瓣膜病的手术时机选择

1、瓣膜病的手术时机选择UUFighting CVD1Indications 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 undergoing surgery on the aorta o

2、r 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)2Indications for Aortic Valve Replacement in pts with

3、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 progression (age, calcifica

4、tion, and CAD) or if surgery might be delayed at the time of symptom onset. (LOE: C)3Indications 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 calcification, that progression

5、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)4Indications for Aortic Valve Replacement in pts with AS Class IIIAVR is not useful for the

6、 prevention of sudden death in asymptomatic patients with AS who have none of the findings listed under the class IIa/IIb recommendations. (LOE: B)5Clinical follow-up, patient education, risk factor modification, annual echoSymptoms?Exercise testLV ejection fractionSevere valve calcification,rapid p

7、rogression, 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 greater than 4 m/sMean g

8、radient 40 mmHg Re- evaluation6Indications 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 dysfunction (EF 0.50) at rest. (

9、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 ESD 55 mm) (LOE: B)7Indi

10、cations 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 pts with severe AR an

11、d 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)8Indications for Aortic Valve Replacement in pts with ARClass IIIAVR is not indicate

12、d 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)9Class IClass IIbClinical eval every 6 mo Echo every 6 moChronic Severe Aortic RegurgitationNoClinical evaluation + EchoSymptoms?YesEquivocalExercise t

13、estLV 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 3moStable?Stable?Yes No .

14、 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 I10Indications for Percutaneous Mitral BalloonValvotomyClass IPMBV is effective for symptomatic pts (

15、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 pulmonary hypertens

16、ion (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 candidates for surgery or

17、are at high risk for surgery. (LOE: C)11Indications 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 severe MR. (LOE: C)

18、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 for pts with mo

19、derate or severe MS who have a nonpliable calcified valve and are in NYHA class IIIIV. (LOE: C)12ndications 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 left atrial thr

20、ombus. (LOE: C)13Indications 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 favorable for P

21、MBV 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)14Indications for Surgery for Mitral StenosisClass IIaMV replacement is rea

22、sonable 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 recurrent e

23、mbolic events while receiving adequate anticoagulation and who have valve morphology favorable for repair. (LOE: C)15Indications 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 patients unde

24、rgoing MV repair; open commissurotomy is the preferred approach. (LOE: C)16Mitral 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 50

25、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+ MR17Symptomatic Mitral Stenosis NYHA Funcltional ClassHistory phyaical exam, cxr,ecc,2D e

26、cho 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-upConsid

27、erPMBVConsiderCommissurotomyOr MVRExclude LA clot,3+ to 4+ MR18NoYesLook 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 sev

28、ere stenosis *MVA 1.5 cm2ExerciseMitral valve repair or MVRClass NoYesClass aConsider PMBVExclude LA clot. 3+ to 4+ MRHigh- risksurgical candidate? NoClass Yes19Indications for Surgery for MRClass IMV surgery is recommended for the symptomatic pts with acute severe MR.* (LOE: B)MV surgery is benefic

29、ial 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

30、mm. (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)20Indications for Surgery for MR Class IIaMV repair is reasonable in experienced surgical cent

31、ers for 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

32、 surgery 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)21Indications 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 repair is