ESC / EACTS Guidelines for the Management of Valvular Heart Disease Management of Aortic Regurgitation Hans-Joachim Schäfers Saarland University Medical Center, Homburg/Saar, Germany On behalf of the ESC/EACTS Task Force European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).
Disclosures ESC Munich 2012 Hans-Joachim Schäfers, MD No financial relationships to disclose
Aetiologies of Single Valvular Heart Diseases in the Euro Heart Survey 100% 43% 13% 32% 12% 80% Other Ischemic 60% 40% 20% Congenital Inflammatory Endocarditis Rheumatic Degenerative 0% AS AR MR MS Iung et al. Eur Heart J 2003;24:1244-53 European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).
Essential Components in the Management of Aortic Regurgitation Natural history of aortic aneurysm (Natural history of aortic regurgitation) Surgical options in AR / aortic aneurysm Indications for surgery European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).
Prognosis of Aortic Aneurysm with BAV 212 patients (20 y follow-up) 40% asc. aorta > 40mm 10% mortality identical to the general population 24% aortic valve surgery 5% aortic surgery no aortic dissection Independent predictors: age > 50 and valve degeneration at diagnosis Circulation 2008; 117 : 2776
Prognosis of Aortic Aneurysm with BAV 642 patients Follow-up : 9y Mortality 4% vs 3% Cardiac surgery 22% Aortic dissection 0.4% JAMA 2008; 300 (11) : 1317 * * *
Prognosis of Aortic Aneurysm with BAV AADA: n=1!
Aortic Aneurysm in Marfan s Syndrome 7 aortic events during 4110 years of patient follow-up: mean annual risk of death or aortic dissection 0 17% 0 12% risk of death 0 05% risk of aortic dissection This risk dropped below 0 05% when only patients with an aortic diameter <50 mm were considered
Risk Factors in Aortic Aneurysm Risk of death/dissection increased with: Positive family history for acute dissection or sudden death Hypertension Coarctation Size progression Pregnancy (Marfan s syndrome) (smoking, not documented for ascending aorta)
Essential Components in the Management of Aortic Regurgitation Natural history of aortic aneurysm Natural history of aortic regurgitation Surgical options in AR / aortic aneurysm Indications for surgery European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).
Aortic Valve Replacement Thromboembolism Anticoagulation/Hemorrhage Structural failure PV endocarditis Incidence of valverelated complications Hammermeister et al, JACC 2000
ALL REOPERATIONS % Reoperation after Aortic Valve Replacement p=0.004 17% 9% 29% 10% YEARS AFTER VALVE REPLACEMENT Hammermeister et al JACC 2000; 36:1152-
Mechanical AV Replacement Prosthesis-related Mortality years after valve replacement Ikonomidis JS, JTCVS 2003 THG
Composite AV & Aortic Replacement 15 publications 1999-2010 N=4713, mean pooled age 50 yrs Marfan 3-46%, BAV 2-46% Acute dissection 0-30% Operative mortality 0.7-11.8% Reoperation TE complications Bleeding Linearized rates of occurence 2.3%/yr (1.1% root related) 2.5%/yr 1.6%/yr Courtesy of JJH Takkenberg
Aortic Valve Repair
Aortic Valve Repair THG
Essential Components in the Management of Aortic Regurgitation Natural history of aortic aneurysm Natural history of aortic regurgitation Surgical options in AR / aortic aneurysm Indications for surgery European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).
Indications for surgery in severe aortic regurgitation Class Level Surgery is indicated in symptomatic patients. I B Surgery is indicated in asymptomatic patients with resting LVEF 50%. I B Surgery is indicated in patients undergoing CABG or surgery of ascending aorta, or on another valve. Surgery should be considered in asymptomatic patients with resting EF > 50% with severe LV dilatation: LVEDD > 70 mm, or LVESD > 50 mm or LVESD > 25 mm/m 2 BSA. I IIa C C European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).
Indications for surgery in aortic root disease (whatever the severity of AR) Surgery is indicated in patients who have aortic root disease with maximal ascending aortic diameter 50 mm for patients with Marfan syndrome Surgery should be considered in patients who have aortic root disease with maximal ascending aortic diameter: 45 mm for patients with Marfan syndrome with risk factors, 50 mm for patients with bicuspid valve with risk factors, 55 mm for other patients. Class I IIa Level C C European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).
Indications for surgery in aortic root disease (whatever the severity of AR) Comments: Lower thresholds can be used for patients who have an indication for surgery on the aortic valve (e.g. 4.5 cm) Risk factors Marfan s syndr.: Positive family history for acute dissection/sudden death, severe AR or MR, (desired) pregnancy, size progression BAV: Positive family history for acute dissection/sudden death, systemic hypertension, coarctation, size progression Size increase defined as increase > 2mm/year (on repeated measurements using the same imaging technique, measured at the same level with side-by-side comparison and corfirmed by another technique
Special Aspects Aortic valve: Aorta conservative th. Aorta surgical th.
Management of aortic regurgitation No AR with significant enlargement of ascending aorta Yes AR severe No Yes Symptoms No Yes LVEF 50% or LVEDD > 70 mm or LVESD > 50 mm (or > 25 mm/m 2 BSA) No Yes Follow-up Surgery European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).
European Heart Journal doi:10.1093/eurheartj/ehs109 Guidelines on the management of valvular heart disease (version 2012) The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Authors/Task Force Members: Alec Vahanian (Chairperson) (France), Ottavio Alfieri (Chairperson) (Italy), Felicita Andreotti (Italy), Manuel J. Antunes (Portugal),Gonzalo Barón-Esquivias (Spain), Helmut Baumgartner (Germany), Michael Andrew Borger (Germany),Thierry P. Carrel (Switzerland), Michele De Bonis (Italy), Arturo Evangelista (Spain), Volkmar Falk (Switzerland), Bernard Iung (France), Patrizio Lancellotti (Belgium), Luc Pierard (Belgium), Susanna Price (UK), Hans-Joachim Schäfers (Germany), Gerhard Schuler (Germany), Janina Stepinska (Poland), Karl Swedberg (Sweden), Johanna Takkenberg (The Netherlands), Ulrich Otto Von Oppell (UK), Stephan Windecker (Switzerland), Jose Luis Zamorano (Spain), Marian Zembala (Poland) ESC Committee for Practice Guidelines (CPG): Jeroen J. Bax (Chairperson) (The Netherlands), Helmut Baumgartner (Germany), Claudio Ceconi (Italy), Veronica Dean (France), Christi Deaton (UK), Robert Fagard (Belgium), Christian Funck-Brentano (France), David Hasdai (Israel), Arno Hoes (The Netherlands), Paulus Kirchhof (United Kingdom), Juhani Knuuti (Finland), Philippe Kolh (Belgium), Theresa McDonagh (UK), Cyril Moulin (France), Bogdan A. Popescu (Romania), Željko Reiner (Croatia), Udo Sechtem (Germany), Per Anton Sirnes (Norway), Michal Tendera (Poland), Adam Torbicki (Poland), Alec Vahanian (France), Stephan Windecker (Switzerland) Document Reviewers: Bogdan A. Popescu (ESC CPG Review Coordinator) (Romania), Ludwig Von Segesser (EACTS). Review Coordinator) (Switzerland), Luigi P. Badano (Italy), Matjaž Bunc (Slovenia), Marc J. Claeys (Belgium), Niksa Drinkovic (Croatia), Gerasimos Filippatos (Greece), Gilbert Habib (France), A. Pieter Kappetein (The Netherlands), Roland Kassab (Lebanon), Gregory Y.H. Lip (UK), Neil Moat (UK), Georg Nickenig (Germany), Catherine M. Otto (USA), John Pepper, (UK), Nicolo Piazza (Germany), Petronella G. Pieper (The Netherlands), Raphael Rosenhek (Austria), Naltin Shuka (Albania), Ehud Schwammenthal (Israel), Juerg, Schwitter (Switzerland), Pilar Tornos Mas (Spain), Pedro T. Trindade (Switzerland), Thomas Walther (Germany). European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).