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(/* ACC/AHA Guidelines- Indications for Aortic Valve Replacement (AVR) for Aortic Stenosis (DO NOT EDIT) {{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| title=2008 focused update incorporated into...)
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It should be noted that left ventricular contractile reserve is a better predictor of surgical outcomes than  markers of stenosis. Aortic valve surgery is indicated if there is severe AS along with an increase in the systolic velocity integral by >20% during a dobutamine infusion.
It should be noted that left ventricular contractile reserve is a better predictor of surgical outcomes than  markers of stenosis. Aortic valve surgery is indicated if there is severe AS along with an increase in the systolic velocity integral by >20% during a dobutamine infusion.


==ACC/AHA Guidelines- Indications for Aortic Valve Replacement (AVR) for Aortic Stenosis (DO NOT EDIT) <ref name="pmid18848134">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| title=2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 13 | pages= e1-142 | pmid=18848134 | doi=10.1016/j.jacc.2008.05.007 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18848134  }} </ref>==
== ACC/AHA 2006 Guidelines for the Management of Patients with valvular Heart Disease - Indications for Aortic Valve Replacement in Aortic Stenosis (DO NOT EDIT)<ref name="pmid16880336">{{cite journal |author=Bonow RO, Carabello BA, Kanu C, ''et al.'' |title=ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons |journal=Circulation |volume=114 |issue=5 |pages=e84–231 |year=2006 |month=August |pmid=16880336 |doi=10.1161/CIRCULATIONAHA.106.176857 |url=}}</ref>====
{{cquote|
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]===


'''1.''' AVR is indicated for symptomatic patients with severe AS. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|
<nowiki>"</nowiki>'''1.''' [[AVR]] is indicated for symptomatic patients with severe [[AS]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level: B]])<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|
<nowiki>"</nowiki>'''2.''' [[AV]]R is indicated for patients with severe [[AS]] undergoing [[coronary artery bypass graft surgery]] (CABG). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level: C]])<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|
<nowiki>"</nowiki>'''3.''' [[AVR]] is indicated for patients with severe [[AS]] undergoing surgery on the [[aorta]] or other [[heart valves]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level: C]])<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|
<nowiki>"</nowiki>'''4.''' [[AVR]] is recommended for patients with severe [[AS]] and [[LV]] systolic dysfunction (ejection fraction less
than 0.50). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level: C]])<nowiki>"</nowiki>
|}


'''2.''' AVR is indicated for patients with severe AS undergoing coronary artery bypass graft surgery (CABG). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[AVR]] is not useful for the prevention of sudden death in asymptomatic patients with [[AS]] who have none of the findings listed under the Class IIa/IIb recommendations. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level: B]])<nowiki>"</nowiki>
|}


'''3.''' AVR is indicated for patients with severe AS undergoing surgery on the aorta or other heart valves. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[AVR]] is reasonable for patients with moderate [[AS]] undergoing [[CABG]] or surgery on the [[aorta]] or other [[heart valves]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level: B]])<nowiki>"</nowiki>
|}


'''4.''' AVR is recommended for patients with severe AS* and LV systolic dysfunction (ejection fraction less than 0.50). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])
{|class="wikitable"
 
|-
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]===
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
 
|-
'''1.''' AVR is reasonable for patients with moderate AS undergoing CABG or surgery on the aorta or other heart valves (see Section 3.7 on combined multiple valve disease and Section 10.4 on AVR in patients undergoing CABG). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
|bgcolor="LemonChiffon"|
 
<nowiki>"</nowiki>'''1.''' [[AVR]] may be considered for asymptomatic patients with severe [[AS]] and abnormal response to exercise (e.g., development of symptoms or asymptomatic [[hypotension]]). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level: C]])<nowiki>"</nowiki>
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]===
|-
 
|bgcolor="LemonChiffon"|
'''1.''' AVR may be considered for asymptomatic patients with severe AS and abnormal response to exercise (e.g., development of symptoms or asymptomatic hypotension). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])
<nowiki>"</nowiki>'''2.''' [[AVR]] may be considered for adults with severe asymptomatic [[AS]] if there is a high likelihood of rapid
 
progression (age, [[calcification]], and [[CAD]]) or if surgery might be delayed at the time of symptom onset. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level: C]])<nowiki>"</nowiki>
'''2.''' AVR may be considered for adults with severe asymptomatic AS if there is a high likelihood of rapid progression (age, calcification, and CAD) or if surgery might be delayed at the time of symptom onset. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])
|-
 
|bgcolor="LemonChiffon"|
'''3.''' AVR may be considered in patients undergoing CABG who have mild AS when there is evidence, such as moderate to severe valve calcification, that progression may be rapid. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])
<nowiki>"</nowiki>'''3.''' [[AVR]] may be considered in patients undergoing [[CABG]] who have mild [[AS]] when there is evidence, such as moderate to severe [[valve calcification]], that progression may be rapid. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level: C]])<nowiki>"</nowiki>
 
|-
'''4.''' AVR may be considered for asymptomatic patients with extremely severe AS (aortic valve area less than 0.6 cm2, mean gradient greater than 60 mm Hg, and jet velocity greater than 5.0 m per second) when the patient’s expected operative mortality is 1.0% or less. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])
|bgcolor="LemonChiffon"|
 
<nowiki>"</nowiki>'''4.''' [[AVR]] may be considered for asymptomatic patients with extremely severe [[AS]] (aortic valve area less than
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]===
0.6 cm2, mean gradient greater than 60 mm Hg, and jet velocity greater than 5.0 m per second) when the patient’s expected operative mortality is 1.0% or less. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level: C]])<nowiki>"</nowiki>
 
|}
'''1.''' AVR is not useful for the prevention of sudden death in asymptomatic patients with AS who have none of the findings listed under the Class IIa/IIb recommendations. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])}}


==Sources==
==Sources==

Revision as of 16:18, 19 October 2012

Aortic stenosis surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Mohammed A. Sbeih, M.D. [2]

Overview

Aortic stenosis requires aortic valve replacement if medical management does not successfully control symptoms. According to a prospective, single-center, nonrandomized study of 25 patients, percutaneous implantation of an aortic valve prosthesis in high risk patients with aortic stenosis results in marked hemodynamic and clinical improvement when successfully completed [1].

Indications

Aortic valve replacement is indicated in the following situations:

  • If the patient has symptoms due to aortic stenosis, such as angina, dizziness, syncope, dyspnea or heart failure symptoms [2]. Average survival after the onset of these symptoms is around two to three years [3]. With the presence of symptoms; the patient may be at risk for sudden death [3].
  • Severe oartic stenosis (valve area < 1.0 cm2, or the aortic jet velocity is over 4.0 m/sec and the mean transvalvular gradient exceeds 40 mmHg) if the patient has symptoms, left ventricular dysfunction (ejection fraction < 50%) or undergoing coronary artery bypass grafting. Valve replacement should not be performed for isolated severe AS in asymptomatic patients.
  • Usually performed in patients with moderate AS with symptoms to improve symptoms and prolong life expectancy, or if the patient undergoing coronary artery bypass grafting or aortic root reconstruction surgery.

If there are no contraindications to anticoagulants, mechanical prostheses are preferred in patients < 65 years of age. If the patient > 65 years or has any contraindication to anticoagulants; then bioprosetheses are preferred (biologic valve).

Age is not a contraindication to aortic valve replacement in aortic stenosis.

Low Flow Aortic Stenosis

If there is a decline in left ventricular function due to systolic dysfunction, there may be only a moderate transvalvular gradient or low flow aortic stenosis. If there is fibrosis of the left ventricle, there may be incomplete recovery after aortic valve replacement. This scenario can also occur among patients in whom there is a history of myocardial infarction: there is insufficient contractility to mount an aortic gradient.

Definition

  1. An aortic valve areas < 1.0 cm2
  2. A left ventricular ejection fraction < 40%
  3. A mean pressure difference or gradient across the aortic valve of < 30 mm Hg

With a dobutamine infusion, the aortic valve area should increase to > 1.2 cm2, and the mean pressure gradient should rise above 30 mm Hg. If there is a failure to acheive these improvements, early surgical mortality is 32-33%, but it is only 5–7% in those patients who can augment their contractility and gradient. Survival at five years was 88% after surgery if the patient can augment their contractility, but only 10–25% if the patient cannot augment their contractility.

It should be noted that left ventricular contractile reserve is a better predictor of surgical outcomes than markers of stenosis. Aortic valve surgery is indicated if there is severe AS along with an increase in the systolic velocity integral by >20% during a dobutamine infusion.

ACC/AHA 2006 Guidelines for the Management of Patients with valvular Heart Disease - Indications for Aortic Valve Replacement in Aortic Stenosis (DO NOT EDIT)[4]==

Class I

"1. AVR is indicated for symptomatic patients with severe AS. (Level: B)"

"2. AVR is indicated for patients with severe AS undergoing coronary artery bypass graft surgery (CABG). (Level: C)"

"3. AVR is indicated for patients with severe AS undergoing surgery on the aorta or other heart valves. (Level: C)"

"4. AVR is recommended for patients with severe AS and LV systolic dysfunction (ejection fraction less than 0.50). (Level: C)"

Class IIa
"1. AVR is not useful for the prevention of sudden death in asymptomatic patients with AS who have none of the findings listed under the Class IIa/IIb recommendations. (Level: B)"
Class IIa
"1. AVR is reasonable for patients with moderate AS undergoing CABG or surgery on the aorta or other heart valves. (Level: B)"
Class IIb

"1. AVR may be considered for asymptomatic patients with severe AS and abnormal response to exercise (e.g., development of symptoms or asymptomatic hypotension). (Level: C)"

"2. AVR may be considered for adults with severe asymptomatic AS if there is a high likelihood of rapid progression (age, calcification, and CAD) or if surgery might be delayed at the time of symptom onset. (Level: C)"

"3. AVR may be considered in patients undergoing CABG who have mild AS when there is evidence, such as moderate to severe valve calcification, that progression may be rapid. (Level: C)"

"4. AVR may be considered for asymptomatic patients with extremely severe AS (aortic valve area less than 0.6 cm2, mean gradient greater than 60 mm Hg, and jet velocity greater than 5.0 m per second) when the patient’s expected operative mortality is 1.0% or less. (Level: C)"

Sources

  • 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease [5].

References

  1. ↑ Grube E, Laborde JC, Gerckens U; et al. (2006). "Percutaneous implantation of the CoreValve self-expanding valve prosthesis in high-risk patients with aortic valve disease: the Siegburg first-in-man study". Circulation. 114 (15): 1616–24. doi:10.1161/CIRCULATIONAHA.106.639450. PMID 17015786.
  2. ↑ Freeman RV, Otto CM (2005). "Spectrum of calcific aortic valve disease: pathogenesis, disease progression, and treatment strategies". Circulation. 111 (24): 3316–26. doi:10.1161/CIRCULATIONAHA.104.486738. PMID 15967862.
  3. ↑ 3.0 3.1 Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD; et al. (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172.
  4. ↑ Bonow RO, Carabello BA, Kanu C; et al. (2006). "ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons". Circulation. 114 (5): e84–231. doi:10.1161/CIRCULATIONAHA.106.176857. PMID 16880336. Unknown parameter |month= ignored (help)
  5. ↑ Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD; et al. (2008). "2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 52 (13): e1–142. doi:10.1016/j.jacc.2008.05.007. PMID 18848134.

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