Aortic stenosis surgery indications

Jump to navigation Jump to search

Aortic stenosis surgery

Home

Overview

Epidemiology and Demographics

Indications

Treatment

Preoperative Evaluation

Procedure

Recovery

Outcomes and Prognosis

Complications

Videos

Aortic stenosis surgery indications On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Aortic stenosis surgery indications

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Aortic stenosis surgery indications

CDC on Aortic stenosis surgery indications

Aortic stenosis surgery indications in the news

Blogs on Aortic stenosis surgery indications

Directions to Hospitals Performing Aortic stenosis Surgery

Risk calculators and risk factors for Aortic stenosis surgery indications

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Sara Zand, M.D.[2] Mohammed A. Sbeih, M.D. [3]; Usama Talib, BSc, MD [4] Synonyms and keywords: As; Aortic stenosis; AVR; Aortic valve replacement; LVEF; Left ventricular ejection fraction; LV; Left ventricle

Overview

In symptomatic patients with severe high-gradient AS (Stage D1), AVR has beneficial effect on survival, symptoms, and LV systolic function. In asymptomatic patients with severe AS and normal LV systolic function, the risk of sudden death (<1% per year) is low. In patients with a low LVEF and severe AS, survival is better with AVR than medical therapy.

Indications

. The rate of symptom onset is strongly dependent on the severity of AS.

2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines[8]

Therapeutic Recommendations for Subaortic Stenosis

Class I
1. Surgical intervention is recommended for adults with subAS, a maximum gradient 50 mm Hg or more and symptoms attributable to the subAS.(Level of Evidence: C-EO)
2.Surgical intervention is recommended for adults with subAS and less than 50 mm Hg maximum gradient and HF or ischemic symptoms, and/or LV systolic dysfunction attributable to subAS.

(Level of Evidence: C-LD)

Class IIb
1.To prevent the progression of AR, surgical intervention may be considered for asymptomatic adults with subAS and at least mild AR and a maximum gradient of 50 mm Hg or more.

(Level of Evidence: C-LD)





Recommendations for intervention in aortic stenosis
Symptomatic aortic stenosis:
(Class I, Level of Evidence B):

Intervention is considered in symptomatic patients with severe, high-gradient aortic stenosis, mean gradient ≥ 40 mmHg, peak velocity ≥ 4.0 m/s, and valve area ≤ 1.0 cm2 (or ≤ 0.6 cm2/m2)
❑ntervention is considered in symptomatic patients with severe low-flow (SVi ≤35 mL/m2), low-gradient (<40 mmHg) aortic stenosis with reduced ejection fraction (<50%), and evidence of flow (contractile) reserve

(Class IIa, Level of Evidence C):

Intervention is recommended in symptomatic severe AS with low-flow, low-gradient (<40 mmHg) aortic stenosis with normal ejection fraction
Intervention is recommended in symptomatic patients with low-flow, low-gradient severe aortic stenosis and reduced ejection fraction without flow (contractile) reserve, severe aortic stenosis proven by CCT calcium score

(Class III, Level of Evidence C) :

Intervention is not recommended in patients with severe comorbidities when the intervention is unlikely to improve quality of life or prolong survival >1 year

Asymptomatic severe aortic stenosis :
(Class I, Level of Evidence B):

Intervention is recommended in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF < 50%) without another cause

(Class I, Level of Evidence C):

Intervention is recommended in asymptomatic patients with severe aortic stenosis, symptomtomatic on exercise testing

(Class IIa, Level of Evidence B):

Intervention should be considered in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF <55%) without another cause

(Class IIa, Level of Evidence C):

Interventin is recommended in asymptomatic patients with severe aortic stenosis and a sustained fall inblood pressure (>20 mmHg) during exercise testing

(Class IIa, Level of Evidence B):

Intervention is considered in asymptomatic patients with LVEF >55% and a normal exercise test if the procedural risk is low and in the presence of one of the following:

Type of intervention:
(Class I, Level of Evidence C):

Aortic valve interventions should be performed in an experienced center

(Class I, Level of Evidence B):

SAVR is recommended in younger patients who are low risk for surgery (<75 yearse and STS PROM/EuroSCORE II <4%), or in patients who are operable and unsuitable for transfemoral TAVI
SAVR or TAVI are recommended for patients based on clinical, anatomical, and procedural characteristics

(Class I, Level of Evidence A):

TAVI is recommended in older patients (≥75 years), or in those who are high risk (STS PROM/EuroSCORE IIf>8%) or unsuitable for surgery

(Class IIb, Level of Evidence C):

❑ Non-transfemoral TAVI may be considered in patients who are inoperable and unsuitable for transfemoral TAVI
Balloon aortic valvotomy may be considered as a bridge to SAVR or TAVI in hemodynamically unstable patients and (if feasible) in those with severe aortic stenosis who require urgent high risk non-cardiac surgery

Abbreviations: BNP: B-type natriuretic peptide; CABG: Coronary artery bypass grafting; LV: Left ventricle; LVEF:Left ventricular ejection fraction ; CCT:Cardiac computed tomography; SAVR: Surgical aortic valve replacement; STS-PROM: Society of Thoracic Surgeons - predicted risk of mortality; SVi: Stroke volume index; TAVI:Transcatheter aortic valve implantation ; Vmax:Peak transvalvular velocity


The above table adopted from 2021 ESC Guideline[9]


 
 
 
 
Valvular AS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low-gradient AS
  • Vmax < 4 m/s
  • ΔPm < 40 mmHg
 
 
 
High-gradient AS
  • Vmax ≥ 4 m/s,
  • ΔPm ≥ 40 mmHg
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    AVA ≤ 1.0 cm2
     
     
     
     
    High flow status
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
    NO
  • Moderate AS
  •  
    Yes
  • Assessment of normal flow condition
  •  
     
    NO
  • Severe AS
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Normal flow
     
    Low flow
  • SVi ≤ 35 mL/m2
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Severe AS unlikely
     
    LVEF ≥ 50%
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    NO
     
    Yes
  • CCT to assess AV calcification
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    NO, CCT to assess AV calcification
     
    Yes, AVA ≤ 1.0 cm2
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
    NO
  • Pseudo-severe AS
  •  
     
     
     
     
     
     
     
     
     
     
     

    Abbreviations: AS: Aortic stenosis; AV: Aortic valve; AVA: Aortic valve area; LVEF: Left ventricular ejection fraction ; CT: Computed tomography; △Pm: Mean pressure gradient; DSE: Dobutamine stress echocardiography; LV: Left ventricular; SVi: Stroke volume index; Vmax: Peak transvalvular velocity



    The above table adopted from 2021 ESC Guideline[9]


    Recommendations for choice of Mechanical Versus Bioprosthetic AVR
    (Class I, Level of Evidence C):

    ❑ Decision should be made based on patients preference and values after discussion about the risks of anticoagulant therapy or the need for valve intervention
    ❑ Bioprothesis AVR is recommended when anticoagulant theray with VKA is contraindicated, not desired, or can not be managed

    (Class IIa, Level of Evidence B):

    ❑Mechanical aortic prothesis is preferred over bioprosthetic valve for patients < 50 years of age and no contraindication of anticoagulant therapy
    ❑For patients 50-65 years of age without contraindication of anticoagulant therapy, choosing either mechanical or bioprothesis aortic valve should be individualized based on patient factors
    ❑ For patients > 65 years of age, bioprosthetic aortic valve is preferred over mechanical aortic valve

    (Class IIb, Level of Evidence B):

    ❑For patients <50 years of age who desire bioprosthetic valve and appropriate anatomy, the Rose procedure including replacement of aortic valve by a pulmonic autograft may be considered

    The above table adopted from 2020 AHA Guideline[11]

    Abbreviations: AVR: Aortic valve replacement; VKA: Vitamin K antagonist

    References

    1. Rosenhek R, Binder T, Porenta G, Lang I, Christ G, Schemper M, Maurer G, Baumgartner H (August 2000). "Predictors of outcome in severe, asymptomatic aortic stenosis". N Engl J Med. 343 (9): 611–7. doi:10.1056/NEJM200008313430903. PMID 10965007.
    2. Tribouilloy C, Lévy F, Rusinaru D, Guéret P, Petit-Eisenmann H, Baleynaud S, Jobic Y, Adams C, Lelong B, Pasquet A, Chauvel C, Metz D, Quéré JP, Monin JL (May 2009). "Outcome after aortic valve replacement for low-flow/low-gradient aortic stenosis without contractile reserve on dobutamine stress echocardiography". J Am Coll Cardiol. 53 (20): 1865–73. doi:10.1016/j.jacc.2009.02.026. PMID 19442886.
    3. Rosenhek R, Zilberszac R, Schemper M, Czerny M, Mundigler G, Graf S, Bergler-Klein J, Grimm M, Gabriel H, Maurer G (January 2010). "Natural history of very severe aortic stenosis". Circulation. 121 (1): 151–6. doi:10.1161/CIRCULATIONAHA.109.894170. PMID 20026771.
    4. Bergler-Klein J, Klaar U, Heger M, Rosenhek R, Mundigler G, Gabriel H, Binder T, Pacher R, Maurer G, Baumgartner H (May 2004). "Natriuretic peptides predict symptom-free survival and postoperative outcome in severe aortic stenosis". Circulation. 109 (19): 2302–8. doi:10.1161/01.CIR.0000126825.50903.18. PMID 15117847.
    5. Taniguchi T, Morimoto T, Shiomi H, Ando K, Kanamori N, Murata K, Kitai T, Kawase Y, Izumi C, Miyake M, Mitsuoka H, Kato M, Hirano Y, Matsuda S, Nagao K, Inada T, Murakami T, Takeuchi Y, Yamane K, Toyofuku M, Ishii M, Minamino-Muta E, Kato T, Inoko M, Ikeda T, Komasa A, Ishii K, Hotta K, Higashitani N, Kato Y, Inuzuka Y, Maeda C, Jinnai T, Morikami Y, Sakata R, Kimura T (December 2015). "Initial Surgical Versus Conservative Strategies in Patients With Asymptomatic Severe Aortic Stenosis". J Am Coll Cardiol. 66 (25): 2827–2838. doi:10.1016/j.jacc.2015.10.001. PMID 26477634.
    6. Kang DH, Park SJ, Lee SA, Lee S, Kim DH, Kim HK, Yun SC, Hong GR, Song JM, Chung CH, Song JK, Lee JW, Park SW (January 2020). "Early Surgery or Conservative Care for Asymptomatic Aortic Stenosis". N Engl J Med. 382 (2): 111–119. doi:10.1056/NEJMoa1912846. PMID 31733181.
    7. Taniguchi T, Morimoto T, Shiomi H, Ando K, Kanamori N, Murata K, Kitai T, Kadota K, Izumi C, Nakatsuma K, Sasa T, Watanabe H, Kuwabara Y, Makiyama T, Ono K, Shizuta S, Kato T, Saito N, Minatoya K, Kimura T (January 2018). "Prognostic Impact of Left Ventricular Ejection Fraction in Patients With Severe Aortic Stenosis". JACC Cardiovasc Interv. 11 (2): 145–157. doi:10.1016/j.jcin.2017.08.036. PMID 29289632.
    8. Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM; et al. (2019). "2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". J Am Coll Cardiol. 73 (12): 1494–1563. doi:10.1016/j.jacc.2018.08.1028. PMID 30121240.
    9. 9.0 9.1 Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W (February 2022). "2021 ESC/EACTS Guidelines for the management of valvular heart disease". Eur Heart J. 43 (7): 561–632. doi:10.1093/eurheartj/ehab395. PMID 34453165 Check |pmid= value (help).
    10. Fougères E, Tribouilloy C, Monchi M, Petit-Eisenmann H, Baleynaud S, Pasquet A, Chauvel C, Metz D, Adams C, Rusinaru D, Guéret P, Monin JL (October 2012). "Outcomes of pseudo-severe aortic stenosis under conservative treatment". Eur Heart J. 33 (19): 2426–33. doi:10.1093/eurheartj/ehs176. PMID 22733832.
    11. Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C (February 2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e35–e71. doi:10.1161/CIR.0000000000000932. PMID 33332149 Check |pmid= value (help).

    Template:WH Template:WS CME Category::Cardiology