Aortic stenosis surgery indications: Difference between revisions
/* 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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* [[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 | *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. | ||
* [[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]]. | * [[Out come]] 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%). | ||
* 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]]. | ||
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* [[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/ | *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/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]]. | ||
* 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 ]]. | ||
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*[[Hemodynamic]] progression eventually leading to symptom onset occurs in nearly all asymptomatic [[patients]] with [[AS]]. | *[[Hemodynamic]] progression eventually leading to symptom onset 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. | ||
Revision as of 06:17, 10 June 2022
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Aortic stenosis surgery | |
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Treatment | |
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Aortic stenosis surgery indications On the Web | |
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American Roentgen Ray Society Images of Aortic stenosis surgery indications | |
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Risk calculators and risk factors for Aortic stenosis surgery indications | |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Mohammed A. Sbeih, M.D. [2]; Usama Talib, BSc, MD [3]
Overview
Aortic stenosis requires aortic valve replacement if medical management does not successfully control symptoms. 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.[1]
Indications
- 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.
- 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.
- Improvement in exercise tolerance has been shown by exercise test after AVR.
- 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.
- 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.
- 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.
- Out come in patients without contractil reserve is poor with either surgical or medical therapy.
- 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, presence of small LV cavity with thick walls, diastolic dysfunction, and a normal LVEF (≥50%).
- 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.
- An aortic valve area index ≤0.6 cm2/m2 suggests severe AS.
- 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.
- 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/s showed significant survival benefit.
- An elevated serum BNP level is a marker of subclinical HF and LV decompensation in [[severe] AS.
- In asymptomatic patients with AS with the aortic velocity reaches ≥2 m/s, hemodynamic progression leading to symptom .
- 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.
- Elective AVR may be considered In patients with an aortic velocity >4 m/s, and the presence of predictors of rapid disease progression.
- 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.
- Hemodynamic progression eventually leading to symptom onset occurs in nearly all asymptomatic patients with 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.
| Recommendations for intervention in aortic stenosis |
| Symptomatic aortic stenosis: |
| (Class I, Level of Evidence B): |
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❑ 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) |
| (Class IIa, Level of Evidence C): |
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❑ Intervention is recommended in symptomatic severe AS with low-flow, low-gradient (<40 mmHg) aortic stenosis with normal ejection fraction |
| (Class III, Level of Evidence C) : |
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❑ 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): |
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❑ 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): |
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❑ Intervention is recommended in asymptomatic patients with severe aortic stenosis, symptomtomatic on exercise testing |
| (Class IIa, Level of Evidence B): |
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❑ 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): |
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❑ 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): |
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❑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:
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| Type of intervention: |
| (Class I, Level of Evidence C): |
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❑Aortic valve interventions should be performed in an experienced center |
| (Class I, Level of Evidence B): |
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❑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 |
| (Class I, Level of Evidence A): |
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❑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): |
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❑ Non-transfemoral TAVI may be considered in patients who are inoperable and unsuitable for transfemoral TAVI |
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[2] |
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| Valvular AS | |||||||||||||||||||||||||||||||||||||||||||||||||
Low-gradient AS
| High-gradient AS
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| AVA ≤ 1.0 cm2 | High flow status | ||||||||||||||||||||||||||||||||||||||||||||||||
| Yes | NO
| Yes
| NO
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Normal flow
| Low flow
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| Severe AS unlikely | LVEF ≥ 50% | ||||||||||||||||||||||||||||||||||||||||||||||||
| NO | Yes
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| NO, CCT to assess AV calcification | Yes, AVA ≤ 1.0 cm2 | ||||||||||||||||||||||||||||||||||||||||||||||||
Yes
| NO
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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[2] |
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- High flow is reversible in conditions such as anemia, hyperthyroidism orarterio-venous fistula and may also be present in patients with hypertrophic obstructive cardiomyopathy.
- The definition of Normal flow by pulsed Doppler echocardiography is :
- 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.
- CT measurement of aortic valve calcification (Agatston units) for definition of high likely severe AS:
References
- ↑ Grube E, Laborde JC, Gerckens U; et al. (2006). "Percutaneous implantation of the CoreValve self-expanding valve prosthesis in high-risk patients with aortic valve disease: the Siegburg first-in-man study". Circulation. 114 (15): 1616–24. doi:10.1161/CIRCULATIONAHA.106.639450. PMID 17015786.
- ↑ 2.0 2.1 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).