Cardiology overview valvular heart disease

Cardiology Overview
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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 Stenosis according to ACC/AHA Guidelines

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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)

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

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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)

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

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

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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.