Aortic stenosis surgery indications: Difference between revisions
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==Indications== | ==Indications== | ||
In symptomatic patients with severe high-gradient AS (Stage D1), ample evidence demonstrates the beneficial effects of AVR on survival, symptoms, and LV systolic function.35,41–46 The most common initial symptom of AS is exertional dyspnea or decreased exercise tolerance. Clinical vigilance is needed to recognize these early symptoms and proceed promptly to AVR. 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 in patients who do not have a high procedural risk.41,43–45 Surgical series demonstrate improved symptoms after AVR, and most patients have an improvement in exercise tolerance, as documented in studies with pre- and post-AVR exercise stress testing.41,43–46 Historical observation studies on outcomes in symptomatic patients with severe AS have been confirmed in RCTs comparing TAVI with palliative care in patients with a prohibitive surgical risk. The choice of surgical versus transcatheter AVR for patients with an indication for AVR is discussed in Section 3.2.4.1–3,5,6,12–16,35,42,47–55 | |||
2. | |||
In asymptomatic patients with severe AS and normal LV systolic function, the survival rate during the asymptomatic phase is similar to that of age-matched controls, with a low risk of sudden death (<1% per year) when patients are followed prospectively and when patients promptly report symptom onset. However, in patients with a low LVEF and severe AS, survival is better in those who undergo AVR than in those treated medically. The depressed LVEF in many patients is caused by excessive afterload (afterload mismatch), and LV function improves after AVR in such patients. If LV dysfunction is not caused by afterload mismatch, survival is still improved, likely because of the reduced afterload with AVR, but improvement in LV function and resolution of symptoms might not be complete after AVR.17,23,24,56–62 | |||
3. | |||
Prospective clinical studies demonstrate that disease progression occurs in nearly all patients with severe asymptomatic AS. Symptom onset within 2 to 5 years is likely when aortic velocity is ≥4.0 m/s or mean pressure gradient is ≥40 mm Hg. The additive risk of AVR at the time of other cardiac surgery is less than the risk of reoperation within 5 years.12–16,63–65 | |||
4. | |||
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, particularly when contractile reserve is present. The document “Echocardiographic Assessment of Valve Stenosis: EAE/ASE Recommendations for Clinical Practice” defines severe AS on dobutamine stress testing as 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.66 The recommendation for AVR in these patients is based on outcome data in several prospective nonrandomized studies. LVEF typically increases by 10 LVEF units and may return to normal if afterload mismatch was the cause of LV systolic dysfunction. If dobutamine stress testing indicates moderate, not severe AS, GDMT for HF can be continued without AVR. Patients without contractile reserve may also benefit from AVR, but decisions in these high-risk patients must be individualized because outcomes are poor with either surgical or medical therapy. The role of TAVI in these patients is currently under investigation.17,22–24,59,60,67 | |||
5. | |||
A subset of patients with severe AS presents with symptoms and with a low velocity, low gradient, and low stroke volume index, despite a normal LVEF. 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 when stroke volume index is <35 mL/m2. Typically, the LV is small, with thick walls, diastolic dysfunction, and a normal LVEF (≥50%). The first diagnostic step is to ensure that data were recorded and measured correctly. If hypertension is present, blood pressure is controlled before reevaluation of AS severity. Next, 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. Measurement of a CT calcium score often is helpful. Evaluation for other potential causes of symptoms ensures that symptoms are most likely attributable to valve obstruction. Although the survival rate after TAVI is lower in patients with low-flow severe AS than in patients with normal-flow severe AS, AVR appears beneficial, with an increase in stroke volume and improved survival as compared with medical therapy.18,25–27,54,68–76 | |||
6. | |||
Exercise testing may be helpful in clarifying symptom status in patients with severe AS. When symptoms are provoked by exercise testing, the patient is considered symptomatic and meets a COR 1 recommendation for AVR; symptoms are symptoms, whether reported spontaneously by the patient or provoked on exercise testing. The rate of symptom onset within 1 to 2 years is high (about 60% to 80%) in patients without overt symptoms who demonstrate 1) a fall of ≥10 mm Hg in systolic blood pressure from baseline to peak exercise or 2) a significant decrease in exercise tolerance as compared with age and sex normal standards. Management of patients with a lack of appropriate rise in BP with exercise is less clear. Decisions about elective AVR in these patients include consideration of surgical risk, patient preferences, and clinical factors, such as age and comorbid conditions.13,28,77–82 | |||
7. | |||
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. On multivariable analysis of a large cohort of adults with asymptomatic AS (>500 patients), an aortic velocity ≥5 m/s was associated with a >6-fold increased risk of cardiovascular mortality (hazard ratio [HR]: 6.31; 95% CI: 2.61–15.9).33 A randomized trial of SAVR versus continued surveillance showed a significant survival benefit to early surgery in patients with aortic velocity ≥4.5 m/s.31 In patients very severe asymptomatic AS and low surgical risk, a decision to proceed with AVR or continue watchful waiting takes into account patient age, avoidance of patient–prosthesis mismatch, anticoagulation issues, and patient preferences.31–33,39 | |||
8. | |||
An elevated serum BNP level is a marker of subclinical HF and LV decompensation. In a cohort of 387 asymptomatic adults with severe AS, elevated BNP levels were associated with an increased 5-year risk of AS-related events, with a hazard ratio for a BNP level >300 pg/mL (3 times normal) of 7.38 (CI: 3.21 to 16.9).32 Serum BNP levels also are predictive of symptom onset during follow-up and persistent symptoms after AVR.36 | |||
9. | |||
Hemodynamic progression eventually leading to symptom onset occurs in nearly all asymptomatic patients with AS once the aortic velocity reaches ≥2 m/s. Although the average rate of hemodynamic progression for calcific stenosis of a trileaflet valve is an increase in aortic velocity of about 0.3 m/s per year, an increase in mean gradient of 7 to 8 mm Hg per year, and a decrease in valve area of 0.15 cm2 per year, there is marked variability between patients in disease progression. Predictors of rapid disease progression include older age, more severe valve calcification, and a faster rate of hemodynamic progression on serial studies. In patients with an aortic velocity >4 m/s in addition to predictors of rapid disease progression, symptom onset is likely in the near future, so there is less benefit to waiting for symptom onset. Thus, elective AVR may be considered if the surgical risk is low and after consideration of other clinical factors and patient preferences. | |||
10. | |||
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% each is associated with higher all-cause and cardiovascular mortality rates in the absence of AVR.31 A multivariate analysis of predictors of death in a large cohort (>500 patients) showed a >4-fold higher risk of cardiovascular death for those with an LVEF <60% than for those with a higher LVEF (HR: 4.47; 95% CI: 2.06 to 9.70).33 A progressive decrease in LVEF is most likely in those with an LVEF <60% before AS becomes severe.8,9,11 Evaluation for other causes of a decline in LVEF is appropriate, particularly when AS is not yet severe, but a progressive decline in LV systolic function is of concern and should prompt more frequent evaluation; and consideration of AVR when repeat studies show a progressive decline in LVEF without other cause with a lack of response to medical therapy. The presence of at least 3 serial imaging studies showing a consistent decline in LVEF ensures that the changes seen are not simply attributable to recording, measurement, or physiological variability.8–11 | |||
11. | |||
Hemodynamic progression eventually leading to symptom onset occurs in nearly all asymptomatic patients with AS. The survival rate during the asymptomatic phase is similar to age-matched controls, with a low risk of sudden death (<1% per year) when patients are followed prospectively and when patients promptly report symptom onset. The rate of symptom onset is strongly dependent on the severity of AS, with an event-free survival rate of about 75% to 80% at 2 years in those with a jet velocity <3.0 m/s, compared with only 30% to 50% in those with a jet velocity ≥4.0 m/s. Patients with asymptomatic AS require periodic monitoring for development of symptoms and progressive disease (Section 3.1). In patients with moderate calcific AS undergoing cardiac surgery for other indications, the risk of progressive VHD is balanced against the risk of repeat surgery or TAVI (Sections 4.3.3 and 10). This decision must be individualized on the basis of the specific operative risk in each patient, clinical factors such as age and comorbid conditions, valve durability, and patient preferences. | |||
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Revision as of 05:54, 5 June 2022
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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: Mohammed A. Sbeih, M.D. [2]; Usama Talib, BSc, MD [3]
Overview
Aortic stenosis requires aortic valve replacement if medical management does not successfully control symptoms. According to a prospective, single-center, nonrandomized study of 25 patients, percutaneous implantation of an aortic valve prosthesis in high risk patients with aortic stenosis results in marked hemodynamic and clinical improvement when successfully completed.[1]
Indications
In symptomatic patients with severe high-gradient AS (Stage D1), ample evidence demonstrates the beneficial effects of AVR on survival, symptoms, and LV systolic function.35,41–46 The most common initial symptom of AS is exertional dyspnea or decreased exercise tolerance. Clinical vigilance is needed to recognize these early symptoms and proceed promptly to AVR. 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 in patients who do not have a high procedural risk.41,43–45 Surgical series demonstrate improved symptoms after AVR, and most patients have an improvement in exercise tolerance, as documented in studies with pre- and post-AVR exercise stress testing.41,43–46 Historical observation studies on outcomes in symptomatic patients with severe AS have been confirmed in RCTs comparing TAVI with palliative care in patients with a prohibitive surgical risk. The choice of surgical versus transcatheter AVR for patients with an indication for AVR is discussed in Section 3.2.4.1–3,5,6,12–16,35,42,47–55 2. In asymptomatic patients with severe AS and normal LV systolic function, the survival rate during the asymptomatic phase is similar to that of age-matched controls, with a low risk of sudden death (<1% per year) when patients are followed prospectively and when patients promptly report symptom onset. However, in patients with a low LVEF and severe AS, survival is better in those who undergo AVR than in those treated medically. The depressed LVEF in many patients is caused by excessive afterload (afterload mismatch), and LV function improves after AVR in such patients. If LV dysfunction is not caused by afterload mismatch, survival is still improved, likely because of the reduced afterload with AVR, but improvement in LV function and resolution of symptoms might not be complete after AVR.17,23,24,56–62 3. Prospective clinical studies demonstrate that disease progression occurs in nearly all patients with severe asymptomatic AS. Symptom onset within 2 to 5 years is likely when aortic velocity is ≥4.0 m/s or mean pressure gradient is ≥40 mm Hg. The additive risk of AVR at the time of other cardiac surgery is less than the risk of reoperation within 5 years.12–16,63–65 4. 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, particularly when contractile reserve is present. The document “Echocardiographic Assessment of Valve Stenosis: EAE/ASE Recommendations for Clinical Practice” defines severe AS on dobutamine stress testing as 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.66 The recommendation for AVR in these patients is based on outcome data in several prospective nonrandomized studies. LVEF typically increases by 10 LVEF units and may return to normal if afterload mismatch was the cause of LV systolic dysfunction. If dobutamine stress testing indicates moderate, not severe AS, GDMT for HF can be continued without AVR. Patients without contractile reserve may also benefit from AVR, but decisions in these high-risk patients must be individualized because outcomes are poor with either surgical or medical therapy. The role of TAVI in these patients is currently under investigation.17,22–24,59,60,67 5. A subset of patients with severe AS presents with symptoms and with a low velocity, low gradient, and low stroke volume index, despite a normal LVEF. 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 when stroke volume index is <35 mL/m2. Typically, the LV is small, with thick walls, diastolic dysfunction, and a normal LVEF (≥50%). The first diagnostic step is to ensure that data were recorded and measured correctly. If hypertension is present, blood pressure is controlled before reevaluation of AS severity. Next, 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. Measurement of a CT calcium score often is helpful. Evaluation for other potential causes of symptoms ensures that symptoms are most likely attributable to valve obstruction. Although the survival rate after TAVI is lower in patients with low-flow severe AS than in patients with normal-flow severe AS, AVR appears beneficial, with an increase in stroke volume and improved survival as compared with medical therapy.18,25–27,54,68–76 6. Exercise testing may be helpful in clarifying symptom status in patients with severe AS. When symptoms are provoked by exercise testing, the patient is considered symptomatic and meets a COR 1 recommendation for AVR; symptoms are symptoms, whether reported spontaneously by the patient or provoked on exercise testing. The rate of symptom onset within 1 to 2 years is high (about 60% to 80%) in patients without overt symptoms who demonstrate 1) a fall of ≥10 mm Hg in systolic blood pressure from baseline to peak exercise or 2) a significant decrease in exercise tolerance as compared with age and sex normal standards. Management of patients with a lack of appropriate rise in BP with exercise is less clear. Decisions about elective AVR in these patients include consideration of surgical risk, patient preferences, and clinical factors, such as age and comorbid conditions.13,28,77–82 7. 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. On multivariable analysis of a large cohort of adults with asymptomatic AS (>500 patients), an aortic velocity ≥5 m/s was associated with a >6-fold increased risk of cardiovascular mortality (hazard ratio [HR]: 6.31; 95% CI: 2.61–15.9).33 A randomized trial of SAVR versus continued surveillance showed a significant survival benefit to early surgery in patients with aortic velocity ≥4.5 m/s.31 In patients very severe asymptomatic AS and low surgical risk, a decision to proceed with AVR or continue watchful waiting takes into account patient age, avoidance of patient–prosthesis mismatch, anticoagulation issues, and patient preferences.31–33,39 8. An elevated serum BNP level is a marker of subclinical HF and LV decompensation. In a cohort of 387 asymptomatic adults with severe AS, elevated BNP levels were associated with an increased 5-year risk of AS-related events, with a hazard ratio for a BNP level >300 pg/mL (3 times normal) of 7.38 (CI: 3.21 to 16.9).32 Serum BNP levels also are predictive of symptom onset during follow-up and persistent symptoms after AVR.36 9. Hemodynamic progression eventually leading to symptom onset occurs in nearly all asymptomatic patients with AS once the aortic velocity reaches ≥2 m/s. Although the average rate of hemodynamic progression for calcific stenosis of a trileaflet valve is an increase in aortic velocity of about 0.3 m/s per year, an increase in mean gradient of 7 to 8 mm Hg per year, and a decrease in valve area of 0.15 cm2 per year, there is marked variability between patients in disease progression. Predictors of rapid disease progression include older age, more severe valve calcification, and a faster rate of hemodynamic progression on serial studies. In patients with an aortic velocity >4 m/s in addition to predictors of rapid disease progression, symptom onset is likely in the near future, so there is less benefit to waiting for symptom onset. Thus, elective AVR may be considered if the surgical risk is low and after consideration of other clinical factors and patient preferences. 10. 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% each is associated with higher all-cause and cardiovascular mortality rates in the absence of AVR.31 A multivariate analysis of predictors of death in a large cohort (>500 patients) showed a >4-fold higher risk of cardiovascular death for those with an LVEF <60% than for those with a higher LVEF (HR: 4.47; 95% CI: 2.06 to 9.70).33 A progressive decrease in LVEF is most likely in those with an LVEF <60% before AS becomes severe.8,9,11 Evaluation for other causes of a decline in LVEF is appropriate, particularly when AS is not yet severe, but a progressive decline in LV systolic function is of concern and should prompt more frequent evaluation; and consideration of AVR when repeat studies show a progressive decline in LVEF without other cause with a lack of response to medical therapy. The presence of at least 3 serial imaging studies showing a consistent decline in LVEF ensures that the changes seen are not simply attributable to recording, measurement, or physiological variability.8–11 11. Hemodynamic progression eventually leading to symptom onset occurs in nearly all asymptomatic patients with AS. The survival rate during the asymptomatic phase is similar to age-matched controls, with a low risk of sudden death (<1% per year) when patients are followed prospectively and when patients promptly report symptom onset. The rate of symptom onset is strongly dependent on the severity of AS, with an event-free survival rate of about 75% to 80% at 2 years in those with a jet velocity <3.0 m/s, compared with only 30% to 50% in those with a jet velocity ≥4.0 m/s. Patients with asymptomatic AS require periodic monitoring for development of symptoms and progressive disease (Section 3.1). In patients with moderate calcific AS undergoing cardiac surgery for other indications, the risk of progressive VHD is balanced against the risk of repeat surgery or TAVI (Sections 4.3.3 and 10). This decision must be individualized on the basis of the specific operative risk in each patient, clinical factors such as age and comorbid conditions, valve durability, and patient preferences.
| 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[2] |
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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[2] |
|---|
- High flow is reversible in conditions such as anemia, hyperthyroidism orarterio-venous fistula and may also be present in patients with hypertrophic obstructive cardiomyopathy.
- The definition of Normal flow by pulsed Doppler echocardiography is :
- DSE flow reserve is defined as > 20% increase in stroke volume in response to low-dose dobutamine.
- Pseudo-severe aortic stenosis is defined as AVA >1.0 cm2 with increased flow.
- CT measurement of aortic valve calcification (Agatston units) for definition of high likely severe AS:
Shown below is an algorithm summarizing the management of symptomatic and asymptomatic patients with aortic stenosis and the indications for AVR. If the patient does not meet any of the decision pathways in the algorithm, regular monitoring is recommended and AVR is not indicated.[3][4]
Abbreviations: AVR: Aortic valve replacement; LVEF: Left ventricular ejection fraction; ΔPmean: mean pressure gradient; Vmax: maximum velocity
| Abnormal aortic valve AND Reduction in systolic opening | |||||||||||||||||||||||||||||||||||||||||||||||||||
| Severe aortic stenosis: Vmax≥4m/s AND ΔPmean≥40 mmHg | Vmax3-3.9 m/s AND ΔPmean20-39 mmHg | ||||||||||||||||||||||||||||||||||||||||||||||||||
| Is the patient symptomatic? | Is the patient symptomatic? | ||||||||||||||||||||||||||||||||||||||||||||||||||
| Yes (Stage D1) | No (Stage C) | Yes | No (Stage B) | ||||||||||||||||||||||||||||||||||||||||||||||||
| LVEF <50% (Stage C2) | Is LVEF <50%? | The patient is undergoing another cardiac surgery | |||||||||||||||||||||||||||||||||||||||||||||||||
| The patient is undergoing another cardiac surgery | Yes | No | |||||||||||||||||||||||||||||||||||||||||||||||||
| Vmax≥5m/s AND ΔPmean≥60 mmHg (Very severe stage C1) AND Low surgical risk | Dobutamine stress echocardiography: Aortic valve area ≤1 cm2 AND Vmax≥4 ms (Stage D2) | Aortic valve area ≤1 cm2 AND LVEF ≥50% (Stage D3) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Abnormal exercise treadmill test | The symptoms are likely the result of the aortic stenosis | ||||||||||||||||||||||||||||||||||||||||||||||||||
| ΔVmax>0.3 m/s/y AND Low surgical risk | |||||||||||||||||||||||||||||||||||||||||||||||||||
| AVR (Class I) | AVR (Class IIa) | AVR (Class IIb) | AVR (Class IIa) | AVR (Class IIa) | AVR (Class IIa) | ||||||||||||||||||||||||||||||||||||||||||||||
Shown below is an algorithm summarizing the approach to patients with low flow, low gradient aortic stenosis.[5]
Abbreviations: AVR: Aortic valve replacement; EOA: Effective orifice area; ΔPmean: mean pressure gradient
| Ultrasound evaluation of aortic stenosis Effective orifice area (EOA)≤ 1 cm2 Pressure gradient (ΔP)<40 mmHg | |||||||||||||||||||||||
| Low grade low flow aortic stenosis | |||||||||||||||||||||||
| Normal left ventricular ejection fraction | Left ventricular ejection fraction≤ 40-50%[4] | ||||||||||||||||||||||
| No specific recommendations: - Surgical AVR, or - Transcather AVR, or - Medical treatment | |||||||||||||||||||||||
| Dobutamine stress test | |||||||||||||||||||||||
| Increase in stroke volume by ≥ 20% | Increase in stroke volume by <20% | ||||||||||||||||||||||
| Presence of left ventricular flow reserve | Absence of left ventricular flow reserve | ||||||||||||||||||||||
| ΔP≥40 EOA<1-1.2 | ΔP<40 EOA≥1-1.2 | EOA<1-1.2 | |||||||||||||||||||||
| True severe aortic stenosis | Pseudo-severe aortic stenosis | True severe aortic stenosis | |||||||||||||||||||||
| Surgical AVR with/without CABG | Medical treatment Close follow up | Transcather AVR | |||||||||||||||||||||
Aortic valve replacement is indicated in the following situations:
- If the patient has symptoms due to aortic stenosis, such as angina, dizziness, syncope, dyspnea or heart failure symptoms [6]. Average survival after the onset of these symptoms is around two to three years [7]. With the presence of symptoms; the patient may be at risk for sudden death [7].
- Severe aortic stenosis (valve area < 1.0 cm2, or the aortic jet velocity is over 4.0 m/sec and the mean transvalvular gradient exceeds 40 mm Hg) if the patient has symptoms, left ventricular dysfunction (ejection fraction < 50%) or undergoing coronary artery bypass grafting. Valve replacement should not be performed for isolated severe AS in asymptomatic patients.
- Usually performed in patients with moderate AS with symptoms to improve symptoms and prolong life expectancy, or if the patient undergoing coronary artery bypass grafting or aortic root reconstruction surgery.
If there are no contraindications to anticoagulants, mechanical prostheses are preferred in patients < 65 years of age. If the patient > 65 years or has any contraindication to anticoagulants; then bioprosetheses are preferred (biologic valve).
Age is not a contraindication to aortic valve replacement in aortic stenosis.
Low Flow Aortic Stenosis
If there is a decline in left ventricular function due to systolic dysfunction, there may be only a moderate transvalvular gradient or low flow aortic stenosis. If there is fibrosis of the left ventricle, there may be incomplete recovery after aortic valve replacement. This scenario can also occur among patients in whom there is a history of myocardial infarction; there is insufficient contractility to mount an aortic gradient.
Definition
- An aortic valve areas < 1.0 cm2
- A left ventricular ejection fraction < 40%
- A mean pressure difference or gradient across the aortic valve of < 30 mm Hg
With a dobutamine infusion, the aortic valve area should increase to > 1.2 cm2, and the mean pressure gradient should rise above 30 mm Hg. If there is a failure to acheive these improvements, early surgical mortality is 32–33%, but it is only 5–7% in those patients who can augment their contractility and gradient. Survival at five years was 88% after surgery if the patient can augment their contractility, but only 10–25% if the patient cannot augment their contractility.
It should be noted that left ventricular contractile reserve is a better predictor of surgical outcomes than markers of stenosis. Aortic valve surgery is indicated if there is severe AS along with an increase in the systolic velocity integral by >20% during a dobutamine infusion.
AHA/ACC 2014 Guideline for the Management of Patients With Valvular Heart Diseases
Timing of Intervention
| Class I |
| "1. AVR is recommended with severe high-gradient AS who have symptoms by history or on exercise testing (stage D1)(Level of Evidence: B)" |
| "2. AVR is recommended for asymptomatic patients with severe AS (stage C2)and LVEF <50% (Level of Evidence: B)" |
| "3. AVR is indicated for patients with severe AS (stage C or D) when undergoing other cardiac surgery (Level of Evidence: B)" |
| Class IIa |
| "1. AVR is reasonable for asymptomatic patients with very severe AS (stage C1, aortic velocity ≥5.0 m/s) and low surgical risk (Level of Evidence: B)" |
| "2. AVR is reasonable in asymptomatic patients (stage C1) with severe AS and decreased exercise tolerance or an exercise fall in BP (Level of Evidence: B)" |
| "3. AVR is reasonable in symptomatic patients with low-flow/low-gradient severe AS with reduced LVEF (stage D2) with a low-dose dobutamine stress study that shows an aortic velocity ≥ 4.0 m/s (or mean pressure gradient ≥ 40 mm Hg) with a valve area ≤ 1.0 cm2 at any dobutamine dose (Level of Evidence: B)" |
| "4. AVR is reasonable in symptomatic patients who have low-flow/low-gradient severe AS (stage D3) who are normotensive and have an LVEF ≥50% if clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms (Level of Evidence: C)" |
| "5. AVR is reasonable for patients with moderate AS (stage B) (aortic velocity 3.0–3.9 m/s) who are undergoing other cardiac surgery (Level of Evidence: C)" |
| Class IIb |
| "1. AVR may be considered for asymptomatic patients with severe AS (stage C1) and rapid disease progression and low surgical risk (Level of Evidence: C)" |
Choice of Surgical or Transcatheter Intervention
| Class I |
| "1. Surgical AVR is recommended in patients who meet an indication for AVR with low or intermediate surgical risk. (Level of Evidence: A)" |
| "2. For patients in whom TAVR or high-risk surgical AVR is being considered, members of a Heart Valve Team should collaborate to provide optimal patient care (Level of Evidence: C)" |
| "3. TAVR is recommended in patients who meet an indication for AVR for AS who have a prohibitive surgical risk and a predicted post-TAVR survival >12 months (Level of Evidence: B)" |
| Class IIa |
| "1. TAVR is a reasonable alternative to surgical AVR in patients who meet an indication for AVR and who have high surgical risk (Level of Evidence: B)" |
| Class IIb |
| "1. Percutaneous aortic balloon dilation may be considered as a bridge to surgical or transcatheter AVR in severely symptomatic patients with severe AS. (Level of Evidence: C)" |
| Class III |
| "1. TAVR is not recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of AS. (Level of Evidence: B)" |
2008 Focused Update Incorporated Into the 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT) [7]
Aortic Valve Replacement Indications (DO NOT EDIT) [7]
| Class I |
| "1. AVR is indicated for symptomatic patients with severe AS. (Level of Evidence: B)" |
| "2. AVR is indicated for patients with severe AS undergoing coronary artery bypass graft surgery (CABG). (Level of Evidence: C)" |
| "3. AVR is indicated for patients with severe AS undergoing surgery on the aorta or other heart valves. (Level of Evidence: C)" |
| "4. Aortic valve replacement is indicated for patients with severe AS and LV dysfunction (LV ejection fraction less than 50%). (Level of Evidence: C)" |
| "5. In patients with bicuspid valves undergoing AVR because of severe AS or AR, repair of the aortic root or replacement of the ascending aorta is indicated if the diameter of the aortic root or ascending aorta is greater than 4.5 cm. (Level of Evidence: C)" |
| Class III |
| "1. AVR is not useful for the prevention of sudden death in asymptomatic patients with AS who have none of the findings listed under the Class IIa/IIb recommendations(Level of Evidence: B)" |
| Class IIa |
| "1. AVR is reasonable for patients with moderate AS undergoing CABG or surgery on the aorta or other heart valves. (Level of Evidence: B)" |
| Class IIb |
| "1. AVR may be considered for asymptomatic patients with severe AS and abnormal response to exercise (e.g., development of symptoms or asymptomatic hypotension). (Level of Evidence: C)" |
| "2. AVR may be considered for adults with severe asymptomatic AS if there is a high likelihood of rapid progression (age, calcification, and CAD) or if surgery might be delayed at the time of symptom onset. (Level of Evidence: C)" |
| "3. AVR may be considered in patients undergoing CABG who have mild AS when there is evidence, such as moderate to severe valve calcification, that progression may be rapid. (Level of Evidence: C)" |
| "4. AVR may be considered for asymptomatic patients with extremely severe AS (aortic valve area less than 0.6 cm2, mean gradient greater than 60 mm Hg, and jet velocity greater than 5.0 m per second) when the patient's expected operative mortality is 1.0% or less. (Level of Evidence: C)" |
References
- ↑ Grube E, Laborde JC, Gerckens U; et al. (2006). "Percutaneous implantation of the CoreValve self-expanding valve prosthesis in high-risk patients with aortic valve disease: the Siegburg first-in-man study". Circulation. 114 (15): 1616–24. doi:10.1161/CIRCULATIONAHA.106.639450. PMID 17015786.
- ↑ 2.0 2.1 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). - ↑ Bonow RO, Carabello B, de Leon AC, Edmunds LH, Fedderly BJ, Freed MD; et al. (1998). "ACC/AHA Guidelines for the Management of Patients With Valvular Heart Disease. Executive Summary. 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 Heart Valve Dis. 7 (6): 672–707. PMID 9870202.
- ↑ 4.0 4.1 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.
- ↑ Pibarot P, Dumesnil JG (2012). "Low-flow, low-gradient aortic stenosis with normal and depressed left ventricular ejection fraction". J Am Coll Cardiol. 60 (19): 1845–53. doi:10.1016/j.jacc.2012.06.051. PMID 23062546.
- ↑ Freeman RV, Otto CM (2005). "Spectrum of calcific aortic valve disease: pathogenesis, disease progression, and treatment strategies". Circulation. 111 (24): 3316–26. doi:10.1161/CIRCULATIONAHA.104.486738. PMID 15967862.
- ↑ 7.0 7.1 7.2 7.3 Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD; et al. (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.