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1、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,Indications for Aortic Valve Replacement in pts with AS,Class I AVR 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 th
2、e 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 IIa AVR is reasonable for pts with moderate AS undergoing CABG or surgery on the aorta or other heart valves (LOE: B),Indications for Aortic Valve Replacement
3、in pts with AS,Class IIb AVR 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 (
4、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 AS,Class IIb AVR may be considered in pts undergoing CABG who have mild AS when there is evidence, such as moderate to severe valve calcification, t
5、hat 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 III AVR is
6、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),Indications for Aortic Valve Replacement in pts with AR,Class I AVR is indicated for symptomatic pts with severe AR irrespective of LV
7、 systolic function. (LOE: B) AVR is indicated for asymptomatic pts with chronic severe AR and LV systolic dysfunction (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 IIa AVR is reasonable f
8、or 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),Indications for Aortic Valve Replacement in pts with AR,Class IIb AVR may be considered in pts with moderate AR while undergoing surgery on the ascending aorta. (L
9、OE: 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 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 toler
10、ance, or abnormal hemodynamic responses to exercise .(LOE: C),Indications for Aortic Valve Replacement in pts with AR,Class III AVR 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),Cla
11、ss I,Class IIb,Clinical eval every 6 mo Echo every 6 mo,Chronic Severe Aortic Regurgitation,No,Clinical evaluation + Echo,Yes,Equivocal,Exercise test,EF borderline of uncertain,Normal EF,EF of 50% or less,RVG or MRI,SD 45-50 mm or DD 60-70 mm,No symptoms,SD 50-55 mm or DD 70-75 mm,SD 45 mm or DD 60
12、mm,Symptoms,Yes,Yes,No . or initial study,Reevaluate and Echo 3mo,Clinical eval every 6-12 mo Echo every 12 mo,Yes,Reevaluation,Consider hemodynamic response to exercise,Class IIa,SD 55 mm or DD 75 mm,Abnormal,Normal,Class I,AVR,Class I,Indications for Percutaneous Mitral Balloon Valvotomy,Class I P
13、MBV is effective for 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 favora
14、ble for it who have pulmonary 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 IIa PMBV is reasonable for pts with moderate or severe MS* who have a nonpliable calcified valve, are in NYHA functional classIIIIV, and
15、are either not candidates for surgery or are at high risk for surgery. (LOE: C),Indications for Percutaneous Mitral Balloon Valvotomy,Class IIb PMBV 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
16、thrombus or moderate to severe 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
17、 as an alternative to surgery 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 Balloon Valvotomy,Class III PMBV is not indicated for patients with mild MS. (LOE: C) PMBV should not be performed in patien
18、ts with moderate to severe MR or left atrial thrombus. (LOE: C),Indications for Surgery for Mitral Stenosis,Class I MV 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
19、or 3) the valve morphology is not favorable 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
20、for Mitral Stenosis,Class IIa MV replacement 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 IIb MV repair may be considered for asymptomatic pts
21、 with moderate or severe MS* who have had recurrent embolic events while receiving adequate anticoagulation and who have valve morphology favorable for repair. (LOE: C),Indications for Surgery for Mitral Stenosis,Class III MV repair for MS is not indicated for patients with mild MS. (LOE: C) Closed
22、commissurotomy should not be performed in patients undergoing MV repair; open commissurotomy is the preferred approach. (LOE: C),Mitral Stenosis,Symptoms?,History, Physical exam CXR, ECG, 2D echa/Doppler,Asymptomatic,Symptomatic （ see Figures 6 and 7 ）,Mild stenosis MVA 1.5 cm2,Moderate or severe st
23、enosis* MVA 1.5 cm2,Valve morphology favorable for PMBV?,PASP 50 mmHg ?,Exercise,Class ,Class ,Yes,No,Poor exercise tolerance or PASP 60 mmHg or PAWP 25 mmHg,Yes,No,New-onset AF?,Class b,Yes,Yes,No,Yearly follow-up History, Physical exam CXR . ECG,No,ConsiderPMBV,Exclude LA clot. 3+ to 4+ MR,Exclude
24、 LA clot, 3+ to 4+ MR,No,Yes,Look for other causes,PSAP60mmHg PAWP25mmHg MVG15mmHg,Class b,Mitral valve repair or MVR,Class ,No,Yes,Class a,Consider PMBV,Exclude LA clot. 3+ to 4+ MR,No,Class ,Yes,Indications for Surgery for MR,Class I MV surgery is recommended for the symptomatic pts with acute sev
25、ere MR.* (LOE: B) MV surgery is beneficial 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 dysf
26、unction (EF 0.30 to 0.60, and/or ESD 40 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),Indications for Surgery for MR,Class IIa MV repair i
27、s reasonable in experienced surgical centers 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 L
28、V function, and new onset of AF (LOE: C) MV 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),Indications for Surgery for MR,Class IIa MV surgery is reasonable for pts with
29、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 highly likely. (LOE: C) Class IIb MV repair may be considered for pts with chronic severe secondary MR* due to se
30、vere LV dysfunction (EF 0.30) who have persistent NYHA functional class III-IV symptoms despite optimal therapy for heart failure, including biventricular pacing. (LOE: C),Indications for Surgery for MR,Class III MV surgery is not indicated for asymptomatic patients with MR and preserved LV function
31、 (ejection fractiongreaterthan0.60 and end-systolic dimension less than 40 mm) in whom significant doubt about the feasibility of repair exists. (LOE: C) Isolated MV surgery is not indicated for patients with mild or moderate MR. (LOE: C),Chronic Severe Mitral Regurgitation,Clinical evaluation + Ech
32、o,Chordal preservation likely?,No,Yes,Yes,Yes,Yes,No,No,No,Medical therapy,EF 0.30 ESD 55mm,Normal LV function EF 0.60 ESD 40mm,LV dysfunction EF 0.60and/or ESD 40mm,EF 55mm,Class I,Class I,Class IIa,Class IIa,MV repair if not possible, MVR,Class IIa,MV repair,Clinical eval every 6 mos Echo every 6 mos,感 谢！,