ECHO 2013 / Asymptomatic Valvular Disease When to Intervene
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ACC/AHA Practice Guideline
Indications for Aortic Valve Replacement
IIa Indications
•AVR is reasonable for pts with moderate AS undergoing CABG or aortic surgery or other heart valves
Adapted from ACC/AHA 2006 Valvular Disease Practice Guidelines J Am Coll Cardiol 2006;48:e1-148
J Am Coll Cardiol 2008;52:e1-142 (Focused Update)
ACC/AHA Practice Guideline
Indications for Aortic Valve Replacement
IIb Indications
• Abnormal response to exercise
(development of sx or asx hypotension)
• High liklihood of rapid progression
(age, calcification, CAD)
•Extremely severe AS when op mortality ≤ 1.0%
-valve area < 0.6 cm2
-mean gradient >60 mm Hg
-jet velocity >5.0 m/s
Adapted from ACC/AHA 2006 Valvular Disease Practice Guidelines J Am Coll Cardiol 2006;48:e1-148
J Am Coll Cardiol 2008;52:e1-142 (Focused Update)
ACC/AHA Practice Guideline
Indications for Aortic Valve Replacement
Class III
1.AVR 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
Adapted from ACC/AHA 2006 Valvular Disease Practice Guidelines J Am Coll Cardiol 2006;48:e1-148
J Am Coll Cardiol 2008;52:e1-142 (Focused Update)
Algorithm for Management of Asx AS
Severe AS |
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Dal-Bianco, J. P. et al. J Am Coll Cardiol 2008;52:1279-1292 |
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AVA |
< 1.0 cm2 (?) |
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Blue = ACC/AHA |
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iAVA |
< 0.6 cm2/m2 |
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Green = ESC |
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Mean Grad |
> 40 mmHg |
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Black = Both |
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Jet Velocity |
> 4.0 m/s |
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No |
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Unclear |
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Symptoms |
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Moderate-severe AVC and peak |
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High likelihood of rapid AS |
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Exercise Stress Echo |
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Vel progression 0.3 m/s/yr |
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progression (age, calcification, |
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(IaC) |
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CAD) or if surgery might be |
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Symptoms (IIbC;IC) |
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delayed at the time of |
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Excessive LVH ( 1.5 mm) |
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symptom onset (IIbC) |
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unless HTN (IIbC) |
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BP drops below baseline |
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Extremely severe AS (valve |
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(IIbC; IIaC) |
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Emerging Indications: BNP, |
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area <0.6 cm2 , mean gradient |
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Complex Ventricular |
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>500 AU by EBCT |
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> 60 mmHg, velocity >5 m/s) |
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Arrythmias (-;IIbC) |
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when expected operative |
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No |
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mortality 1% (IIbC) |
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Yes |
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Yes |
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Patient education |
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Risk factor Modification +/-Statin |
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Aortic Valve Replacement |
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Clinical and Echo reevaluation 6- |
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No |
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“Surgery Before it is too Late” |
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12 months |
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“Watchful Waiting”
