Aortic regurgitation surgery: Difference between revisions
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==Surgical Management of Chronic Aortic Insufficiency== | |||
Surgical treatment is controversial in asymptomatic patients. Surgery may be recommended if the [[ejection fraction]] falls below 50% or in the face of progressive and severe left ventricular dilatation. For both groups of patients, surgery before the development of worse aortic insufficiency [[ejection fracture]]/LV systolic dilatation, is expected to reduce the risk of [[sudden death]], and is associated with lower peri-operative mortality. | Surgical treatment is controversial in asymptomatic patients. Surgery may be recommended if the [[ejection fraction]] falls below 50% or in the face of progressive and severe left ventricular dilatation. For both groups of patients, surgery before the development of worse aortic insufficiency [[ejection fracture]]/LV systolic dilatation, is expected to reduce the risk of [[sudden death]], and is associated with lower peri-operative mortality. | ||
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Majority of patients with severe aortic regurgitation requiring surgery undergo [[aortic valve replacement]] against [[aortic valve repair]] which are preformed at few surgical centers which have appropriate technical expertise and experience in selecting potential patients. | Majority of patients with severe aortic regurgitation requiring surgery undergo [[aortic valve replacement]] against [[aortic valve repair]] which are preformed at few surgical centers which have appropriate technical expertise and experience in selecting potential patients. | ||
==Indications for [[Aortic valve replacement]]/Repair(AVR) in Chronic [[Aortic Insufficiency]] as per 2006 ACC/AHA Guidelines== | ===Indications for [[Aortic valve replacement]]/Repair(AVR) in Chronic [[Aortic Insufficiency]] as per 2006 ACC/AHA Guidelines=== | ||
{{cquote|'''Class I''' | {{cquote|'''Class I''' | ||
Revision as of 17:59, 28 March 2011
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.
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Surgical Management of Chronic Aortic Insufficiency
Surgical treatment is controversial in asymptomatic patients. Surgery may be recommended if the ejection fraction falls below 50% or in the face of progressive and severe left ventricular dilatation. For both groups of patients, surgery before the development of worse aortic insufficiency ejection fracture/LV systolic dilatation, is expected to reduce the risk of sudden death, and is associated with lower peri-operative mortality.
| Symptoms | Ejection fraction | Other information |
|---|---|---|
| NYHA class III - IV | ≥ 50 % | |
| NYHA class II | ≥ 50 % | Progression of symptoms or worsening parameters on echocardiography |
| CHA class ≥ II angina | ≥ 50 % | |
| Regardless of symptoms | 25 - 49 % | |
| Cardiac surgery for other cause (ie: CAD, other valvular disease, ascending aortic aneurysm) | ||
Majority of patients with severe aortic regurgitation requiring surgery undergo aortic valve replacement against aortic valve repair which are preformed at few surgical centers which have appropriate technical expertise and experience in selecting potential patients.
Indications for Aortic valve replacement/Repair(AVR) in Chronic Aortic Insufficiency as per 2006 ACC/AHA Guidelines
| “ | Class I
Class IIa AVR is reasonable for asymptomatic patients with severe aortic insufficiency with normal left ventricular systolic function (ejection fraction greater than 0.50) but with severe left ventricular dilatation (end-diastolic dimension greater than 75 mm or end-systolic dimension greater than 55 mm). Class IIb
Class III AVR is not indicated for asymptomatic patients with mild, moderate, or severe aortic insufficiency and normal left ventricular systolic function at rest (ejection fraction greater than 0.50) when the degree of dilatation is not moderate or severe (end-diastolic dimension less than 70 mm, end-systolic dimension less than 50 mm). |
” |
Surgical corrections of regurgitant aortic valve have shown to improve symptoms in symptomatic patients with severe aortic insufficiency. In some studies, the left ventricular function (ejection fraction) also was seen to improve with AVR[2] [3]. In severe aortic insufficiency, new onset of mild symptoms are also candidates for AVR. It is recommended that surgery should not be delayed till development of advanced symptoms as this may result in development of some degree of irreversible left ventricular dysfunction [4] [5]. Patients who are symptomatic with NYHA Class IV, have poor outcome post AVR with less likelihood of improvement of left ventricular systolic function [6] [7] [8] [9].But with AVR, ventricular loading conditions are improved and expedite subsequent management of left ventricular dysfunction[10].
Symptomatic patients even with mild to moderate left ventricular systolic dysfunction (ejection fraction 0.25 to 0.50) should also undergo AVR. AHA/ACC guidelines[11] recommends that patients with NYHA Class II and III symptoms should undergo valve replacement if:
| “ |
|
” |
Aortic valve replacement/repair is not recommended in a truly asymptomatic patient with normal left ventricular function (left ventricular ejection fraction ≥50%) without severe left ventricular dilatation because this would expose the patient to perioperative mortality risk of 4% against less than 0.2% mortality risk without surgery and other long-term complications of a prosthetic heart valve[12].In such patients 2006 AHA/ACC guidelines [11]recommends:
- Patients with mild chronic aortic insufficiency with normal left ventricular ejection fraction should undergo clinical evaluation yearly and echocardiography every two to three years.
- Patients with severe chronic aortic insufficiency with normal left ventricular ejection fraction should be followed up based on ventricular dimensions:
- Patients with end-systolic ventricular dimension <45 mm and end-diastolic ventricular dimension <60 mm should undergo clinical evaluation every 6-12months and echocardiography every 12months. However, if the patient is not stable or this is the initial study, he should be re-evaluated and echocardiography performed in 3months.
- Patients with end-systolic ventricular dimension 45-50 mm and end-diastolic ventricular dimension 60-70 mm should undergo clinical evaluation every 6months and echocardiography every 12months. However, if the patient is not stable or this is the initial study, he should be re-evaluated and echocardiography performed in 3months.
- Patients with end-systolic ventricular dimension 50-55 mm and end-diastolic ventricular dimension 70-75 mm with normal hemodynamic response to exercise should undergo clinical evaluation every 6months and echocardiography every 6months. However, if the patient is not stable or this is the initial study, he should be re-evaluated and echocardiography performed in 3months.
While interpreting these breakpoints of left ventricular dimensions, body size of the patients should also be taken into consideration. Because women or patients with small body size may not be able to achieve ventricular dimensions mentioned above as they were established in men [13] [14]. Body surface area when considered for left ventricular dimension, tend to mask the diagnosis of left ventricular enlargement, especially in patients who are overweight[15]. Therefore patient's height and gender should be considered during interpretation of ventricular dimensions. [16]
Other aortic root diseases like marfan syndrome, bicuspid aortic valve and aortic dissection which can cause chronic aortic regurgitation should be treated with AVR and aortic root reconstruction when degree of dilatation of aorta or aortic root ≥ 50mm in diameter [17]
Severe aortic insufficiency in patient after aortic valve replacement 1
<googlevideo>-3829359717394053857&hl=en</googlevideo>
Severe aortic insufficiency in patient after aortic valve replacement 2
<googlevideo>-1139143783733805104&hl=en</googlevideo>
Severe aortic insufficiency in patient after aortic valve replacement 3
<googlevideo>-7501177211861270942&hl=en</googlevideo>
Severe aortic insufficiency in patient after aortic valve replacement 4
<googlevideo>-4027195456056520519&hl=en</googlevideo>
Severe aortic insufficiency in patient after aortic valve replacement 5
<googlevideo>3983126063629833286&hl=en</googlevideo>
Severe aortic insufficiency in patient after aortic valve replacement 6
<googlevideo>5313961274473108141&hl=en</googlevideo>
Severe aortic insufficiency in patient after aortic valve replacement 7
<googlevideo>-1049019986268408841&hl=en</googlevideo>
Severe aortic insufficiency in patient after aortic valve replacement 8
<googlevideo>1577454681656420080&hl=en</googlevideo>
References
- ↑ "ACC/AHA 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 (Committee on Management of Patients with Valvular Heart Disease)". J. Am. Coll. Cardiol. 32 (5): 1486–588. 1998. PMID 9809971.
- ↑ Daniel WG, Hood WP, Siart A, Hausmann D, Nellessen U, Oelert H, Lichtlen PR (1985). "Chronic aortic regurgitation: reassessment of the prognostic value of preoperative left ventricular end-systolic dimension and fractional shortening". Circulation. 71 (4): 669–80. PMID 3156010. Retrieved 2011-03-27. Unknown parameter
|month=ignored (help) - ↑ Carabello BA, Usher BW, Hendrix GH, Assey ME, Crawford FA, Leman RB (1987). "Predictors of outcome for aortic valve replacement in patients with aortic regurgitation and left ventricular dysfunction: a change in the measuring stick". Journal of the American College of Cardiology. 10 (5): 991–7. PMID 3668112. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Klodas E, Enriquez-Sarano M, Tajik AJ, Mullany CJ, Bailey KR, Seward JB (1997). "Optimizing timing of surgical correction in patients with severe aortic regurgitation: role of symptoms". Journal of the American College of Cardiology. 30 (3): 746–52. PMID 9283535. Retrieved 2011-03-27. Unknown parameter
|month=ignored (help) - ↑ Carabello BA (2004). "Is it ever too late to operate on the patient with valvular heart disease?". Journal of the American College of Cardiology. 44 (2): 376–83. doi:10.1016/j.jacc.2004.03.061. PMID 15261934. Retrieved 2011-03-27. Unknown parameter
|month=ignored (help) - ↑ Bonow RO, Dodd JT, Maron BJ, O'Gara PT, White GG, McIntosh CL, Clark RE, Epstein SE (1988). "Long-term serial changes in left ventricular function and reversal of ventricular dilatation after valve replacement for chronic aortic regurgitation". Circulation. 78 (5 Pt 1): 1108–20. PMID 2972417. Retrieved 2011-03-27. Unknown parameter
|month=ignored (help) - ↑ Greves J, Rahimtoola SH, McAnulty JH, DeMots H, Clark DG, Greenberg B, Starr A (1981). "Preoperative criteria predictive of late survival following valve replacement for severe aortic regurgitation". American Heart Journal. 101 (3): 300–8. PMID 6451163. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Bonow RO, Picone AL, McIntosh CL, Jones M, Rosing DR, Maron BJ, Lakatos E, Clark RE, Epstein SE (1985). "Survival and functional results after valve replacement for aortic regurgitation from 1976 to 1983: impact of preoperative left ventricular function". Circulation. 72 (6): 1244–56. PMID 4064269. Retrieved 2011-03-27. Unknown parameter
|month=ignored (help) - ↑ Cunha CL, Giuliani ER, Fuster V, Seward JB, Brandenburg RO, McGoon DC (1980). "Preoperative M-mode echocardiography as a predictor of surgical results in chronic aortic insufficiency". The Journal of Thoracic and Cardiovascular Surgery. 79 (2): 256–65. PMID 7351849. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Clark DG, McAnulty JH, Rahimtoola SH (1980). "Valve replacement in aortic insufficiency with left ventricular dysfunction". Circulation. 61 (2): 411–21. PMID 7351067. Retrieved 2011-03-28. Unknown parameter
|month=ignored (help) - ↑ 11.0 11.1 Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS (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. Retrieved 2011-03-28. Unknown parameter
|month=ignored (help) - ↑ Bekeredjian R, Grayburn PA (2005). "Valvular heart disease: aortic regurgitation". Circulation. 112 (1): 125–34. doi:10.1161/CIRCULATIONAHA.104.488825. PMID 15998697. Retrieved 2011-03-28. Unknown parameter
|month=ignored (help) - ↑ Stone PH, Clark RD, Goldschlager N, Selzer A, Cohn K (1984). "Determinants of prognosis of patients with aortic regurgitation who undergo aortic valve replacement". Journal of the American College of Cardiology. 3 (5): 1118–26. PMID 6707364. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Klodas E, Enriquez-Sarano M, Tajik AJ, Mullany CJ, Bailey KR, Seward JB (1996). "Surgery for aortic regurgitation in women. Contrasting indications and outcomes compared with men". Circulation. 94 (10): 2472–8. PMID 8921790. Retrieved 2011-03-28. Unknown parameter
|month=ignored (help) - ↑ Mathew RK, Gaasch WH, Guilmette NE, Schick EC, Labib SB (2003). "Anthropometric normalization of left ventricular size in chronic mitral regurgitation". The American Journal of Cardiology. 91 (6): 762–4. PMID 12633821. Retrieved 2011-03-28. Unknown parameter
|month=ignored (help) - ↑ Vasan RS, Larson MG, Levy D, Evans JC, Benjamin EJ (1997). "Distribution and categorization of echocardiographic measurements in relation to reference limits: the Framingham Heart Study: formulation of a height- and sex-specific classification and its prospective validation". Circulation. 96 (6): 1863–73. PMID 9323074. Retrieved 2011-03-28. Unknown parameter
|month=ignored (help) - ↑ Lindsay J (1997). "Diagnosis and treatment of diseases of the aorta". Current Problems in Cardiology. 22 (10): 485–542. PMID 9339352. Retrieved 2011-03-28. Unknown parameter
|month=ignored (help)