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Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Optimal timing of operation The goal is to operate late enough in the natural history to.

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Presentation on theme: "Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Optimal timing of operation The goal is to operate late enough in the natural history to."— Presentation transcript:

1 Cattedra di Cardiochirurgia UNIVERSITA’ 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

2 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Guidelines for the management of Patients with valvular heart disease ACC / AHA presented march 1999 American College of Cardiology 48 Annual Scientific Session

3 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE 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 effectiveClass 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 treatmentClass 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 harmfulClass 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 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE AORTIC STENOSIS Mild: aortic valve area > 1.5 cm 2Mild: aortic valve area > 1.5 cm 2 Moderate: aortic valve area cm 2Moderate: aortic valve area cm 2 Severe: aortic valve area < 1.0 cm 2Severe: aortic valve area < 1.0 cm 2 ( Critical: aortic valve area = 0.75 cm 2 )( Critical: aortic valve area = 0.75 cm 2 )

5 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Symptoms

6 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE AS, Rate of progression - Hemodynamic Cardiac Catheterisation (3-9 year f/u )Cardiac Catheterisation (3-9 year f/u ) ProgressionProgression –Valve area decreases = cm 2 /year –Pressure gradient increases = 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 cm 2 /year –Pressure gradient increases = mm Hg/year Little or no progression in 50 % of reported patientsLittle or no progression in 50 % of reported patients Faggiano, et al. Am Heart J 1996

7 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE AS, Rate of progression-Symptoms/Need for surgery Prospective follow up of asymptomatic patients with severe aortic stenosis (Doppler velocity > 4 m/s)Prospective follow up of asymptomatic patients with severe aortic stenosis (Doppler velocity > 4 m/s) Symptoms developed in 30% within 2 yearsSymptoms developed in 30% within 2 years – Pellikka, 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, 1997

8 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE 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 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE AS, Exercise Testing Patient population (n=123)Patient population (n=123) –Asymptomatic adults with AS –Max (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 –no morbidity or mortality –BP fell in 25 (9%), eligible for AVR –ST depression in 4 (2%) – Otto, et al. Circ 1997

10 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE 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 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Low-gradient AS Problem: Low cardiac output and low pressure gradient. Calculated valve area indicates severe stenosisProblem: Low cardiac output and low pressure gradient. Calculated valve area indicates severe stenosis Determine pressure gradient, valve area/resistance during: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 stenosisIf dobutamine produces an increment in stroke volume and an increase in valve area, the baseline calculation probably overestimates the severity of the stenosis

12 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE 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 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE 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 cm2 IIb 6 Prevention of SCD in asymptomatic patients with III findings under 5

14 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE 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 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Mitral Stenosis Etiology Rheumatic fever Leaflet thickening Commissural fusion Chordal fusion

16 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Mitral Stenosis Pathophysiology Transmitral Pressure Gradient Narrow Orifice Elevated LAP

17 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Mitral Stenosis What is new ? - 2D and doppler echo - Percutaneous Mitral Balloon valvotomy (PMBV) Recommendations for patient care -Asymptomatic -Symptomatic

18 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Mitral Stenosis 2 D echo is the Gold Standard for MS

19 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Mitral Stenosis Doppler echo is the Gold Standard for the quantification of mitral stenosis

20 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Mitral Stenosis Doppler echo is more accurate than conventional catheterization

21 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Mitral Stenosis Percutaneous Mitral Balloon Valvotomy PMBV

22 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE PMBV, immediate results Doubling of MVA % reduction gradient Success rate 80-95%

23 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Mitral Stenosis Farhat et al: Circ;97: Results PMBV Results are even better than for Valve replacement

24 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE –PMBV: Dependent upon mitral morphology –Non calcified, pliable –No commissural fusion –Success > 90% –Complications < 3% Mitral Stenosis

25 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Mitral Stenosis Asymptomatic Mild stenosis MVA > 1.5 cm 2 Yearly exam Mod-severe stenosis MVA < 1.5 cm 2 ? Suitable for PMBV ?

26 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Mitral Stenosis Asymptomatic No Yearly exam Yes ? Suitable for PMBV ? PAP > 50 PMBV PAP < 50

27 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Mitral Stenosis Exercise induced pulmonary HTN PMBV Calculated PAP

28 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Mitral Stenosis Symptoms Mild stenosis MVA > 1.5 cm 2 Exercise Mod-severe stenosis MVA < 1.5 cm 2 PMBV Look elsewhere PAP > 60 Grad > 15 ? Suitable For PMBV? yes Pap < 60 Grad<15

29 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Mitral Stenosis Symptoms No Follow Class II Yes ? Suitable for PMBV ? PMBV Surgery Class III, IV

30 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Mitral Stenosis Other issuesOther issues –Rheumatic fever prophylaxis –Anticoagulation –Treatment for atrial fibrillation –Recommendations for exercise –Pregnancy –Cost-effective follow-up

31 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Aortic 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 : 90 %; Pre-op LVEF < 0.50 : 60 % –Forman et al, Am J Cardiol, 1980 Cheitlin et al Dilemmas in clinical cardiology 1990

32 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE 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 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Chronic Aortic Regurgitation 2 Preoperative prediction of survival after AVR: Predictor # LVEF LVFS LVSD Taniguchi x x* Klodas x Turina x x* Total 1108 *LVSV

34 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE LV dysfunktion in valvular AR Reversible alteration in LV loading (afterload mismatch ) versus Irreversible LV myocardial dysfunction

35 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE 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 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE 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 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Timing of operation for asymptomatic AR Management considerations: 1 Survival and functional results after aortic valve replacement 2 Natural history of asymptomatic patients

38 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE 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 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Asymptomatic AR with normal LVF Natural history Likelihood of developing asymptomatic LV dysfunction n Mean F/U Rate Bonow, Circ 1984, / yr 0.5%/yr Scognamiglio, Clin Cardiol, / yr 2.1%/yr Siemenczuk, Ann Int Med / yr 0.5%/yr Scognamiglio, N Engl J Med / yr 3.4%/yr Tornos, Am Heart J / yr 1.3%/yr Borer, Circ / yr 0.9%/yr Total 36/ yr 1.3%/yr

40 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Asymptomatic AR with normal LVF Event Rate Death < 0.2 % / yr Asymptomatic LV Dysfunction 1.3 % / yr Symptoms and/or LV dysfunction 4.3 % / yr

41 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE 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 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Asymptomatic AR with normal LVF Likelihood of death, development of symptoms and/or LV dysfunction (Risk Stratification). LV end systolic dimension/volume > 50 19%/yr %/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%/yr Bonow, Circ 1984, 1991

43 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE 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 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Asymptomatic AR with normal LVF Risk of sudden Cardiac Death:. LV end-diastolic volume > 200 ml/m 2 Turina et al, Circ LV end-diastolic dimension >= 80 mm. LV end-systolic dimension > 55 mm Bonow et al, Circ 1991

45 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE 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 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Chronic AR Indications for operation:. Symptoms. LV systolic dysfunction (subnormal EF at rest). Marked LV dilatation (LVSD >= 55 mm; LVDD >= 75mm)

47 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE 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 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE 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 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Mitral Regurgitation

50 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE 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 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE 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 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE 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 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE 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 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE 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 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE 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 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Recommendations for MV surgery in non-ischemic severe MR 2 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 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 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE 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 0.60 and end-systolic dimension 45 to 55 mm 8 Patients with severe LV dysfunction (EF IIa 55 mm) in whom chordal preservation is highly likely

58 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE 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 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE 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 repair MVR MV repair likely ? LV Dysfunction EF <= 0.60 and EDS >= 45 mm Normal LVF EF > 0.60 and EDS < 45 mm No Yes No Chronic severe Mitral Regurgitation

60 Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Symptoms NYHA FC III-IV MVR Medical therapy MVR repair EF >= 0.30 MV repair likely No Yes No Yes Chronic severe Mitral Regurgitation


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