Indications for Aortic Valve Replacement in AS

Indications for Aortic Valve Replacement in AS Prof. Ibrahim Kasb Professor of Cardiology, Faculty of Medicine, Cairo University Ass. Prof. Of cardiothoracic surgery, Banha Universuty

Class ı

1. Symptomatic patients with severe AS.

2. Severe AS* undergoing coronary artery bypass graft surgery.

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

4. Severe AS*and LV systolic dysfunction (ejection fraction less than 50%). Class ııa Patients with moderate AS*undergoing CABG or surgery on the aorta or other heart valves).

Class ııb

1. Asymptomatic patients with severe AS* and abnormal response to exercise(e.g., development of symptoms or asymptomatic hypotension).

2. AVR may be considered for asymptomatic patients with extremely severe AS (aortic valve area less than 0.6 cm2, mean gradient greater than 60 mm Hg, and jet velocity greater than 5.0 m per second) .

3. Asymptomatic patients with severe AS if there is a high likelihood of rapid progression (age, calcification, and CAD) or if surgery might be delayed at the time of symptom onset.

4. AVR may be considered in patients undergoing CABG who have mild AS* when there is moderate to severe valve calcification, that progression may be rapid. Class ııı AVR is not useful for the prevention of sudden death in asymptomatic patients with AS who have none of the findings listed under the Class ııa/ııb recommendations.

Indications for Aortic Valve Replacement or Repair in AR

Class ı

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. Patients with chronic severe AR while undergoing CABG or surgery on the aorta or other heart valves. Class ııa Asymptomatic patients with severe AR with normal LV systolic function (ejection fraction greater than 0.50) but with severe LV dilatation (end-diastolic dimension greater than 75 mm or end-systolic dimension greater than 55 mm).*

Class IIb

1. Patients with moderate AR while undergoing surgery on the ascending aorta.

2. Patients with moderate AR while undergoing CABG.

3. Asymptomatic patients with severe AR and normal LV systolic function at rest (ejection fraction greater than 0.50) when the degree of LV dilatation exceeds an end-diastolic dimension of 70 mm or end-systolic dimension of 50 mm, when there is evidence of progressive LV dilatation, declining exercise tolerance, or abnormal hemodynamic responses to exercise.*

Class ııı

AVR is not indicated for asymptomatic patients with mild, moderate, or severe AR and normal LV systolic function at rest (ejection fraction greater than 0.50) when the degree of dilatation is not moderate or severe (end-diastolic dimension less than 70 mm, end-systolic dimension less than 50 mm).*

Indications for Surgery for Mitral Stenosis

Class ı

1. Mitral Valve (MV) surgery (repair if possible) is indicated in patients with symptomatic (NYHA functional class III–IV) moderate or severe MS* when

1) Percutaneous mitral balloon valvotomy is unavailable,

2) Percutaneous mitral balloon valvotomy is contraindicated because of left atrial thrombus despite anticoagulation or because concomitant moderate to severe mitral regurge (MR) is present, or

3) The valve morphology is not favorable for percutaneous mitral balloon valvotomy in a patient with acceptable operative risk

2. Symptomatic patients with moderate to severe MS* who also have moderate to severe MR should receive MV replacement, unless valve repair is possible at the time of surgery.

Class ııa

MV replacement is reasonable for patients with severe Mitral Stenoses* 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 MV repair. Class ııb MV repair may be considered for asymptomatic patients with moderate or severe MS* who have had recurrent embolic events while receiving adequate anticoagulation and who have valve morphology favorable for repair. Class ııı

1. MV repair for MS is not indicated for patients with mild MS.

2. Closed commissurotomy should not be performed in patients undergoing MV repair; open commissurotomy is the preferred approach.

Indications for Mitral Valve Operation in MR

Class ı

1. Symptomatic patient with acute severe MR.

2. Patients with chronic severe MR* and NYHA functional class II, III, or IV symptoms in the absence of severe LV dysfunction (severe LV dysfunction is defined as ejection fraction less than 0.30) and/or end-systolic dimension greater than 55 mm.

3. Asymptomatic patients with chronic severe MR* and mild to moderate LV dysfunction, ejection fraction 0.30 to 0.60, and/or end-systolic dimension greater than or equal to 40 mm.

4. MV repair is recommended over MV replacement in the majority of patients with severe chronic MR* who require surgery, and patients should be referred to surgical centers experienced in MV repair.

Class ııa

1. MV repair is reasonable in experienced surgical centers for asymptomatic patients with chronic severe MR* with preserved LV function (ejection fraction greater than 0.60 and end-systolic dimension less than 40 mm) in whom the likelihood of successful repair without residual MR is greater than 90%.

2. MV surgery is reasonable for asymptomatic patients with chronic severe MR,* preserved LV function, and new onset of atrial fibrillation.

3. MV surgery is reasonable for asymptomatic patients with chronic severe MR,* preserved LV function, and pulmonary hypertension (pulmonary artery systolic pressure greater than 50 mm Hg at rest or greater than 60 mm Hg with exercise).

4. MV surgery is reasonable for patients with chronic severe MR* due to a primary abnormality of the mitral apparatus and NYHA functional class III–IV symptoms and severe LV dysfunction (ejection fraction less than 0.30 and/or end-systolic dimension greater than 55 mm) in whom MV repair is highly likely. Class ııb MV repair may be considered for patients with chronic severe secondary MR* due to severe LV dysfunction (ejection fraction less than 0.30) who have persistent NYHA functional class III–IV symptoms despite optimal therapy for heart failure, including biventricular pacing.

Class ııı

1. MV surgery is not indicated for asymptomatic patients with MR and preserved LV function (ejection fraction greater than 0.60 and end-systolic dimension less than 40 mm) in whom signi.cant doubt about the feasibility of repair exists.

2. Isolated MV surgery is not indicated for patients with mild or moderate MR.