Sandbox:Arzu
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Aortic Stenosis Microchapters |
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Diagnosis |
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Treatment |
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Percutaneous Aortic Balloon Valvotomy (PABV) or Aortic Valvuloplasty |
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Transcatheter Aortic Valve Replacement (TAVR) |
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Case Studies |
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Sandbox:Arzu On the Web |
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American Roentgen Ray Society Images of Sandbox:Arzu |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Arzu Kalayci, M.D. [2]
Overview
2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease (VHD) [1][2]
Aortic Stenosis
Choice of Intervention
| COR | LOE | RECOMMENDATION | COMMENT/RATIONALE |
|---|---|---|---|
| I | C | For patients in whom TAVR or high-risk surgical AVR is being considered, a heart valve team consisting of an integrated, multidisciplinary group of healthcare professionals with expertise in VHD, cardiac imaging, interventional cardiology, cardiac anesthesia, and cardiac surgery should collaborate to provide optimal patient care. | 2014 recommendation remains current. |
| I | B-NR | Surgical AR is recommended for symptomatic patients with severe AS (Stage D) and asymptomatic patients with severe AS (Stage C) who meet an indication for AVR when surgical risk is low or intermediate. | MODIFIED: LOE updated from A to B-NR. Prior recommendations for intervention choice did not specify patient symptoms. The patient population recommended for surgical AVR encompasses both symptomatic and asymptomatic patients who meet an indication for AVR with low-to-intermediate surgical risk. This is opposed to the patient population recommended for TAVR, in whom symptoms are required to be present. Thus, all recommendations for type of intervention now specify the symptomatic status of the patient. |
| I | A | Surgical AVR or TAVR is recommended for symptomatic patients with severe AS (Stage D) and high risk for surgical AVR, depending on patient specific procedural risks, values, and preferences. | MODIFIED: COR updated from IIa to I, LOE updated from B to A. Longer-term follow-up and additional RCTs have demonstrated that TAVR is equivalent to surgical AVR for severe symptomatic AS when surgical risk is high. |
| I | A | TAVR is recommended for symptomatic patients with severe AS (Stage D) and a prohibitive risk for surgical AVR who have a predicted post-TAVR survival greater than 12 months. | MODIFIED: LOE updated from B to A. Longer-term follow-up from RCTs and additional observational studies has demonstrated the benefit of TAVR in patients with a prohibitive surgical risk. |
| IIa | B-R | TAVR is a reasonable alternative to surgical AVR for symptomatic patients with severe AS (Stage D) and an intermediate surgical risk, depending on patient-specific procedural risks, values, and preferences. | NEW: New RCT showed noninferiority of TAVR to surgical AVR in symptomatic patients with severe AS at intermediate surgical risk. |
| IIb | C | Percutaneous aortic balloon dilation may be considered as a bridge to surgical AVR or TAVR for symptomatic patients with severe AS. | 2014 recommendation remains current. |
| III: No Benefit | C | TAVR is not recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of AS. | 2014 recommendation remains current. |
References
- ↑ Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Fleisher LA, Jneid H, Mack MJ, McLeod CJ, O'Gara PT, Rigolin VH, Sundt TM, Thompson A (2017). "2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". Circulation. 135 (25): e1159–e1195. doi:10.1161/CIR.0000000000000503. PMID 28298458.
- ↑ Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Fleisher LA, Jneid H, Mack MJ, McLeod CJ, O'Gara PT, Rigolin VH, Sundt TM, Thompson A (2017). "2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". J. Am. Coll. Cardiol. 70 (2): 252–289. doi:10.1016/j.jacc.2017.03.011. PMID 28315732.
2017 ESC/EACTS Guidelines for the management of valvular heart disease [1]
Aortic Stenosis
Choice of Intervention
Aspects to be considered by the Heart Team for decision between SAVR and TAVI in patients at increased surgical risk
| FAVOURS TAVI | FAVOURS SAVR | |
|---|---|---|
| Clinical Characteristics | ||
| STS/EuroSCORE II <4% (logistic EuroSCORE I <10%) | + | |
| STS/EuroSCORE II ≥4% (logistic EuroSCORE I ≥10%) | + | |
| Presence of severe comorbidity ( not adequately reflected by scores) | + | |
| Age <75 | + | |
| Age ≥75 | + | |
| Previous cardiac surgery | + | |
| Frailty | + | |
| Restricted mobility and conditions that may affect the rehabilitation process after the procedure | + | |
| Suspicion of endocarditis | + | |
| Anatomical and technical aspects | ||
| Favourable access for transferral TAVI | + | |
| Sequelae of chest radiation | + | |
| Porcelain aorta | + | |
| Presence of intact coronary bypass grafts at risk when sternotomy is performed | + | |
| Expected patients-Prosthesis mismatch | + | |
| Severe chest deformation or scoliosis | + | |
| Short distance between coronary ostia and aortic valve annulus | + | |
| Size of aortic valve annulus out of range for TAVI | + | |
| Valve morphology (bicuspid, degree of calcification, calcification pattern) unfavourable for TAVI | + | |
| Presence of thrombi in aorta or LV | + | |
| Cardiac conditions in addition to aortic stenosis that require consideration for concomitant intervention | ||
| Severe CAD requiring revascularisation by CABG | + | |
| Severe primary mitral valve disease, which could be treated surgically | + | |
| Severe tricuspid valve disease | + | |
| Aneurysm of the ascending aorta | + | |
| Septal hypertrophy requiring myectomy | + |
References
- ↑ Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, Iung B, Lancellotti P, Lansac E, Muñoz DR, Rosenhek R, Sjögren J, Tornos Mas P, Vahanian A, Walther T, Wendler O, Windecker S, Zamorano JL (2017). "2017 ESC/EACTS Guidelines for the management of valvular heart disease". Eur. Heart J. 38 (36): 2739–2791. doi:10.1093/eurheartj/ehx391. PMID 28886619.
Recommendation for IE Prophylaxis
| COR | LOE | RECOMMENDATION | COMMENT/RATIONALE |
|---|---|---|---|
| IIa | L-CD | Prophylaxis against IE is reasonable before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa in patients with the following (13,15,23–29):
1. Prosthetic cardiac valves, including transcatheter- implanted prostheses and homografts. 2. Prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords. 3. Previous IE. 4. Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device. 5. Cardiac transplant with valve regurgitation due to a structurally abnormal valve. || MODIFIED: LOE updated from B to C-LD. Patients with transcatheter prosthetic valves and patients with prosthetic material used for valve repair, such as annuloplasty rings and chords, were specifically identified as those to whom it is reasonable to give IE prophylaxis. This addition is based on observational studies demonstrating the increased risk of developing IE and high risk of adverse outcomes from IE in these subgroups. Categories were rearranged for clarity to the caregiver. |
Recommendation for Anticoagulation for Atrial Fibrillation (AF) in patients with VHD
| COR | LOE | RECOMMENDATION | COMMENT/RATIONALE |
|---|---|---|---|
| I | B-NR | Anticoagulation with a vitamin K antagonist (VKA) is indicated for patients with rheumatic mitral stenosis (MS) and AF | MODIFIED: VKA as opposed to the direct oral anticoagulants (DOACs) are indicated in patients with AF and rheumatic MS to prevent thromboembolic events. The RCTs of DOACs versus VKA have not included patients with MS. The specific recommendation for anticoagulation of patients with MS is contained in a subsection of the topic on anticoagulation. |
| I | L-CD | Anticoagulation is indicated in patients with AF and a CHA2DS2-VASc score of 2 or greater with native aortic valve disease, tricuspid valve disease, or mitral regurgitation. | NEW: Post hoc subgroup analyses of large RCTs comparing DOAC versus warfarin in patients with AF have analyzed patients with native valve disease other
than MS and patients who have undergone cardiac surgery. These analyses consistently demonstrated that the risk of stroke is similar to or higher than that of patients without VHD. Thus, the indication for anticoagulation in these patients should follow GDMT according to the CHA2DS2-VASc score. |
| IIa | L-CD | It is reasonable to use a DOAC as an alternative to a VKA in patients with AF and native aortic valve disease, tricuspid valve disease, or MR and a CHA2DS2-VASc score of 2 or greater. | NEW: Several thousand patients with native VHD (exclusive of more than mild rheumatic MS) have been evaluated in RCTs comparing DOACs versus warfarin. Subgroup analyses have demonstrated that DOACs, when compared with warfarin, appear as effective and safe in patients with VHD as in those without VHD. |
Recommendations for Chronic Primary Mitral Regurgitation (MR) Intervention
| COR | LOE | RECOMMENDATION | COMMENT/RATIONALE |
|---|---|---|---|
| I | B | Mitral valve surgery is recommended for symptomatic patients with chronic severe primary MR (stage D) and LVEF greater than 30%. | 2014 recommendation remains current. |
| I | B | Mitral valve surgery is recommended for asymptomatic patients with chronic severe primary MR and LV dysfunction (LVEF 30% to 60% and/or left ventricular end-systolic diameter [LVESD] ≥40 mm, stage C2) | 2014 recommendation remains current. |
| I | B | Mitral valve repair is recommended in preference to MVR when surgical treatment is indicated for patients with chronic severe primary MR limited to the posterior leaflet. | 2014 recommendation remains current. |
| I | B | Mitral valve repair is recommended in preference to MVR when surgical treatment is indicated for patients with chronic severe primary MR involving the anterior leaflet or both leaflets when a successful and durable repair can be accomplished. | 2014 recommendation remains current. |
| I | B | Concomitant mitral valve repair or MVR is indicated in patients with chronic severe primary MR undergoing cardiac surgery for other indications. | 2014 recommendation remains current. |
| IIa | B | Mitral valve repair is reasonable in asymptomatic patients with chronic severe primary MR (stage C1) with preserved LV function (LVEF >60% and LVESD <40 mm) in whom the likelihood of a successful and durable repair without residual MR is greater than 95% with an expected mortality rate of less than 1% when performed at a Heart Valve Center of Excellence. | 2014 recommendation remains current. |
| IIa | L-CD | Mitral valve surgery is reasonable for asymptomatic patients with chronic severe primary MR (stage C1) and preserved LV function (LVEF >60% and LVESD <40 mm) with a progressive increase in LV size or decrease in ejection fraction (EF) on serial imaging studies. | NEW: Patients with severe MR who reach an EF ≤60% or LVESD ≥40 have already developed LV systolic dysfunction, so operating before reaching these parameters, particularly with a progressive increase in LV size or decrease in EF on serial studies, is reasonable. |
| IIa | B | Mitral valve repair is reasonable for asymptomatic patients with chronic severe nonrheumatic primary MR (stage C1) and preserved LV function (LVEF >60% and LVESD <40 mm) in whom there is a high likelihood of a successful and durable repair with 1) new onset of AF or 2) resting pulmonary hypertension (pulmonary artery systolic arterial pressure >50 mm Hg). | 2014 recommendation remains current. |
| IIa | C | Concomitant mitral valve repair is reasonable in patients with chronic moderate primary MR (stage B) when undergoing cardiac surgery for other indications. | 2014 recommendation remains current. |
| IIb | C | Mitral valve surgery may be considered in symptomatic patients with chronic severe primary MR and LVEF less than or equal to 30%. | 2014 recommendation remains current. |
| IIb | B | Transcatheter mitral valve repair may be considered for severely symptomatic patients (NYHA class III to IV) with chronic severe primary MR (stage D) who have favorable anatomy for the repair procedure and a reasonable life expectancy but who have a prohibitive surgical risk because of severe comorbidities and remain severely symptomatic despite optimal GDMT for heart failure (HF). | 2014 recommendation remains current. |
| IIb | B | Transcatheter mitral valve repair may be considered for severely symptomatic patients (NYHA class III to IV) with chronic severe primary MR (stage D) who have favorable anatomy for the repair procedure and a reasonable life expectancy but who have a prohibitive surgical risk because of severe comorbidities and remain severely symptomatic despite optimal GDMT for heart failure (HF). | 2014 recommendation remains current. |
| III:Harm | B | MVR should not be performed for the treatment of isolated severe primary MR limited to less than one half of the posterior leaflet unless mitral valve repair has been attempted and was unsuccessful. | 2014 recommendation remains current. |
Recommendations for Chronic Secondary Mitral Regurgitation (MR) Intervention
| COR | LOE | RECOMMENDATION | COMMENT/RATIONALE |
|---|---|---|---|
| IIa | C | Mitral valve surgery is reasonable for patients with chronic severe secondary MR (stages C and D) who are undergoing CABG or AVR. | 2014 recommendation remains current. |
| IIa | B-R | It is reasonable to choose chordal-sparing MVR over downsized annuloplasty repair if operation is considered for severely symptomatic patients (NYHA class III to IV) with chronic severe ischemic MR (stage D) and persistent symptoms despite GDMT for HF. | NEW: An RCT has shown that mitral valve repair is associated with a higher rate of recurrence of moderate or severe MR than that associated with mitral valve replacement (MVR) in patients with severe, symptomatic, ischemic MR, without a difference in mortality rate at 2 years' follow-up. |
| IIb | B | Mitral valve repair or replacement may be considered for severely symptomatic patients (NYHA class III to IV) with chronic severe secondary MR (stage D) who have persistent symptoms despite optimal GDMT for HF. | 2014 recommendation remains current. |
| IIb | B-R | In patients with chronic, moderate, ischemic MR (stage B) undergoing CABG, the usefulness of mitral valve repair is uncertain. | MODIFIED: LOE updated from C to B-R. The 2014 recommendation supported mitral valve repair in this group of patients. An RCT showed no clinical benefit of mitral repair in this population of patients, with increased risk of postoperative complications. |