Aortic regurgitation surgery valve selection: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Aortic insufficiency surgery}} | {{Aortic insufficiency surgery}} | ||
{{CMG}} | {{CMG}} {{AE}} {{USAMA}} | ||
==Overview== | ==Overview== | ||
Prior to surgery, the surgeon and patient must make a choice as to whether a mechanical or bioprosthetic valve should be inserted. | Prior to surgery, the surgeon and patient must make a choice as to whether a mechanical or bioprosthetic valve should be inserted. | ||
==Valve Selection== | |||
===Type of Valve and Discharge Anticoagulation Therapy=== | |||
Shown below is an algorithm depicting the factors that influence the choice of the type of the prosthetic valve and the discharge anticoagulation therapy.<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=2014 AHA/ACC Guideline 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|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref> | |||
<span style="font-size:85%">'''Abbreviations:''' '''AVR:''' Aortic valve replacement; '''INR:''' International normalized ratio; '''TAVR''' Tansthoracic aortic valve replacement </span> | |||
{{Family tree/start}} | |||
{{Family tree | | | | | | | A01 | | | | | A01= <div style="float: left; text-align: left; width: 18em; padding:1em;"> '''Determine:''' <br> ❑ '''Age''' <br> ❑ '''Contraindications for anticoagulation'''<span style="font-size:80%"> | |||
: ❑ Major [[bleeding diathesis]] or [[coagulopathy]] | |||
: ❑ Uncontrolled severe hypertension ([[systolic blood pressure]] >200 mmHg) | |||
: ❑ Recent [[head trauma]] | |||
: ❑ Platelet count < 100 000 | |||
: ❑ [[Pregnancy]] | |||
: ❑ Hypersensitivity to [[warfarin]] | |||
: ❑ [[Hemorrhagic stroke]]</span></div>}} | |||
{{Family tree | | | |,|-|-|-|+|-|-|-|.| | |}} | |||
{{Family tree | | | B01 | | B03 | | B02 | | | B01=<div style="float: left; text-align: left; width: 15em; padding:1em;"> ❑ Patients ≤ 60 years old <br> ''AND'' <br> ❑ No contraindication for anticoagulation ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]])</div>| B03= <div style="float: left; text-align: left; width: 15em; padding:1em;"> ❑ Patients 60 - 70 years old <br> ''AND'' <br> ❑ No contraindication for anticoagulation</div> | B02= <div style="float: left; text-align: left; width: 15em; padding:1em;"> ❑ Patients ≥ 70 years old ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]])<br> ''OR'' <br> ❑ Patients at any age AND contraindications for anticoagulation therapy ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: C]]) </div> }} | |||
{{Family tree | | | |!| | | |!| | | |!| | | }} | |||
{{Family tree | | | |!| | | C00 | | |!| | | C00='''[[Aortic stenosis surgery procedure#Types of Valves|Bioprosthesic]]''' <br> OR <br> '''[[Aortic stenosis surgery procedure#Types of Valves|Mechanical prosthesis]]''' ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]])}} | |||
{{Family tree | | | |!|,|-|-|^|-|-|.|!| | | }} | |||
{{Family tree | | | C01 | | | | | | C02 | | | C01= '''[[Aortic stenosis surgery procedure#Types of Valves|Mechanical prosthesis]]''' <br> <div style="float: left; text-align: left; width: 15em; padding:1em;"><span style="font-size:80%;color:red"> Avoid the use of direct thrombin inhibitors or anti-Xa agents in patients with mechanical prosthesis ([[ACC AHA guidelines classification scheme|Class III; Level of Evidence: B]]) </span></div>|C02='''[[Aortic stenosis surgery procedure#Types of Valves|Bioprosthesis]]'''}} | |||
{{Family tree | | | |!| | | | | | | |!| | | }} | |||
{{Family tree | | | C04 | | | | | | C05 | | C04= Does the patient have risk factors for thromboembolism†?| C05= '''Surgical [[AVR]]''' <br> OR <br> '''[[Transcatheter aortic valve implantation|TAVR]]'''}} | |||
{{Family tree | |,|-|^|-|.| | | |,|-|^|-|.| }} | |||
{{Family tree | D01 | | D02 | | D03 | | D04 | | D01= <div style="float: left; text-align: center; width: 14em; padding:1em;"> Yes </div> | D02=<div style="float: left; text-align: center; width: 14em; padding:1em;"> No </div>| D03=<div style="float: left; text-align: center; width: 14em; padding:1em;"> '''Surgical [[AVR]]''' </div> | D04=<div style="float: left; text-align: center; width: 14em; padding:1em;"> '''[[Transcatheter aortic valve implantation|TAVR]]''' </div>}} | |||
{{Family tree | |!| | | |!| | | |!| | | |!| | | }} | |||
{{Family tree | E01 | | E02 | | E03 | | E04 | | E01=<div style="float: left; text-align: left; width: 15em; padding:1em;"> Administer for long term: <br> ❑ [[Warfarin]] to achieve [[INR]] of 3.0 ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]])<br> ''AND'' <br> ❑ [[Aspirin]] 75-100 mg/d ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: A]])</div> | E02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> Administer for long term: <br> ❑ [[Warfarin]] to achieve [[INR]] of 2.5 ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]])<br> ''AND'' <br>❑ [[Aspirin]] 75-100 mg/d ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: A]])</div>| E03= <div style="float: left; text-align: left; width: 15em; padding:1em;"> Administer <br> ❑ [[Warfarin]] to achieve [[INR]] of 2.5 for 3 months ([[ACC AHA guidelines classification scheme|Class IIb; Level of Evidence: B]])<br> ''AND'' <br>❑ [[Aspirin]] 75-100 mg/d long term ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]])</div>| E04=<div style="float: left; text-align: left; width: 15em; padding:1em;"> | |||
Administer: | |||
:❑ [[Warfarin]] to achieve [[INR]] of 2.5 for 3 months ([[ACC AHA guidelines classification scheme|Class IIb; Level of Evidence: B]]), ''OR''<br> | |||
:❑ [[Clopidogrel]] 75 mg/d (first 6 months) ([[ACC AHA guidelines classification scheme|Class IIb; Level of Evidence: C]])<br> ''AND'' <br>❑ [[Aspirin]] 75-100 mg/d (for life) ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]])</div> }} | |||
{{Family tree/end}} | |||
<br> | |||
<div style="font-size:80%">†Risk factors for [[thromboembolism]] include [[atrial fibrillation]], [[hypercoagulable conditions]], [[left ventricle]] dysfunction, and previous [[thromboembolism]].</div> | |||
==Advanatges of A Mechanical Valve== | ==Advanatges of A Mechanical Valve== | ||
Latest revision as of 15:44, 5 January 2017
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Aortic Insufficiency Surgery | |
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Treatment | |
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Aortic regurgitation surgery valve selection On the Web | |
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Directions to Hospitals Performing Aortic insufficiency Surgery | |
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Risk calculators and risk factors for Aortic regurgitation surgery valve selection | |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2]
Overview
Prior to surgery, the surgeon and patient must make a choice as to whether a mechanical or bioprosthetic valve should be inserted.
Valve Selection
Type of Valve and Discharge Anticoagulation Therapy
Shown below is an algorithm depicting the factors that influence the choice of the type of the prosthetic valve and the discharge anticoagulation therapy.[1]
Abbreviations: AVR: Aortic valve replacement; INR: International normalized ratio; TAVR Tansthoracic aortic valve replacement
Determine: ❑ Age ❑ Contraindications for anticoagulation
| |||||||||||||||||||||||||||||||||
❑ Patients ≤ 60 years old AND ❑ No contraindication for anticoagulation (Class IIa; Level of Evidence: B) | ❑ Patients 60 - 70 years old AND ❑ No contraindication for anticoagulation | ❑ Patients ≥ 70 years old (Class IIa; Level of Evidence: B) OR ❑ Patients at any age AND contraindications for anticoagulation therapy (Class I; Level of Evidence: C) | |||||||||||||||||||||||||||||||
| Bioprosthesic OR Mechanical prosthesis (Class IIa; Level of Evidence: B) | |||||||||||||||||||||||||||||||||
| Mechanical prosthesis Avoid the use of direct thrombin inhibitors or anti-Xa agents in patients with mechanical prosthesis (Class III; Level of Evidence: B) | Bioprosthesis | ||||||||||||||||||||||||||||||||
| Does the patient have risk factors for thromboembolism†? | Surgical AVR OR TAVR | ||||||||||||||||||||||||||||||||
Yes | No | Surgical AVR | |||||||||||||||||||||||||||||||
Administer for long term: ❑ Warfarin to achieve INR of 3.0 (Class I; Level of Evidence: B) AND ❑ Aspirin 75-100 mg/d (Class I; Level of Evidence: A) | Administer for long term: ❑ Warfarin to achieve INR of 2.5 (Class I; Level of Evidence: B) AND ❑ Aspirin 75-100 mg/d (Class I; Level of Evidence: A) | Administer ❑ Warfarin to achieve INR of 2.5 for 3 months (Class IIb; Level of Evidence: B) AND ❑ Aspirin 75-100 mg/d long term (Class IIa; Level of Evidence: B) | Administer:
| ||||||||||||||||||||||||||||||
†Risk factors for thromboembolism include atrial fibrillation, hypercoagulable conditions, left ventricle dysfunction, and previous thromboembolism.
Advanatges of A Mechanical Valve
Mechanical valves are made of man-made (synthetic) materials, such as a metal like titanium. Mechanical heart valves do not fail often. They last from 12 to 20 years[2][3]. However, blood clots develop on them. If a blood clot forms, the patient may have a stroke. Anticoagulation with warfarin will be required which can be associated with bleeding.
Advantages of A Bioprosthetic Valve
Bioprosthetic valves are made of human or animal tissue.Biological valves do not require anticoagulation, but they tend to fail over time [4][3]. Patients with a biological valve may need to have the valve replaced in 10 to 15 years.
Selecting A Mechanical Verssus a Bioprosthetic Valve
The 2006 American College of Cardiology/American Heart Association (ACC/AHA) recommendations for the choice of aortic valve [5][6]:
- If the patient is under 65 years of age and does not have a contraindication to anticoagulation then a mechanical valve is preferred.
- If the patient is ≥65 years of age and does not have risk factors for thromboembolism, then a bioprosthetic valve is reasonable
- If the patient already has a mechanical valve in the mitral or tricuspid position and already requires anticoagulation, then a mechical valve is preferred
- If the patient has active prosthetic valve endocarditis, then the valve should be replaced
- If the patient has contraindications to anticoagulation therapy regardless his or her age, then a bioprosthetic valve is indicated
- If the oartic root is small then a mechanical valve is indicated as there is a risk of aortic annular enlargement if a bioprosthetic valve is used
References
- ↑ Nishimura, R. A.; Otto, C. M.; Bonow, R. O.; Carabello, B. A.; Erwin, J. P.; Guyton, R. A.; O'Gara, P. T.; Ruiz, C. E.; Skubas, N. J.; Sorajja, P.; Sundt, T. M.; Thomas, J. D. (2014). "2014 AHA/ACC Guideline 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". Circulation. doi:10.1161/CIR.0000000000000031. ISSN 0009-7322.
- ↑ Bloomfield P, Wheatley DJ, Prescott RJ, Miller HC (1991). "Twelve-year comparison of a Bjork-Shiley mechanical heart valve with porcine bioprostheses". N Engl J Med. 324 (9): 573–9. doi:10.1056/NEJM199102283240901. PMID 1992318.
- ↑ 3.0 3.1 Hammermeister K, Sethi GK, Henderson WG, Grover FL, Oprian C, Rahimtoola SH (2000). "Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs randomized trial". J Am Coll Cardiol. 36 (4): 1152–8. PMID 11028464.
- ↑ Hammermeister KE, Sethi GK, Henderson WG, Oprian C, Kim T, Rahimtoola S (1993). "A comparison of outcomes in men 11 years after heart-valve replacement with a mechanical valve or bioprosthesis. Veterans Affairs Cooperative Study on Valvular Heart Disease". N Engl J Med. 328 (18): 1289–96. doi:10.1056/NEJM199305063281801. PMID 8469251.
- ↑ 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.
- ↑ Vahanian A, Baumgartner H, Bax J, Butchart E, Dion R, Filippatos G; et al. (2007). "Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology". Eur Heart J. 28 (2): 230–68. doi:10.1093/eurheartj/ehl428. PMID 17259184.