Aortic stenosis surgery indications: Difference between revisions
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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''d.''' Extremely severe [[AS]] ([[aortic valve]] area less than 0.6 cm and/or mean Doppler systolic AV gradient greater than 60 mm Hg) in an otherwise good operative candidate. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''d.''' Extremely severe [[AS]] ([[aortic valve]] area less than 0.6 cm and/or mean Doppler systolic AV gradient greater than 60 mm Hg) in an otherwise good operative candidate. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | ||
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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''e.''' Moderate [[AR]] undergoing [[coronary artery bypass grafting | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''e.''' Moderate [[AR]] undergoing [[coronary artery bypass grafting]] or other cardiac surgery. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | ||
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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''f.''' Severe [[AR]] with rapidly progressive [[LV]] dilation, when the degree of [[LV]] dilation exceeds an end-[[diastolic]] dimension of 70 mm or end-[[systolic]] dimension of 50 mm, with declining exercise tolerance, or with abnormal [[hemodynamic]] response to exercise. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''f.''' Severe [[AR]] with rapidly progressive [[LV]] dilation, when the degree of [[LV]] dilation exceeds an end-[[diastolic]] dimension of 70 mm or end-[[systolic]] dimension of 50 mm, with declining exercise tolerance, or with abnormal [[hemodynamic]] response to exercise. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | ||
Revision as of 14:43, 22 October 2012
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Aortic stenosis surgery | |
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Treatment | |
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Aortic stenosis surgery indications On the Web | |
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American Roentgen Ray Society Images of Aortic stenosis surgery indications | |
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Risk calculators and risk factors for Aortic stenosis surgery indications | |
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
- An aortic valve areas < 1.0 cm2
- A left ventricular ejection fraction < 40%
- 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 2008 Guidelines for the Management of Patients with Valvular Heart Diseases - Indications for Aortic Valvuloplasty in Aortic Stenosis (DO NOT EDIT)[4]
| Class I |
| "1. Aortic stenosis valvuloplasty, aortic valve replacement, or Ross repair is indicated in patients with severe [[AS] or chronic severe AR while they undergo coronary artery bypass grafting surgery on the aorta, or surgery on other heart valves. (Level of Evidence: C) " |
| "2. Aortic valve replacement is indicated for patients with severe AS and LV dysfunction (LV ejection fraction less than 50%). (Level of Evidence: C) " |
| "3. Aortic valve replacement is indicated in adolescents or young adults with severe AR who have: " |
| "a. Development of symptoms. (Level of Evidence: C) " |
| "b. Development of persistent LV dysfunction (LV ejection fraction less than 50%) or progressive LV dilatation (LV end-diastolic diameter 4 standard deviations above normal). (Level of Evidence: C) " |
| "4. Surgery to repair or replace the ascending aorta in a patient with a BAV is recommended when the ascending aorta diameter is 5.0 cm or more or when there is progressive dilation at a rate greater than or equal to 5 mm per year. (Level of Evidence: C) " |
| Class III |
| "1. Aortic valve replacement is not useful for prevention of sudden death in asymptomatic adults with AS who have none of the findings listed under the Class IIa/IIb indications.(Level of Evidence: B) " |
| "2. AVR is not indicated in asymptomatic patients with AR who have normal LV size and function. (Level of Evidence: B) " |
| Class IIa |
| "1. AVR is reasonable for asymptomatic patients with severe AR and normal systolic function (ejection fraction greater than 50%) but with severe LV dilatation (LV end-diastolic diameter greater than 75 mm or end-systolic dimension greater than 55 mm).(Level of Evidence: B) " |
| "2. Surgical aortic valve repair or replacement is reasonable in patients with moderate AS undergoing coronary artery bypass grafting or other cardiac or aortic root surgery. (Level of Evidence: B) " |
| Class IIb |
| "1. AVR may be considered for asymptomatic patients with any of the following indications: " |
| "a. Severe AS and abnormal response to exercise. (Level of Evidence: C) " |
| "b. Evidence of rapid progression of AS or AR. (Level of Evidence: C) " |
| "c. Mild AS while undergoing coronary artery bypass grafting or other cardiac surgery and evidence of a calcific aortic valve. (Level of Evidence: C) " |
| "d. Extremely severe AS (aortic valve area less than 0.6 cm and/or mean Doppler systolic AV gradient greater than 60 mm Hg) in an otherwise good operative candidate. (Level of Evidence: C) " |
| "e. Moderate AR undergoing coronary artery bypass grafting or other cardiac surgery. (Level of Evidence: C) " |
| "f. Severe AR with rapidly progressive LV dilation, when the degree of LV dilation exceeds an end-diastolic dimension of 70 mm or end-systolic dimension of 50 mm, with declining exercise tolerance, or with abnormal hemodynamic response to exercise. (Level of Evidence: C) " |
| "2. Surgical repair may be considered in adults with AS or AR and concomitant ascending aortic dilatation (ascending aorta diameter greater than 4.5 cm) coexisting with AS or AR. (Level of Evidence: B) " |
| "3. Early surgical repair may be considered in adults with the following indications: " |
| "a. AS and a progressive increase in ascending aortic size.(Level of Evidence: C) " |
| "b. Mild AR if valve-sparing aortic root replacement is being considered.(Level of Evidence: C) " |
Sources
- 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease [4].
References
- ↑ 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.
- ↑ 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.
- ↑ 3.0 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.
- ↑ 4.0 4.1 Bonow RO, Carabello BA, Chatterjee K; 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. Unknown parameter
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