Sandbox Rim

Jump to navigation Jump to search

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)

❑ Every 3 -5 years for mild regurgitation
❑ Every 1 - 2 years for moderate regurgitation

❑ Control hypertension preferably with

❑ Dihydropyridine CCB, or
ACE inhibitors or ARBs (Class I; Level of Evidence: B)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
❑ Dihydropyridine CCB, or
ACE inhibitors or ARBs (Class I; Level of Evidence: B)
 
 
 
 
 
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
 
Administer antibiotics
Follow up the patient
Click here for more details
 
 
 
  1. 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.
  2. 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. 3.0 3.1 "http://circ.ahajournals.org/content/121/13/e266.full". External link in |title= (help)
  4. 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)