Optimal timing of operation
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Optimal timing of operation The goal is to operate late enough in the natural history to justify the risk but early enough to prevent irreversible left ventricular dysfunction. Guidelines for the management of Patients with valvular heart disease. ACC / AHA presented march 1999

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Optimal timing of operation

Optimal timing of operation

The goal is to operate late enough in the natural history to justify the risk but early enough to prevent irreversible left ventricular dysfunction


Guidelines for the management of patients with valvular heart disease

Guidelines for the management of Patients with valvular heart disease

ACC / AHA

presented march 1999

American College of Cardiology

48 Annual Scientific Session


Guidelines for classifying indications

Guidelines for classifying Indications

  • Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective

  • Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness of a procedure or treatment

    • II a: Weight of evidence/opinion is in favour of usefulness/efficacy

    • II b: Usefulness/efficacy is less well established by evidence/opinion

  • Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful and in some cases may be harmful


Aortic stenosis

AORTIC STENOSIS

  • Mild: aortic valve area > 1.5 cm2

  • Moderate: aortic valve area 1.0 - 1.5 cm2

  • Severe: aortic valve area < 1.0 cm2

  • ( Critical: aortic valve area = 0.75 cm2 )


Symptoms

Symptoms


As rate of progression hemodynamic

AS, Rate of progression - Hemodynamic

  • Cardiac Catheterisation (3-9 year f/u )

  • Progression

    • Valve area decreases = 0.1 - 0.3 cm2 /year

    • Pressure gradient increases = 10-15 mm Hg/year

  • Little or no progression in 50% of reported patients

  • Echocardiography (1-3 year f/u)

  • Progression

    • Valve area decreases = 0.1 cm2/year

    • Pressure gradient increases = 15-19 mm Hg/year

  • Little or no progression in 50 % of reported patients

    • Faggiano, et al. Am Heart J 1996


As rate of progression symptoms need for surgery

AS, Rate of progression-Symptoms/Need for surgery

  • Prospective follow up of asymptomatic patients with severe aortic stenosis (Doppler velocity > 4 m/s)

  • Symptoms developed in 30% within 2 years

    • Pellikka, et al. JACC 15: 1012, 1990

  • Surgery was performed in 70% within 2 years

    • Otto, et al. Circ 95:2262, 1997


Recommendations for echo in as

Recommendations for Echo in AS

IndicationClass

1 Diagnosis and assessment of severity of AS I

2 Assessment of LV size, function, and or hemodynamics I

3 Reevaluation of patients with known AS with changing I

symptoms or signs

4 Assessment of changes in hemodynamic severity and ventricular I

compensation in patients with known AS during pregnancy

5 Reevaluation of asymptomatic patients with severe AS I

6 Reevaluation of asymptomatic patients with mild to moderate AS IIa

and evidence of LV-dysfunction or hypertrophy

7 Routine reevaluation of asymptomatic adult patients with mild AS III

having stable physical signs and normal LV size and function


As exercise testing

AS, Exercise Testing

  • Patient population (n=123)

    • Asymptomatic adults with AS

    • Max (Doppler) velocity: average 3.6 m/s

  • Results (274 tests in 104 patients)

    • > 80% of max predicted Heart rate in 87% of patients

    • no morbidity or mortality

    • BP fell in 25 (9%), eligible for AVR

    • ST depression in 4 (2%)

    • Otto, et al. Circ 1997


Recommendations for catheterizaion in as

Recommendations for Catheterizaion in AS

IndicationClass

1 CAG before AVR in patients at risk for CAD (see section VIII.B of these I

guidelines).

2 Assessment of severity of AS in symptomatic patients when AVR is planned I

or when noninvasive tests are inconclusive or there is a discrepancy with

clinical findings regarding severity of AS or need for surgery

3 Assessment of severity of AS before AVR when noninvasive tests are IIb

adequate and concordant with clinical findings and CAG is not needed

4 Assessment of LV function and severity of AS in asymptomatic patients III

when noninvasive tests are adequate


Low gradient as

Low-gradient AS

  • Problem: Low cardiac output and low pressure gradient. Calculated valve area indicates severe stenosis

  • Determine pressure gradient, valve area/resistance during:

    • 1 Resting - baseline state

    • 2 Stress - dobutamine (or exercise)

  • If dobutamine produces an increment in stroke volume and an increase in valve area, the baseline calculation probably overestimates the severity of the stenosis


Recommendations for avr in as 1

Recommendations for AVR in AS 1

IndicationClass

1 Sympomatic patients with severe AS I

2 Patients with severe AS undergoing CABG I

3 Patients with severe AS undergoing surgery of the I

aorta or other heart valves

4 Patients with moderate AS (>30) undergoing CABG IIa

surgery on the Aorta or other heart valves

(see III.F and Viii.D)


Recommendations for avr in as 2

Recommendations for AVR in AS 2

IndicationClass

5 Asymptomatic patients with severe AS and

. LV systolic dysfunction IIa

. Abnormal response to exercise (eg Hypotension) IIa

. Ventricular tachycardia IIb

. Marked or excessive LVH (>= 15mm) IIb

. Valve are < 0.6 cm2 IIb

6 Prevention of SCD in asymptomatic patients with III

findings under 5


Recommendations for balloon valvulotomy in as

Recommendations for Balloon Valvulotomy in AS

IndicationClass

1 A bridge to surgery in hemodynamically unstable patients IIa

who are at high risk for AVR

2 Palliation in patients with serious comorbid conditions IIb

3 Patients who require urgent noncardiac surgery IIb

4 An alternative to AVR III

Recommendations for PTVP Ao in adolescents and young adults with AS are provided in VI.A


Mitral stenosis

Mitral Stenosis

Etiology

Rheumatic

fever

Leaflet thickening

Commissural fusion

Chordal fusion


Mitral stenosis1

Mitral Stenosis

Pathophysiology

Narrow Orifice

Transmitral Pressure

Gradient

Halmark of MS

Elevated

LAP


Mitral stenosis2

Mitral Stenosis

What is new ?

- 2D and doppler echo

- Percutaneous Mitral Balloon valvotomy (PMBV)

Recommendations for patient care

-Asymptomatic

-Symptomatic


Mitral stenosis3

Mitral Stenosis

2 D echo is the Gold Standard for MS


Mitral stenosis4

Mitral Stenosis

Doppler echo is the

Gold Standard for

the quantification of

mitral stenosis


Mitral stenosis5

Mitral Stenosis

Doppler echo is more accurate than conventional catheterization


Mitral stenosis6

Mitral Stenosis

Percutaneous

Mitral Balloon

Valvotomy

PMBV


Pmbv immediate results

PMBV, immediate results

Doubling of MVA

50-60 % reduction gradient

Success rate 80-95%


Mitral stenosis7

Mitral Stenosis

Results PMBV

Results are even better than for Valve replacement

Farhat et al: Circ;97:245-25


Mitral stenosis8

Mitral Stenosis

  • PMBV: Dependent upon mitral morphology

  • Non calcified, pliable

  • No commissural fusion

  • Success > 90%

  • Complications < 3%


Mitral stenosis9

Mitral Stenosis

Asymptomatic

Mild stenosis

MVA > 1.5 cm2

Mod-severe stenosis

MVA < 1.5 cm2

Yearly exam

? Suitable for PMBV ?


Mitral stenosis10

Mitral Stenosis

Asymptomatic

? Suitable for PMBV ?

Yes

No

PAP > 50

PAP < 50

Yearly exam

PMBV


Mitral stenosis11

Mitral Stenosis

Exercise induced pulmonary HTN

PMBV

Calculated PAP


Mitral stenosis12

Mitral Stenosis

Symptoms

Mild stenosis

MVA > 1.5 cm2

Mod-severe stenosis

MVA < 1.5 cm2

PAP > 60

Grad > 15

Exercise

? Suitable For PMBV?

Pap < 60

Grad<15

yes

PMBV

Look elsewhere


Mitral stenosis13

Mitral Stenosis

Symptoms

? Suitable for PMBV ?

No

Yes

Follow

Class II

Surgery

Class III, IV

PMBV


Mitral stenosis14

Mitral Stenosis

  • Other issues

    • Rheumatic fever prophylaxis

    • Anticoagulation

    • Treatment for atrial fibrillation

    • Recommendations for exercise

    • Pregnancy

    • Cost-effective follow-up


Aortic regurgitation

Aortic Regurgitation

  • Percent Survival 3 yr after operation for AR:

  • Pre-op LVEF >= 0.50 : 90 %; Pre-op LVEF < 0.50 : 60 %

    • Forman et al, Am J Cardiol, 1980

Cheitlin et al Dilemmas in clinical cardiology

1990


Chronic aortic regurgitation 1

Chronic Aortic Regurgitation 1

Preoperative prediction of survival after AVR:

Predictor

#LVEFLVFSLVSD

Forman 1980 90 x

Henry 1980 50 x x

Gunha 1980 86 x x

Greves 1981 45 x

Kumpuris 1982 43 x

Bonow 1985 80 x x x

Daniel 1985 84 x x

Cormier 1986 73 x x

Shelban 1986 84 x x


Chronic aortic regurgitation 2

Chronic Aortic Regurgitation 2

Preoperative prediction of survival after AVR:

Predictor

#LVEFLVFSLVSD

Taniguchi 1987 62 x x*

Klodas 1996 219 x

Turina 1998 192 x x*

---------------------------------------------------------------------------------------

Total 1108

*LVSV


Lv dysfunktion in valvular ar

LV dysfunktion in valvular AR

Reversible alteration in LV loading (afterload mismatch)

versus

Irreversible LV myocardial dysfunction


Chronic ar with lv dysfunktion

Chronic AR with LV dysfunktion

Factors influencing survival and functional results after AVR:

1 Severity of preoperative symptoms

2 Severity of LV dysfunction

3 Duration of LV dysfunction


Chronic ar with lv dysfunktion1

Chronic AR with LV dysfunktion

Asymptomatic patients with aortic regurgitation and LV dysfunction should undergo operation beforethe onset of symptoms and limitation of exercise capacity


Timing of operation for asymptomatic ar

Timing of operation for asymptomatic AR

Management considerations:

1 Survival and functional results

after aortic valve replacement

2 Natural history of asymptomatic

patients


Asymptomatic ar with normal lvf

Asymptomatic AR with normal LVF

Natural history

Rate of progression to symptoms and/or LV dysfunction

nRate

Bonow, Circ 1984, 1991 104 3.8%/yr

Scognamiglio, Clin Cardiol, 1986 30 2.1%/yr

Siemenczuk, Ann Int Med 1989 50 4.0%/yr

Scognamiglio, N Engl J Med 1994 74 5.7%/yr (+digoxin)

Tornos, Am Heart J 1995 101 3.0%/yr

Ishii, Am J Cardiol 1996 27 3.6%/yr (incomplete data)

Borer, Circ 1998 104 6.2%/yr

---------------------------------------------------------------------------

Total 490 4.3%/yr


Asymptomatic ar with normal lvf1

Asymptomatic AR with normal LVF

Natural history

Likelihood of developing asymptomatic LV dysfunction

nMean F/URate

Bonow, Circ 1984, 1991 4/105 8.0 yr 0.5%/yr

Scognamiglio, Clin Cardiol, 1986 3/30 4.7 yr 2.1%/yr

Siemenczuk, Ann Int Med 1989 1/50 3.7 yr 0.5%/yr

Scognamiglio, N Engl J Med 1994 15/74 6.0 yr 3.4%/yr

Tornos, Am Heart J 1995 6/101 4.6 yr 1.3%/yr

Borer, Circ 1998 7/104 7.3 yr 0.9%/yr

--------------------------------------------------------------------------------------

Total 36/463 5.9 yr 1.3%/yr


Asymptomatic ar with normal lvf2

Asymptomatic AR with normal LVF

Event Rate

Death < 0.2 % / yr

Asymptomatic LV Dysfunction 1.3 % / yr

Symptoms and/or LV dysfunction 4.3 % / yr


Asymptomatic ar with normal lvf3

Asymptomatic AR with normal LVF

Factors predictive of symptoms and/or LV dysfunction

. LV end systolic dimension/volume

. LV end diastolic dimension/volume

. LV ejection fraction with exercise

Bonow, Circ 1984, 1991

Siemenczuk, Ann Int Med 1989

Tornos, Am Heart J 1995


Asymptomatic ar with normal lvf4

Asymptomatic AR with normal LVF

Likelihood of death, development of symptoms and/or LV

dysfunction (Risk Stratification)

. LV end systolic dimension/volume > 50 19%/yr

40-49 6%/yr

< 50 0%/yr

. LV end diastolic dimension/volume >= 70 10%/yr

< 70 2%/yr

. LVEF response to exercise decrease >5% 12%/yr

decrease 0-5% 4%/yr

increase > 0% 1%/yr

Bonow, Circ 1984, 1991


Asymptomatic ar with normal lvf5

Asymptomatic AR with normal LVF

Predictive variables in multivariate analysis:

Initial evaluation:

. Age

. LV end-systolic dimension

Serial evaluation:

. Increase in LVSD

. Decrease in resting LVEF

Bonow et al, Circ 1984,1991


Asymptomatic ar with normal lvf6

Asymptomatic AR with normal LVF

Risk of sudden Cardiac Death:

. LV end-diastolic volume > 200 ml/m2

Turina et al, Circ 1984

. LV end-diastolic dimension >= 80 mm

. LV end-systolic dimension > 55 mm

Bonow et al, Circ 1991


Chronic ar with marked lv dilatation

Chronic AR with marked LV dilatation

Outcome after AVR:

Low risk group:

. Asymptomatic with normal EF

High risk groups:

. Symptoms

. LV Dysfunction

Klodas et al, JACC 1996, 31 patients with LVDD > =80 mm


Chronic ar

Chronic AR

Indications for operation:

. Symptoms

. LV systolic dysfunction

(subnormal EF at rest)

. Marked LV dilatation

(LVSD >= 55 mm; LVDD >= 75mm)


Asymptomatic ar with normal lvf7

Asymptomatic AR with normal LVF

Follow-up strategy

. Monitoring for onset of symptoms and

changes in effort tolerance

. Serial echocardiograms

frequency based on LV size and function

. Ancillary tests

.Exercise treadmill testing if symptoms unclear

.Radionuclide angiography if echo data

equivocal


Mitral regurgitation

Mitral Regurgitation

Chronic compensated MI:

EDV 240, ESV 50, Filling pressure 15 mm Hg

Chronic decompensated MI:

EDV 260, ESV 110, Filling pressure 25 mm Hg


Mitral regurgitation1

Mitral Regurgitation


Mitral valve surgery

Mitral Valve Surgery

EF after repair: the same or better

EF after replacement:

. Chords preserved: the same

. Chords severed: worse, sometimes even

becomes half of the

original value


Recommendations for tte in mr

Recommendations for TTE in MR

IndicationClass

1 For baseline evaluation to quantify severety of MR and LV I

function in any patient suspected of having MR

2 For deleneation of mechanism of MR I

3 For annual or semiannual surveillance of LV function (esti- I

mated by EF and end-systolic dimension) in asymptomatic

severe MR

4 To establish cardiac status after a change in symptoms I

5 For evaluation after MVR or MV-repair to establish baseline I

status

6 Routine follow-up evaluation of mild MR with normal LV III

size and systolic function


Recommendations for tee in mr

Recommendations for TEE in MR

IndicationClass

1 Intraoperative TEE to establish the anatomic basis for MR I

and guide to repair

2 For evaluation of MR patients in whom TTE provides non- I

diagnostic images regarding severety of MR, mechanism

of MR, and/or status of LV function

3 In routine follow-up or surveillance of patients with native III

valve MR


Recommendations for cag in mr

Recommendations for CAG in MR

IndicationClass

1 When mitral valve surgery contemplated in patients with I

angina or previous myocardial infarction

2 When mitral valve surgery is contemplated in patients with I

>= 1 risk factor for CAD (see section VIII.B)

3 When ischemia is suspected as an etiologic factor in MR I

4 To confirm noninvasive tests in patients not suspected of IIb

having CAD

5 When mitral valve surgery is contemplated in patients aged III

< 35 years and there is no clinical suspicion of CAD


Recommendations for cine in mr

Recommendations for Cine in MR

Left ventricular and hemodynamic measurements

IndicationClass

1 When non-invasive tests are inconclusive regarding the se- I

verity of MR, LV function, or the need for surgery

2 When there is a discrepancy between clinical and noninvasive I

findings regarding severety of MR

3 In patients in whom valve surgery is not contemplated III


Recommendations for mv surgery in non ischemic severe mr 1

Recommendations for MV surgery in non-ischemic severe MR 1

IndicationClass

1 Acute symptomatic MR in which repair is likely I

2 Patients with NYHA functional class II, III, or IV symptoms I

with normal LV function defined as EF > 0.60 and end-

systolic dimension < 45 mm

3 Symptomatic or asymptomatic patients with mild LV dys- I

function, ejection fraction 0.50 to 0.60, and end systolic

dimension 45 to 50 mm


Recommendations for mv surgery in non ischemic severe mr 2

Recommendations for MV surgery in non-ischemic severe MR 2

IndicationClass

4 Symptomatic or asymptomatic patients with moderate LV I

dysfunction, ejection fraction 0.30 to 0.50, and/or end-

systolic dimension 50 to 55 mm

5 Asymptomatic patients with preserved LV function and IIa

atrial fibrillation

6 Asymptomatic patients with preserved LV function and IIa

pulmonary hypertension (pulmonary artery systolic

pressure > 50 mm Hg at rest or > 60 mm Hg with exercise)


Recommendations for mv surgery in non ischemic severe mr 3

Recommendations for MV surgery in non-ischemic severe MR 3

IndicationClass

7 Asymptomatic patients with EF 0.50 to 0.60 and end-systolic IIa

dimension < 45 mm and asymptomatic patients with EF > 0.60

and end-systolic dimension 45 to 55 mm

8 Patients with severe LV dysfunction (EF < 0.30 and/or ESD > IIa

55 mm) in whom chordal preservation is highly likely


Recommendations for mv surgery in non ischemic severe mr 4

Recommendations for MV surgery in non-ischemic severe MR 4

IndicationClass

9 Asymptomatic patients with chronic MR with preserved LV IIb

function in whom mitral valve repair is highly likely

10 Patients with MVP and preserved LV function who have IIb

recurrent ventricular arrhythmias despite medical therapy

11 Asymptomatic patients with preserved LV function in whom III

significant doubt about the feasibility of repair exists


Chronic severe mitral regurgitation

Symptoms

NYHA FC II

NYHA FC I

Normal LVF

EF > 0.60 and

EDS < 45 mm

Normal LVF

EF > 0.60 and

EDS < 45 mm

LV Dysfunction

EF <= 0.60 and

EDS >= 45 mm

AF

PHT

MV repair

likely ?

Yes

Yes

No

No

Clinical eval 6 mo

Echo 12 mo

MVR or

repair

MV

repair

MVR

Chronic severe Mitral Regurgitation


Chronic severe mitral regurgitation1

Symptoms

NYHA FC III-IV

MV repair likely

No

Yes

EF >= 0.30

Yes

No

MVR repair

Medical therapy

MVR

Chronic severe Mitral Regurgitation


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