1. 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

2. Guidelines for the management of Patients with valvular heart disease
ACC / AHA
presented march 1999
American College of Cardiology
48 Annual Scientific Session

3. Guidelines for classifying Indications
Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective
Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness of a procedure or treatment
II a: Weight of evidence/opinion is in favour of usefulness/efficacy
II b: Usefulness/efficacy is less well established by evidence/opinion
Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful and in some cases may be harmful

4. AORTIC STENOSIS Mild: aortic valve area > 1.5 cm2
Moderate: aortic valve area cm2
Severe: aortic valve area < 1.0 cm2
( Critical: aortic valve area = 0.75 cm2 )

5. Symptoms

6. AS, Rate of progression - Hemodynamic
Cardiac Catheterisation (3-9 year f/u )
Progression
Valve area decreases = cm2 /year
Pressure gradient increases = mm Hg/year
Little or no progression in 50% of reported patients
Echocardiography (1-3 year f/u)
Valve area decreases = 0.1 cm2/year
Pressure gradient increases = mm Hg/year
Little or no progression in 50 % of reported patients
Faggiano, et al. Am Heart J 1996

7. AS, Rate of progression-Symptoms/Need for surgery
Prospective follow up of asymptomatic patients with severe aortic stenosis (Doppler velocity > 4 m/s)
Symptoms developed in 30% within 2 years
Pellikka, et al. JACC 15: 1012, 1990
Surgery was performed in 70% within 2 years
Otto, et al. Circ 95:2262, 1997

8. Recommendations for Echo in AS
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

9. AS, Exercise Testing Patient population (n=123)
Asymptomatic adults with AS
Max (Doppler) velocity: average 3.6 m/s
Results (274 tests in 104 patients)
> 80% of max predicted Heart rate in 87% of patients
no morbidity or mortality
BP fell in 25 (9%), eligible for AVR
ST depression in 4 (2%)
Otto, et al. Circ 1997

10. Recommendations for Catheterizaion 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

11. Low-gradient AS
Problem: Low cardiac output and low pressure gradient. Calculated valve area indicates severe stenosis
Determine pressure gradient, valve area/resistance during:
1 Resting - baseline state
2 Stress - dobutamine (or exercise)
If dobutamine produces an increment in stroke volume and an increase in valve area, the baseline calculation probably overestimates the severity of the stenosis

12. Recommendations for AVR in 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)

13. Recommendations for AVR in 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 cm IIb
6 Prevention of SCD in asymptomatic patients with III
findings under 5

14. Recommendations for Balloon Valvulotomy 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

15. Mitral Stenosis Etiology Rheumatic fever Leaflet thickening
Commissural fusion
Chordal fusion

16. Mitral Stenosis Halmark of MS Pathophysiology Narrow Orifice
Transmitral Pressure
Gradient
Halmark of MS
Elevated
LAP

17. Mitral Stenosis What is new ? Recommendations for patient care
- 2D and doppler echo
- Percutaneous Mitral Balloon valvotomy (PMBV)
Recommendations for patient care
-Asymptomatic
-Symptomatic

18. Mitral Stenosis
2 D echo is the Gold Standard for MS

19. Mitral Stenosis Doppler echo is the Gold Standard for
the quantification of
mitral stenosis

20. Mitral Stenosis
Doppler echo is more accurate than conventional catheterization

21. Mitral Stenosis
Percutaneous
Mitral Balloon
Valvotomy
PMBV

22. PMBV, immediate results
Doubling of MVA
50-60 % reduction gradient
Success rate 80-95%

23. Mitral Stenosis Results PMBV
Results are even better than for Valve replacement
Farhat et al: Circ;97:245-25

24. Mitral Stenosis PMBV: Dependent upon mitral morphology
Non calcified, pliable
No commissural fusion
Success > 90%
Complications < 3%

25. Mitral Stenosis Asymptomatic Mild stenosis MVA > 1.5 cm2
Mod-severe stenosis
MVA < 1.5 cm2
Yearly exam
? Suitable for PMBV ?

26. Mitral Stenosis Asymptomatic ? Suitable for PMBV ? Yes No PAP > 50
Yearly exam
PMBV

27. Mitral Stenosis
Exercise induced pulmonary HTN
PMBV
Calculated PAP

28. Mitral Stenosis PMBV Symptoms Mild stenosis MVA > 1.5 cm2
Mod-severe stenosis
MVA < 1.5 cm2
PAP > 60
Grad > 15
Exercise
? Suitable For PMBV?
Pap < 60
Grad<15
yes
PMBV
Look elsewhere

29. Mitral Stenosis Symptoms ? Suitable for PMBV ? No Yes Follow Class II
Surgery
Class III, IV
PMBV

30. Mitral Stenosis Other issues Rheumatic fever prophylaxis
Anticoagulation
Treatment for atrial fibrillation
Recommendations for exercise
Pregnancy
Cost-effective follow-up

31. Aortic Regurgitation Percent Survival 3 yr after operation for AR:
Pre-op LVEF >= 0.50 : 90 %; Pre-op LVEF < : 60 %
Forman et al, Am J Cardiol, 1980
Cheitlin et al Dilemmas in clinical cardiology
1990

32. Chronic Aortic Regurgitation 1
Preoperative prediction of survival after AVR:
Predictor
# LVEF LVFS LVSD
Forman x
Henry x x
Gunha x x
Greves x
Kumpuris x
Bonow x x x
Daniel x x
Cormier x x
Shelban x x

33. Chronic Aortic Regurgitation 2
Preoperative prediction of survival after AVR:
Predictor
# LVEF LVFS LVSD
Taniguchi x x*
Klodas x
Turina x x*
Total
*LVSV

34. LV dysfunktion in valvular AR
Reversible alteration in LV loading (afterload mismatch)
versus
Irreversible LV myocardial dysfunction

35. Chronic AR with LV dysfunktion
Factors influencing survival and functional results after AVR:
1 Severity of preoperative symptoms
2 Severity of LV dysfunction
3 Duration of LV dysfunction

36. Chronic AR with LV dysfunktion
Asymptomatic patients with aortic regurgitation and LV dysfunction should undergo operation before the onset of symptoms and limitation of exercise capacity

37. Timing of operation for asymptomatic AR
Management considerations:
1 Survival and functional results
after aortic valve replacement
2 Natural history of asymptomatic
patients

38. Asymptomatic AR with normal LVF
Natural history
Rate of progression to symptoms and/or LV dysfunction
n Rate
Bonow, Circ 1984, %/yr
Scognamiglio, Clin Cardiol, %/yr
Siemenczuk, Ann Int Med %/yr
Scognamiglio, N Engl J Med %/yr (+digoxin)
Tornos, Am Heart J %/yr
Ishii, Am J Cardiol %/yr (incomplete data)
Borer, Circ %/yr
Total %/yr

39. Asymptomatic AR with normal LVF
Natural history
Likelihood of developing asymptomatic LV dysfunction
n Mean F/U Rate
Bonow, Circ 1984, / yr %/yr
Scognamiglio, Clin Cardiol, / yr %/yr
Siemenczuk, Ann Int Med / yr %/yr
Scognamiglio, N Engl J Med / yr %/yr
Tornos, Am Heart J / yr %/yr
Borer, Circ / yr %/yr
Total / yr %/yr

40. Asymptomatic AR with normal LVF
Event Rate
Death < 0.2 % / yr
Asymptomatic LV Dysfunction % / yr
Symptoms and/or LV dysfunction % / yr

41. Asymptomatic AR with normal LVF
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 1989
Tornos, Am Heart J 1995

42. Asymptomatic AR with normal LVF
Likelihood of death, development of symptoms and/or LV
dysfunction (Risk Stratification)
. LV end systolic dimension/volume > %/yr
%/yr
< %/yr
. LV end diastolic dimension/volume >= %/yr
< %/yr
. LVEF response to exercise decrease >5% 12%/yr
decrease 0-5% 4%/yr
increase > 0% %/yr
Bonow, Circ 1984, 1991

43. Asymptomatic AR with normal LVF
Predictive variables in multivariate analysis:
Initial evaluation:
. Age
. LV end-systolic dimension
Serial evaluation:
. Increase in LVSD
. Decrease in resting LVEF
Bonow et al, Circ 1984,1991

44. Asymptomatic AR with normal LVF
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

45. Chronic AR with marked LV dilatation
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

46. Chronic AR Indications for operation: . Symptoms
. LV systolic dysfunction
(subnormal EF at rest)
. Marked LV dilatation
(LVSD >= 55 mm; LVDD >= 75mm)

47. Asymptomatic AR with normal LVF
Follow-up strategy
. Monitoring for onset of symptoms and
changes in effort tolerance
. Serial echocardiograms
frequency based on LV size and function
. Ancillary tests
.Exercise treadmill testing if symptoms unclear
.Radionuclide angiography if echo data
equivocal

48. Mitral 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

49. Mitral Regurgitation

50. Mitral 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

51. Recommendations for TTE in MR
Indication Class
1 For baseline evaluation to quantify severety of MR and LV I
function in any patient suspected of having MR
2 For deleneation of mechanism of MR I
3 For annual or semiannual surveillance of LV function (esti I
mated by EF and end-systolic dimension) in asymptomatic
severe MR
4 To establish cardiac status after a change in symptoms I
5 For evaluation after MVR or MV-repair to establish baseline I
status
6 Routine follow-up evaluation of mild MR with normal LV III
size and systolic function

52. Recommendations for TEE in MR
Indication Class
1 Intraoperative TEE to establish the anatomic basis for MR I
and guide to repair
2 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 function
3 In routine follow-up or surveillance of patients with native III
valve MR

53. Recommendations for CAG in MR
Indication Class
1 When mitral valve surgery contemplated in patients with I
angina or previous myocardial infarction
2 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 I
4 To confirm noninvasive tests in patients not suspected of IIb
having CAD
5 When mitral valve surgery is contemplated in patients aged III
< 35 years and there is no clinical suspicion of CAD

54. Recommendations for Cine in 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 surgery
2 When there is a discrepancy between clinical and noninvasive I
findings regarding severety of MR
3 In patients in whom valve surgery is not contemplated III

55. Recommendations for MV surgery in non-ischemic severe MR 1
Indication Class
1 Acute symptomatic MR in which repair is likely I
2 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

56. Recommendations for MV surgery in non-ischemic severe MR 2
Indication Class
4 Symptomatic or asymptomatic patients with moderate LV I
dysfunction, ejection fraction to 0.50, and/or end-
systolic dimension 50 to 55 mm
5 Asymptomatic patients with preserved LV function and IIa
atrial fibrillation
6 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)

57. Recommendations for MV surgery in non-ischemic severe MR 3
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 mm
8 Patients with severe LV dysfunction (EF < 0.30 and/or ESD > IIa
55 mm) in whom chordal preservation is highly likely

58. Recommendations for MV surgery in non-ischemic severe MR 4
Indication Class
9 Asymptomatic patients with chronic MR with preserved LV IIb
function in whom mitral valve repair is highly likely
10 Patients with MVP and preserved LV function who have IIb
recurrent ventricular arrhythmias despite medical therapy
11 Asymptomatic patients with preserved LV function in whom III
significant doubt about the feasibility of repair exists

59. Chronic severe Mitral Regurgitation
Symptoms
NYHA FC II
NYHA FC I
Normal LVF
EF > 0.60 and
EDS < 45 mm AF
PHT
Clinical eval 6 mo
Echo 12 mo
MVR or
repair MV
MVR
MV repair
likely ?
LV Dysfunction
EF <= 0.60 and
EDS >= 45 mm No
Yes

60. Chronic severe Mitral Regurgitation
Symptoms
NYHA FC III-IV
MVR
Medical therapy
MVR repair
EF >= 0.30
MV repair likely No
Yes