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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
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Guidelines for the
management of Patients with
valvular heart disease
ACC / AHA
presented march 1999
American College of Cardiology
48 Annual Scientific Session
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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
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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 )
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Symptoms
Valvular aortic stenosis
Onset of
100
symptoms
Asymptomatic period
%
Survival
CHF
Syncope
AP
25
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30 yr
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
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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
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Recommendations for Echo in AS
Indication
Class
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
having stable physical signs and normal LV size and function
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III
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
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Recommendations for Catheterizaion
in AS
Indication
1 CAG before AVR in patients at risk for CAD (see section VIII.B of these
Class
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
when noninvasive tests are adequate
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III
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
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Recommendations for AVR in
AS 1
Indication
Class
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)
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Recommendations for AVR in
AS 2
Indication
Class
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
findings under 5
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III
Recommendations for Balloon Valvulotomy
in AS
Indication
1 A bridge to surgery in hemodynamically unstable patients
Class
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
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Mitral Stenosis
Etiology
Rheumatic
fever
Leaflet thickening
Commissural fusion
Chordal fusion
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Mitral Stenosis
Pathophysiology
Narrow
Orifice
Transmitral Pressure
Gradient
Elevated
LAP
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Mitral Stenosis
What is new ?
- 2D and doppler echo
- Percutaneous Mitral Balloon valvotomy (PMBV)
Recommendations for patient care
-Asymptomatic
-Symptomatic
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Mitral Stenosis
2 D echo is the Gold Standard for MS
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Mitral Stenosis
Doppler echo is the
Gold Standard for
the quantification of
mitral stenosis
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Mitral Stenosis
Doppler echo is
more accurate than
conventional
catheterization
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Mitral Stenosis
Percutaneous
Mitral Balloon
Valvotomy
PMBV
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PMBV, immediate results
Doubling of MVA
50-60 % reduction gradient
Success rate 80-95%
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Mitral Stenosis
Results PMBV
Results are
even better
than for Valve
replacement
2,5
2
MVA
1,5
BMC
OMC
CMC
1
0,5
0
Base
6 months
7 yr
Farhat et al: Circ;97:245-25
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Mitral Stenosis
– PMBV: Dependent upon mitral
morphology
– Non calcified, pliable
– No commissural fusion
– Success > 90%
– Complications < 3%
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Mitral Stenosis
Asymptomatic
Mild stenosis
Mod-severe stenosis
MVA > 1.5 cm2
MVA < 1.5 cm2
Yearly exam
? Suitable for PMBV ?
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Mitral Stenosis
Asymptomatic
? Suitable for PMBV ?
Yes
No
PAP < 50
Yearly
exam
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PAP > 50
PMBV
Mitral Stenosis
Exercise induced pulmonary HTN
PMBV
Calculated
PAP
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Mitral Stenosis
Symptoms
Mild stenosis
Mod-severe stenosis
MVA > 1.5 cm2
MVA < 1.5 cm2
PAP > 60
Exercise
Pap < 60
Grad<15
Grad > 15
? Suitable
For PMBV?
Look elsewhere
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yes
PMBV
Mitral Stenosis
Symptoms
? Suitable for PMBV ?
No
Yes
Follow
Class
II
Surgery
Class III, IV
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PMBV
Mitral Stenosis
• Other issues
– Rheumatic fever prophylaxis
– Anticoagulation
– Treatment for atrial fibrillation
– Recommendations for exercise
– Pregnancy
– Cost-effective follow-up
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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
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Chronic Aortic Regurgitation 1
Preoperative prediction of survival after AVR:
Forman
Henry
Gunha
Greves
Kumpuris
Bonow
Daniel
Cormier
Shelban
1980
1980
1980
1981
1982
1985
1985
1986
1986
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#
90
50
86
45
43
80
84
73
84
Predictor
LVEF LVFS
x
x
x
x
x
x
x
x
x
LVSD
x
x
x
x
x
x
x
Chronic Aortic Regurgitation 2
Preoperative prediction of survival after AVR:
Predictor
# LVEF LVFS LVSD
Taniguchi 1987
62
x
x*
Klodas
1996
219
x
Turina
1998
192 x
x*
--------------------------------------------------------------------------------------Total
1108
*LVSV
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LV dysfunktion in valvular AR
Reversible alteration in LV loading (afterload mismatch)
versus
Irreversible LV myocardial dysfunction
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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
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Chronic AR with LV dysfunktion
Asymptomatic patients with aortic
regurgitation and LV dysfunction should
undergo operation before the onset of
symptoms and limitation of exercise
capacity
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Timing of operation for
asymptomatic AR
Management considerations:
1 Survival and functional results
after aortic valve replacement
2 Natural history of asymptomatic
patients
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Asymptomatic AR with normal
LVF
Natural history
Rate of progression to symptoms and/or LV dysfunction
n
Rate
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
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Asymptomatic AR with normal
LVF
Natural history
Likelihood of developing asymptomatic LV dysfunction
n
Mean F/U
Rate
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
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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
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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
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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
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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
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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
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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
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Chronic AR
Indications for operation:
. Symptoms
. LV systolic dysfunction
(subnormal EF at rest)
. Marked LV dilatation
(LVSD >= 55 mm; LVDD >= 75mm)
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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
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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
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Mitral Regurgitation
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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
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Recommendations for TTE in MR
Indication
Class
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
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Recommendations for TEE in
MR
Indication
Class
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 nonI
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
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Recommendations for CAG in
MR
Indication
1 When mitral valve surgery contemplated in patients with
angina or previous myocardial infarction
2 When mitral valve surgery is contemplated in patients with
>= 1 risk factor for CAD (see section VIII.B)
3 When ischemia is suspected as an etiologic factor in MR
4 To confirm noninvasive tests in patients not suspected of
having CAD
5 When mitral valve surgery is contemplated in patients aged
< 35 years and there is no clinical suspicion of CAD
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Class
I
I
I
IIb
III
Recommendations for Cine in
MR
Left ventricular and hemodynamic measurements
Indication
Class
1 When non-invasive tests are inconclusive regarding the seI
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
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Recommendations for MV surgery in non-ischemic
severe MR 1
Indication
1 Acute symptomatic MR in which repair is likely
2 Patients with NYHA functional class II, III, or IV symptoms
with normal LV function defined as EF > 0.60 and endsystolic dimension < 45 mm
3 Symptomatic or asymptomatic patients with mild LV dysfunction, ejection fraction 0.50 to 0.60, and end systolic
dimension 45 to 50 mm
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Class
I
I
I
Recommendations for MV surgery in non-ischemic
severe MR 2
Indication
4 Symptomatic or asymptomatic patients with moderate LV
dysfunction, ejection fraction 0.30 to 0.50, and/or endsystolic dimension 50 to 55 mm
5 Asymptomatic patients with preserved LV function and
atrial fibrillation
6 Asymptomatic patients with preserved LV function and
pulmonary hypertension (pulmonary artery systolic
pressure > 50 mm Hg at rest or > 60 mm Hg with exercise)
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Class
I
IIa
IIa
Recommendations for MV surgery in non-ischemic
severe MR 3
Indication
Class
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
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Recommendations for MV surgery in non-ischemic
severe MR 4
Indication
Class
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
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Chronic severe Mitral Regurgitation
Symptoms
NYHA FC II
NYHA FC I
Normal LVF
EF > 0.60 and
EDS < 45 mm
AF
PHT
Normal LVF
EF > 0.60 and
EDS < 45 mm
LV Dysfunction
EF <= 0.60 and
EDS >= 45 mm
Yes
No
Clinical eval 6 mo
Echo 12 mo
Yes
No
MVR or
repair
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MV repair
likely ?
MV
repair
MVR
Chronic severe Mitral Regurgitation
Symptoms
NYHA FC III-IV
MV repair likely
No
EF >= 0.30
Yes
MVR
No
Medical therapy
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Yes
MVR repair