EACTS Guidelines on Management of Valvular Heart Disease Flashcards
Management of coronary artery disease in patients with valvular disease (class I indications only
Coronary angiogram is recommended before valve surgery in patients with severe valvular heart disease and any of the following
1) history of coronary artery disease
2) suspected myocardial infarction
3) left ventricluar dysfunction
4) in men over age of 40 or postmenopausal
5) > 1 cardiocascular risk factor
6) All patients with consideration for secondary MR
CABG is recommended when primary indication and coronary artery diameter stenosis of >70&
IIa indication to do lesions that are between 50 and 70%
Classes of recommedations
Class I: Evidence or general agreement that a given treatment or procedure is beneficial
Class II: conflicting evidence and/or a diveregence of opinion about efficacy of treatment
IIa “should be considered” weight of evidence is in favor
IIb “may be considered” usefulness is less well established
Class III: Evidence or general agreement that given procedure causes harm “not recommended”
Indications for surgery for severe Aortic regurgitation
Symptomatic patients (Class I)
Asymptomatic patients with resting LVEF < 50% (Class I)
Patient undergoing CABG or surgery of ascending aorta, or on another valve (Class I)
Asymptomatic patients with resting LVEF > 50% with severe LV dilation (LVEDD > 70 mm, or LVESD > 50 mm or LVESD ? 25 mm.m3 BSA. (class II a)
Indications for surgery of the aortic root disease (whatever the severity of AR)
all patients who have aortic root disease with maximal ascending aortic diameter > 50 mm with Marfan Syndrome (Class I indication)
Surgery should be considered in patients who have aortic root disease with maximal ascending aortic diameter:
> 45 mm for patients with Marfan Syndrome and Risk factors
> 50 mm for patients with bicuspid valve with risk factors
> 55 mm for other patients
risk factors for Marfan pts are family history, > 2mm increase/year, desire for pregnancy, severe AR, MR
risk factors for bicuspid, coarcatation of aorta, systemic HTN, family history, aortic diameter >2mm,
Class I indications for Aortic valve replacement for Stenosis
Severe AS and any symptoms related to AS
Severe AS and undergoing CABG, surgery of the ascending aorta, or another valve
Asymptomatic patients with severe AS and systolic LV dysfunction (LVEF < 50%) not due to another cause
asymptomatic patients with severe AS and abnormal exercise test showing symptoms on exercise clearly related to AS.
Class IIa indications for Aortic valve replacement in patients with AS
High risk patients with severe symptomatic AS who are suitable for TAVI but in whom surgery is favoured by a heart team based on individual risk profile and anatomic suitability
Asymptomatic patients with severe AS and abnormal stress test showing fall in blood pressure below baseline
Moderate AS undergoing CABG or surgery of the ascending aorta or another valve
Symptomatic patients with low flow, low gradietn (<40mmHg) AS with normal EF only after careful confirmation of severe AS
symptomatic patients with severe AS, low flow, low gradient with reduced EF< and evidence of flow reserve
asymptomatic patients with normal EF and non of the above, if the surgical risk is low and one of the following is present
Very severe AS with peak transvalcular velocity of ?5.5 m/s
Severe valave calcification and a rate of peak transvalvular velocity progression of > 0.3 m/s per year
Class IIb indications for AVR in patients with Aortic stenosis
symptomatic patients with severe AS, low flow, low gradient, and LV dynsfunction without flow reserve.
Asymptomatic patients with severe AS normal EF and one of the following is present
marked elevation of natriuretic peptide levels
increase in mean pressure gradient with exerise by > 20 mmHg
Excessive LV hypertrophy in the absence of hypertension
Contraindications for Transcatheter aortic valve impltation
Absolute contraindications
Absence of a heart team and no cardiac surgery on the site
Appropriateness of TAVI as an alternative to AVR, not confirmed by a heart team
Clinical
Estimated life expectancy of < 1 year
Improvement of quality of life by TAVI unlikely because of comorbidities
Severe primary associated disease of other valves with major contribution to the patients symptoms that can treated only by surgery
Anatomical
Inadequate annulus size ( < 18 mm or > 29 mm)
Thrombus in the left ventricle
Active endocarditis
Elevated risk of coroanry ostium obstruction (asymmetric valve calcification, short distance between annulus and coronary osium, small aortic sinuses)
Plaques with mobile thrombi in the ascending aorta or arch
For transfemoral/subclavian approach: inadequate vascular acess (vessel size, calcification, tortuosity)
Relative indications
Bicuspid or non calcified valves
Untreated CAD
LVEF < 20%
Indications for transcatheter aortic valve implantation
Only be undertaken with multidisciplinary “heart team” including cardiologists and cardiac surgeons and other specialists if necessary
Only performed in hospitals with cardiac surgery on site
Patients with severe symptomatic AS who are suitable for AVR and who are likely to gain improvement in QOL and to have a life expectancy of more than 1 year after consideration of their comorbidities
IIb
“high-risk” patients with severe symptomatic AS who may still be suitable for surgery but in whom TAVI is favored by a heart team based on the individual risk profile and antomic suitability
Class I and IIa indications for surgery in severe primary mitral regurgitation
Repair should be the preferred techqniue when it is expected to be durable
symptomatic patients with LVEF > 30% and a LVESD < 55 mm
Asymptomatic patients with LV dysfunction (LVESD > 45mm and/or LVEF < 60%
Class IIa
Asymptomatic with preserved LV function and new onset of atrial fibrillation or pulmonary hypertension (systolic pulmonary pressure at rest > 50mmHg)
Asymptomatic patients with preserved LV funcation, high liklihood of durable repair, low surgical risk, and fail leaflet and LVESD > 40mm.
Severe LV dysfunction LVEF < 3-% and/or LVESD > 55 mm refractory to medical theraoy with high likelihood of durable repair
indications for mitral valve surgery in chronic secondary MR
Surgery indicated in patients with severe MR undergoing CABG and LVEF > 30% -Class I
Surgery should be considered in patients with moderate MR undergoing CABG– Class IIa
Symptomatic patients with severe MR LVEF < 30% for revascularixation and evidence of viability –Class IIa
Contraindications to percutaneous mitral commissurotomy
Mitral valve area > 1.5 cm2
Left atrial thrombus
More then mild mitral regurgitation
Severe or bicommissural calcification
Absence of commissural fusion
severe concomittant aortic vavle disease or severe combined tricuspid stenosis and regurgitation
concomitant coronary artery disease requiring bypass surgery
Indications for Tricuspid valve surgery
Class I
Symptomatic severe TS
severe TS undergoing left sided intervention
severe primary or secondary TR undergoing left sided surgery
symptomatic patients with severe isolated primary TR without severe right ventricular dysfunction
Class IIA
moderate primary TR undergoing left sided surgery
mild or moderate TR with dilated annulus (>40 mm) undergoing left sided surgery
asymptomatic severe islated primary TR and progressive right ventricular dilation or right ventricular function
after left sided surgery in patients with severe TR who are symptomatic or have progressive right ventricular dysfunction in the absence of left sided valve dysfunction, severe right or left ventriculr dysfunction and severe pulmonary vascular disease.
