瓣膜病的手术时机选择ppt课件

1、瓣膜病的手术时机选择瓣膜病的手术时机选择 福建医科大学附属协和医院心内科 陈良龙Fighting CVDIndications for Aortic Valve Replacement in pts with AS Class IAVR is indicated for symptomatic patients with severe AS (LOE: B)AVR is indicated for patients with severe AS undergoing CABG (LOE: C)AVR is indicated for patients with severe AS underg

2、oing surgery on the aorta or other heart valves. (LOE: C)AVR is recommended for patients with severe AS and LV systolic dysfunction (EF 0.50). (LOE: C)Class IIaAVR is reasonable for pts with moderate AS undergoing CABG or surgery on the aorta or other heart valves (LOE: B)Indications for Aortic Valv

3、e Replacement in pts with AS Class IIbAVR may be considered for asymptomatic pts with severe AS and abnormal response to exercise (e.g., development of symptoms or asymptomatic hypotension). (LOE: C)AVR may be considered for adults with severe asymptomatic AS if there is a high likelihood of rapid p

4、rogression (age, calcification, and CAD) or if surgery might be delayed at the time of symptom onset. (LOE: C)Indications for Aortic Valve Replacement in pts with ASClass IIbAVR may be considered in pts undergoing CABG who have mild AS when there is evidence, such as moderate to severe valve calcifi

5、cation, that progression may be rapid. (LOE: C)AVR may be considered for asymptomatic pts with extremely severe AS (AVA 0.6 cm2 , MPG 60 mm Hg, and jet velocity 5.0m/sec) when the patients expected operative mortality is 1.0% (LOE: C)Indications for Aortic Valve Replacement in pts with AS Class IIIA

6、VR is not useful for the prevention of sudden death in asymptomatic patients with AS who have none of the findings listed under the class IIa/IIb recommendations. (LOE: B)Clinical follow-up, patient education, risk factor modification, annual echoSymptoms?Exercise testLV ejection fractionSevere valv

7、e calcification,rapid progression, and/or expected delays in surgeryYesLess than 0.50NormalNoPreoperative coronary angiographyClass Aortic Valve ReplacementClass bClass Class Class bSymptomsBPNormalEquivocalYesNoUndergoing CABGor other heart surgery?Severe Aortic Stenosis AVA less than 1.0 cm2Vmax g

8、reater than 4 m/sMean gradient 40 mmHg Re- evaluationIndications for Aortic Valve Replacement in pts with ARClass IAVR is indicated for symptomatic pts with severe AR irrespective of LV systolic function. (LOE: B)AVR is indicated for asymptomatic pts with chronic severe AR and LV systolic dysfunctio

9、n (EF 0.50) at rest. (LOE:B)AVR is indicated for pts with chronic severe AR while undergoing CABG or surgery on the aorta or other heart valves. (LOE: C)Class IIaAVR is reasonable for asymptomatic pts with severe AR with normal LV systolic function (EF 0.50) but severe LV dilatation (EDD 75 mm or ES

10、D 55 mm) (LOE: B)Indications for Aortic Valve Replacement in pts with ARClass IIbAVR may be considered in pts with moderate AR while undergoing surgery on the ascending aorta. (LOE: C)AVR may be considered in pts with moderate AR while undergoing CABG. (LOE: C)AVR may be considered for asymptomatic

11、pts with severe AR and normal LV systolic function at rest (EF 0.50 ) when EDD 70 mm or ESD 50 mm, when there is evidence of progressive LV dilatation, declining exercise tolerance, or abnormal hemodynamic responses to exercise .(LOE: C)Indications for Aortic Valve Replacement in pts with ARClass II

12、IAVR is not indicated for asymptomatic patients with mild, moderate, or severe AR and normal LV systolic function at rest (EF 0.50) when EDD 70 mm or ESD 50 mm. (LOE: B)Class IClass IIbClinical eval every 6 mo Echo every 6 moChronic Severe Aortic RegurgitationNoClinical evaluation + EchoSymptoms?Yes

13、EquivocalExercise testLV function?EF borderline of uncertainNormal EFEF of 50% or lessRVG or MRILV dimensions?SD 45-50 mm or DD 60-70 mmNo symptomsSD 50-55 mm or DD 70-75 mmSD 45 mm or DD 60 mmSymptomsStable?YesClinical eval every 6 mo Echo every 12 mo No . or initial studyReevaluate and Echo 3moSta

14、ble?Stable?Yes No . or initial studyReevaluate and Echo 3moClinical eval every 6-12 mo Echo every 12 moYesReevaluationConsider hemodynamic response to exerciseClass IIaSD 55 mm or DD 75 mmAbnormalNormalClass IAVRClass IIndications for Percutaneous Mitral BalloonValvotomyClass IPMBV is effective for

15、symptomatic pts (NYHA functional class II, III, or IV), with moderate or severe MS and valve morphology favorable for it in the absence of LA thrombus or moderate to severe MR. (LOE: A)PMBV is effective for asymptomatic pts with moderate or severe MS and valve morphology favorable for it who have pu

16、lmonary hypertension (PPP 50 mm Hg at rest or 60 mm Hg with exercise) in the absence of LA thrombus or moderate to severe MR. (LOE: C)Class IIaPMBV is reasonable for pts with moderate or severe MS* who have a nonpliable calcified valve, are in NYHA functional classIIIIV, and are either not candidate

17、s for surgery or are at high risk for surgery. (LOE: C)Indications for Percutaneous Mitral BalloonValvotomyClass IIbPMBV may be considered for asymptomatic pts with moderate or severe MS* and valve morphology favorable for it who have new onset of AF in the absence of LA thrombus or moderate to seve

18、re MR. (LOE: C)PMBV may be considered for symptomatic pts (NYHA functional class II-IV) with MVA 1.5cm if there is evidence of heamodynamically significant MS based on PPP60 mm Hg, PAWP 25mmHg, or mean MV gradient 15 mm Hg during exercise. (LOE: C)PMBV may be considered as an alternative to surgery

19、for pts with moderate or severe MS who have a nonpliable calcified valve and are in NYHA class IIIIV. (LOE: C)ndications for Percutaneous Mitral BalloonValvotomyClass IIIPMBV is not indicated for patients with mild MS. (LOE: C)PMBV should not be performed in patients with moderate to severe MR or le

20、ft atrial thrombus. (LOE: C)Indications for Surgery for Mitral StenosisClass IMV surgery (repair if possible) is indicated in pts with symptomatic (NYHA IIIIV) moderate or severe MS* when 1) PMBV is unavailable, 2) PMBV is contraindicated because of LA thrombus or 3) the valve morphology is not favo

21、rable for PMBV in pts with acceptable operative risk. (LOE: B)Symptomatic pts 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. (LOE: C)Indications for Surgery for Mitral StenosisClass IIaMV replaceme

22、nt is reasonable for pts with severe MS* and severe pulmonary hypertension (PASP 60) with NYHA functional class III symptoms who are not considered candidates for PMBV or surgical MV repair. (LOE: C)Class IIbMV repair may be considered for asymptomatic pts with moderate or severe MS* who have had re

23、current embolic events while receiving adequate anticoagulation and who have valve morphology favorable for repair. (LOE: C)Indications for Surgery for Mitral StenosisClass IIIMV repair for MS is not indicated for patients with mild MS. (LOE: C)Closed commissurotomy should not be performed in patien

24、ts undergoing MV repair; open commissurotomy is the preferred approach. (LOE: C)Mitral StenosisSymptoms?History, Physical exam CXR, ECG, 2D echa/DopplerAsymptomaticSymptomatic see Figures 6 and 7 Mild stenosisMVA 1.5 cm2Moderate or severe stenosis* MVA 1.5 cm2Valve morphologyfavorable for PMBV?PASP

25、50 mmHg ?ExerciseClass Class YesNoPoor exercise tolerance or PASP 60 mmHg or PAWP 25 mmHg YesNoNew-onset AF?Class bYesYesNo Yearly follow-up History, Physical exam CXR . ECGNoConsiderPMBV Exclude LA clot. 3+ to 4+ MRSymptomatic Mitral Stenosis NYHA Funcltional ClassHistory phyaical exam, cxr,ecc,2D

26、echo Doppler Mid stenosisMVA 1.5 cm2Moderate or severe stenosisMVA 1.5 cm2ExercisePSAP60mmHgPAWP25mmHgMVG15mmHgValve morphologyFavorable for PMBV?Valve morphologyFavorable for PMBV?Class IIbClass IClass IIaNoNoNoNoYesYesYesYesYearlyFollow-upSevere PHPAP60-80mm Hg6-monthFollow-up6-monthFollow-upConsi

27、derPMBVConsiderCommissurotomyOr MVRExclude LA clot,3+ to 4+ MRNoYesLook for other causesPSAP60mmHgPAWP25mmHgMVG15mmHgValve morphologyFavorable for PMBV?Class bSymptomatic Mitral Stenosis NYHA Funcltional Class-History, phyaical exam, CXR, ECG, 2D echo/Doppler Mild stenosisMVA 1.5 cm2Moderate or seve

28、re stenosis *MVA 1.5 cm2ExerciseMitral valve repair or MVRClass NoYesClass aConsider PMBVExclude LA clot. 3+ to 4+ MRHigh- risksurgical candidate? NoClass YesIndications for Surgery for MRClass IMV surgery is recommended for the symptomatic pts with acute severe MR.* (LOE: B)MV surgery is beneficial

29、 for pts with chronic severe MR* and NYHA functional class II, III, or IV symptoms in the absence of severe LV dysfunction (EF 0.30) and/or ESD 55 mm. (LOE: B)MV surgery is beneficial for asymptomatic pts with chronic severe MR* and mild to moderate LV dysfunction (EF 0.30 to 0.60, and/or ESD 40 mm.

30、 (LOE: B)MV repair is recommended over MV replacement in the majority of pts with severe chronic MR* who require surgery, and pts should be referred to surgical centers experienced in MV repair. (LOE: C)Indications for Surgery for MR Class IIaMV repair is reasonable in experienced surgical centers f

31、or asymptomatic pts with chronic severe MR* with preserved LV function (EF 0.60 and 40 mm) in whom the likelihood of successful repair without residual MR is 90%. (LOE: B)MV surgery is reasonable for asymptomatic pts with chronic severe MR,* preserved LV function, and new onset of AF (LOE: C)MV surg

32、ery is reasonable for asymptomatic pts with chronic severe MR,* preserved LV function, and pulmonary hypertension (PPP 50 mm Hg at rest or 60 mm Hg with exercise). (LOE: C)Indications for Surgery for MRClass IIa MV surgery is reasonable for pts with chronic severe MR* due to a primary abnormality of the mitral apparatus and NYHA functional class IIIIV symptoms and severe LV dysfunction (EF 0.30 and/or ESD 55 mm) in whom MV rep