Aortic stenosis surgery indications: Difference between revisions

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/* 2008 Focused Update Incorporated Into the 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT) {{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, et al. |title=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
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{{Aortic stenosis surgery}}
{{Aortic stenosis surgery}}


{{CMG}}; '''Associate Editor-In-Chief:''' [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:msbeih@wikidoc.org]; {{USAMA}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{Sara.Zand}} [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:msbeih@wikidoc.org]; {{USAMA}}
{{SK}} As; Aortic stenosis; AVR; Aortic valve replacement; LVEF; Left ventricular ejection fraction; LV; Left ventricle


==Overview==
==Overview==
Aortic stenosis requires aortic valve replacement if medical management does not successfully control symptoms.
In symptomatic [[patients]] with severe high-gradient [[AS]] (Stage D1), [[AVR]] has beneficial effect on [[survival]], [[symptoms]], and [[LV systolic function]]. In asymptomatic [[patients]] with [[severe AS]] and normal [[LV]] [[systolic function]], the risk of [[sudden death]] (<1% per year) is low. In [[patients]] with a low [[LVEF]] and severe [[AS]], [[survival]] is better with [[AVR]] than [[medical therapy]].
According to a prospective, single-center, nonrandomized study of 25 patients, percutaneous implantation of an aortic valve prosthesis in high risk patients with aortic stenosis results in marked hemodynamic and clinical improvement when successfully completed.<ref>{{cite journal |author=Grube E, Laborde JC, Gerckens U, ''et al'' |title=Percutaneous implantation of the CoreValve self-expanding valve prosthesis in high-risk patients with aortic valve disease: the Siegburg first-in-man study |journal=Circulation |volume=114 |issue=15 |pages=1616-24 |year=2006 |pmid=17015786 |doi=10.1161/CIRCULATIONAHA.106.639450}}</ref>


==Indications==
==Indications==
* in [[symptomatic]] [[patients]] with severe [[high-gradient]] [[AS]] (Stage D1), [[AVR]] has beneficial effects on [[survival]], [[symptoms]], and [[LV systolic function]].
* In [[symptomatic]] [[patients]] with severe [[high-gradient]] [[AS]] (Stage D1), [[AVR]] has beneficial effects on [[survival]], [[symptoms]], and [[LV systolic function]].
* The most common initial symptom of [[ AS]] is [[exertional dyspnea]] or decreased [[exercise tolerance]].
* The most common initial [[symptom]] of [[ AS]] is [[exertional dyspnea]] or decreased [[exercise tolerance]].
* More severe classical symptoms of [[AS]], including [[HF]], [[syncope]], or [[angina]], can be avoided by appropriate treatment at the onset of even mild symptoms.
* More severe classical symptoms of [[AS]], including [[HF]], [[syncope]], or [[angina]], can be avoided by appropriate treatment at the onset of even mild symptoms.
* [[Outcomes]] after [[surgical]] or [[transcatheter]] [[AVR]] are excellent.
* [[Outcomes]] after [[surgical]] or [[transcatheter]] [[AVR]] are excellent.
* Improvement in [[exercise tolerance]] has been shown by [[exercise test]] after [[AVR]].
* Improvement in [[exercise tolerance]] has been shown by [[exercise test]] after [[AVR]].
*In [[asymptomatic]] [[patients]] with severe [[AS]] and normal [[LV systolic function]], the [[survival rate]] during the asymptomatic phase is similar to that of age-matched controls, with a low risk of [[sudden death]] (<1% per year). However, in [[patients]] with a low [[LVEF]] and severe [[AS]], survival is better in those who undergo [[AVR]] than in those treated medically.
*In [[asymptomatic]] [[patients]] with severe [[AS]] and normal [[LV systolic function]], the risk of [[sudden death]] is low (<1% per year). However, in [[patients]] with a low [[LVEF]] and severe [[AS]], [[survival]] is better in those who undergo [[AVR]] than in those treated medically.<ref name="pmid10965007">{{cite journal |vauthors=Rosenhek R, Binder T, Porenta G, Lang I, Christ G, Schemper M, Maurer G, Baumgartner H |title=Predictors of outcome in severe, asymptomatic aortic stenosis |journal=N Engl J Med |volume=343 |issue=9 |pages=611–7 |date=August 2000 |pmid=10965007 |doi=10.1056/NEJM200008313430903 |url=}}</ref>
* [[Disease]] progression occurs in nearly all [[patients]] with severe asymptomatic [[AS]]. Initiation of [[symptoms]]  within 2 to 5 years is likely when [[aortic]] velocity is ≥4.0 m/s or [[mean pressure gradient]] is ≥40 mm Hg.
* [[Disease]] progression occurs in nearly all [[patients]] with severe asymptomatic [[AS]]. Initiation of [[symptoms]]  within 2 to 5 years is likely when [[aortic]] velocity is ≥4.0 m/s or [[mean pressure gradient]] is ≥40 mm Hg.
*Mean [[pressure gradient]] is a strong predictor of outcome after [[AVR]], with better outcomes seen in [[patients]] with higher [[gradients]].
*Mean [[pressure gradient]] is a strong predictor of outcome after [[AVR]], with better outcomes seen in [[patients]] with higher [[gradients]].
* [[Outcomes]] are poor with severe [[low-gradient]] [[AS]] but are still better with [[AVR]] than with medical therapy in those with a low [[LVEF]], especially in the presence of [[contractile reserve]].
* [[Outcomes]] are poor with severe [[low-gradient]] [[AS]] but are still better with [[AVR]] than with medical therapy in those with a low [[LVEF]], especially in the presence of [[contractile reserve]].
*  Severe [[AS]] on [[dobutamine stress testing]]  is defined when a maximum [[velocity]] >4.0 m/s with a [[valve area]] ≤1.0 cm2 at any point during the test protocol, with a maximum dobutamine dose of 20 mcg/kg per minute.
*  Severe [[AS]] on [[dobutamine stress testing]]  is defined when a maximum [[velocity]] >4.0 m/s with a [[valve area]] ≤1.0 cm2 at any point during the test protocol, with a maximum [[dobutamine]] dose of 20 mcg/kg per minute.
* [[Out come]] in [[patients]] without contractil reserve is poor with either [[surgical]] or [[medical therapy]].
* [[Outcome]] in [[patients]] without contractil reserve is poor with either [[surgical]] or [[medical therapy]].
* [[LVEF]] typically increases by 10 [[LVEF]] units and may return to normal if [[afterload]] mismatch was the cause of [[LV systolic dysfunction]].
* In [[patients]] undergone [[AVR]], [[LVEF]] typically increases by 10 [[LVEF]] units and may return to normal if [[afterload]] mismatch was the cause of [[LV systolic dysfunction]].
* Low-flow, low-gradient severe [[AS]] with preserved [[LVEF]] should be considered in [[patients]] with a severely calcified [[aortic valve]], an [[aortic velocity]] <4.0 m/s (mean [[pressure gradient]] <40 mm Hg), and a [[valve area]] ≤1.0 cm2, [[stroke volume index]] <35 mL/m2, small [[LV cavity]] with thick walls, [[diastolic dysfunction]], and a normal [[LVEF]] (≥50%).
* Low-flow, low-gradient severe [[AS]] with preserved [[LVEF]] should be considered in [[patients]] with a severely calcified [[aortic valve]], an [[aortic velocity]] <4.0 m/s (mean [[pressure gradient]] <40 mm Hg), and a [[valve area]] ≤1.0 cm2, [[stroke volume index]] <35 mL/m2, presence of small [[LV cavity]] with thick walls, [[diastolic dysfunction]], and a normal [[LVEF]] (≥50%).<ref name="pmid19442886">{{cite journal |vauthors=Tribouilloy C, Lévy F, Rusinaru D, Guéret P, Petit-Eisenmann H, Baleynaud S, Jobic Y, Adams C, Lelong B, Pasquet A, Chauvel C, Metz D, Quéré JP, Monin JL |title=Outcome after aortic valve replacement for low-flow/low-gradient aortic stenosis without contractile reserve on dobutamine stress echocardiography |journal=J Am Coll Cardiol |volume=53 |issue=20 |pages=1865–73 |date=May 2009 |pmid=19442886 |doi=10.1016/j.jacc.2009.02.026 |url=}}</ref>
* If [[hypertension]] is present, [[blood pressure]]  should is controlled before reevaluation of [[AS]] severity.
* If [[hypertension]] is present, [[blood pressure]]  should is controlled before reevaluation of [[AS]] severity.
*[[Valve area]] is indexed to [[body]] size because an apparent small [[valve area]] may be only moderate [[AS]] in a small [[patient]].
* [[Valve area]] is indexed to [[body]] size because an apparent small [[valve area]] may be only moderate [[AS]] in a small [[patient]].
* An [[aortic valve area]] index ≤0.6 cm2/m2 suggests severe [[AS]].
* An [[aortic valve area]] index ≤0.6 cm2/m2 suggests severe [[AS]].
* [[Transaortic]] [[stroke volume] is calculated by [[Doppler] or [[2D]] imaging.
* [[Transaortic]] [[stroke volume]] is calculated by [[Doppler]] or [[2D]] imaging.
*[[Exercise testing]] may be helpful in clarifying symptom status in [[patients]] with severe [[AS]] including a fall of ≥10 mm Hg in [[systolic blood pressure]] from baseline to peak [[exercise]] or a significant decrease in [[exercise]] tolerance as compared with [[age]] and [[sex]] normal standards.
* [[Exercise testing]] may be helpful in clarifying symptom status in [[patients]] with severe [[AS]] including a fall of ≥10 mm Hg in [[systolic blood pressure]] from baseline to peak [[exercise]] or a significant decrease in [[exercise]] tolerance as compared with [[age]] and [[sex]] normal standards.
*In [[patients]] with very severe [[AS]] and an [[aortic velocity]] ≥5.0 m/s or mean [[pressure gradient]] ≥60 mm Hg, the rate of symptom onset is approximately 50% at 2 years. *Early [[surgery]] in [[patients]] with [[aortic velocity]] ≥4.5 m/sa showed significant [[survival]] benefit.
* In [[patients]] with very severe [[AS]] and an [[aortic velocity]] ≥5.0 m/s or mean [[pressure gradient]] ≥60 mm Hg, the rate of [[symptom]] onset is approximately 50% at 2 years. <ref name="pmid20026771">{{cite journal |vauthors=Rosenhek R, Zilberszac R, Schemper M, Czerny M, Mundigler G, Graf S, Bergler-Klein J, Grimm M, Gabriel H, Maurer G |title=Natural history of very severe aortic stenosis |journal=Circulation |volume=121 |issue=1 |pages=151–6 |date=January 2010 |pmid=20026771 |doi=10.1161/CIRCULATIONAHA.109.894170 |url=}}</ref> *Early [[surgery]] in [[patients]] with [[aortic velocity]] ≥4.5 m/s showed significant [[survival]] benefit.
*An elevated serum [[BNP]] level is a marker of subclinical [[HF]] and [[LV ]] decompensation in [[severe] [[AS]].  
* An elevated [[serum]] [[BNP]] level is a marker of subclinical [[HF]] and [[LV ]] decompensation in [[severe]] [[AS]].<ref name="pmid15117847">{{cite journal |vauthors=Bergler-Klein J, Klaar U, Heger M, Rosenhek R, Mundigler G, Gabriel H, Binder T, Pacher R, Maurer G, Baumgartner H |title=Natriuretic peptides predict symptom-free survival and postoperative outcome in severe aortic stenosis |journal=Circulation |volume=109 |issue=19 |pages=2302–8 |date=May 2004 |pmid=15117847 |doi=10.1161/01.CIR.0000126825.50903.18 |url=}}</ref>
* In [[asymptomatic]] [[patients]] with [[AS]] with the [[aortic]] velocity reaches ≥2 m/s, [[hemodynamic]] progression leading to [[symptom ]].  
* In [[asymptomatic]] [[patients]] with [[AS]] with the [[aortic]] velocity reaches ≥2 m/s, [[hemodynamic]] progression leading to [[symptom ]]. <ref name="pmid26477634">{{cite journal |vauthors=Taniguchi T, Morimoto T, Shiomi H, Ando K, Kanamori N, Murata K, Kitai T, Kawase Y, Izumi C, Miyake M, Mitsuoka H, Kato M, Hirano Y, Matsuda S, Nagao K, Inada T, Murakami T, Takeuchi Y, Yamane K, Toyofuku M, Ishii M, Minamino-Muta E, Kato T, Inoko M, Ikeda T, Komasa A, Ishii K, Hotta K, Higashitani N, Kato Y, Inuzuka Y, Maeda C, Jinnai T, Morikami Y, Sakata R, Kimura T |title=Initial Surgical Versus Conservative Strategies in Patients With Asymptomatic Severe Aortic Stenosis |journal=J Am Coll Cardiol |volume=66 |issue=25 |pages=2827–2838 |date=December 2015 |pmid=26477634 |doi=10.1016/j.jacc.2015.10.001 |url=}}</ref>
* [[Hemodynamic]] progression occurs when [[aortic]] velocity increases about 0.3 m/s per year, an increase in the [[mean gradient]] of 7 to 8 mm Hg per year, and a decrease in [[valve area]] of 0.15 cm2 per year.
* [[Hemodynamic]] progression occurs when [[aortic]] velocity increases about 0.3 m/s per year, an increase in the [[mean gradient]] of 7 to 8 mm Hg per year, and a decrease in [[valve area]] of 0.15 cm2 per year.
* Predictors of [[rapid]] [[disease]] progression include [[older age]], more severe [[valve calcification]], and a faster rate of [[hemodynamic]] progression in serial studies.
* Predictors of [[rapid]] [[disease]] progression include [[older age]], more severe [[valve calcification]], and a faster rate of [[hemodynamic]] progression in serial studies.
* Elective [[AVR]] may be considered In [[patients]] with an [[aortic]] [[velocity]] >4 m/s, and the presence of predictors of rapid disease progression.
* Elective [[AVR]] may be considered In [[patients]] with an [[aortic]] [[velocity]] >4 m/s, and the presence of predictors of rapid disease progression.<ref name="pmid31733181">{{cite journal |vauthors=Kang DH, Park SJ, Lee SA, Lee S, Kim DH, Kim HK, Yun SC, Hong GR, Song JM, Chung CH, Song JK, Lee JW, Park SW |title=Early Surgery or Conservative Care for Asymptomatic Aortic Stenosis |journal=N Engl J Med |volume=382 |issue=2 |pages=111–119 |date=January 2020 |pmid=31733181 |doi=10.1056/NEJMoa1912846 |url=}}</ref>
*In [[adults]] with initially asymptomatic severe [[AS]], the rate of [[sudden death]] is low (<1% per year). However, an [[aortic velocity]] ≥5 m/s or an [[LVEF]] <60% is associated with higher all-cause and cardiovascular [[mortality rates]] in the absence of [[AVR]].
* In [[adults]] with initially asymptomatic severe [[AS]], the rate of [[sudden death]] is low (<1% per year). However, an [[aortic velocity]] ≥5 m/s or an [[LVEF]] <60% is associated with higher all-cause and [[cardiovascular]] [[mortality rates]] in the absence of [[AVR]].
* A progressive decrease in [[LVEF]] is most likely in those with an LVEF <60% before [[AS]] becomes severe.
* A progressive decrease in [[LVEF]] is most likely in those with an [[LVEF]] <60% before [[AS]] becomes severe.<ref name="pmid29289632">{{cite journal |vauthors=Taniguchi T, Morimoto T, Shiomi H, Ando K, Kanamori N, Murata K, Kitai T, Kadota K, Izumi C, Nakatsuma K, Sasa T, Watanabe H, Kuwabara Y, Makiyama T, Ono K, Shizuta S, Kato T, Saito N, Minatoya K, Kimura T |title=Prognostic Impact of Left Ventricular Ejection Fraction in Patients With Severe Aortic Stenosis |journal=JACC Cardiovasc Interv |volume=11 |issue=2 |pages=145–157 |date=January 2018 |pmid=29289632 |doi=10.1016/j.jcin.2017.08.036 |url=}}</ref>
*[[Hemodynamic]] progression eventually leading to symptom onset occurs in nearly all asymptomatic [[patients]] with [[AS]].
* [[Hemodynamic]] progression eventually leading to onset of [[symptom]] occurs in nearly all asymptomatic [[patients]] with [[AS]].
. The rate of [[symptom]] onset is strongly dependent on the severity of [[AS]].
. The rate of [[symptom]] onset is strongly dependent on the severity of [[AS]].
*[[Patients]] with asymptomatic [[AS]] require periodic monitoring for the development of symptoms and progressive disease.
* [[Patients]] with asymptomatic [[AS]] require periodic monitoring for the development of [[symptoms]] and progressive [[disease]].


== 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines<ref name="pmid30121240">{{cite journal| author=Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM | display-authors=etal| title=2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. | journal=J Am Coll Cardiol | year= 2019 | volume= 73 | issue= 12 | pages= 1494-1563 | pmid=30121240 | doi=10.1016/j.jacc.2018.08.1028 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30121240  }}</ref> ==
=== Therapeutic Recommendations for Subaortic Stenosis ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |'''1.''' Surgical intervention is recommended for adults with subAS, a maximum gradient 50 mm Hg or more and symptoms attributable to the subAS.''(Level of Evidence: C-EO)''
|-
| bgcolor="LightGreen" | '''2.'''Surgical intervention is recommended for adults with subAS and less than 50 mm Hg maximum gradient and HF or ischemic symptoms, and/or LV systolic dysfunction attributable to subAS.
''(Level of Evidence: C-LD)''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |'''1.'''To prevent the progression of AR, surgical intervention may be considered for asymptomatic adults with subAS and at least mild AR and a maximum gradient of 50 mm Hg or more.
''(Level of Evidence: C-LD)''
|}




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|-
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑  [[Intervention]] is considered in [[symptomatic]] [[patients]] with severe, high-gradient [[aortic stenosis]] [[mean gradient]] ≥ 40 mmHg, peak velocity
❑  [[Intervention]] is considered in [[symptomatic]] [[patients]] with severe, high-gradient [[aortic stenosis]], [[mean gradient]] ≥ 40 mmHg, peak velocity
≥ 4.0 m/s, and [[valve]] area ≤ 1.0 cm2 (or ≤ 0.6 cm2/m2)<br>
≥ 4.0 m/s, and [[valve]] area ≤ 1.0 cm2 (or ≤ 0.6 cm2/m2)<br>
❑ntervention is considered in symptomatic [[patients]] with severe low-[[flow]] ([[SVi]] ≤35 mL/m2), low-[[gradient]] (<40 mmHg) [[aortic stenosis]] with reduced [[ejection fraction]] (<50%), and evidence of [[flow]] (contractile) reserve<br>
❑ntervention is considered in symptomatic [[patients]] with severe low-[[flow]] ([[SVi]] ≤35 mL/m2), low-[[gradient]] (<40 mmHg) [[aortic stenosis]] with reduced [[ejection fraction]] (<50%), and evidence of [[flow]] (contractile) reserve<br>
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</span>
 
<br>
<br>


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*High flow is reversible in [[conditions]] such as [[anemia]], [[hyperthyroidism]] or[[ arterio-venous fistula]] and may also be present in [[patients]] with [[hypertrophic obstructive cardiomyopathy]].
*High flow is reversible in [[conditions]] such as [[anemia]], [[hyperthyroidism]] or[[ arterio-venous fistula]] and may also be present in [[patients]] with [[hypertrophic obstructive cardiomyopathy]].
* The definition of  Normal flow by [[pulsed Doppler echocardiography]] is :
* Normal flow by [[pulsed Doppler echocardiography]] is defined as:
*: [[Cardiac index]] 4.1 L/min/m2 in [[men]] and [[women]]
*: [[Cardiac index]] 4.1 L/min/m2 in [[men]] and [[women]]
*: [[SVi]] 54 mL/m2 in [[men]], 51 mL/m2 in [[women]]
*: [[SVi]] 54 mL/m2 in [[men]], 51 mL/m2 in [[women]]
*[[DSE]] flow reserve is defined as > 20% increase in [[stroke volume]] in response to low-dose [[dobutamine]].
*[[DSE]] flow reserve is defined as > 20% increase in [[stroke volume]] in response to low-dose [[dobutamine]].
*Pseudo-severe [[aortic stenosis]] is defined as  [[AVA]] >1.0 cm2 with increased [[flow]].
*Pseudo-severe [[aortic stenosis]] is defined when [[AVA]] >1.0 cm2 with increased [[flow]].<ref name="pmid22733832">{{cite journal |vauthors=Fougères E, Tribouilloy C, Monchi M, Petit-Eisenmann H, Baleynaud S, Pasquet A, Chauvel C, Metz D, Adams C, Rusinaru D, Guéret P, Monin JL |title=Outcomes of pseudo-severe aortic stenosis under conservative treatment |journal=Eur Heart J |volume=33 |issue=19 |pages=2426–33 |date=October 2012 |pmid=22733832 |doi=10.1093/eurheartj/ehs176 |url=}}</ref>
*[[ CT]] measurement of [[aortic valve ]] [[calcification]] (Agatston units) for definition of high likely [[severe]] [[AS]]:  
*[[CT]] measurement of [[aortic valve ]] [[calcification]] (Agatston units) for definition of [[AS]] severity:  
*:men >3000, [[ women]]>1600  
*: High likely: [[men]] >3000, [[ women]]>1600  
*:Likely: [[men]] >2000, [[women]] >1200
*:Likely: [[men]] >2000, [[women]] >1200
*:Unlikely: [[men]] <1600, [[women]] <800
*:Unlikely: [[men]] <1600, [[women]] <800
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for choice of Mechanical Versus Bioprosthetic AVR'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''  ([[AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Decision should be made  based on [[patients]] preference and values after discussion about the risks of [[anticoagulant]] therapy or the need for valve [[intervention]]<br>
❑ Bioprothesis [[AVR]] is recommended when [[anticoagulant]] theray with [[VKA]] is contraindicated, not desired, or can not be managed<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''  ([[ AHA guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Mechanical [[aortic]] [[prothesis]] is preferred over [[bioprosthetic]] [[valve]] for [[patients]] < 50 years of age and no contraindication of [[anticoagulant therapy]]<br>
❑For [[patients]] 50-65 years of age without contraindication of [[anticoagulant]] therapy, choosing either [[mechanical]] or [[bioprothesis]] [[aortic]] [[valve]] should be individualized based on [[patient]] factors<br>
❑ For [[patients]] > 65 years of age, [[bioprosthetic]] [[aortic]] [[valve]] is preferred over [[mechanical aortic valve]]<br> 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''  ([[ AHA guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For [[patients]] <50 years of age who desire bioprosthetic valve and appropriate anatomy, the [[Rose procedure]] including replacement of aortic valve by a [[pulmonic autograft]] may be considered
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}
<span style="font-size:85%">'''Abbreviations:'''
'''AVR:''' [[Aortic valve replacement]];
'''VKA:''' [[Vitamin K antagonist]]
</span>


==References==
==References==

Latest revision as of 13:52, 14 December 2022

Aortic stenosis surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Sara Zand, M.D.[2] Mohammed A. Sbeih, M.D. [3]; Usama Talib, BSc, MD [4] Synonyms and keywords: As; Aortic stenosis; AVR; Aortic valve replacement; LVEF; Left ventricular ejection fraction; LV; Left ventricle

Overview

In symptomatic patients with severe high-gradient AS (Stage D1), AVR has beneficial effect on survival, symptoms, and LV systolic function. In asymptomatic patients with severe AS and normal LV systolic function, the risk of sudden death (<1% per year) is low. In patients with a low LVEF and severe AS, survival is better with AVR than medical therapy.

Indications

. The rate of symptom onset is strongly dependent on the severity of AS.

2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines[8]

Therapeutic Recommendations for Subaortic Stenosis

Class I
1. Surgical intervention is recommended for adults with subAS, a maximum gradient 50 mm Hg or more and symptoms attributable to the subAS.(Level of Evidence: C-EO)
2.Surgical intervention is recommended for adults with subAS and less than 50 mm Hg maximum gradient and HF or ischemic symptoms, and/or LV systolic dysfunction attributable to subAS.

(Level of Evidence: C-LD)

Class IIb
1.To prevent the progression of AR, surgical intervention may be considered for asymptomatic adults with subAS and at least mild AR and a maximum gradient of 50 mm Hg or more.

(Level of Evidence: C-LD)





Recommendations for intervention in aortic stenosis
Symptomatic aortic stenosis:
(Class I, Level of Evidence B):

❑ Intervention is considered in symptomatic patients with severe, high-gradient aortic stenosis, mean gradient ≥ 40 mmHg, peak velocity ≥ 4.0 m/s, and valve area ≤ 1.0 cm2 (or ≤ 0.6 cm2/m2)
❑ntervention is considered in symptomatic patients with severe low-flow (SVi ≤35 mL/m2), low-gradient (<40 mmHg) aortic stenosis with reduced ejection fraction (<50%), and evidence of flow (contractile) reserve

(Class IIa, Level of Evidence C):

❑ Intervention is recommended in symptomatic severe AS with low-flow, low-gradient (<40 mmHg) aortic stenosis with normal ejection fraction
❑ Intervention is recommended in symptomatic patients with low-flow, low-gradient severe aortic stenosis and reduced ejection fraction without flow (contractile) reserve, severe aortic stenosis proven by CCT calcium score

(Class III, Level of Evidence C) :

❑ Intervention is not recommended in patients with severe comorbidities when the intervention is unlikely to improve quality of life or prolong survival >1 year

Asymptomatic severe aortic stenosis :
(Class I, Level of Evidence B):

❑ Intervention is recommended in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF < 50%) without another cause

(Class I, Level of Evidence C):

❑ Intervention is recommended in asymptomatic patients with severe aortic stenosis, symptomtomatic on exercise testing

(Class IIa, Level of Evidence B):

❑ Intervention should be considered in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF <55%) without another cause

(Class IIa, Level of Evidence C):

❑ Interventin is recommended in asymptomatic patients with severe aortic stenosis and a sustained fall inblood pressure (>20 mmHg) during exercise testing

(Class IIa, Level of Evidence B):

❑Intervention is considered in asymptomatic patients with LVEF >55% and a normal exercise test if the procedural risk is low and in the presence of one of the following:

Type of intervention:
(Class I, Level of Evidence C):

❑Aortic valve interventions should be performed in an experienced center

(Class I, Level of Evidence B):

❑SAVR is recommended in younger patients who are low risk for surgery (<75 yearse and STS PROM/EuroSCORE II <4%), or in patients who are operable and unsuitable for transfemoral TAVI
❑SAVR or TAVI are recommended for patients based on clinical, anatomical, and procedural characteristics

(Class I, Level of Evidence A):

❑TAVI is recommended in older patients (≥75 years), or in those who are high risk (STS PROM/EuroSCORE IIf>8%) or unsuitable for surgery

(Class IIb, Level of Evidence C):

❑ Non-transfemoral TAVI may be considered in patients who are inoperable and unsuitable for transfemoral TAVI
❑Balloon aortic valvotomy may be considered as a bridge to SAVR or TAVI in hemodynamically unstable patients and (if feasible) in those with severe aortic stenosis who require urgent high risk non-cardiac surgery

Abbreviations: BNP: B-type natriuretic peptide; CABG: Coronary artery bypass grafting; LV: Left ventricle; LVEF:Left ventricular ejection fraction ; CCT:Cardiac computed tomography; SAVR: Surgical aortic valve replacement; STS-PROM: Society of Thoracic Surgeons - predicted risk of mortality; SVi: Stroke volume index; TAVI:Transcatheter aortic valve implantation ; Vmax:Peak transvalvular velocity


The above table adopted from 2021 ESC Guideline[9]


 
 
 
 
Valvular AS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low-gradient AS
  • Vmax < 4 m/s
  • ΔPm < 40 mmHg
 
 
 
High-gradient AS
  • Vmax ≥ 4 m/s,
  • ΔPm ≥ 40 mmHg
    •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    		AVA ≤ 1.0 cm2
     
     
     
     
    		High flow status
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    		Yes
     
    		NO
  • Moderate AS
    •  
    		Yes
  • Assessment of normal flow condition
    •  
     
    		NO
  • Severe AS
    •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Normal flow
     
    		Low flow
  • SVi ≤ 35 mL/m2
    •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Severe AS unlikely
     
    		LVEF ≥ 50%
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    		NO
     
    		Yes
  • CCT to assess AV calcification
    •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    NO, CCT to assess AV calcification
     
    		Yes, AVA ≤ 1.0 cm2
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    		Yes
     
    		NO
  • Pseudo-severe AS
    •  
     
     
     
     
     
     
     
     
     
     
     

    Abbreviations: AS: Aortic stenosis; AV: Aortic valve; AVA: Aortic valve area; LVEF: Left ventricular ejection fraction ; CT: Computed tomography; △Pm: Mean pressure gradient; DSE: Dobutamine stress echocardiography; LV: Left ventricular; SVi: Stroke volume index; Vmax: Peak transvalvular velocity



    The above table adopted from 2021 ESC Guideline[9]


    Recommendations for choice of Mechanical Versus Bioprosthetic AVR
    (Class I, Level of Evidence C):

    ❑ Decision should be made based on patients preference and values after discussion about the risks of anticoagulant therapy or the need for valve intervention
    ❑ Bioprothesis AVR is recommended when anticoagulant theray with VKA is contraindicated, not desired, or can not be managed

    (Class IIa, Level of Evidence B):

    ❑Mechanical aortic prothesis is preferred over bioprosthetic valve for patients < 50 years of age and no contraindication of anticoagulant therapy
    ❑For patients 50-65 years of age without contraindication of anticoagulant therapy, choosing either mechanical or bioprothesis aortic valve should be individualized based on patient factors
    ❑ For patients > 65 years of age, bioprosthetic aortic valve is preferred over mechanical aortic valve

    (Class IIb, Level of Evidence B):

    ❑For patients <50 years of age who desire bioprosthetic valve and appropriate anatomy, the Rose procedure including replacement of aortic valve by a pulmonic autograft may be considered

    The above table adopted from 2020 AHA Guideline[11]

    Abbreviations: AVR: Aortic valve replacement; VKA: Vitamin K antagonist

    References

    1. ↑ Rosenhek R, Binder T, Porenta G, Lang I, Christ G, Schemper M, Maurer G, Baumgartner H (August 2000). "Predictors of outcome in severe, asymptomatic aortic stenosis". N Engl J Med. 343 (9): 611–7. doi:10.1056/NEJM200008313430903. PMID 10965007.
    2. ↑ Tribouilloy C, Lévy F, Rusinaru D, Guéret P, Petit-Eisenmann H, Baleynaud S, Jobic Y, Adams C, Lelong B, Pasquet A, Chauvel C, Metz D, Quéré JP, Monin JL (May 2009). "Outcome after aortic valve replacement for low-flow/low-gradient aortic stenosis without contractile reserve on dobutamine stress echocardiography". J Am Coll Cardiol. 53 (20): 1865–73. doi:10.1016/j.jacc.2009.02.026. PMID 19442886.
    3. ↑ Rosenhek R, Zilberszac R, Schemper M, Czerny M, Mundigler G, Graf S, Bergler-Klein J, Grimm M, Gabriel H, Maurer G (January 2010). "Natural history of very severe aortic stenosis". Circulation. 121 (1): 151–6. doi:10.1161/CIRCULATIONAHA.109.894170. PMID 20026771.
    4. ↑ Bergler-Klein J, Klaar U, Heger M, Rosenhek R, Mundigler G, Gabriel H, Binder T, Pacher R, Maurer G, Baumgartner H (May 2004). "Natriuretic peptides predict symptom-free survival and postoperative outcome in severe aortic stenosis". Circulation. 109 (19): 2302–8. doi:10.1161/01.CIR.0000126825.50903.18. PMID 15117847.
    5. ↑ Taniguchi T, Morimoto T, Shiomi H, Ando K, Kanamori N, Murata K, Kitai T, Kawase Y, Izumi C, Miyake M, Mitsuoka H, Kato M, Hirano Y, Matsuda S, Nagao K, Inada T, Murakami T, Takeuchi Y, Yamane K, Toyofuku M, Ishii M, Minamino-Muta E, Kato T, Inoko M, Ikeda T, Komasa A, Ishii K, Hotta K, Higashitani N, Kato Y, Inuzuka Y, Maeda C, Jinnai T, Morikami Y, Sakata R, Kimura T (December 2015). "Initial Surgical Versus Conservative Strategies in Patients With Asymptomatic Severe Aortic Stenosis". J Am Coll Cardiol. 66 (25): 2827–2838. doi:10.1016/j.jacc.2015.10.001. PMID 26477634.
    6. ↑ Kang DH, Park SJ, Lee SA, Lee S, Kim DH, Kim HK, Yun SC, Hong GR, Song JM, Chung CH, Song JK, Lee JW, Park SW (January 2020). "Early Surgery or Conservative Care for Asymptomatic Aortic Stenosis". N Engl J Med. 382 (2): 111–119. doi:10.1056/NEJMoa1912846. PMID 31733181.
    7. ↑ Taniguchi T, Morimoto T, Shiomi H, Ando K, Kanamori N, Murata K, Kitai T, Kadota K, Izumi C, Nakatsuma K, Sasa T, Watanabe H, Kuwabara Y, Makiyama T, Ono K, Shizuta S, Kato T, Saito N, Minatoya K, Kimura T (January 2018). "Prognostic Impact of Left Ventricular Ejection Fraction in Patients With Severe Aortic Stenosis". JACC Cardiovasc Interv. 11 (2): 145–157. doi:10.1016/j.jcin.2017.08.036. PMID 29289632.
    8. ↑ Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM; et al. (2019). "2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". J Am Coll Cardiol. 73 (12): 1494–1563. doi:10.1016/j.jacc.2018.08.1028. PMID 30121240.
    9. ↑ 9.0 9.1 Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W (February 2022). "2021 ESC/EACTS Guidelines for the management of valvular heart disease". Eur Heart J. 43 (7): 561–632. doi:10.1093/eurheartj/ehab395. PMID 34453165 Check |pmid= value (help).
    10. ↑ Fougères E, Tribouilloy C, Monchi M, Petit-Eisenmann H, Baleynaud S, Pasquet A, Chauvel C, Metz D, Adams C, Rusinaru D, Guéret P, Monin JL (October 2012). "Outcomes of pseudo-severe aortic stenosis under conservative treatment". Eur Heart J. 33 (19): 2426–33. doi:10.1093/eurheartj/ehs176. PMID 22733832.
    11. ↑ Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C (February 2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e35–e71. doi:10.1161/CIR.0000000000000932. PMID 33332149 Check |pmid= value (help).

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