Aortic stenosis surgery indications
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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: Sara Zand, M.D.[2] Mohammed A. Sbeih, M.D. [3]; Usama Talib, BSc, MD [4] Synonyms and keywords: As; Aortic stenosis; AVR; Aortic valve replacement; LVEF; Left ventricular ejection fraction; LV; Left ventricle
Overview
In symptomatic patients with severe high-gradient AS (Stage D1), AVR has beneficial effect on survival, symptoms, and LV systolic function. In asymptomatic patients with severe AS and normal LV systolic function, the risk of sudden death (<1% per year) is low. In patients with a low LVEF and severe AS, survival is better with AVR than medical therapy.
Indications
- In symptomatic patients with severe high-gradient AS (Stage D1), AVR has beneficial effects on survival, symptoms, and LV systolic function.
- The most common initial symptom of AS is exertional dyspnea or decreased exercise tolerance.
- More severe classical symptoms of AS, including HF, syncope, or angina, can be avoided by appropriate treatment at the onset of even mild symptoms.
- Outcomes after surgical or transcatheter AVR are excellent.
- Improvement in exercise tolerance has been shown by exercise test after AVR.
- In asymptomatic patients with severe AS and normal LV systolic function, the risk of sudden death is low (<1% per year). However, in patients with a low LVEF and severe AS, survival is better in those who undergo AVR than in those treated medically.[1]
- Disease progression occurs in nearly all patients with severe asymptomatic AS. Initiation of symptoms within 2 to 5 years is likely when aortic velocity is ≥4.0 m/s or mean pressure gradient is ≥40 mm Hg.
- Mean pressure gradient is a strong predictor of outcome after AVR, with better outcomes seen in patients with higher gradients.
- Outcomes are poor with severe low-gradient AS but are still better with AVR than with medical therapy in those with a low LVEF, especially in the presence of contractile reserve.
- Severe AS on dobutamine stress testing is defined when a maximum velocity >4.0 m/s with a valve area ≤1.0 cm2 at any point during the test protocol, with a maximum dobutamine dose of 20 mcg/kg per minute.
- Outcome in patients without contractil reserve is poor with either surgical or medical therapy.
- In patients undergone AVR, LVEF typically increases by 10 LVEF units and may return to normal if afterload mismatch was the cause of LV systolic dysfunction.
- Low-flow, low-gradient severe AS with preserved LVEF should be considered in patients with a severely calcified aortic valve, an aortic velocity <4.0 m/s (mean pressure gradient <40 mm Hg), and a valve area ≤1.0 cm2, stroke volume index <35 mL/m2, presence of small LV cavity with thick walls, diastolic dysfunction, and a normal LVEF (≥50%).[2]
- If hypertension is present, blood pressure should is controlled before reevaluation of AS severity.
- Valve area is indexed to body size because an apparent small valve area may be only moderate AS in a small patient.
- An aortic valve area index ≤0.6 cm2/m2 suggests severe AS.
- Transaortic stroke volume is calculated by Doppler or 2D imaging.
- Exercise testing may be helpful in clarifying symptom status in patients with severe AS including a fall of ≥10 mm Hg in systolic blood pressure from baseline to peak exercise or a significant decrease in exercise tolerance as compared with age and sex normal standards.
- In patients with very severe AS and an aortic velocity ≥5.0 m/s or mean pressure gradient ≥60 mm Hg, the rate of symptom onset is approximately 50% at 2 years. [3] *Early surgery in patients with aortic velocity ≥4.5 m/s showed significant survival benefit.
- An elevated serum BNP level is a marker of subclinical HF and LV decompensation in severe AS.[4]
- In asymptomatic patients with AS with the aortic velocity reaches ≥2 m/s, hemodynamic progression leading to symptom . [5]
- Hemodynamic progression occurs when aortic velocity increases about 0.3 m/s per year, an increase in the mean gradient of 7 to 8 mm Hg per year, and a decrease in valve area of 0.15 cm2 per year.
- Predictors of rapid disease progression include older age, more severe valve calcification, and a faster rate of hemodynamic progression in serial studies.
- Elective AVR may be considered In patients with an aortic velocity >4 m/s, and the presence of predictors of rapid disease progression.[6]
- In adults with initially asymptomatic severe AS, the rate of sudden death is low (<1% per year). However, an aortic velocity ≥5 m/s or an LVEF <60% is associated with higher all-cause and cardiovascular mortality rates in the absence of AVR.
- A progressive decrease in LVEF is most likely in those with an LVEF <60% before AS becomes severe.[7]
- Hemodynamic progression eventually leading to onset of symptom occurs in nearly all asymptomatic patients with AS.
. The rate of symptom onset is strongly dependent on the severity of AS.
- Patients with asymptomatic AS require periodic monitoring for the development of symptoms and progressive disease.
2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines[8]
Therapeutic Recommendations for Subaortic Stenosis
| Class I |
| 1. Surgical intervention is recommended for adults with subAS, a maximum gradient 50 mm Hg or more and symptoms attributable to the subAS.(Level of Evidence: C-EO) |
| 2.Surgical intervention is recommended for adults with subAS and less than 50 mm Hg maximum gradient and HF or ischemic symptoms, and/or LV systolic dysfunction attributable to subAS.
(Level of Evidence: C-LD) |
| Class IIb |
| 1.To prevent the progression of AR, surgical intervention may be considered for asymptomatic adults with subAS and at least mild AR and a maximum gradient of 50 mm Hg or more.
(Level of Evidence: C-LD) |
| Recommendations for intervention in aortic stenosis |
| Symptomatic aortic stenosis: |
| (Class I, Level of Evidence B): |
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❑ Intervention is considered in symptomatic patients with severe, high-gradient aortic stenosis, mean gradient ≥ 40 mmHg, peak velocity
≥ 4.0 m/s, and valve area ≤ 1.0 cm2 (or ≤ 0.6 cm2/m2) |
| (Class IIa, Level of Evidence C): |
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❑ Intervention is recommended in symptomatic severe AS with low-flow, low-gradient (<40 mmHg) aortic stenosis with normal ejection fraction |
| (Class III, Level of Evidence C) : |
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❑ Intervention is not recommended in patients with severe comorbidities when the intervention is unlikely to improve quality of life or prolong survival >1 year |
| Asymptomatic severe aortic stenosis : |
| (Class I, Level of Evidence B): |
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❑ Intervention is recommended in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF < 50%) without another cause |
| (Class I, Level of Evidence C): |
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❑ Intervention is recommended in asymptomatic patients with severe aortic stenosis, symptomtomatic on exercise testing |
| (Class IIa, Level of Evidence B): |
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❑ Intervention should be considered in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF <55%) without another cause |
| (Class IIa, Level of Evidence C): |
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❑ Interventin is recommended in asymptomatic patients with severe aortic stenosis and a sustained fall inblood pressure (>20 mmHg) during exercise testing |
| (Class IIa, Level of Evidence B): |
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❑Intervention is considered in asymptomatic patients with LVEF >55% and a normal exercise test if the procedural risk is low and in the presence of one of the following:
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| Type of intervention: |
| (Class I, Level of Evidence C): |
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❑Aortic valve interventions should be performed in an experienced center |
| (Class I, Level of Evidence B): |
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❑SAVR is recommended in younger patients who are low risk for surgery (<75 yearse and STS PROM/EuroSCORE II <4%), or in patients who are operable and unsuitable for transfemoral TAVI |
| (Class I, Level of Evidence A): |
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❑TAVI is recommended in older patients (≥75 years), or in those who are high risk (STS PROM/EuroSCORE IIf>8%) or unsuitable for surgery |
| (Class IIb, Level of Evidence C): |
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❑ Non-transfemoral TAVI may be considered in patients who are inoperable and unsuitable for transfemoral TAVI |
Abbreviations: BNP: B-type natriuretic peptide; CABG: Coronary artery bypass grafting; LV: Left ventricle; LVEF:Left ventricular ejection fraction ; CCT:Cardiac computed tomography; SAVR: Surgical aortic valve replacement; STS-PROM: Society of Thoracic Surgeons - predicted risk of mortality; SVi: Stroke volume index; TAVI:Transcatheter aortic valve implantation ; Vmax:Peak transvalvular velocity
| The above table adopted from 2021 ESC Guideline[9] |
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| Valvular AS | |||||||||||||||||||||||||||||||||||||||||||||||||
Low-gradient AS
| High-gradient AS
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| AVA ≤ 1.0 cm2 | High flow status | ||||||||||||||||||||||||||||||||||||||||||||||||
| Yes | NO
| Yes
| NO
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Normal flow
| Low flow
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| Severe AS unlikely | LVEF ≥ 50% | ||||||||||||||||||||||||||||||||||||||||||||||||
| NO | Yes
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| NO, CCT to assess AV calcification | Yes, AVA ≤ 1.0 cm2 | ||||||||||||||||||||||||||||||||||||||||||||||||
Yes
| NO
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Abbreviations: AS: Aortic stenosis; AV: Aortic valve; AVA: Aortic valve area; LVEF: Left ventricular ejection fraction ; CT: Computed tomography; △Pm: Mean pressure gradient; DSE: Dobutamine stress echocardiography; LV: Left ventricular; SVi: Stroke volume index; Vmax: Peak transvalvular velocity
| The above table adopted from 2021 ESC Guideline[9] |
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- High flow is reversible in conditions such as anemia, hyperthyroidism orarterio-venous fistula and may also be present in patients with hypertrophic obstructive cardiomyopathy.
- Normal flow by pulsed Doppler echocardiography is defined as:
- DSE flow reserve is defined as > 20% increase in stroke volume in response to low-dose dobutamine.
- Pseudo-severe aortic stenosis is defined when AVA >1.0 cm2 with increased flow.[10]
- CT measurement of aortic valve calcification (Agatston units) for definition of AS severity:
| Recommendations for choice of Mechanical Versus Bioprosthetic AVR |
| (Class I, Level of Evidence C): |
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❑ Decision should be made based on patients preference and values after discussion about the risks of anticoagulant therapy or the need for valve intervention |
| (Class IIa, Level of Evidence B): |
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❑Mechanical aortic prothesis is preferred over bioprosthetic valve for patients < 50 years of age and no contraindication of anticoagulant therapy |
| (Class IIb, Level of Evidence B): |
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❑For patients <50 years of age who desire bioprosthetic valve and appropriate anatomy, the Rose procedure including replacement of aortic valve by a pulmonic autograft may be considered |
| The above table adopted from 2020 AHA Guideline[11] |
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Abbreviations: AVR: Aortic valve replacement; VKA: Vitamin K antagonist
References
- ↑ Rosenhek R, Binder T, Porenta G, Lang I, Christ G, Schemper M, Maurer G, Baumgartner H (August 2000). "Predictors of outcome in severe, asymptomatic aortic stenosis". N Engl J Med. 343 (9): 611–7. doi:10.1056/NEJM200008313430903. PMID 10965007.
- ↑ Tribouilloy C, Lévy F, Rusinaru D, Guéret P, Petit-Eisenmann H, Baleynaud S, Jobic Y, Adams C, Lelong B, Pasquet A, Chauvel C, Metz D, Quéré JP, Monin JL (May 2009). "Outcome after aortic valve replacement for low-flow/low-gradient aortic stenosis without contractile reserve on dobutamine stress echocardiography". J Am Coll Cardiol. 53 (20): 1865–73. doi:10.1016/j.jacc.2009.02.026. PMID 19442886.
- ↑ Rosenhek R, Zilberszac R, Schemper M, Czerny M, Mundigler G, Graf S, Bergler-Klein J, Grimm M, Gabriel H, Maurer G (January 2010). "Natural history of very severe aortic stenosis". Circulation. 121 (1): 151–6. doi:10.1161/CIRCULATIONAHA.109.894170. PMID 20026771.
- ↑ Bergler-Klein J, Klaar U, Heger M, Rosenhek R, Mundigler G, Gabriel H, Binder T, Pacher R, Maurer G, Baumgartner H (May 2004). "Natriuretic peptides predict symptom-free survival and postoperative outcome in severe aortic stenosis". Circulation. 109 (19): 2302–8. doi:10.1161/01.CIR.0000126825.50903.18. PMID 15117847.
- ↑ Taniguchi T, Morimoto T, Shiomi H, Ando K, Kanamori N, Murata K, Kitai T, Kawase Y, Izumi C, Miyake M, Mitsuoka H, Kato M, Hirano Y, Matsuda S, Nagao K, Inada T, Murakami T, Takeuchi Y, Yamane K, Toyofuku M, Ishii M, Minamino-Muta E, Kato T, Inoko M, Ikeda T, Komasa A, Ishii K, Hotta K, Higashitani N, Kato Y, Inuzuka Y, Maeda C, Jinnai T, Morikami Y, Sakata R, Kimura T (December 2015). "Initial Surgical Versus Conservative Strategies in Patients With Asymptomatic Severe Aortic Stenosis". J Am Coll Cardiol. 66 (25): 2827–2838. doi:10.1016/j.jacc.2015.10.001. PMID 26477634.
- ↑ Kang DH, Park SJ, Lee SA, Lee S, Kim DH, Kim HK, Yun SC, Hong GR, Song JM, Chung CH, Song JK, Lee JW, Park SW (January 2020). "Early Surgery or Conservative Care for Asymptomatic Aortic Stenosis". N Engl J Med. 382 (2): 111–119. doi:10.1056/NEJMoa1912846. PMID 31733181.
- ↑ Taniguchi T, Morimoto T, Shiomi H, Ando K, Kanamori N, Murata K, Kitai T, Kadota K, Izumi C, Nakatsuma K, Sasa T, Watanabe H, Kuwabara Y, Makiyama T, Ono K, Shizuta S, Kato T, Saito N, Minatoya K, Kimura T (January 2018). "Prognostic Impact of Left Ventricular Ejection Fraction in Patients With Severe Aortic Stenosis". JACC Cardiovasc Interv. 11 (2): 145–157. doi:10.1016/j.jcin.2017.08.036. PMID 29289632.
- ↑ Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM; et al. (2019). "2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". J Am Coll Cardiol. 73 (12): 1494–1563. doi:10.1016/j.jacc.2018.08.1028. PMID 30121240.
- ↑ 9.0 9.1 Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W (February 2022). "2021 ESC/EACTS Guidelines for the management of valvular heart disease". Eur Heart J. 43 (7): 561–632. doi:10.1093/eurheartj/ehab395. PMID 34453165 Check
|pmid=value (help). - ↑ Fougères E, Tribouilloy C, Monchi M, Petit-Eisenmann H, Baleynaud S, Pasquet A, Chauvel C, Metz D, Adams C, Rusinaru D, Guéret P, Monin JL (October 2012). "Outcomes of pseudo-severe aortic stenosis under conservative treatment". Eur Heart J. 33 (19): 2426–33. doi:10.1093/eurheartj/ehs176. PMID 22733832.
- ↑ Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C (February 2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e35–e71. doi:10.1161/CIR.0000000000000932. PMID 33332149 Check
|pmid=value (help).