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===Indications for Aortic Valve Replacement=== | ===Indications for Aortic Valve Replacement=== | ||
Shown below is an algorithm depicting the indications for [[aortic valve replacement]] (AVR) in chronic aortic regurgitation. Patients that fulfill the indications for AVR but have existing comorbidities that do not permit AVR should be treated for hypertension if the [[blood pressure]] is more than 140 mmHg. | Shown below is an algorithm depicting the indications for [[aortic valve replacement]] (AVR) in chronic aortic regurgitation. Patients that fulfill the indications for AVR but have existing comorbidities that do not permit AVR should be treated for hypertension if the [[blood pressure]] is more than 140 mmHg. Patients with [[Aortic regurgitation stages|stage A]] AR do not require any treatment.<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><ref name="BonowCarabello2008">{{cite journal|last1=Bonow|first1=R. O.|last2=Carabello|first2=B. A.|last3=Chatterjee|first3=K.|last4=de Leon|first4=A. C.|last5=Faxon|first5=D. P.|last6=Freed|first6=M. D.|last7=Gaasch|first7=W. H.|last8=Lytle|first8=B. W.|last9=Nishimura|first9=R. A.|last10=O'Gara|first10=P. T.|last11=O'Rourke|first11=R. A.|last12=Otto|first12=C. M.|last13=Shah|first13=P. M.|last14=Shanewise|first14=J. S.|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=Circulation|volume=118|issue=15|year=2008|pages=e523–e661|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.108.190748}}</ref> | ||
'''Abbreviations:''' '''LVEF:''' left ventricular ejection fraction; '''LVEDD:''' left ventricular end diastolic diameter; '''LVESV:''' left ventricular end systolic diameter | '''Abbreviations:''' '''LVEF:''' left ventricular ejection fraction; '''LVEDD:''' left ventricular end diastolic diameter; '''LVESV:''' left ventricular end systolic diameter | ||
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{{Family tree | | | | | | | B03 | | | | | | | | | | | | | | | | | | B04 | B03= Is the patient symptomatic?|B04=Is the patient undergoing<br> another surgery?}} | {{Family tree | | | | | | | B03 | | | | | | | | | | | | | | | | | | B04 | B03= Is the patient symptomatic?|B04=Is the patient undergoing<br> another surgery?}} | ||
{{Family tree | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | | | | |,|-|^|-|.| }} | {{Family tree | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | | | | |,|-|^|-|.| }} | ||
{{Family tree | C01 | | | | | | | | | | C02 | | | | | | | | | | C03 | | C04 |C01= Yes <br> (Stage D)| C02=No <br> (Stage C)| C03= No| C04= Yes}} | {{Family tree | C01 | | | | | | | | | | C02 | | | | | | | | | | C03 | | C04 |C01= Yes <br> ([[Aortic regurgitation stages|Stage D]])| C02=No <br> ([[Aortic regurgitation stages|Stage C]])| C03= No| C04= Yes}} | ||
{{Family tree | |!| | | |,|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|.| | | |!| | | |!| | }} | {{Family tree | |!| | | |,|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|.| | | |!| | | |!| | }} | ||
{{Family tree | |!| | | D01 | | D02 | | D03 | | D04 | | D05 | | D06 | | |!| D01= ❑ LVEF<50% <br> (Stage C2)|D02=❑ The patient is undergoing another surgery| D03= ❑ [[LVEF]] ≥ 50% <br>AND <br> ❑ LVESD > 50mm <br>(Stage C2)| D04= ❑ [[LVEF]] ≥ 50% <br>AND <br> ❑ LVEDD > 65mm <br>AND <br> ❑ Low surgical risk| D05= ❑ [[LVEF]] ≥ 50% <br>AND <br> ❑ LVESD ≤ 50mm <br>AND <br> ❑ LVEDD ≤ 65mm| D06= <div style="float: left; text-align: left; width:12em"> | {{Family tree | |!| | | D01 | | D02 | | D03 | | D04 | | D05 | | D06 | | |!| D01= ❑ LVEF<50% <br> ([[Aortic regurgitation stages|Stage C2]])|D02=❑ The patient is undergoing another surgery| D03= ❑ [[LVEF]] ≥ 50% <br>AND <br> ❑ LVESD > 50mm <br>([[Aortic regurgitation stages|Stage C2]])| D04= ❑ [[LVEF]] ≥ 50% <br>AND <br> ❑ LVEDD > 65mm <br>AND <br> ❑ Low surgical risk| D05= ❑ [[LVEF]] ≥ 50% <br>AND <br> ❑ LVESD ≤ 50mm <br>AND <br> ❑ LVEDD ≤ 65mm| D06= <div style="float: left; text-align: left; width:12em"> | ||
❑ Perform a periodic [[echocardiogram]] ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence:B]]) <br> | ❑ Perform a periodic [[echocardiogram]] ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence:B]]) <br> | ||
: ❑ Every 3 -5 years for mild regurgitation | : ❑ Every 3 -5 years for mild regurgitation | ||
Revision as of 16:28, 21 July 2014
Indications for Aortic Valve Replacement
Shown below is an algorithm depicting the indications for aortic valve replacement (AVR) in chronic aortic regurgitation. Patients that fulfill the indications for AVR but have existing comorbidities that do not permit AVR should be treated for hypertension if the blood pressure is more than 140 mmHg. Patients with stage A AR do not require any treatment.[1][2]
Abbreviations: LVEF: left ventricular ejection fraction; LVEDD: left ventricular end diastolic diameter; LVESV: left ventricular end systolic diameter
| What is the severity of the aortic regurgitation? | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Severe regurgitation ❑ Vena contracta >0.6 cm ❑ Doppler jet width ≥ 65% of LVOT ❑ Regurgitant volume ≥60 mL/beat ❑ Regurgitant fraction ≥50% ❑ Effective regurgitant orifice ≥ 0.30 cm² ❑ Holodiastolic flow reversal in the proximal abdominal aorta ❑ Left ventricle dilatation | Progressive regurgitation (Stage B) ❑ Vena contracta <0.6 cm ❑ Regurgitant volume <60 mL/beat ❑ Regurgitant fraction <50% ❑ Effective regurgitant orifice <0.30 cm² | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Is the patient symptomatic? | Is the patient undergoing another surgery? | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Yes (Stage D) | No (Stage C) | No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| ❑ LVEF<50% (Stage C2) | ❑ The patient is undergoing another surgery | ❑ LVEF ≥ 50% AND ❑ LVESD > 50mm (Stage C2) | ❑ LVEF ≥ 50% AND ❑ LVEDD > 65mm AND ❑ Low surgical risk | ❑ LVEF ≥ 50% AND ❑ LVESD ≤ 50mm AND ❑ LVEDD ≤ 65mm | ❑ Perform a periodic echocardiogram (Class I; Level of Evidence:B)
❑ Control hypertension preferably with
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| AVR (Class I) | AVR (Class I) | AVR (Class I) | AVR (Class IIa) | AVR (Class IIb) | ❑ Perform a periodic echocardiogram every 6 - 12 months (Class I, Level of Evidence C) ❑ Control hypertension preferably with
| AVR (Class IIa) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Acute AR
| What is the cause of acute AR? | |||||||||||||||||||||||||||||
| Infective endocarditis | Aortic dissection | ||||||||||||||||||||||||||||
Does the patient have AR related heart failure symptoms? | Emergent surgery[3] | ||||||||||||||||||||||||||||
| Yes | No | ||||||||||||||||||||||||||||
Schedule for early aortic valve replacement (Class I, level of evidence B)[3][4] Click here for more details | |||||||||||||||||||||||||||||
- ↑ 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.
- ↑ Bonow, R. O.; Carabello, B. A.; Chatterjee, K.; de Leon, A. C.; Faxon, D. P.; Freed, M. D.; Gaasch, W. H.; Lytle, B. W.; Nishimura, R. A.; O'Gara, P. T.; O'Rourke, R. A.; Otto, C. M.; Shah, P. M.; Shanewise, J. S. (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–e661. doi:10.1161/CIRCULATIONAHA.108.190748. ISSN 0009-7322.
- ↑ 3.0 3.1 "http://circ.ahajournals.org/content/121/13/e266.full". External link in
|title=(help) - ↑ Baddour, LM.; Wilson, WR.; Bayer, AS.; Fowler, VG.; Bolger, AF.; Levison, ME.; Ferrieri, P.; Gerber, MA.; Tani, LY. (2005). "Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): e394–434. doi:10.1161/CIRCULATIONAHA.105.165564. PMID 15956145. Unknown parameter
|month=ignored (help)