Guidelines for the Management of Patients With Aortic Valve Disease Dr sajeer K T Senior Resident, Dept. of Cardiology, MCH, Calicut

Guidelines for the Management ofPatients With Aortic Valve Disease

Dr sajeer K TSenior Resident,

Dept. of Cardiology, MCH, Calicut

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

2012 ACCF/AATS/SCAI/STS Expert Consensus Document onTranscatheter Aortic Valve Replacement

Guidelines on the management of valvular heart disease - ESC guidelines 2007

Aortic Stenosis

Aortic stenosis Severity

Mild Moderate Severe

1. Jet velocity (m/sec) <3.0 3.0-4.0 >4.0

2. Mean gradient (mm Hg) <25 25-40 >40

3. Valve area (cm2) 1.5 1.0-1.5 <1.0

4. Valve area index (cm2/m2) <0.6

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

Role of Echocardiography in Aortic Stenosis

Diagnosis and assessment of AS severity

Assessment of LV wall thickness, size, and function

Re-evaluation of asymptomatic patients: Severe AS : every year Moderate AS : every 1 to 2 years Mild AS : every 3 to 5 years

Exercise Testing

Poor diagnostic accuracy for evaluation of concurrent CAD - abnormal baseline ECG - LV hypertrophy - limited coronary flow reserve

ST depression during exercise occurs in 80% of adults with asymptomatic AS - No prognostic significance

Exercise Testing

To elicit exercise-induced symptoms and abnormal blood pressure responses


Exercise testing should not be performed in symptomatic patients with AS.


Indications for Cardiac Catheterization

- Before AVR in patients with AS at risk for CAD



- Before AVR in patients with AS for whom a pulmonary auto graft (Ross procedure) is contemplated ( If the origin of the coronary arteries was not identified by noninvasive technique)

Coronary angiography :

Cardiac catheterization for hemodynamic measurements : - assessment of severity of AS in symptomatic patients when noninvasive tests are inconclusive or - when there is a discrepancy between noninvasive tests and clinical findings regarding severity of AS

Indications for Cardiac CatheterizationIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

Cardiac Catheterization in AS

Not recommended for the assessment of severity of AS before AVR when noninvasive tests are adequate and concordant with clinical findings

III IIa IIb IIIIIIIIIIIIIII

Not recommended for the assessment of LV function and severity of AS in asymptomatic patients

Definition - Valve area smaller than 1.0 cm2

- LV ejection fraction less than 40% - Mean gradient less than 30 to 40 mm Hg

Low-Flow/Low-Gradient Aortic Stenosis

After Dobutamine:

Severe AS : - increase in aortic velocity to at least 4 m/sec at any flow rate - with a valve area less than 1.0 cm2

AS is not severe :- valve area is increased to more than 1.0 cm2

Low-Flow/Low-Gradient Aortic StenosisIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

Dobutamine stress echocardiography : - reasonable to evaluate patients with low-flow/low-gradient AS and LV dysfunction

Cardiac catheterization for hemodynamic measurements with infusion of Dobutamine - useful for evaluation of patients with low-flow/low-gradient AS and LV dysfunction

Dobutamine infusion:

Increment in SV Increase in AVA greater than 0.2 cm2 little change in gradient

Increase in SV Fixed valve areaIncrease in gradient

Baseline evaluation overestimated the severity of stenosis

Respond favorably tosurgery

Patients who fail to show an increase in stroke volume with Dobutamine (less than 20%) - “lack of contractile reserve” - Appear to have a very poor prognosis with either medical or surgical therapy

Indications for Aortic Valve Replacement

1. Symptomatic patients with severe AS

2. Severe AS undergoing CABG

3. Severe AS undergoing surgery on the aorta or other heart valves

4. Severe AS and LV systolic dysfunction



AVR is reasonable for patients with Moderate AS undergoing CABG or surgery on the aorta or other heart valves

Indications for Aortic Valve Replacement contd..


AVR is not useful for the prevention of sudden death in asymptomatic patients with AS


Management Strategy for Patients With Severe AS

Aortic Balloon Valvotomy

As a bridge to surgery in hemodynmically unstable adult patients with AS who are at high risk for AVR

For palliation in adult patients with AS in whom AVR cannot be performed because of serious co-morbid conditions

III IIa

IIb IIIIIIIIIIIIIII

Not recommended as an alternative to AVR in adult patients with ASException : younger adults with AS without valve calcification

III IIa

IIb IIIIIIIIIIIIIII

Medical Therapy

Medical Therapy contd……

Antibiotic prophylaxis is indicated in all patients with AS For prevention of IERheumatic AS : for prevention of recurrent RF

Patients with associated systemic HTN - treated cautiously with appropriate antihypertensive agents

Role of statins: Prospective, randomized, placebo-controlled trial in patients with calcific aortic valve disease failed to demonstrate a benefit of atorvastatin in reducing the progression of aortic valve stenosis over a 3-year period

Intensive lipid-lowering therapy in calcific aortic stenosis. N Engl J Med 2005;352:2389 –97.

Medical Therapy for the Inoperable AS patients

-There is no therapy available that prolongs life

- AS patients with evidence of pulmonary congestion: - can benefit from cautious treatment with digitalis, diuretics, and ACE inhibitors- AS with acute Pulmonary edema: - Nitroprusside infusion (reduces congestion and improve LV performance) - Digitalis - reserved for AS with depressed systolic function or AF

If angina is the predominant symptom: - cautious use of nitrates and beta blockers can provide relief.

Special Considerations in the Elderly

- AVR must be considered in all elderly patients who have symptoms caused by AS - Valve replacement is technically possible at any age - Older patients with symptoms due to severe AS, normal coronary arteries, and preserved LV function can expect a better outcome than those with CAD or LV dysfunction

- Elderly women→ a narrow LV OT and a small aortic annulus - require enlargement of the annulus

- Heavy calcification of the valve, annulus, and aortic root may require debridement

2012 ACCF/AATS/SCAI/STS Expert Consensus Document onTranscatheter Aortic Valve Replacement

Aortic Regurgitation

Aortic Regurgitation

Mild Moderate Severe

Angiographic grade 1+ 2+ 3-4+

Color Doppler jet width Central jet, width < 25% of LVOT

> Mild but no signs of severe AR

Central jet, width>65% LVOT

Doppler VC width (cm) <0.3 0.3-0.6 >0.6

Regurgitant volume (mL/beat) <30 30-59 ≥60

Regurgitant fraction (% ) <30 30-49 ≥50

Regurgitant orifice area (cm2) <0.10 0.10-0.29 ≥0.30

DIAGNOSIS AND INITIAL EVALUATION

Role of Echocardiography:- severity of acute or chronic AR- Valve morphology and aortic root size and morphology - LV hypertrophy, dimension (or vol.), and systolic function


Radionuclide angiography or magnetic resonance imaging : - initial and serial assessment of LV volume and function at rest in patients with AR and suboptimal echocardiograms.

Role of Exercise stress testing in chronic MR

- for assessment of functional capacity and symptomatic response in patients with a history of equivocal symptoms


INDICATIONS FOR CARDIAC CATHETERIZATION

- Cardiac catheterization with aortic root angiography and measurement of LV pressure : - for assessment of severity of regurgitation - LV function - Aortic root size ( when non-invasive tests are inconclusive or discordant with clinical findings in patients with AR)


- Coronary angiography is indicated before AVR in patients at risk for CAD

INDICATIONS FOR AORTIC VALVE REPLACEMENT OR AORTIC VALVE REPAIR

“AVR” applies to both aortic valve replacement and aortic valve repair

Aortic valve repair should be considered only in those surgical centres' that have developed the appropriate technical expertise, gained experience in patient selection, and demonstrated outcomesequivalent to those of valve replacement

The indications for valve replacement and repair do not differ


1. Symptomatic patients with severe AR irrespective of LV systolic function.2. Asymptomatic patients with chronic severe AR and LV systolic dysfunction (ejection fraction 0.50 or less) at rest

3. AVR is indicated for patients with chronic severe AR while undergoing CABG or surgery on the aorta or other heart valves. (level of evidence C)


- Asymptomatic patients with severe AR with normal LV systolic function (EF> 0.50) but with severe LV dilatation (EDD > 75 mm or ESD> 55 mm)



- Moderate AR while undergoing surgery on the ascending aorta - Moderate AR while undergoing CABG

- Asymptomatic severe AR and normal LV systolic function at rest (EF> 0.50), - when the degree of LV dilatation exceeds an EDD of 70 mm or ESD of 50 mm - when there is evidence of progressive LV dilatation, declining exercise tolerance, or abnormal hemodynamic responses to exercise

III IIa

IIbIIIIIIIIIIIIIII

AVR is not indicated

1. Asymptomatic patients with mild, moderate, or severe AR and normal LV systolic function at rest ( EF> 0.50) when degree of

dilatation is not mod. or severe ( EDD< 70 mm, ESD< 50 mm)


Indications for surgery in aortic regurgitation

Guideline for Medical therapy

Vasodilator therapy:

- Chronic therapy is indicated in patients with severe AR who have symptoms or LV dysfunction when surgery is not recommended because of additional cardiac or non-cardiac factors.


- As a short-term therapy to improve the hemodynamic profile of patients with severe heart failure symptoms and severe LV dysfunction before proceeding with AVR


Vasodilator therapy not indicated (Class III)

1. Asymptomatic patients with mild to moderate AR and normal LV systolic function

2. Asymptomatic patients with LV systolic dysfunction who are otherwise candidates for AVR

3. Symptomatic patients with either normal LV function or mild to moderate LV systolic dysfunction who are otherwise

candidates for AVR.

Concomitant Aortic Root Disease

Dilatation of the ascending aorta is among the most common causes of isolated AR

In addition to causing acute AR, diseases of the proximal aorta may also contribute to chronic AR

- Marfan syndrome- Dissection- Chronic dilatation of the aortic root related to HTN or a BAV

AVR and aortic root reconstruction are indicated in patients with disease of the aortic root or proximal aorta and AR of any severity when the degree of dilatation of the aorta or aortic root reaches or exceeds 5.0 cm by echocardiography

Evaluation of Patients After Aortic Valve Replacement

An echocardiogram should be performed soon after surgery to assess the results of surgery on LV size and function

A better predictor of LV systolic function following AVR is the reduction in LV end-diastolic dimension(LVEDD), which declines significantly within the first week or 2 after AVR

This is an excellent marker of the functional success of valvereplacement(because 80% of the overall reduction in EDD observed during the long-term postoperative course occurs within the first 10 to 14 daysafter AVR)

Bicuspid Aortic Valve With Dilated Ascending Aorta class I- Initial TTE to assess the diameters of the aortic root and Asc.Ao

- CMR or CT indicated when morphology cannot be assessed accurately by TTE- Diameter > 4.0 cm should undergo serial evaluation of aortic root /ascending aorta size and morphology by echo, CMR, or CT on a yearly basis

Surgery to repair the aortic root or replace the ascending aorta is indicated: - if the diameter of the aortic root or ascending aorta is > 5.0 cm or if the rate of increase in diam. is 0.5 cm per year or more

Bicuspid Aortic Valve With Dilated Ascending Aorta class IIaBeta-adrenergic blocking agents- (diameter > 4.0 cm): - who are not candidates for surgical correction and who do not have moderate to severe AR.

MCQs

1. True about severe AS except?a) Aortic jet velocity- 4.5 m/secb) Mean gradient- 42 mmHgc) Valve area index- 0.7 (cm2/m2)d) Valve area – 1 cm2

2. True about low-flow/low-gradient AS except?a) Valve area - 0.8 cm2 b) LV ejection fraction - 46% c) Mean gradient - 30 mm Hgd) AVR is reasonable

3. All are indications of AVR in except?a) Severe AS - NYHA class IIb) Severe AS with EF 40%c) Severe AS with TVDd) Asymptomatic AS with positive TMTe) Asymptomatic AS with family history of SCD

4. All are true about medical therapy of AS except?

a) ACEI should be used with cautionb) Metoprolol is the only Beta blocker that can

be given in AS patientsc) No definite role for atorvastatind) Digitalis is useful in AS with LV dysfunction

5.All are true about AS in elderly?a) AVR is technically possible at 80 years of ageb) Elderly men usually require enlargement of

aortic annuls at the time of AVRc) TAVI indicated when predicted survival- 15

monthsd) TAVI is reasonable alternative to surgical AVR

in patients with high surgical risk

6.All are indications of AVR in AR except?a) Severe AR NYHA class IIb) Severe AR with EF 35%c) Asymptomatic severe AR with EF 50%d) Asymptomatic severe AR with EF 55%, LV

EDD-75mm, LVESD-55mm

7. Severe AR true except?a) Doppler VC width 0.28cmb) Regurgitant volume- 70 (mL/beat)c) Regurgitant fraction 56 % d) Regurgitant orifice area 0.4 cm2

8. True about Indication of surgery in AR with aortic root disease?

a) Aortic root diameter>45mm in patients with Marfan syndrome

b) Aortic root diameter>50 mm in patients with BAV

c) Diameter increase more than 0.5 cm/yeard) All of the above

Answers

1. True about severe AS except?a) Aortic jet velocity- 4.5 m/secb) Mean gradient- 42 mmHgc) Valve area index- 0.7 (cm2/m2)d) Valve area – 1 cm2

2. True about low-flow/low-gradient AS except?a) Valve area - 0.8 cm2 b) LV ejection fraction - 46% c) Mean gradient - 30 mm Hgd) AVR is reasonable

3. All are indications of AVR in except?a) Severe AS - NYHA class IIb) Severe AS with EF 40%c) Severe AS with TVDd) Asymptomatic AS with positive TMTe) Asymptomatic AS with family history of SCD

4. All are true about medical therapy of AS except?

a) ACEI should be used with cautionb) Metoprolol is the only Beta blocker that can

be given in AS patientsc) No definite role for atorvastatind) Digitalis is useful in AS with LV dysfunction

5.All are true about AS in elderly?a) AVR is technically possible at 80 years of ageb) Elderly men usually require enlargement of

aortic annuls at the time of AVRc) TAVI indicated when predicted survival- 15

monthsd) TAVI is reasonable alternative to surgical AVR

in patients with high surgical risk

6.All are indications of AVR in severe AR except?a) Severe AR NYHA class IIb) Severe AR with EF 35%c) Asymptomatic severe AR with EF 50%d) Asymptomatic severe AR with EF 55%, LV

EDD-75mm, LVESD-55mm

7. Severe AR true except?a) Doppler VC width - 0.28cmb) Regurgitant volume- 70 (mL/beat)c) Regurgitant fraction 56 % d) Regurgitant orifice area 0.4 cm2

8. True about Indication of surgery in AR with aortic root disease?

a) Aortic root diameter>45mm in patients with Marfan syndrome

b) Aortic root diameter>50 mm in patients with BAV

c) Diameter increase more than 0.5 cm/yeard) All of the above

Thank you

Documents

Guidelines for the Management of Patients With Aortic Valve Disease Dr sajeer K T Senior Resident, Dept. of Cardiology, MCH, Calicut