Aortic stenosis surgery indications: Difference between revisions
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| colspan="1" style="text-align:center; background:LightGreen"|[[EHS ESC guidelines classification scheme#Classification of Recommendations|Class I]] | | colspan="1" style="text-align:center; background:LightGreen"|[[EHS ESC guidelines classification scheme#Classification of Recommendations|Class I]] | ||
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1. '''[[AVR]] is recommended with severe high-gradient [[AS]] who have symptoms by history or on exercise testing (stage D1)([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1. '''[[AVR]] is recommended with severe high-gradient [[AS]] who have symptoms by history or on exercise testing ([[Aortic stenosis stages|stage D1]])([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2. '''[[AVR]] is recommended for asymptomatic patients with severe [[AS]] (stage C2)and LVEF <50% ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2. '''[[AVR]] is recommended for asymptomatic patients with severe [[AS]] ([[Aortic stenosis stages|stage C2]])and LVEF <50% ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3. '''[[AVR]] is indicated for patients with severe [[AS]] (stage C or D) when undergoing other cardiac surgery ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''3. '''[[AVR]] is indicated for patients with severe [[AS]] ([[Aortic stenosis stages|stage C or D]]) when undergoing other cardiac surgery ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[EHS ESC guidelines classification scheme#Classification of Recommendations|Class IIa]] | | colspan="1" style="text-align:center; background:LemonChiffon"|[[EHS ESC guidelines classification scheme#Classification of Recommendations|Class IIa]] | ||
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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1. '''[[AVR]] is reasonable for asymptomatic patients with very severe [[AS]] (stage C1, aortic velocity ≥5.0 m/s) and low surgical risk ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1. '''[[AVR]] is reasonable for asymptomatic patients with very severe [[AS]] ([[Aortic stenosis stages|stage C1]], aortic velocity ≥5.0 m/s) and low surgical risk ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2. '''[[AVR]] is reasonable in asymptomatic patients (stage C1) with severe [[AS]] and decreased exercise tolerance or an exercise fall in BP ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2. '''[[AVR]] is reasonable in asymptomatic patients ([[Aortic stenosis stages|stage C1]]) with severe [[AS]] and decreased exercise tolerance or an exercise fall in [[BP]] ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3. '''[[AVR]] is reasonable in symptomatic patients with low-flow/low-gradient severe [[AS]] with reduced LVEF (stage D2) with a low-dose [[dobutamine]] stress study that shows an aortic velocity ≥ 4.0 m/s (or mean pressure gradient ≥ 40 mm Hg) with a valve area ≤ 1.0 cm2 at any [[dobutamine]] dose ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3. '''[[AVR]] is reasonable in symptomatic patients with low-flow/low-gradient severe [[AS]] with reduced LVEF ([[Aortic stenosis stages|stage D2]]) with a low-dose [[dobutamine]] stress study that shows an aortic velocity ≥ 4.0 m/s (or mean pressure gradient ≥ 40 mm Hg) with a valve area ≤ 1.0 cm2 at any [[dobutamine]] dose ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4. '''[[AVR]] is reasonable in symptomatic patients who have low-flow/low-gradient severe AS (stage D3) who are normotensive and have an LVEF ≥50% if clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4. '''[[AVR]] is reasonable in symptomatic patients who have low-flow/low-gradient severe AS ([[Aortic stenosis stages|stage D3]]) who are normotensive and have an LVEF ≥50% if clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5. '''[[AVR]] is reasonable for patients with moderate [[AS]] (stage B) (aortic velocity 3.0–3.9 m/s) who are undergoing other [[cardiac surgery]] ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5. '''[[AVR]] is reasonable for patients with moderate [[AS]] ([[Aortic stenosis stages|stage B]]) (aortic velocity 3.0–3.9 m/s) who are undergoing other [[cardiac surgery]] ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[EHS ESC guidelines classification scheme#Classification of Recommendations|Class IIb]] | | colspan="1" style="text-align:center; background:LemonChiffon"|[[EHS ESC guidelines classification scheme#Classification of Recommendations|Class IIb]] | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1. '''[[AVR]] may be considered for asymptomatic patients with severe [[AS]] (stage C1) and rapid disease progression and low surgical risk ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1. '''[[AVR]] may be considered for asymptomatic patients with severe [[AS]] ([[Aortic stenosis stages|stage C1]]) and rapid disease progression and low surgical risk ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
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Revision as of 16:08, 5 March 2014
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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 aortic stenosis (valve area < 1.0 cm2, or the aortic jet velocity is over 4.0 m/sec and the mean transvalvular gradient exceeds 40 mm Hg) 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.
2008 Focused Update Incorporated Into the 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT) [3]
Aortic Valve Replacement Indications (DO NOT EDIT) [3]
| Class I |
| "1. AVR is indicated for symptomatic patients with severe AS. (Level of Evidence: B)" |
| "2. AVR is indicated for patients with severe AS undergoing coronary artery bypass graft surgery (CABG). (Level of Evidence: C)" |
| "3. AVR is indicated for patients with severe AS undergoing surgery on the aorta or other heart valves. (Level of Evidence: C)" |
| "4. Aortic valve replacement is indicated for patients with severe AS and LV dysfunction (LV ejection fraction less than 50%). (Level of Evidence: C)" |
| "5. In patients with bicuspid valves undergoing AVR because of severe AS or AR, repair of the aortic root or replacement of the ascending aorta is indicated if the diameter of the aortic root or ascending aorta is greater than 4.5 cm. (Level of Evidence: C)" |
| Class III |
| "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 of Evidence: B)" |
| Class IIa |
| "1. AVR is reasonable for patients with moderate AS undergoing CABG or surgery on the aorta or other heart valves. (Level of Evidence: 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 of Evidence: 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 of Evidence: 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 of Evidence: 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 of Evidence: C)" |
AHA/ACC 2014 Guideline for the Management of Patients With Valvular Heart Diseases
Timing of Intervention
| Class I |
| "1. AVR is recommended with severe high-gradient AS who have symptoms by history or on exercise testing (stage D1)(Level of Evidence: B)" |
| "2. AVR is recommended for asymptomatic patients with severe AS (stage C2)and LVEF <50% (Level of Evidence: B)" |
| "3. AVR is indicated for patients with severe AS (stage C or D) when undergoing other cardiac surgery (Level of Evidence: B)" |
| Class IIa |
| "1. AVR is reasonable for asymptomatic patients with very severe AS (stage C1, aortic velocity ≥5.0 m/s) and low surgical risk (Level of Evidence: B)" |
| "2. AVR is reasonable in asymptomatic patients (stage C1) with severe AS and decreased exercise tolerance or an exercise fall in BP (Level of Evidence: B)" |
| "3. AVR is reasonable in symptomatic patients with low-flow/low-gradient severe AS with reduced LVEF (stage D2) with a low-dose dobutamine stress study that shows an aortic velocity ≥ 4.0 m/s (or mean pressure gradient ≥ 40 mm Hg) with a valve area ≤ 1.0 cm2 at any dobutamine dose (Level of Evidence: B)" |
| "4. AVR is reasonable in symptomatic patients who have low-flow/low-gradient severe AS (stage D3) who are normotensive and have an LVEF ≥50% if clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms (Level of Evidence: C)" |
| "5. AVR is reasonable for patients with moderate AS (stage B) (aortic velocity 3.0–3.9 m/s) who are undergoing other cardiac surgery (Level of Evidence: C)" |
| Class IIb |
| "1. AVR may be considered for asymptomatic patients with severe AS (stage C1) and rapid disease progression and low surgical risk (Level of Evidence: C)" |
Choice of Surgical or Transcatheter Intervention
| Class I |
| "1. Surgical AVR is recommended in patients who meet an indication for AVR with low or intermediate surgical risk. (Level of Evidence: A)" |
| "2. For patients in whom TAVR or high-risk surgical AVR is being considered, members of a Heart Valve Team should collaborate to provide optimal patient care (Level of Evidence: C)" |
| "3. TAVR is recommended in patients who meet an indication for AVR for AS who have a prohibitive surgical risk and a predicted post-TAVR survival >12 months (Level of Evidence: B)" |
| Class IIa |
| "1. TAVR is a reasonable alternative to surgical AVR in patients who meet an indication for AVR and who have high surgical risk (Level of Evidence: B)" |
| Class IIb |
| "1. Percutaneous aortic balloon dilation may be considered as a bridge to surgical or transcatheter AVR in severely symptomatic patients with severe AS. (Level of Evidence: C)" |
| Class III |
| "1. TAVR is not recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of AS. (Level of Evidence: B)" |
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 3.2 3.3 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.