Cardiology overview valvular heart disease

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Mitral Valve Repair Versus Mitral Valve Replacement

  • Mitral valve repair is preferred over mitral valve replacement given the preservation of the chordal structures and the improved survival following the procedure.

Indications for mitral valve replacement/repair for Mitral Regurgitation according to ACC/AHA Guidelines[1]

“

Class I

1. Mitral valve surgery is recommended for the symptomatic patient with acute severe mitral regurgitation. (Level of Evidence: B)

2. Mitral valve surgery is beneficial for patients with chronic severe mitral regurgitation and NYHA functional class II, III, or IV symptoms in the absence of severe LV dysfunction (severe LV dysfunction is defined as ejection fraction less than 0.30) and/or end-systolic dimension greater than 55 mm. (Level of Evidence: B)

3. Mitral valve surgery is beneficial for asymptomatic patients with chronic severe mitral regurgitation and mild to moderate LV dysfunction, ejection fraction 0.30 to 0.60, and/or end-systolic dimension greater than or equal to 40 mm. (Level of Evidence: B)

4. Mitral valve repair is recommended over mitral valve replacement in the majority of patients with severe chronic mitral regurgitation who require surgery, and patients should be referred to surgical centers experienced in Mitral valve repair. (Level of Evidence: C)

Class IIa

1. Mitral valve repair is reasonable in experienced surgical centers for asymptomatic patients with chronic severe mitral regurgitation with preserved LV function (ejection fraction greater than 0.60 and end-systolic dimension less than 40 mm) in whom the likelihood of successful repair without residual mitral regurgitation is greater than 90%. (Level of Evidence: B)

2. Mitral valve surgery is reasonable for asymptomatic patients with chronic severe mitral regurgitation, preserved LV function, and new onset of atrial fibrillation. (Level of Evidence: C)

3. Mitral valve surgery is reasonable for asymptomatic patients with chronic severe mitral regurgitation, preserved LV function, and pulmonary hypertension (pulmonary artery systolic pressure greater than 50 mm Hg at rest or greater than 60 mm Hg with exercise). (Level of Evidence: C)

4. Mitral valve surgery is reasonable for patients with chronic severe mitral regurgitation due to a primary abnormality of the mitral apparatus and NYHA functional class III–IV symptoms and severe LV dysfunction (ejection fraction less than 0.30 and/or end-systolic dimension greater than 55 mm) in whom Mitral valve repair is highly likely. (Level of Evidence: C)

Class IIb

1. Mitral valve repair may be considered for patients with chronic severe secondary mitral regurgitation due to severe LV dysfunction (ejection fraction less than 0.30) who have persistent NYHA functional class III–IV symptoms despite optimal therapy for heart failure, including biventricular pacing. (Level of Evidence: C)

Class III

1. Mitral valve surgery is not indicated for asymptomatic patients with mitral regurgitation and preserved LV function (ejection fraction greater than 0.60 and end-systolic dimension less than 40 mm) in whom significant doubt about the feasibility of repair exists. (Level of Evidence: C)

2. Isolated Mitral valve surgery is not indicated for patients with mild or moderate mitral regurgitation. (Level of Evidence: C)

”


Indications for mitral valve replacement/repair for Mitral Stenosis according to ACC/AHA Guidelines [1]

“

Class I

1. Mitral valve surgery (repair if possible) is indicated in patients with symptomatic (NYHA functional class III–IV) moderate or severe mitral stenosis when

a) percutaneous mitral balloon valvotomy is unavailable,
b) percutaneous mitral balloon valvotomy is contraindicated because of left atrial thrombus despite anticoagulation or because concomitant moderate to severe mitral regurgitation is present, or
c) the valve morphology is not favorable for percutaneous mitral balloon valvotomy in a patient with acceptable operative risk. (Level of Evidence: B)

2. Symptomatic patients with moderate to severe mitral stenosis who also have moderate to severe mitral regurgitation should receive Mitral valve replacement, unless valve repair is possible at the time of surgery. (Level of Evidence: C)

Class IIa

1. Mitral valve replacement is reasonable for patients with severe mitral stenosis and severe pulmonary hypertension (pulmonary artery systolic pressure greater than 60 mm Hg) with NYHA functional class I–II symptoms who are not considered candidates for percutaneous mitral balloon valvotomy or surgical mitral valve repair. (Level of Evidence: C)

Class IIb

1. Mitral valve repair may be considered for asymptomatic patients with moderate or severe mitral stenosis who have had recurrent embolic events while receiving adequate anticoagulation and who have valve morphology favorable for repair. (Level of Evidence: C)

Class III

1. Mitral valve repair for mitral stenosis is not indicated for patients with mild stenosis. (Level of Evidence: C)

2. Closed commissurotomy should not be performed in patients undergoing mitral valve repair; open commissurotomy is the preferred approach. (Level of Evidence: C)

”

Indications for aortic valve replacement (AVR) for Aortic Stenosis according to ACC/AHA Guidelines[1]

“

Class I

1. AVR is indicated for symptomatic patients with severe aortic stenosis. (Level of Evidence: B)

2. AVR is indicated for patients with severe aortic stenosis undergoing coronary artery bypass graft surgery (CABG). (Level of Evidence: C)

3. AVR is indicated for patients with severe aortic stenosis undergoing surgery on the aorta or other heart valves. (Level of Evidence: C)

4. AVR is recommended for patients with severe aortic stenosis and LV systolic dysfunction (ejection fraction less than 0.50). (Level of Evidence: C)

Class IIa

1. AVR is reasonable for patients with moderate aortic stenosis undergoing CABG or surgery on the aorta or other heart valves (see Section 3.7 on combined multiple valve disease and Section 10.4 on AVR in patients undergoing CABG). (Level of Evidence: B)

Class IIb

1. AVR may be considered for asymptomatic patients with severe aortic stenosis 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 aortic stenosis 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 aortic stenosis 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 aortic stenosis (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)

Class III

1. AVR is not useful for the prevention of sudden death in asymptomatic patients with aortic stenosis who have none of the findings listed under the Class IIa/IIb recommendations. (Level of Evidence: B)

”

Indications for aortic valve replacement/repair(AVR) in Chronic Aortic Insufficiency according to ACC/AHA Guidelines[1]

  • Aortic insufficiency with reduced ejection fraction is a class I indication for aortic valve replacement.
  • Aortic insufficiency with symptoms is a class I indication for aortic valve replacement.
  • Aortic insufficiency with no symptoms and preserved EF is a class III contraindication for aortic valve replacement if the cavitary dimensions are not dilated (LV diastolic > 7.5 cm or LV systolic > 5.5 cm).
“

Class I

1.AVR is indicated for symptomatic patients with severe aortic insufficiency irrespective of left ventricular systolic function. (Level of Evidence: B)

2.AVR is indicated for asymptomatic patients with chronic severe aortic insufficiency and left ventricular systolic dysfunction (ejection fraction 50% or less) at rest.(Level of Evidence: B)

3.AVR is indicated for patients with chronic severe aortic insufficiency while undergoing coronary artery bypass graft(CABG) or surgery on the aorta or other heart valves.(Level of Evidence: C)

Class IIa

1. AVR is reasonable for asymptomatic patients with severe aortic insufficiency with normal left ventricular systolic function (ejection fraction greater than 50%) but with severe left ventricular dilatation (end-diastolic dimension greater than 75 mm or end-systolic dimension greater than 55 mm). (Level of Evidence: B)

Class IIb

1.AVR may be considered in patients with moderate aortic insufficiency while undergoing surgery on the ascending aorta.(Level of Evidence: C)

2.AVR may be considered in patients with moderate aortic insufficiency while undergoing CABG. (Level of Evidence: C)

3.AVR may be considered for asymptomatic patients with severe aortic insufficiency and normal left ventricular systolic function at rest (ejection fraction greater than 50%) when the degree of left ventricular dilatation exceeds an end-diastolic dimension of 70mm or end-systolic dimension of 50 mm, when there is evidence of progressive left ventricular dilatation, declining exercise tolerance, or abnormal hemodynamic responses to exercise. (Level of Evidence: C)

Class III

1.AVR is not indicated for asymptomatic patients with mild, moderate, or severe aortic insufficiency and normal left ventricular systolic function at rest (ejection fraction greater than 50%) when the degree of dilatation is not moderate or severe (end-diastolic dimension less than 70 mm, end-systolic dimension less than 50 mm). (Level of Evidence: B)

”

Symptomatic patients even with mild to moderate left ventricular systolic dysfunction (ejection fraction 25%- 50%) should also undergo AVR. AHA/ACC guidelines[2] recommends that patients with NYHA Class II and III symptoms should undergo valve replacement if:

“
  1. symptoms and evidence of left ventricular dysfunction are of recent onset
  2. intensive short-term therapy with vasodilators and diuretics results in symptomatic improvement
  3. intravenous positive inotropic agents result in substantial improvement in hemodynamics or systolic function.
 ”

Bridging Therapy in the Patient with a Prosthetic Valve

  • Patients with a prosthetic mitral valve are at higher risk of thrombosis than the patient with a prosthetic valve in the aortic position. Mitral valve patients therefore need a careful bridging strategy.

Antibiotic Prophylaxis to Prevent Infective Endocarditis

The AHA now recommends the administration of pre-endodontic procedural prophylactic antibiotics to patients with the highest risk of adverse outcomes subsequent to the development of endocarditis[3]:

  • Patients with unrepaired cyanotic congenital heart disease in which shunts and conduits are present
  • Patients who have undergone complete repair of a congential heart defect within the past 6 months
  • Patient with repaired congenital heart disease with residual defects at the site of a prosthetic patch or device

The following endodontal procedures require coverage in this high risk population:

  • Any type of dental extractions
  • Any type of periodontal procedures and gingival surgery
    • Placement of dental implants and avulsed teeth replantation
    • Dental canal or root surgery
    • Antibiotic fibres or strips placement at subgingival area
    • Initial placement of orthodontic brackets
    • Intraligamentous injection of local anesthetic drugs
    • Bleeding during prophylactic cleaning of teeth or implants

References

  1. ↑ 1.0 1.1 1.2 1.3 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". J Am Coll Cardiol. 52 (13): e1–142. doi:10.1016/j.jacc.2008.05.007. PMID 18848134.
  2. ↑ 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 2011-03-28. Unknown parameter |month= ignored (help)
  3. ↑ Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT (2007). "American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group". Circulation. 116 (15): 1736–54. PMID 17446442.

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