Southampton NHS Trust. He is also the current president of the British Heart valve Society so there's no one better to navigate us through this common Paces station. Benoit thank you so much for joining us today. Thanks for having me on some and if I can just start off by asking how often do you come across patients with prosthetic valves in your clinical practice? Well I come across them really quite frequently every single week without exception. I with my colleagues help run the Westex Heart valve clinic in Southampton so we see patients with prosthetic valves every week. And this is not only a very common finding in clinical practice but also these patients are generally very stable and make perfects patients because they can attend any paces centre anywhere and present without much risk. Correct, yeah and they're perfect patients for exams. So before we get started Benoit is going to also be featuring in our regular feature quiz the consultant, the quiz where our bosses take on a quick fire quiz on a specialist subject of their own choosing on the proviso that it can't be anything to do with medicine. So Benoit what have you named as your specialist subject and why? Well I'm not sure it's a specialist subject but I've chosen cricket and in particular I guess we could talk about cricket world cups it's certainly a lifelong hobby and passion. Perfect we'll be hearing a bit more from Benoit about that later where I'll be trying to stump him with my questions but before that let's get started on prosthetic heart valves. So just to start off by recapping the structure of the cardiology station it's a purely examination station where the candidates will have six minutes of examination followed by four minutes of questions from the examiners and their own presentation. We're going to be talking about the expected findings on examination of a patient with prosthetic heart valves and then discuss some common examiner questions. So Benoit if you could tell us what are the most common prosthetic valves that are most likely to come up in a paces exam? For paces really it's the mechanical heart valves that we need to think about when it comes to exams. I think that the examination findings of a patient that has a biological heart valve are so subtle that it would be very unfair to include that. So I think for the purposes of paces in terms of the examination you should focus very much on mechanical heart valves. Of course for the discussion afterwards you need to have a broader knowledge but I wouldn't expect someone to be asked to examine someone with a bioprocesis. Last time we covered an examination station it was aortic stenosis. We looked at the most significant finding first in that station which is obviously the murmur. However I thought with prosthetic valves there were often more peripheral signs that might indicate a patient has a prosthetic heart valve. So we're going to proceed through the examination as the candidates would perform it and try and tease out some of the signs that they may find along the way and then finally we'll come to oscaltation where hopefully they will ascertain the correct diagnosis. When the patient is at the end of the bed hopefully at that point they'll already have their chest exposed and I think it would be fair to say the first sign that you may suspect a patient has a prosthetic valve would be the fact they've got a midline stenotomy because patients with a midline stenotomy are only really going to have a few indications for that procedure. One of the things that I found really helped in my experience was looking at the chest for the midline stenotomy and if it was present looking then at the legs to look for a vein harvesting scar. I don't know what you think about this Benoid but one of the things that I thought was not necessarily particularly specific but if there was an absence of a harvesting scar there that would make me think a lot more about a prosthetic valve rather than thinking this patient might have had a bypass. Would you agree with that? Yeah, I mean of course it's possible they could have had both but yes I think that if you check the legs and also when you come to checking the arms important to remember that some some surgeons like to use as many arteries for grafts rather than veins so sometimes the radial artery may be harvested so if you don't see a scar on the leg don't forget the fact that they could well have had an internal mammary graft used internally but also they could have had one of their radial arteries taken if for example it was a double vessel bypass. Absolutely so definitely important to keep your mind open in that respects and the cardiology exam is very systematic there's a clear system and everyone will have their own wave of proceeding through it but one of the things I thought is first of all you'd have a look at the hands and the main thing you may be looking for in the hands is signs of infective endocarditis for example which would have necessitated the knee for a prosthetic heart valve and the presence of clubbing. Now I've never been a particular fan of shamroth sign when you put your or put the patient's fingers together and demonstrate that diamond there but I was interested in what you might think about that sign Benoit do you think that's a reliable sign or do you think you can just detect clubbing just from observing the hands. I think clubbing is so pronounced that it's very unlikely that you would think to do shamroth sign without having already tweaked that ends of the fingers look a bit like the so-called chicken drumsticks and so I personally don't do it in my practice it's obviously taught widely in medical school but I'm not sure that paces candidates need to know anything more about it than the fact that it exists but it's not a routine part of my examination routine. I have to say I completely agree I've never been a huge fan of shamroth sign and I would completely agree that if it's there hopefully it's going to be plainly obvious to you. So the next part as we said as observing for any signs of endocarditis in the hands and then you go to feel the pulse and the presence of atrial fibrillation could be an indication of valveular disease at some point but again this is not 100% obviously patients can have atrial fibrillation in the absence of valveular heart disease but that's just another thing which may make you think that this possibly this patient has had valveular pathology and possibly more likely to be much of valveular disease. Moving through the examination as Ben already said observing in the arms for any scars of possible radial artery harvest and also one of the things which we'll touch on later is these patients with mechanical valves anti-cogulated so if there's any obvious bleeding or bruising that may indicate war for use as well if the patient has any pick or midlines in situ, it's likely that those patients are more likely to be in patients, but those are also signs which may just indicate that you're going to have significant findings when you come to the chest. When it comes to assessing for decomposition of valveila heart disease or evidence of heart failure, these sort of come as a cluster of symptoms. I always try to use sort of a triad of looking at the JVP, listening to the lung bases and looking for peripheral edema because Beno, I think part of the presentation which will come on too later as well is if you've found any valve lesions is part of your presentation should be to describe if there's any evidence of decompensation there. Yeah, correct, exactly that. So you definitely want to be sure that that prosthetic valve is working normally and you're right that part of the the pattern that you develop for presenting these cases in the exam setting is definitely relying upon saying that there was evidence of valveila dysfunction as evidenced by or there is no evidence of valveila dysfunction as evidenced by a normal venous pressure, clear chest and absence of peripheral edema, for example. I guess one of the things we're trying to try to exemplify here is that you're looking for clusters of symptoms and finding individual signs here and there may not demonstrate any particular pathology, but it's looking for clusters of symptoms which lend credence to your conclusions that you'll come to present to the examiner. Part of the examination is routinely as to look in the face. One of the things we touched on briefly in our AILT stenosis episode was the presence of conjunctible pala as a result of hemolysis. We discussed at that time that this is very rare in a native valve, but Beno, do you find patients with mechanical valves or other prosthetic valves are they more prone to hemolysis as a complication of having these valves put in? So certainly patients with mechanical valves can have hemolysis as a complication. I must say it's really quite rare these days. Hemolysis was more of a problem with the old-fashioned ball and cage valves, the styrofoid valves, because you had still quite a physical obstruction to flow even when the valve was open because the ball was still something that had the blood had to get around. There was a lot of turbulence with those valves and that turbulence caused hemolysis, but modern valves, the by-leaf-flip mechanical valves, which have been around for over 20 years now, were longer actually, but the hemolysis is quite rare. I think it would be extremely harsh to expect someone to pick up hemolysis of conjunctible pala, unless they were literally completely white. But in that case, they're probably not going to be in your exam. So yes, we do see hemolysis of mechanical valves. You don't generally see it with other valves. And I think in a similar way as to what we said about AOS extinertis was that this would be quite a soft sign to include and as well there's many other reasons why a patient may be anemic, but it might be something you put in your presentation as a very small soft point to the examiner and I would say again only if it's extremely pronounced would it be worth doing that? Right, so you've proceeded through the systematic examination of the patient and you've come to the chest and this is where the majority of your points are going to be scored because this is where you're going to get your definitive diagnosis. Now a lot of information can be gained just from the inspection of the chest. I found certainly that as you approach the chest, you can hear an audible click a lot of the time in a metallic valve, which you can't hear often in a biopostetic valve. So if the signs you've picked up previously look like this is a valve replacement, I always found that a really useful place to start. Just touching on this as well, Beno, this is where the station becomes a little bit contrived because in your clinical practice and in mind and probably all every other listener's clinical practice, you're going to know before you see the patient. So this is where it becomes a little bit contrived because most of the time you'll know before you see the patient that they have a valve replacement and paces is one of those rare circumstances where you're going to be asked to diagnose a patient where previously it would be plainly obvious in their medical history. This part of the examination, the inspection and we're trying to diagnose a patient without knowing the medical history is a little bit contrived and much less realistic than what we see regularly. I think for a clinic setting, that's absolutely true, but you're right. The vast majority of the time we know our patient's history either from the GP referral letter into secondary care or whatever you say. I think you're right. It's probably a, it's a real minority of cases where someone might present to ED or to GP that has arrived in the country or that cannot speak the language and you're having to try to work out purely from your physical examination alone. What their background is, what their history is. I think that's pretty rare. So yeah, I think that's fair. I think the reason they do it the way they do, of course, is to try and encourage the clinical acumen of detecting these things, but you're right that most of the time we know what they've had when we're seeing them. So as I was saying, we get to the inspection and I always found one of the best ways of determining between a metallic valve and a bifurc. That's it was an audible click which can often be heard outside of the chest and if I actually used to lower my ear to the chest and if I heard the click, I was pretty sure that it was a metallic click. We've already mentioned the midline stenotomy which hopefully was clear from the start of the station. Benoit, are there any other particular scars that patients may have after they've had a valve replacement? Yeah, so there's a couple of things that are worth thinking about. The aortic valve is right next to the atrium and tricular node, the AV node. So when the aortic valve is being instrumented at the time of surgery, it's not uncommon for the AV node to take a bit of a hit as well. So up to 10% of people that have an aortic valve replacement might also need a permanent pacemaker. So it's certainly worth having a look at the just under the clavicles to see if you can see a pacemaker scar or even the generator, the box itself may be visible. So it's certainly worth looking for that. And then it's worth also thinking about the fact that some patients will have had their valve operation to treat infective endocarditis. And depending on the organism and the duration of antibiotics that were required, they may have scars from tunneled lines which they had to put in for those antibiotics. More often than not, they are pick lines in the arm. But occasionally if that's a problem for some reason, then they may have had a tunneled line or even possibly a hickman star line. So it's worth checking the chest wall for that. Perfect. And proceeding systematically, the next part after inspection will be palpation. And again, detecting the differences between a metallic valve and a bioprostetic, often you can palpate the metallic click of the valve on the chest wall. And again, that's one of the things which I would always routinely do. In a similar way where the candidates will feel for thrills over the valve, that's always something which I found very, very helpful in detecting metallic valves, feeling for the apex beat which may be deviated as a result of cardiomegally, as a result of previous valve elisions and feeling for heaves in the usual way, where there may be evidence of a right ventricular heat from pulmonary hypertension which could have been a result of previous valve elitazase. But again, these all sort of play second fiddle a little bit too, the osculation which is where you're going to score the majority of points and hopefully nail the diagnosis. So the osculation of the chest is absolutely critical. And one thing I'd say about the timing of this station is that you should really try and be systematic and thorough as you can, but at the same time try and get to this point as quickly as possible. Beno, you touched at the top of the show about differentiating between bioprostetic and metallic valves and you said it would be almost harsh of the examines to include a bioprostetic valve just because it's so similar to normal anatomy. But would you still expect there to be a bioprostetic valve? Do you think that's is that still something the candidates should see and if so, how would they reliably detect a bioprostetic valve from normal heart sounds? So I'm not sure that you can to be honest with you. So I think that a normally functioning bioprostesis is probably almost impossible to include in the exam. The only reason you would have a biological valve in the exam is if it's failing, bioprostesis don't last forever. And so if you have a biological valve that is developing itself, re-stenosis or is failing and is becoming regurgent and there's a clear diastolic murmur, that's potentially quite an interesting case from the examiner's point of view because you've got a you've got a midline sternotomy scar and you've got a patient with a murmur. Right there your candidate's differential could only be either the sternotomy was for something separate like a bypass procedure and they happened to have native valve disease or if the examiner then gives you a hint and says no there was no bypass before then then then the guess could be well well maybe this patient previously had a biological valve and that's now problematic and it's stenosed because I can hear an injection systolic murmur with a slow rising creative pulse etc. So that's to be honest the only reason reason, I think you would include a biological valve. I think, as you say, a completely normally functioning biological valve, apart from the stilotomy scar. The examination really doesn't give you a strong reason to say to the examiner that this patient's got a biological valve. So I think that you're really looking out for one of three possibilities, I think. You're looking out for a mechanical aortic valve replacement, a mechanical mitral valve replacement, or occasionally both two mechanical valves. I think that any sort of biological valve, whether it's a surgical biological valve or even a keyhole transcaphid or aortic valve, a tabby valve, would not make a good piece's case if the valve is working normally. So you've already touched on the system which I used to use when I was revising. And the first step I would try and ascertain is, are the valves both native, both prosthetic or is just one prosthetic. And like you've already said, it's not unheard of to have multiple metallic or mechanical valves in the exam. If you only hear one metallic click, it's obviously important to ascertain which valve has been replaced. So obviously if you're hearing the metallic click on S1, it's going to be the mitral valve. And if you're hearing it on S2, it's going to be the aortic valve. The next part was always time the valves you're hearing on the pulse because from that you can then determine the function of the valve. The importance of that as Benoit's already touched on is you're going to probably be asked, is the valve function normally or are there any signs of dysfunction of the valve. So what might these be Benoit if the examers are looking for you to pick up whether or not the valve is functioning as it should. Any valve that goes wrong would essentially go wrong in two ways. I always explain when I'm explaining half valve disease to patients, I always tell them to think of valves as a pair of gates which cause them to be open and close. And so I say to them that if you imagine a pair of gates and I told you the gates weren't working properly, there's only two things that can really go wrong with gates. Either they don't open properly when they're supposed to open or they don't close properly when they're supposed to close. And that's pretty much the same with heart valves. If the mechanical valve or the prosthetic heart valve is not working normally, either the leaflets, the occluders are not opening normally so the valve has become stenotic. In which case you'll be looking out for a stenotic murmur. And I think that it would be quite hard to expect to candidate to pick up a stenotic mitral prosthesis because mitral stenosis is probably the hardest murmur to pick up. And I think if you're having to work around mechanical heart sounds anyway, then picking up a diastolic grumble of a slightly narrow mechanical mitral valve is, you know, I think most consultants would struggle with that. That's harsh. But I think for a mechanical aortic valve, of course, because it's an artificial heart valve, it has been inherently slightly stenotic. There is always a soft cystolic murmur with these valves. But if you can hear a really quite pronounced ejection cystolic murmur, that would be a clue that the valve is not working normally. And equally, although mechanical valves are designed to have a very, very trivial amount of regurgitation over them, the so-called washing jets or closure jets, at the hinge points to prevent thrombus formation there, that amount of regurgitation is trivial and is not audible as a murmur. So you would still be looking out to see if you can hear an early diastolic murmur of aortic regurgitation, because clearly that would be abnormal in someone that's had a previous aortic valve replacement. Yeah, and I guess if you do hear a cystolic murmur, the fact a usual flow murmur is often, in my experience, it's very soft, not prolonged and short-lived in the cardiac cycle, whereas would you say that a pathological cystolic murmur or a murmur which indicates progressive stenosis becomes more like what you may hear in a patient, for example, who has a severe aortic stenosis and becomes harsh and louder. Yeah, exactly that. Exactly that. The murmur would be much more harsh and much more pronounced. And I guess one other point which would go with that is if you've got the other peripheral signs of severe aortic stenosis, as you mentioned earlier, slow rising pulse, etc. So hopefully that gives you a good system with which to approach your oscaltation when you examine these sorts of patients who frequently come up in paces. After that, you're going to be expected to present the patient back to the examiner. So after the break, we're going to be talking about how best to combat those tricky examiner questions and how to structure your presentation of these patients when it comes to presenting after the six minutes of examination is up. [Music] So coming back to the presentation part of the station where you will have finished your examination, you're going to turn to the examiner and you're going to present the patient that you believe has a prosthetic valve. Ben, if you were an examiner on a station like this, what different diagnoses would you expect a candidate to include for a patient who has a possible prosthetic valve? So I think really when you present the patient back to the examiner at the end, you really want to try and tie everything together from your examination. And different people had different styles, but when I did this, we were always encouraged to go for the bang first straight away. So to say what you think it is right at the outset, so to say something like, I have examined Mrs. Smith, for example, and I believe she has a normally functioning mechanical aortic valve replacement as evidenced by, and then list everything that's led you to come to that conclusion. Of course, the alternative is to be very descriptive and to say, "I found this, I found this, I found this, I found this." And then at the end say, "I think that leads me to believe this patient has a mechanical aortic valve." But of course, you've got to remember that actually the examiners, they're sitting there thinking, "Come on, come on, let's just, you know, have you got a ride to the nut?" And so actually, if you just go for the jugular, say to speak from the outset, that would be my advice. That's how I did it when I was doing my exams. So I think that you want to comment on what you have found, you want to comment on the things that lead you to say what you do. So for example, if you've examined someone and you think they've got a mechanical valve, you can be quite clever in your presentation, you can say that the presence of a mid-line sternotomy scar and an audible metallic click before even started the examination alerted me to the presence of a mechanical heart valve, and on examination, the presence of a mechanical second sound and soft systolic murmur combined with the normal venous pressure absence of profordium and absence of any crackles in the chest, leads me to believe this is a normally functioning aortic valve prosthesis. I think that's the way to put it together. I don't I mean, clearly patients have to be stable enough to come into paces, which is obviously an out-to-patient setting. So I certainly would be very surprised. I mean, apart from the fact that it's very unusual for in-patients to take part in paces exams, that almost always only happens if an outpatient has failed to turn up on the day of the exam and they need to quickly grab someone from a ward. That's very unusual, but I wouldn't expect someone with significant dysfunction that has caused hospitalization to turn up in the exam. So I wouldn't expect anyone to have acute, for example, prosthetic valve endocraditis in the exam. I think that's quite unrealistic. Yeah, yeah, agree. And I thought I'd just chuck in a couple of things, which I've only heard out on the grapevine myself, but in some pathological conditions, you do have loud heart sounds as a result of other pathology, which is not related to a prosthetic heart valve. And one of those which I've experienced myself in the past is a patient with pulmonary hypertension for other reasons. They can have very loud second heart sounds, almost to the point where you might suspect that someone has a prosthetic heart valve. I would guess in those situations, you'd still be looking for all the signs that we mentioned earlier in the examination, particularly the middle-line synotomy, but just to fly up to the listeners that having just loud heart sounds and thinking about the differential diagnosis of those could be other differential diagnoses for a loud heart sounds if that's the only thing that you found in that patient. And then the next part will be when the examiner often will want you to explain how you will investigate and manage the patient. And this to a degree will depend on the symptoms, which is on the brief and your findings. I always found if it was clear that the patient had a suspected, or they were trying to set up a patient with suspected endocraditis, for example, they may just put in the brief that the patient has a fever. You should be asking for full blood counts and CRP to look for infection. You should be getting an up-to-date clotting profile, including an I&R, to check if they're I&I's therapeutic. And I always went for an old favourite of mine was renal function and liver function, as these might be affected by any medications that we choose to start. As well as all the investigations we tend to do at the front door, including a chest X-ray looking for signs of heart failure, the seminal investigation. going to be an echocardiogram and essentially that sort of speaks for itself. You're going to be assessing the function of the valve and determining whether or not your findings are congruent with what's found on the echocardiogram. So I think that sort of goes without saying. So now we'll go on to some of the common examiner questions that often come up in these sorts of stations after you've presented your patient. So Beno, one of the common questions which I've come across is what are the merits and drawbacks of mechanical versus biopr aesthetic valves? Yeah, it's probably the most common question that you'll get asked in this setting if you've examined someone with a mechanical heart valve. Mechanical heart valves as a whole of the last 20 years have reduced, have decreased in their implantation rates whilst biological valves have increased. I think that the biggest advantage of mechanical valves is their durability ability. If a 40-year-old or a 50-year-old said to you, "I only want to go through one operation in my lifetime. I want something that has the potential to last me 40 years or more," then they would get a mechanical valve without question. The disadvantage of the mechanical valve, of course, is the need for lifelong anti-cregulation. And it's not just any anti-cregulation, it is warfrontization. Trials that previously investigated the newer oral anti-cregulants, the so-called NOACs, had to be stopped early because of adverse harm in the NOAC arm compared to warfronts. So it is lifelong warfronts, the newer agents and not appropriate for patients with mechanical valves. There are ongoing trials to investigate that again, but at the moment it is a lifelong commitment to warfronts, which of course therefore means a commitment to frequent blood tests and iron R checks. So the single biggest advantage of the biological valves, the bioprocessies, is that you don't need to worry about anti-cregulation. You have a heart valve put in and off you go, you're on your way. The disadvantage of them is their durability. They don't last as long as mechanical valves. How long does a biological valve last? It's a difficult question, but we always quote patients something in the region of 10 to 15 years. Some patients unfortunately might have an experience of less than 10 years and some fortunate patients might get more than 15, but that would generally be it. So depending upon the age of your patient, they may choose differently between the two, but those are the single biggest advantages and disadvantages. The rate of effective NOAC odditis is roughly similar with the two, so that doesn't really come into our decision making on a day-to-day basis. And just going back to what you said about those metallic valves and the NOACs, what was the nature of the harms that were found which caused those trials to be stopped early? So thrombobolics, so thrombus formation, rather than bleeding. Speaking about the anti-cregulation required with metallic heart valves, the therapeutic iron R ranges for each valve are only very slightly different. So in your patients' benoeuvres, what are the ranges which you would want your patients to be within depending on which valve they had replaced? So in my troll valves typically have a slightly higher iron R range than aortic valves. It does depend a little bit upon what sort of valve they've had put in. So the old fashioned ball-in-cage valves, which are no longer put in routinely, but there are some patients that still have those in. They required higher iron R ranges. So for example, if someone had a ball-in-cage valve in the mitral position, many of those patients were told to maintain an iron R between three and four. So really quite high. With modern, with modern bilifflip mechanical valves, a very common iron R range for a mitral valve would be two and a half to three and a half. And for an aortic valve, it could be two and a half to three and a half, or it could be two to three, aiming to keep it at about two and a half. And biological valves do require a short period of anti-cregulation immediately post-stop, but after that it can be stopped. Is that right? Yeah, that's correct. So there isn't an indication for lifelong anti-cregulation or anti-trombotic drug just because you have a biological valve. Practice does vary. In the United States, they do tend to give these patients aspirin. And it's interesting that you ask that because literally right now at the moment we are doing a survey. The British have our societies together with the surgical society serving all surgeons across the country for what their practice is because as you say, in the first three months or so after a biological valve, many do choose to give some sort of blood thinner. But I think we're going to find, I think, practice varies. Some people give three months of aspirin and then stop, some give three months of a no-ac and some give three months of offering. So I think there is variation in practice. Yeah, very, very, very variable there. So I guess the candidates probably wouldn't be expected to know no, or present that. I agree, I agree. Very different practice. And we've already touched on a couple of these, but the complications of having a valve replacement, you just mentioned there about the trials of no-ac and valve thrombus being a significant risk in these patients. But what are the other complications of having a valve replacement? So there's quite a few to bring up as opposed to discussion. Of course, if you've got a mechanical valve and you've got a lifelong need for warfarin, of course there's the risk of bleeding complications from the anti-crugulation. Despite having anti-crugulation, there is still the risk of a thrombus formation and a thrombroembolic event. So patients that have a mechanical valve could still have, for example, an ischemic stroke, for example, it's possible. And certainly it's more likely if patients have had a period in which they were subtherapeutic with their INR. So that's possible. And then valve factors. So infective endocoditis can affect prosthetic valves. So that's something to be aware of if the valves are not followed up routinely and they become dysfunctional. For example, if they develop regurgitation and if that isn't noticed because the patient's not under follow up, they could develop heart failure. So that's important to be aware. And then of course, bog standard degeneration can occur, especially if if the patient had a biological valve, just degeneration of that tissue will occur over the years. Perfect. Well, that's probably hit the nail on the head for the majority of the main questions that you're going to be asked. So we're going to hold it there for time being and now we're going to move on to our regular feature, quiz the consultant. So we all know that consultants are experts in their field. But what else occupies the brilliant minds of the consultants that isn't medicine? I am laying down the gauntlet to each consultant who comes on the show to give me a specialist subject of their own choosing with the one caveat being it can't be to do with medicine. Whoever comes out on top at the end of the series will bag the coveted pre-paces podcast mug. So Ben or you mentioned at the top of the show, but what have you chosen as your specialist subject and why? So I've chosen cricket and in particular, cricket world cups. Had a lot of fun over the years watching world cups. Obviously probably the most thrilling final of all just the year before last. So yeah, I thought let's let's talk about that. Yeah. And did you have a cricket career yourself? Were you a killer batsman or a crafty spin bowler or a perfect all-rounder? I'm insulted that you have to ask. That implies you've not heard of my cricket career at all. I grew up on the tropical paradise that is Jersey and the Channel Islands and I represented Jersey under 12 and under 13 levels. Fantastic. An illustrious career that finished in the last millennium. Perfect. So this is how we play. There are 10 questions in total. If you answer without the multiple choice options, you bag yourself two points and if you aren't sure, you can ask for some multiple choice options. If you get it correct after that, you'll get one point. So here's hoping that I'm going to stump you with these questions on cricket and the cricket world cup. I've done a bit of a mishmash. It's a bit of a bit of a general cricket and a bit of cricket world cup. So are you ready? 10 quick fire questions on the cricket world cup. Okay. In cricket, what is the distance in meters between the two sets of stumps? Oh, in meters. I'll let you have yards as well. Is it not 22? Yeah, 22 yards that right? That is correct for two points. 22 yards or 20 meters. Question number two. What is the name given to the practice where some players seek to gain an advantage by insulting or verbally intimidating an opposing player? Not that I've ever done it, correct. And another two points. Question number three. Your first world cup question. holds the current record for most career runs scored in the cricket world cup. I don't know, I'm going to have to get a section 10. You could have taken the options but you got it correct even without the options for two points. I didn't realise you're going to give me a choice. Well you got it right anyway so you can take the options for one point. Question number four. What is the name for a bold delivery where the ball hits the pitch around the batsman's feet? The yorker. That is correct and it is four for four so far. Question number five. Continuing on the bowling theme, who holds the record for most career wickets taken in the cricket world cup? You can have the options. Go on then. OK, is it A Shane Warn of Australia? Is it B James Anderson of England? Is it C Lassith Malinga of Sri Lanka or is it the Glen Magra of Australia? That's hard. I'm going to go with Shane Warn. It's Glen Magra. I'm a f***. Ben Magra with 71 wickets. Question number six. So this is not a world cup. This is actually the on the ashes. The ashes is a long term rivalry between England and Australia where the trophy is a tiny urn, but what is said to be inside the urn? It is rumored that it's the ashes of the bales from the first match between England and Australia. That is absolutely correct. It's the ashes of the two bales. Question number seven. Which team has won the cricket world cup most times since the first tournament in 1975? That is Australia. That is Australia. Do you know how many times? See the four or five? Yeah, five times. Five times. That's the winners. Question number eight. According to Wikipedia, there are ten ways that a batsman can be dismissed. Five are very common. Being bold, caught out, run out, stumps and leg before wicket. Name any one of the other five less common ways. Hit wicket would be one. Correct. That is two points. I have interest. Do you want to guess the others? I think Jason Roy was out like this was a recently obstruction. If you deliberately try to obstruct the stumps, obstruction is one. There is also hitting the ball twice. Oh yes, handling the ball. Yeah, handling the ball. That is one. Exactly. There is a timeout as well. Which is interesting. Timeout. I have never heard of a timeout before researching for this quiz. Question number nine, with which country is the phrase baggy green associated? Oh, that is the cap that the Aussies wear. Absolutely correct. Number ten. What is the name given to a lower order batsman who comes into bat, higher up the order than usual, nearing the end of a day's play? That is a tailor-ender. Oh, that's not what I've got written down. Oh, sorry. It's come up. Oh, no. No, watch me. I've got to take your first answer, Benoit. No, no, no, no, no. I've not watched, but I guess not. No, you watch, normal. That's correct. There goes the mug. It is. And speaking about the end of a day's play, that is the end of the quiz. And, Dr. Benoit Shah, you have come out. Oh, I do feel cruel not giving you that last one. But, it is still a respectable score of 16 points out of 20. Thank you so much for joining us on this episode of the Pre-Paces podcast where we have been discussing prosthetic valves. We've been delighted to be joined by Dr. Benoit Shah, consultant cardiologist in imaging and president of the British Heart Valve Society. Thank you so much for joining us. Thank you so much for having me on. It's good fun. No problem at all. And it's always a pleasure to bring you these episodes when we are joined by someone who is such an expert in a specific field. So, if you enjoy the podcast, please like, comment and subscribe wherever you get your podcasts. You can get in touch with us through the usual social media channels. It's @prepacespodcast on Twitter and Instagram. And don't forget to share the love, pass the podcast or to anyone you know who's sitting in the diet coming up. Thank you to those of you who have stayed on to listen right to the end. I've got to say, I really enjoyed that episode. Benoit was an absolute delight to have on the show and I still feel bad about that night watchman answer. But sometimes that is just the way the cookie crumbles. For those of you interested in cardiology as a career, I would highly recommend following Benoit on Twitter. He is on @Dr_Benoit_N_Shar. He frequently posts imaging based cardiology cases on Twitter, usually on the form of a valve case of the week. So I highly recommend you check those out if you're interested in a career in cardiology. Meanwhile, here on the Prepaces podcast, we're working very hard behind the scenes, working on a new side project to hopefully provide content for your pace of vision and give you the best chance of passing. We've hopefully got some exciting news on this coming up in the next few weeks. So watch this space and we will catch you next time on the Prepaces podcast.