Special reportAortic Valve and Ascending Aorta Guidelines for Management and Quality Measures: Executive Summary
Section snippets
Introduction and Methodology
The question may be asked why another Guideline manuscript is needed. The reasons are fivefold: (1) to outline pros and cons of treatment options; (2) to outline areas where further research is needed, potentially from updated Society of Thoracic Surgeons (STS) data collection variables as there are few randomized trials that give more absolute answers to questions; (3) to provide technical guidelines for aortic valve and aortic surgery; (4) to provide background for recommended quality
Summary and Update of ACCF/AHA Guidelines for Indications and Timing of Surgery
Major advances in the evaluation and management of patients with valvular heart disease during the past several decades have resulted in substantial improvement in the outcomes of patients in terms of survival and quality of life. These advances, coupled with the growing prevalence of diseases of heart valves in an aging population and the impact on quality of life, health care resources, and need for quality improvement, stimulated the joint guidelines task force of the ACCF/AHA to establish a
Class I
- 1
AVR is recommended for patients with severe AS at the onset of symptoms of dyspnea, angina, or lightheadedness or syncope [27, 28, 29, 30, 31, 32, 33, 34, 35]. (Level of evidence B)
- 2
AVR is recommended, regardless of symptoms, with the identification of left ventricular (LV) systolic dysfunction (ejection fraction [EF] <50%). (Level of evidence C)
- 3
AVR is recommended for patients with severe AS who are scheduled to undergo coronary artery bypass graft surgery (CABG), surgery on other cardiac
Class I
- 1
AVR or repair is indicated for symptomatic patients with severe AR irrespective of LV systolic function (Fig 2) [44, 45, 46, 47, 48, 49, 50]. (Level of evidence B)
- 2
AVR or repair is recommended for asymptomatic patients with chronic severe AR and LV systolic dysfunction (EF ≤50%) at rest [44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60]. (Level of evidence B)
- 3
AVR or repair is recommended in patients with chronic severe AR who are undergoing CABG or surgery on the aorta or other
Class I
- 1
AVR is recommended in patients with aortic valve infective endocarditis and severe heart failure or cardiogenic shock due to aortic valve dysfunction when there is a reasonable likelihood of recovery with satisfactory quality of life after surgery [2, 67, 68, 69, 70]. (Level of evidence B)
- 2
Surgery is recommended in patients with annular or aortic abscesses, heart block, infections resistant to antibiotic therapy, and fungal endocarditis [67, 68, 69, 70, 71]. (Level of evidence B)
Class IIa
- 1
Surgery is
Class IIa
- 1
Performing risk score analysis is reasonable to evaluate patients undergoing surgical AVR or TAVR to quantitate PROM [74, 75, 76]. (Level of evidence B)
Class IIb
- 1
Performing risk score analysis may be reasonable to aid in determining which patients should undergo AVR, TAVR or medical therapy alone in high-risk patients. (Level of evidence C)
Class I
- 1
Transthoracic echocardiography (TTE) is recommended for the diagnosis and assessment of AS or AR severity. (Level of evidence B)
- 2
Echocardiography is recommended in patients with AS or AR for the assessment of LV wall thickness, size, and function (1). (Level of evidence B)
- 3
TTE is recommended for reevaluation of patients with known AS or AR and changing symptoms or signs (1). (Level of evidence B)
- 4
TTE is recommended for the assessment of changes in hemodynamic severity and LV function in patients
Class IIb
- 1
Exercise testing in asymptomatic patients with AS or AR may be considered to elicit exercise-induced symptoms and abnormal blood pressure responses. (Level of evidence B)
Class III
- 1
Exercise testing should not be performed in symptomatic patients with AS or AR. (Level of evidence B)
Class IIa
- 1
Dobutamine stress echocardiography is reasonable to evaluate patients with low-flow/low gradient AS and LV dysfunction for possible AVR or TAVR [75, 77, 78, 79, 80, 81, 82, 83, 84, 85]. (Level of evidence B)
- 2
Cardiac catheterization for hemodynamic measurements with infusion of dobutamine can be useful for evaluation of patients with low-flow/low-gradient AS and LV dysfunction. (Level of evidence C)
Class I
- 1
Coronary angiography is recommended before AVR in patients with AS or AR at risk for CAD. (Level of evidence B)
- 2
Patients aged more than 45 years undergoing a valve procedure should undergo coronary imaging. (Level of evidence C)
- 3
Cardiac catheterization for hemodynamic measurements is recommended for assessment of severity of AS or AR in symptomatic patients when noninvasive tests are inconclusive or when there is a discrepancy between noninvasive tests and clinical findings. (Level of evidence C)
Class IIb
- 1
Class I
- 1
For most patients requiring a simple aortic valve procedure without ascending aortic disease, the distal ascending aorta is recommended as the site for cannulation [16]. (Level of evidence B)
- 2
For complex repairs involving the arch or a calcified aorta or porcelain aorta, use of the axillary artery with a side graft is recommended [16]. (Level of evidence B)
Class I
- 1
Before mechanical AVR, all patients who have known CAD, have had a prior myocardial infarction, have angina pectoris as a symptom, or are more than age 45, should have preoperative screening of their coronary arteries by direct coronary angiography. (Level of evidence C)
- 2
All patients undergoing mechanical AVR should receive perioperative prophylactic antibiotics to cover both Gram-positive and Gram-negative organisms. (Level of evidence C)
- 3
All patients receiving a mechanical aortic valve should
Class I
- 1
A bioprosthesis is recommended for AVR in patients of any age who will not take anticoagulation therapy, either warfarin or the direct factor Xa, or thrombin inhibitors or who have major medical contraindications to anticoagulation [2]. (Level of evidence C)
- 2
A bioprosthesis is recommended for AVR in patients aged 65 years or more without risk factors for thromboembolism [2]. (Level of evidence C)
Class IIa
- 1
Patient preference is a reasonable consideration in the selection of aortic valve prosthesis if
Class I
- 1
Patch enlargement of the aortic annulus should be considered when the aortic annulus does not allow implantation of a heart valve with effective orifice area index greater than 0.65 cm2m2 [90, 91, 92]. (Level of evidence B)
Class IIb
- 1
Patch enlargement of the aortic annulus may be considered when the aortic annulus does not allow implantation of the heart valve with effective orifice area index of 0.85 cm2/m2. (Level of evidence C)
Class I
- 1
Homograft replacement of the aortic root should be considered for patients with extensive active endocarditic destruction of the aortic annulus [93, 94, 95, 96, 97]. (Level of evidence B)
- 2
For patients undergoing homograft replacement of the aortic valve, a total root replacement technique is recommended [98, 99]. (Level of evidence B)
Class IIa
- 1
Homograft replacement of the aortic valve can be considered for patients with endocarditis without annular destruction, especially when the potential for
Class I
- 1
Before subcoronary stentless AVR, all patients who have known CAD, have had a prior myocardial infarction, have angina pectoris as a symptom, or are aged more than 45 years should have preoperative screening of their coronary arteries, by direct coronary angiography. (Level of evidence C)
- 2
Intraoperative TEE is recommended to check the valve function. (Level of evidence C)
- 3
Prophylactic antibiotics for any invasive procedure, including dentistry, are recommended. (Level of evidence C)
Class IIb
- 1
Stentless
Class I
- 1
Before aortic root replacement, all patients who have known CAD, have had a prior myocardial infarction, have angina pectoris as a symptom, or are aged more than 45 years, should have preoperative screening of their coronary arteries, by direct coronary angiography. (Level of evidence C)
- 2
Intraoperative TEE is required to check the valve function. (Level of evidence C)
- 3
Prophylactic antibiotics for any invasive procedure including dentistry are recommended. (Level of evidence C)
Class IIa
- 1
Stentless aortic
Class I
- 1
The Ross procedure is recommended in infants and small children for whom no satisfactory alternative valve substitute exists. (Level of evidence C)
Class IIb
- 1
The Ross procedure may be considered in older children and young adults because of low operative risk, but patients and their families must be informed of the possible need for reoperation which increases over time. (Level of evidence C)
Class III
- 1
The Ross procedure is not recommended for middle-aged or older adults when suitable alternatives to autograft
Class IIa
- 1
Balloon aortic valvuloplasty can be useful as bridge to AVR in hemodynamically unstable adult patients with severe AS when immediate AVR is not feasible. (Level of evidence C)
- 2
BAV should be considered for patients with contra indications to AVR who can potentially be bridged to AVR or TAVR in the future. (Level of evidence C)
- 3
BAV should be considered in severely symptomatic patients with multiple comorbidities where contribution of AS to symptomatology such as chronic pulmonary disease or poor LV
Class I
- 1
Evaluation for TAVR should be performed by a multidisciplinary team and panel [75, 108]. (Level of evidence A)
- 2
TAVR should be performed by a multidisciplinary cardiovascular and cardiac surgery team [75, 108]. (Level of evidence A)
- 3
If available as part of a research protocol or after Food and Drug Administration (FDA) approval, transfemoral AVR is recommended in inoperable patients provided they have an expected survival of greater than 1 year [75]. (Level of evidence A)
- 4
If available as part of a
Class I
- 1
Transapical insertion of a balloon expandable aortic valve is recommended in patients with symptomatic severe AS who are considered to be at excessive risk for conventional AVR and are not candidates for a transfemoral approach owing to preexisting peripheral vasculature disease, and who have an expected survival of at least 1 year [108]. (Level of evidence B)
- 2
Evaluation for TAVR should be performed by a multidisciplinary team and panel [75, 108]. (Level of evidence A)
- 3
TAVR should be performed by
Class I
- 1
Aortic valve repairs should be checked by intraoperative TEE after the repair is completed. (Level of evidence C)
- 2
Patients should be followed postoperatively by yearly echocardiograms after aortic valve repair. (Level of evidence C)
Class IIa
- 1
Root remodeling may be considered for patients with significantly dilated roots and bicuspid valves or patients with acute aortic dissection, including excision of the noncoronary sinus as a remodeling procedure, also known as the Wolfe procedure. (Level of evidence C)
Class I
- 1
Root size, particularly at the sinuses of Valsalva should be measured by CT or MRI using the external diameter at its greatest extent. TEE is conventionally used to measure the internal diameter at its greatest extent, usually from sinus to sinus [3]. (Level of evidence B)
- 2
Intraoperative TEE is recommended to check the repair. (Level of evidence C)
- 3
Reimplantation is recommended for young patients, when feasible, who have aortic root dilation, with or without regurgitation, and a tricuspid aortic
Class I
- 1
All patients undergoing bicuspid repair should undergo intraoperative TEE. (Level of evidence C)
- 2
Prophylactic antibiotics including both Gram-positive and Gram-negative coverage should be used for patients undergoing bicuspid valve repair. (Level of evidence C)
- 3
Postoperative beta-blockers should be considered after bicuspid valve repairs. (Level of evidence C)
- 4
ACE inhibitor drug therapy should be considered in patients with low EF postoperatively. (Level of evidence C)
- 5
Patients should be given
Class I
- 1
Timely diagnosis is recommended utilizing cross-sectional imaging techniques or TEE. The latter can be performed in the operating room before sternotomy if needed to confirm the diagnosis [3]. (Level of evidence B)
- 2
Ascending aortic replacement (including resection of primary aortic tear) should be performed for patients with acute type A aortic dissection [3]. (Level of evidence B)
- 3
An open distal anastomotic, hemiarch, or total arch replacement technique is effective for the distal reconstruction
Class I
- 1
All patients with suspected thoracic aortic disease on the basis of family history, symptoms, or physical examination should have the entire thoracic aorta imaged. (Level of evidence C)
- 2
All patients with a bicuspid aortic valve should undergo imaging of the thoracic aorta (3). (Level of evidence B)
- 3
All patients with Marfan syndrome or Loeys-Dietz syndrome or mutations associated with aortic disease or dissection should have the entire aorta imaged and appropriate blood testing performed for
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The full guideline will appear in a subsequent issue of The Annals of Thoracic Surgery as a Supplement and will be available online at http://ats.ctsnetjournals.org and http://www.sciencedirect.com. The full text of all STS Practice Guidelines are also available at: http://www.sts.org/resources-publications on the official STS Web site (www.sts.org).