Valvular heart disease surgery

Valvular heart disease Microchapters
Patient Information
Classification Aortic stenosis Aortic regurgitation Mitral stenosis Mitral valve prolapse Mitral regurgitation Tricuspid stenosis Tricuspid regurgitation Pulmonary stenosis Pulmonary regurgitation
Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]

Overview

The following section discusses the recommendations for patients with valvular heart disease undergoing surgery and other procedures. For more information about the specific surgical intervention for each valvular pathology, refer to to any of the following:

• Aortic stenosis
• Aortic regurgitation
• Pulmonary stenosis
• Pulmonary regurgitation
• Mitral stenosis
• Mitral regurgitation
• Tricuspid stenosis
• Tricuspid regurgitation

2014 AHA/ACC Guideline for The Management of Patients with Valvular Heart Disease

Surgical Considerations: Recommendations

Evaluation of Coronary Anatomy

Class I

"1. Coronary angiography is indicated before valve intervention in patients with symptoms of angina, objective evidence of ischemia, decreased LV systolic function, history of CAD, or coronary risk factors (including men age >40 years and post- menopausal women).(Level of Evidence: C)"

"2. Coronary angiography should be performed as part of the evaluation of patients with chronic severe secondary MR.(Level of Evidence: C)"

Class IIa

"1. Surgery without coronary angiography is reasonable for patients having emergency valve surgery for acute valve regurgitation, disease of the aortic sinuses or ascending aorta, or IE. (Level of Evidence: C)"

"2. CT coronary angiography is reasonable to exclude the presence of significant obstructive CAD in selected patients with a low/ intermediate pretest probability of CAD. A positive coronary CT angiogram (the presence of any epicardial CAD) can be confirmed with invasive coronary angiography (Level of Evidence: B)"

Concomitant Procedures

Intervention for CAD

Class IIa

"1. CABG or percutaneous coronary intervention is reasonable in patients undergoing valve repair or replacement with significant CAD (≥70% reduction in luminal diameter in major coronary arteries or ≥50% reduction in luminal diameter in the left main coronary artery). (Level of Evidence: C)"

Intervention for AF

Class IIa

"1. A concomitant maze procedure is reasonable at the time of mitral valve repair or replacement for treatment of chronic, persistent AF. (Level of Evidence: C)"

"2. A full biatrial maze procedure, when technically feasible, is reasonable at the time of mitral valve surgery, compared with a lesser ablation procedure, in patients with chronic, persistent AF (Level of Evidence: B)"

Class IIb

"1. A concomitant maze procedure or pulmonary vein isolation may be considered at the time of mitral valve repair or replacement in patients with paroxysmal AF that is symptomatic or associated with a history of embolism on anticoagulation. (Level of Evidence: C)"

"2. Concomitant maze procedure or pulmonary vein isolation may be considered at the time of cardiac surgical procedures other than mitral valve surgery in patients with paroxysmal or persistent AF that is symptomatic or associated with a history of emboli on anticoagulation (Level of Evidence: C)"

Class III (No Benefit)

"1. Catheter ablation for AF should not be performed in patients with severe MR when mitral repair or replacement is anticipated, with preference for the combined maze procedure plus mitral valve repair(Level of Evidence: B)"

Noncardiac Surgery in Patients With VHD: Recommendations

Class IIa

"1. Moderate-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe AS (Level of Evidence: B)"

"2. Moderate-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe MR. (Level of Evidence: C)"

"3. Moderate-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe AR and a normal LVEF. (Level of Evidence: C)"

Class IIb

"1. Moderate-risk elective noncardiac surgery in patients with appropriate intraoperative and postoperative hemodynamic monitoring may be reasonable to perform in asymptomatic patients with severe MS if valve morphology is not favorable for percutaneous balloon mitral commissurotomy (Level of Evidence: C)"

2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT)

Diagnosis of Coronary Artery Disease before the Surgery (DO NOT EDIT)

Class I

"1. Coronary angiography is indicated before valve surgery (including infective endocarditis) or mitral balloon commissurotomy in patients with chest pain, other objective evidence of ischemia, decreased LV systolic function, history of CAD, or coronary risk factors (including age). Patients undergoing mitral balloon valvotomy need not undergo coronary angiography solely on the basis of coronary risk factors. (Level of evidence: C)"

"2. Coronary angiography is indicated in patients with apparently mild to moderate valvular heart disease but with progressive angina (Canadian Heart Association functional Class II or greater), objective evidence of ischemia, decreased LV systolic function, or overt congestive heart failure. (Level of evidence: C)"

"3. Coronary angiography should be performed before valve surgery in men aged 35 years or older, premenopausal women aged 35 years or older who have coronary risk factors, and postmenopausal women. (Level of evidence: C)"

Class III

"1. Coronary angiography is not indicated in young patients undergoing nonemergency valve surgery when no further hemodynamic assessment by catheterization is deemed necessary and there are no coronary risk factors, no history of CAD, and no evidence of ischemia. (Level of evidence C)"

"2. Patients should not undergo coronary angiography before valve surgery if they are severely hemodynamically unstable. (Level of evidence C)"

Class IIa

"1. Surgery without coronary angiography is reasonable for patients having emergency valve surgery for acute valve regurgitation, aortic root disease, or infective endocarditis. (Level of evidence C)"

Class IIb

"1. Coronary angiography may be considered for patients undergoing catheterization to confirm the severity of valve lesions before valve surgery without pre-existing evidence of CAD, multiple coronary risk factors, or advanced age. (Level of evidence C)"

Sources

• 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease