Aortic regurgitation surgery indications: Difference between revisions
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(/* 2008 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT) {{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, et al. |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 Val...) |
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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' AVR may be considered for asymptomatic patients with severe AR and normal [[LV]] systolic function at rest (LVEF ≥50%, stage C1) but with progressive severe LV dilatation (LV end-diastolic dimension >65 mm) if surgical risk is low. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' AVR may be considered for asymptomatic patients with severe AR and normal [[LV]] systolic function at rest (LVEF ≥50%, stage C1) but with progressive severe LV dilatation (LV end-diastolic dimension >65 mm) if surgical risk is low. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
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Revision as of 06:27, 17 June 2022
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Resident Survival Guide |
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Aortic Insufficiency Surgery | |
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Treatment | |
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Aortic regurgitation surgery indications On the Web | |
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American Roentgen Ray Society Images of Aortic regurgitation surgery indications | |
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Directions to Hospitals Performing Aortic insufficiency Surgery | |
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Risk calculators and risk factors for Aortic regurgitation surgery indications | |
For the WikiPatient page for this topic, click here; For the main page of AR, click here
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Mohammed A. Sbeih, M.D.[2]; Rim Halaby, M.D. [3]; Usama Talib, BSc, MD [4]; Sabawoon Mirwais, M.B.B.S, M.D.[5]
Overview
Severe acute AR requires emergency surgery if there are no absolute contraindications to surgery. The surgery should be performed as early as possible without a delay, particularly if hypotension, decreased perfusion, or pulmonary edema are present. In chronic AR, aortic valve replacement (AVR) is indicated in patients with severe AR who are either symptomatic regardless of LV systolic function, or those who are asymptomatic and have left ventricular ejection fraction <55%, or in patients with stage C or D AR who are undergoing cardiac surgery for other indications.[1]
Indications for Surgery for Acute Aortic Regurgitation
Timing of Emergency Surgery
Acute severe AR may cause death due to pulmonary edema, ventricular arrhythmias, electromechanical dissociation, or circulatory collapse. Individuals with bacteremia with aortic valve endocarditis should not wait for treatment with antibiotics to take effect, especially if there is hypotension, pulmonary edema, or low cardiac output given the high mortality associated with the acute AR.
Shown below is an algorithm for the treatment of acute AR.[2]
Abbreviations: AVR: Aortic valve replacement; ACE: Angiotensin converting enzyme; ARB: Angiotensin receptor blocker; CCB: Calcium channel blocker; LVEF: Left ventricle ejection fraction; TTE: Transthoracic echocardiography
| What is the cause of acute AR? | |||||||||||||||||||||||||||||
| Infective endocarditis | Aortic dissection | ||||||||||||||||||||||||||||
Does the patient have AR related heart failure symptoms? | ❑ Schedule for an emergent surgery[3] ❑ Administer beta blockers with caution (beta blockers inhibit compensatory tachycardia) | ||||||||||||||||||||||||||||
| Yes | No | ||||||||||||||||||||||||||||
❑ Schedule for early aortic valve replacement (Class I, level of evidence B)[4] | |||||||||||||||||||||||||||||
Type of Surgery
Replacement with an aortic valve homograft should be performed if feasible. The surgical approach depends upon the cause of AR. Aortic valve replacement or repair may be needed in cases of valvular structural abnormalities and aortic root repair/replacement may be needed in cases of aortic dissection.
Preoperative Medical Therapy
Patients may be temporarily managed before surgery with vasodilators such as nitroprusside and possibly inotropic agents such as dopamine or dobutamine to improve stroke volume and reduce left ventricular end-diastolic pressure.[5] Intra-aortic balloon pump is contraindicated as this would worsen aortic regurgitation by increasing afterload due to the inflation of the balloon during diastole.[6]
Mild Acute AR in the Setting of Aortic Dissection
In mild AR secondary to aortic dissection, the aortic valve can be repaired/replaced at the time of surgery for aortic dissection.
Indications for Surgery for Chronic Aortic Regurgitation
| Management of aortic regurgitation | |||||||||||||||||||||||||||||||||||||||||
| Significant enlargement of ascending aorta | Severe aortic regurgitation | ||||||||||||||||||||||||||||||||||||||||
| Surgery | Symptoms | ||||||||||||||||||||||||||||||||||||||||
| Yes | NO
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| Yes | |||||||||||||||||||||||||||||||||||||||||
| The above algorithm adopted from 2021 ESC Guideline[7] |
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| Recommendations for surgery in severe aortic regurgitation and aortic root or tubular ascending aortic aneurysm |
| Severe aortic regurgitation (Class I, Level of Evidence B): |
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❑ Surgery is recommended in symptomatic patients regardless of LV function |
| (Class IIb, Level of Evidence C): |
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❑ Surgery may be considered in asymptomatic patients with LVESD >20 mm/m2 BSA (especially in patients with small body size) or resting LVEF ≤ 55%, in low risk condition |
| (Class I, Level of Evidence C) : |
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❑ Surgery is recommended in symptomatic and asymptomatic patients with severe aortic regurgitation undergoing CABG or surgery of the ascending aorta or of another valve |
| Aortic root or tubular ascending aortic aneurysmc (irrespective of the severity of aortic regurgitation (Class I, Level of Evidence B): |
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❑ Valve-sparing aortic root replacement is recommended in young patients with aortic root dilation |
| (Class I, Level of Evidence C): |
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❑ Ascending aortic surgery is recommended in patients with Marfan syndrome and ascending aortic diameter ≥ 50 mm |
| (Class IIa, Level of Evidence C): |
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❑ Ascending aortic surgery is recommended with ascending aorta size of:
Risk factors: family history of aortic dissection (or personal history of spontaneous vascular dissection), severe aortic or mitral regurgitation, desire for pregnancy, uncontrolled systemic arterial hypertension , aortic size increase >3 mm/year
❑ In the presence of primarily indication for the surgery of aortic valve, replacement of the aortic root or tubular ascending aorta should be considered
when ≥ 45 mm |
Abbreviations: BSA: Body surface area; CABG: Coronary artery bypass grafting; LV: Left ventricle; LVEF:Left ventricular ejection fraction ; LVESV:Left ventricular end-systolic diamete
| The above table adopted from 2021 ESC Guideline[7] |
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Shown below is an algorithm depicting the indications for aortic valve replacement (AVR) in chronic aortic regurgitation.
| Aortic Regurgitation | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Moderate Aortic Regurgitation> | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Severe Aortic Regurgitation ❑VC>0.6cm ❑ Holodiastolic aortic flow reversal ❑ RVol≥60 ml ❑ RF≥ 50% ❑ ERO≥0.3cm² | Other cardiac surgery | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Symptomatic (stage D) | Asymptomatic (stage C) | AVR (Class IIa) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| ❑ LVEF≤ 55% (stage C2) | ❑ Other cardiac surgerysurgery | ❑ LVEF> 55% AND ❑ LVESD > 50mm (LVESD>25mm/m² ) | ❑ Progressive decrese in LVEF to <55%-60% or increase in LVEDD to >65mm on at least 3 studies | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| AVR (Class I) | AVR (Class I) | AVR (Class I) | AVR (Class IIa) | Low surgical risk | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| AVR (Class IIb) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Abbreviations: LVEF: left ventricular ejection fraction; LVEDD: left ventricular end diastolic diameter; LVESV: left ventricular end systolic diameter; VC: vena contracta; RVol: regurgitant volume; RF: regurgitant fraction; ERO: effective regurgitant orifice
| The above algorithm adopted from 2020 AHA Guideline[8] |
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Shown below is an algorithm depicting the indications for aortic valve replacement (AVR) in chronic aortic regurgitation.
- The AHA/ACC guidelines recommends that patients undergo AVR in the following cases:[9]
- Stage D: presence of symptoms with severe AR regardless of LV systolic function
- Stage C2: absence of symptoms with chronic severe AR + LV systolic dysfunction (LVEF <50%)
- Stage C or D AR in a patient undergoing cardiac surgery for other indications
- The AHA/ACC guidelines considers AVR reasonable in the following cases:[10]
- Stage C2: absence of symptoms with severe AR + normal LV systolic function (LVEF ≥50%) + severe LV dilation (LVESD >50 mm)
- Stage B: moderate AR in a patient undergoing cardiac surgery for other indications
- Stage C1: absence of symptoms with severe AR + normal LV systolic function (LVEF ≥50%)+ progressive severe LV dilation (LVEDD >65 mm) if surgical risk is low
- Aortic valve replacement/repair is not recommended in a truly asymptomatic patient with normal left ventricular function (left ventricular ejection fraction ≥50%) who does not have 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.[11]
- In severe AR, new onset of mild symptoms are also candidates for AVR. Surgery should not be delayed until the development of advanced symptoms as this may result in irreversible left ventricular dysfunction.[12] [13]
- Aortic valve replacement improves symptoms in symptomatic patients with severe AR. In some studies, the left ventricular function (ejection fraction) also improved following AVR.[14] [15] Patients who are symptomatic with NYHA Class IV heart failure have poor outcomes following AVR with less likelihood of an improvement in left ventricular systolic function.[16] [17] [18] [19] Following AVR, ventricular loading conditions may be improved and this may improve the subsequent management of left ventricular dysfunction.[20]
- When interpreting the cutpoints of left ventricular dimensions, the body size of the patients should also be taken into consideration. Women or patients with small body size may not achieve ventricular dimensions mentioned above as these dimensions were established in men.[21] [22] On the other hand, body surface area measures are considered in the assessment of left ventricular dimension, tend to mask the diagnosis of left ventricular enlargement, especially in patients who are overweight.[23] Therefore patient's height and gender should be considered during interpretation of ventricular dimensions.[24]
2017 ESC/EACTS Guidelines
Indications for Surgery in Severe Aortic Regurgitation
| Indications for Surgery | Class of
Recommendation |
Level of
Evidence |
|---|---|---|
| Surgery is indicated in symptomatic patients.[25] | I | B |
| Surgery is indicated in asymptomatic patients with resting LVEF ≤ 50%.[25][26] | I | B |
| Surgery is indicated in patients undergoing CABG or surgery of the ascending aorta or of another valve. | I | C |
| Heart Team discussion is recommended in selected patientsa in whom aortic valve repair may be a feasible alternative to valve replacement. | I | C |
| Surgery should be considered in asymptomatic patients with resting ejection fraction > 50% with severe LV dilatation: LVEDD > 70 mm or LVESD > 50 mm (or LVESD > 25 mm/m2 BSA in patients with small body size).[26][27] | IIa | B |
aPatients with pliable non-calcified tricuspid or bicuspid valves who have a type I (enlargement of the aortic root with normal cusp motion) or type II (cusp prolapse) mechanism of aortic regurgitation.[28][29][30] | ||
2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Diseases (DO NOT EDIT)[31]
Timing of Intervention
| Class I |
| "1. AVR is indicated for symptomatic patients with severe AR regardless of LV systolic function (stage D). (Level of Evidence: B)" |
| "2. AVR is indicated for asymptomatic patients with chronic severe AR and LV systolic dysfunction (LVEF <50%) at rest (stage C2) if no other cause for systolic dysfunction is identified. (Level of Evidence: B)" |
| "3. AVR is indicated for patients with severe AR (stage C or D) while undergoing cardiac surgery for other indications. (Level of Evidence: C)" |
| Class IIa |
| "1. AVR is reasonable for asymptomatic patients with severe AR with normal LV systolic function (LVEF ≥50%) but with severe LV dilation (LVESD >50 mm or indexed LVESD >25 mm/m2) (stage C2). (Level of Evidence: B)" |
| "2. AVR is reasonable in patients with moderate AR (stage B) while undergoing surgery on the ascending aorta, CABG, or mitral valve surgery. (Level of Evidence: C)" |
| Class IIb |
| "1. AVR may be considered for asymptomatic patients with severe AR and normal LV systolic function at rest (LVEF ≥50%, stage C1) but with progressive severe LV dilatation (LV end-diastolic dimension >65 mm) if surgical risk is low. (Level of Evidence: B)" |
References
- ↑ "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary". Retrieved 4 March 2014.
- ↑ 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.
- ↑ "http://circ.ahajournals.org/content/121/13/e266.full". External link in
|title=(help) - ↑ 4.0 4.1 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) - ↑ 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 2011-04-07. Unknown parameter
|month=ignored (help) - ↑ Rius JB, Mercè AS, del Blanco BG, Aguasca GM, Mas PT, García-Dorado García D (2011). "Resolution of shock-induced aortic regurgitation with an intraaortic balloon pump". Circulation. 124 (4): e131. doi:10.1161/CIRCULATIONAHA.111.038653. PMID 21788594.
- ↑ 7.0 7.1 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). - ↑ 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). - ↑ "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary". Retrieved 4 March 2014.
- ↑ "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary". Retrieved 4 March 2014.
- ↑ 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) - ↑ 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) - ↑ 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) - ↑ 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 AR". 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 AR with left ventricular dysfunction". Circulation. 61 (2): 411–21. PMID 7351067. 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) - ↑ 25.0 25.1 Chaliki HP, Mohty D, Avierinos JF, Scott CG, Schaff HV, Tajik AJ, Enriquez-Sarano M (November 2002). "Outcomes after aortic valve replacement in patients with severe aortic regurgitation and markedly reduced left ventricular function". Circulation. 106 (21): 2687–93. doi:10.1161/01.cir.0000038498.59829.38. PMID 12438294.
- ↑ 26.0 26.1
- ↑
- ↑ Lancellotti P, Tribouilloy C, Hagendorff A, Moura L, Popescu BA, Agricola E, Monin JL, Pierard LA, Badano L, Zamorano JL (April 2010). "European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 1: aortic and pulmonary regurgitation (native valve disease)". Eur J Echocardiogr. 11 (3): 223–44. doi:10.1093/ejechocard/jeq030. PMID 20375260.
- ↑ le Polain de Waroux JB, Pouleur AC, Goffinet C, Vancraeynest D, Van Dyck M, Robert A, Gerber BL, Pasquet A, El Khoury G, Vanoverschelde JL (September 2007). "Functional anatomy of aortic regurgitation: accuracy, prediction of surgical repairability, and outcome implications of transesophageal echocardiography". Circulation. 116 (11 Suppl): I264–9. doi:10.1161/CIRCULATIONAHA.106.680074. PMID 17846315.
- ↑ Lansac E, Di Centa I, Raoux F, Al Attar N, Acar C, Joudinaud T, Raffoul R (May 2008). "A lesional classification to standardize surgical management of aortic insufficiency towards valve repair". Eur J Cardiothorac Surg. 33 (5): 872–8, discussion 878–80. doi:10.1016/j.ejcts.2007.12.033. PMID 18258445.
- ↑ "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary". Retrieved 4 March 2014.