Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Optimal timing of operation The...

Cattedra di CardiochirurgiaUNIVERSITA’ DEGLI STUDI DI FIRENZE

Optimal timing of operation

The goal is to operate late enough in the natural history to justify the risk but early enough to prevent irreversible left ventricular dysfunction


Guidelines for the Guidelines for the management of management of

Patients with valvular Patients with valvular heart diseaseheart disease

ACC / AHA ACC / AHA

presented march 1999presented march 1999

American College of CardiologyAmerican College of Cardiology

48 Annual Scientific Session48 Annual Scientific Session


Guidelines for classifying Guidelines for classifying IndicationsIndications

• Class I: Class I: Conditions for which there is evidence and/or general Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effectiveagreement that a given procedure or treatment is useful and effective

• Class II:Class II: Conditions for which there is conflicting evidence and/or a Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness of a procedure or divergence of opinion about the usefulness of a procedure or treatmenttreatment

– II a: II a: Weight of evidence/opinion is in favour of Weight of evidence/opinion is in favour of usefulness/efficacyusefulness/efficacy

– II b: II b: Usefulness/efficacy is less well established by Usefulness/efficacy is less well established by evidence/opinionevidence/opinion

• Class III: Class III: Conditions for which there is evidence and/or general Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful and in some agreement that the procedure/treatment is not useful and in some cases may be harmfulcases may be harmful


AORTIC STENOSISAORTIC STENOSIS

• Mild: aortic valve area > 1.5 cmMild: aortic valve area > 1.5 cm22

• Moderate: aortic valve area 1.0 - 1.5 cmModerate: aortic valve area 1.0 - 1.5 cm22

• Severe: aortic valve area < 1.0 cmSevere: aortic valve area < 1.0 cm2 2

• ( Critical: aortic valve area = 0.75 cm( Critical: aortic valve area = 0.75 cm22 ) )


SymptomSymptomss

Valvular aortic stenosis

100

%

Survival

25 30 yr

Onset of

symptoms

Asymptomatic period

CHF

Syncope

AP


AS, Rate of progression - HemodynamicAS, Rate of progression - Hemodynamic• CCardiac Catheterisation (3-9 year f/u )ardiac Catheterisation (3-9 year f/u )• ProgressionProgression

– Valve area decreases = 0.1 - 0.3 cmValve area decreases = 0.1 - 0.3 cm2 2 /year/year– Pressure gradient increases = 10-15 mm Hg/yearPressure gradient increases = 10-15 mm Hg/year

• Little or no progression in 50% of reported patientsLittle or no progression in 50% of reported patients• Echocardiography (1-3 year f/u)Echocardiography (1-3 year f/u)• ProgressionProgression

– Valve area decreases = 0.1 cmValve area decreases = 0.1 cm22/year/year– Pressure gradient increases = 15-19 mm Hg/yearPressure gradient increases = 15-19 mm Hg/year

• Little or no progression in 50 % of reported patients Little or no progression in 50 % of reported patients

• Faggiano, et al. Am Heart J 1996


AS, Rate of AS, Rate of progression-Symptoms/Need for progression-Symptoms/Need for

surgerysurgery• Prospective follow up of asymptomatic patients Prospective follow up of asymptomatic patients

with severe aortic stenosis (Doppler velocity > 4 with severe aortic stenosis (Doppler velocity > 4 m/s)m/s)

• Symptoms developed in 30% within 2 yearsSymptoms developed in 30% within 2 years– Pellikka, et al. JACC 15: 1012, 1990Pellikka, et al. JACC 15: 1012, 1990

• Surgery was performed in 70% within 2 yearsSurgery was performed in 70% within 2 years– Otto, et al. Circ 95:2262, 1997Otto, et al. Circ 95:2262, 1997


Recommendations for Echo in Recommendations for Echo in ASAS

Indication Class

1 Diagnosis and assessment of severity of AS I

2 Assessment of LV size, function, and or hemodynamics I

3 Reevaluation of patients with known AS with changing I

symptoms or signs

4 Assessment of changes in hemodynamic severity and ventricular I

compensation in patients with known AS during pregnancy

5 Reevaluation of asymptomatic patients with severe AS I

6 Reevaluation of asymptomatic patients with mild to moderate AS IIa

and evidence of LV-dysfunction or hypertrophy

7 Routine reevaluation of asymptomatic adult patients with mild AS III

having stable physical signs and normal LV size and function


AS, AS, Exercise TestingExercise Testing

• Patient population (n=123)Patient population (n=123)– Asymptomatic adults with ASAsymptomatic adults with AS

– Max (Doppler) velocity: average 3.6 m/sMax (Doppler) velocity: average 3.6 m/s

• Results (274 tests in 104 patients)Results (274 tests in 104 patients)– > 80% of max predicted Heart rate in 87% of patients> 80% of max predicted Heart rate in 87% of patients

– no morbidity or mortalityno morbidity or mortality

– BP fell in 25 (9%), BP fell in 25 (9%), eligible for AVReligible for AVR

– ST depression in 4 (2%)ST depression in 4 (2%)

– Otto, et al. Circ 1997Otto, et al. Circ 1997


Recommendations for Recommendations for Catheterizaion in ASCatheterizaion in AS

Indication Class

1 CAG before AVR in patients at risk for CAD (see section VIII.B of these I

guidelines).

2 Assessment of severity of AS in symptomatic patients when AVR is planned I

or when noninvasive tests are inconclusive or there is a discrepancy with

clinical findings regarding severity of AS or need for surgery

3 Assessment of severity of AS before AVR when noninvasive tests are IIb

adequate and concordant with clinical findings and CAG is not needed

4 Assessment of LV function and severity of AS in asymptomatic patients III

when noninvasive tests are adequate


Low-gradient ASLow-gradient AS

• Problem: Low cardiac output and low pressure gradient. Problem: Low cardiac output and low pressure gradient. Calculated valve area indicates severe stenosisCalculated valve area indicates severe stenosis

• Determine pressure gradient, valve area/resistance Determine pressure gradient, valve area/resistance during:during:– 1 Resting - baseline state1 Resting - baseline state

– 2 2 Stress - dobutamine (or exercise)Stress - dobutamine (or exercise)

• If dobutamine produces an increment in stroke volume If dobutamine produces an increment in stroke volume and an increase in valve area, the baseline calculation and an increase in valve area, the baseline calculation probably overestimates the severity of the stenosisprobably overestimates the severity of the stenosis


Recommendations for AVR Recommendations for AVR in AS 1in AS 1

Indication Class

1 Sympomatic patients with severe AS I

2 Patients with severe AS undergoing CABG I

3 Patients with severe AS undergoing surgery of the I

aorta or other heart valves

4 Patients with moderate AS (>30) undergoing CABG IIa

surgery on the Aorta or other heart valves

(see III.F and Viii.D)


Recommendations for AVR Recommendations for AVR in AS 2in AS 2

Indication Class

5 Asymptomatic patients with severe AS and

. LV systolic dysfunction IIa

. Abnormal response to exercise (eg Hypotension) IIa

. Ventricular tachycardia IIb

. Marked or excessive LVH (>= 15mm) IIb

. Valve are < 0.6 cm2 IIb

6 Prevention of SCD in asymptomatic patients with III

findings under 5


Recommendations for Balloon Recommendations for Balloon Valvulotomy in ASValvulotomy in AS

Indication Class

1 A bridge to surgery in hemodynamically unstable patients IIa

who are at high risk for AVR

2 Palliation in patients with serious comorbid conditions IIb

3 Patients who require urgent noncardiac surgery IIb

4 An alternative to AVR III

Recommendations for PTVP Ao in adolescents and young adults with AS are provided in VI.A


Mitral StenosisMitral Stenosis

EtiologyRheumatic

fever

Leaflet thickening

Commissural fusion

Chordal fusion



Pathophysiology

Transmitral Pressure

Gradient

Narrow Orifice

Elevated

LAP



What is new ?

- 2D and doppler echo

- Percutaneous Mitral Balloon valvotomy (PMBV)

Recommendations for patient care

-Asymptomatic

-Symptomatic


Mitral StenosisMitral Stenosis2 D echo is the Gold Standard for MS



Doppler echo is the

Gold Standard for

the quantification of

mitral stenosis



Doppler echo is more accurate than conventional catheterization



Percutaneous

Mitral Balloon

Valvotomy

PMBV


PMBV, immediate resultsPMBV, immediate results

Doubling of MVA

50-60 % reduction gradient

Success rate 80-95%



0

0,5

1

1,5

2

2,5

MVA

Base 6 months 7 yr

BMCOMCCMC

Farhat et al: Circ;97:245-25

Results PMBV

Results are even better than for Valve replacement


– PMBV: Dependent upon mitral morphologyPMBV: Dependent upon mitral morphology

– Non calcified, pliableNon calcified, pliable

– No commissural fusionNo commissural fusion

– Success > 90%Success > 90%

– Complications < 3%Complications < 3%




Asymptomatic

Mild stenosis

MVA > 1.5 cm2

Yearly exam

Mod-severe stenosis

MVA < 1.5 cm2

? Suitable for PMBV ?



Asymptomatic

No

Yearly exam

Yes


PAP > 50

PMBV

PAP < 50



Exercise induced pulmonary HTN

PMBV

Calculated PAP



Symptoms

Mild stenosis

MVA > 1.5 cm2

Exercise

Mod-severe stenosis

MVA < 1.5 cm2

PMBV Look elsewhere

PAP > 60

Grad > 15

? Suitable For PMBV? yes

Pap < 60

Grad<15



Symptoms

No

Follow

Class II

Yes


PMBVSurgery

Class III, IV



• Other issuesOther issues– Rheumatic fever prophylaxisRheumatic fever prophylaxis

– AnticoagulationAnticoagulation

– Treatment for atrial fibrillationTreatment for atrial fibrillation

– Recommendations for exerciseRecommendations for exercise

– PregnancyPregnancy

– Cost-effective follow-upCost-effective follow-up


Aortic RegurgitationAortic Regurgitation• Percent Survival 3 yr after operation for AR:Percent Survival 3 yr after operation for AR:• Pre-op LVEF >= 0.50 : 90 %; Pre-op LVEF < 0.50 : 60 %Pre-op LVEF >= 0.50 : 90 %; Pre-op LVEF < 0.50 : 60 %

– FormanForman et al, Am J Cardiol, 1980 et al, Am J Cardiol, 1980

Cheitlin et al Dilemmas in clinical cardiology

1990


Chronic Aortic Regurgitation 1Chronic Aortic Regurgitation 1Preoperative prediction of survival after AVR: Predictor # LVEF LVFS LVSDForman 1980 90 xHenry 1980 50 x xGunha 1980 86 x x Greves 1981 45 xKumpuris 1982 43 xBonow 1985 80 x x xDaniel 1985 84 x xCormier 1986 73 x xShelban 1986 84 x x


Chronic Aortic Regurgitation Chronic Aortic Regurgitation 22

Preoperative prediction of survival after AVR: Predictor # LVEF LVFS LVSDTaniguchi 1987 62 x x*Klodas 1996 219 xTurina 1998 192 x x*---------------------------------------------------------------------------------------Total 1108

*LVSV


LV dysfunktion in valvular ARLV dysfunktion in valvular AR

Reversible alteration in LV loading (afterload mismatch)

versus

Irreversible LV myocardial dysfunction


Chronic AR with LV Chronic AR with LV dysfunktiondysfunktion

Factors influencing survival and functional results after AVR:

1 Severity of preoperative symptoms2 Severity of LV dysfunction3 Duration of LV dysfunction


Chronic AR with LV Chronic AR with LV dysfunktiondysfunktion

Asymptomatic patients with aortic regurgitation and LV dysfunction should undergo operation before the onset of symptoms and limitation of exercise capacity


Timing of operation for Timing of operation for asymptomatic ARasymptomatic AR

Management considerations:1 Survival and functional results

after aortic valve replacement

2 Natural history of asymptomatic patients


Asymptomatic AR with normal Asymptomatic AR with normal LVFLVF

Natural historyRate of progression to symptoms and/or LV dysfunction n Rate Bonow, Circ 1984, 1991 104 3.8%/yrScognamiglio, Clin Cardiol, 1986 30 2.1%/yrSiemenczuk, Ann Int Med 1989 50 4.0%/yrScognamiglio, N Engl J Med 1994 74 5.7%/yr (+digoxin)

Tornos, Am Heart J 1995 101 3.0%/yrIshii, Am J Cardiol 1996 27 3.6%/yr (incomplete data)

Borer, Circ 1998 104 6.2%/yr---------------------------------------------------------------------------Total 490 4.3%/yr


Asymptomatic AR with Asymptomatic AR with normal LVFnormal LVF

Natural historyLikelihood of developing asymptomatic LV dysfunction n Mean F/U Rate Bonow, Circ 1984, 1991 4/105 8.0 yr 0.5%/yrScognamiglio, Clin Cardiol, 1986 3/30 4.7 yr 2.1%/yrSiemenczuk, Ann Int Med 1989 1/50 3.7 yr 0.5%/yrScognamiglio, N Engl J Med 1994 15/74 6.0 yr 3.4%/yrTornos, Am Heart J 1995 6/101 4.6 yr 1.3%/yrBorer, Circ 1998 7/104 7.3 yr 0.9%/yr--------------------------------------------------------------------------------------Total 36/463 5.9 yr 1.3%/yr



Event Rate

Death < 0.2 % / yr Asymptomatic LV Dysfunction 1.3 % / yrSymptoms and/or LV dysfunction 4.3 % / yr



Factors predictive of symptoms and/or LV dysfunction

. LV end systolic dimension/volume

. LV end diastolic dimension/volume

. LV ejection fraction with exercise

Bonow, Circ 1984, 1991 Siemenczuk, Ann Int Med 1989Tornos, Am Heart J 1995



Likelihood of death, development of symptoms and/or LVdysfunction (Risk Stratification)

. LV end systolic dimension/volume > 50 19%/yr 40-49 6%/yr < 50 0%/yr. LV end diastolic dimension/volume >= 70 10%/yr < 70 2%/yr. LVEF response to exercise decrease >5% 12%/yr decrease 0-5% 4%/yr increase > 0% 1%/yrBonow, Circ 1984, 1991



Predictive variables in multivariate analysis:Initial evaluation:

. Age

. LV end-systolic dimensionSerial evaluation:

. Increase in LVSD

. Decrease in resting LVEF

Bonow et al, Circ 1984,1991



Risk of sudden Cardiac Death:. LV end-diastolic volume > 200 ml/m2

Turina et al, Circ 1984

. LV end-diastolic dimension >= 80 mm

. LV end-systolic dimension > 55 mm Bonow et al, Circ 1991


Chronic AR with marked LV Chronic AR with marked LV dilatationdilatation

Outcome after AVR:

Low risk group:. Asymptomatic with normal EF

High risk groups:. Symptoms. LV Dysfunction

Klodas et al, JACC 1996, 31 patients with LVDD > =80 mm


Chronic ARChronic AR

Indications for operation:

. Symptoms

. LV systolic dysfunction

(subnormal EF at rest)

. Marked LV dilatation

(LVSD >= 55 mm; LVDD >= 75mm)



Follow-up strategy

. Monitoring for onset of symptoms and changes in effort tolerance

. Serial echocardiogramsfrequency based on LV size and function

. Ancillary tests .Exercise treadmill testing if symptoms unclear.Radionuclide angiography if echo data equivocal


Mitral RegurgitationMitral Regurgitation

Chronic compensated MI:

EDV 240, ESV 50, Filling pressure 15 mm Hg

Chronic decompensated MI:

EDV 260, ESV 110, Filling pressure 25 mm Hg


Mitral RegurgitationMitral Regurgitation


Mitral Valve SurgeryMitral Valve Surgery

EF after repair: the same or better

EF after replacement:

. Chords preserved: the same

. Chords severed: worse, sometimes even

becomes half of the

original value


Recommendations for TTE in Recommendations for TTE in MRMR

Indication Class1 For baseline evaluation to quantify severety of MR and LV I function in any patient suspected of having MR2 For deleneation of mechanism of MR I3 For annual or semiannual surveillance of LV function (esti- I mated by EF and end-systolic dimension) in asymptomatic severe MR4 To establish cardiac status after a change in symptoms I5 For evaluation after MVR or MV-repair to establish baseline I status6 Routine follow-up evaluation of mild MR with normal LV III size and systolic function


Recommendations for TEE Recommendations for TEE in MRin MR

Indication Class

1 Intraoperative TEE to establish the anatomic basis for MR I and guide to repair2 For evaluation of MR patients in whom TTE provides non- I diagnostic images regarding severety of MR, mechanism of MR, and/or status of LV function3 In routine follow-up or surveillance of patients with native III valve MR


Recommendations for CAG Recommendations for CAG in MRin MR

Indication Class

1 When mitral valve surgery contemplated in patients with I angina or previous myocardial infarction2 When mitral valve surgery is contemplated in patients with I >= 1 risk factor for CAD (see section VIII.B)3 When ischemia is suspected as an etiologic factor in MR I4 To confirm noninvasive tests in patients not suspected of IIb having CAD5 When mitral valve surgery is contemplated in patients aged III < 35 years and there is no clinical suspicion of CAD


Recommendations for Cine Recommendations for Cine in MRin MR

Left ventricular and hemodynamic measurements

Indication Class

1 When non-invasive tests are inconclusive regarding the se- I verity of MR, LV function, or the need for surgery2 When there is a discrepancy between clinical and noninvasive I findings regarding severety of MR3 In patients in whom valve surgery is not contemplated III


Recommendations for MV surgery in non-Recommendations for MV surgery in non-ischemic severe MR 1ischemic severe MR 1

Indication Class

1 Acute symptomatic MR in which repair is likely I2 Patients with NYHA functional class II, III, or IV symptoms I with normal LV function defined as EF > 0.60 and end- systolic dimension < 45 mm 3 Symptomatic or asymptomatic patients with mild LV dys- I function, ejection fraction 0.50 to 0.60, and end systolic dimension 45 to 50 mm



Indication Class

4 Symptomatic or asymptomatic patients with moderate LV I dysfunction, ejection fraction 0.30 to 0.50, and/or end- systolic dimension 50 to 55 mm5 Asymptomatic patients with preserved LV function and IIa atrial fibrillation6 Asymptomatic patients with preserved LV function and IIa pulmonary hypertension (pulmonary artery systolic pressure > 50 mm Hg at rest or > 60 mm Hg with exercise)



Indication Class

7 Asymptomatic patients with EF 0.50 to 0.60 and end-systolic IIa dimension < 45 mm and asymptomatic patients with EF > 0.60 and end-systolic dimension 45 to 55 mm8 Patients with severe LV dysfunction (EF < 0.30 and/or ESD > IIa 55 mm) in whom chordal preservation is highly likely



Indication Class

9 Asymptomatic patients with chronic MR with preserved LV IIb function in whom mitral valve repair is highly likely10 Patients with MVP and preserved LV function who have IIb recurrent ventricular arrhythmias despite medical therapy11 Asymptomatic patients with preserved LV function in whom III significant doubt about the feasibility of repair exists


Symptoms

NYHA FC IINYHA FC I

Normal LVFEF > 0.60 andEDS < 45 mm

AFPHT

Clinical eval 6 moEcho 12 mo

MVR orrepair

MV repair MVR

MV repairlikely ?

LV DysfunctionEF <= 0.60 andEDS >= 45 mm

Normal LVFEF > 0.60 andEDS < 45 mm

NoYes Yes

No

Chronic severe Mitral Chronic severe Mitral RegurgitationRegurgitation


Symptoms

NYHA FC III-IV

MVR Medical therapy MVR repair

EF >= 0.30

MV repair likely

No

Yes No

Yes

Chronic severe Mitral Chronic severe Mitral RegurgitationRegurgitation

Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Optimal timing of operation The...

Documents

Transcript of Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Optimal timing of operation The...