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Surgical Management of Valvular Heart Disease 2004*

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Surgical Management of Valvular Heart Disease 2004* CANADIAN CARDIOVASCULAR SOCIETY CONSENSUS CONFERENCE Surgical Management of Valvular Heart Disease 2004* PRIMARY PANEL MEMBERS Dr Ivan M Rebeyka Dr John Chambers, United Kingdom Dr WR Eric Jamieson, Co-chair Dr David B Ross Dr Kwan-Leung Chang, Canada Dr Paul C Cartier†, Co-chair Dr Samuel C Siu Dr Lawrence H Cohn, United States Dr William G Williams Dr Carlos MG Duran, United States Members – Authors Members Dr Ronald C Elkins, United States Dr Michael Allard Dr Jack M Colman Dr Robert Freedman, Canada Dr Christine Boutin Dr Tirone E David Dr Hans A Huysmans, Netherlands Dr Ian G Burwash Dr John D Dyck Dr John Jue, Canada Dr Jagdish Butany Dr Christopher MS Feindel Dr Patrick Perier, France Dr Paul C Cartier* Dr Guy J Fradet Dr Harry Rakowski, Canada Dr Benoit de Varennes Dr Derek G Human Dr Hartzell V Schaff, United States Dr Dario Del Rizzo Dr Michel D Lemieux Dr Fred A Schoen, United States Dr Jean Gaston Dumesnil Dr Alan H Menkis Dr Pravin Shah, United States Dr Hugh E Scully Dr George Honos Dr Christopher R Thompson, Canada Dr Alexander GG Turpie Dr Christine Houde Dr Carol Warnes, United States Dr WR Eric Jamieson SECONDARY PANEL MEMBERS Mr Stephen Westaby, United Kingdom Dr Bradley I Munt Dr David H Adams, United States Sir Magdi H Yacoub, United Kingdom Dr Nancy Poirier Dr Alain Berrebi, France †Deceased January 2, 2001 *Original presentation 1999 Canadian Cardiovascular Society here has been remarkable success in the last three decades ventriculography to assess ventricular function at rest and with Tin terms of understanding, diagnosing and managing exercise. The management developments have included valvular heart disease. This has truly been a success story of the monoleaflet and bileaflet mechanical valves, stented and stent- 20th century because in Dr Paul Dudley White’s textbook enti- less bioprosthetic valves, allograft (homograft) valves and auto- tled Heart Disease published just over 50 years ago, it was stated graft valves, mitral valve repair and chordal sparing mitral valve that “there is no specific treatment for mitral valve disease” and replacement (MVR) to maintain the integrity of the mitral “there is no treatment for aortic valve disease.” Twenty-five apparatus in patients with mitral regurgitation, and combined years ago, natural history studies on valvular heart disease pre- valve replacement or repair and coronary artery bypass surgery sented a very ominous prognostic overview on the manage- in patients with concomitant coronary artery disease (CAD) ment of valvular heart disease. During the first half of the 20th and valvular heart disease. The use of blood cardioplegia and century, mortality and morbidity from valvular heart disease retrograde delivery of cardioplegia for intraoperative myocar- had changed very little. The outstanding progress of the last dial protection has been a significant advance. Percutaneous three decades has been in understanding pathophysiological mitral balloon valvotomy has developed over the past decade as processes, development of diagnostic capabilities and develop- an effective treatment for mitral stenosis. ment of surgical and catheter-based techniques now routinely The aging of the population and changes in the etiology of performed by cardiovascular surgeons and cardiologists. The valve disease have modified the spectrum of valvular heart advances have provided patients the promise of improved disease over the last few decades in developed countries. The quality of life and the potential for a normal lifespan. predominant cause of aortic stenosis in middle aged and elderly The progress of the past 30 years has lead to the apprecia- North Americans is now degenerative calcific disease rather tion of the importance of ventricular function in determining than congenital bicuspid disease. Aortic regurgitation also natural history and outcome of the disease processes and man- occurs more frequently from degenerative diseases than from agement. Diagnostic modalities have included M-mode and congenital defects. The predominant cause of mitral regurgi- two-dimensional echocardiography to assess valve pathology, tation is now mitral valve degenerative disease rather than chamber size and ventricular function; Doppler echocardiog- rheumatic heart disease. Rheumatic heart disease continues to raphy to evaluate severity of stenotic and regurgitant lesions be the primary cause of mitral stenosis (MS) in the adult pop- and pulmonary artery pressures (PAP); and radionuclide ulation but the natural history in North America is that of a Correspondence: Dr WR Eric Jamieson, Burrard Building, St Paul’s Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6. Telephone 604-806-8383, fax 604-806-8384, e-mail [email protected] Sponsored by unrestricted educational grants from 3F Therapeutics Inc, ATS Medical Inc, Bayer Inc, Boston Scientific Inc, CarboMedics Inc, CryoCath Technologies Inc, Cryolife Inc, Edwards Lifesciences Corporation, Koehler Medical Inc, Medical Carbon Research Institute LLC, Medical CV Inc, Medtronic (Canada) Inc, St Jude Medical Inc, Shelhigh Inc and Sorin Group Can J Cardiol Vol 20 Suppl E October 2004 ©2004 Pulsus Group Inc. All rights reserved 7E Jamieson et al less virulent disease than in the early part of the 20th century. formulated. Extensive contributions were made in formulating It is not uncommon for symptoms of MS to present in middle the document and it must remain in evolution. The secondary age; one-third of patients requiring management are over panel of nationally and internationally recognized surgeons 65 years of age. and cardiologists validated the document and provided recom- The predictors of survival for any valve lesion are age, mendations. The final 1999 version was made available for severity of symptoms, severity of the valvular lesion, left ven- review by the membership of the CCS. tricular (LV) or right ventricular (RV) systolic dysfunction The American College of Cardiology (ACC) and American and the presence or absence of concomitant CAD. Other Heart Association (AHA) published the Guidelines for the influential factors include atrial fibrillation and pulmonary Management of Patients with Valvular Heart Disease in late 1998. hypertension in mitral valve disease, degree of LV dilation in The ACC/AHA Committee on Management of Patients with mitral or aortic regurgitation, and severity of LV hypertrophy Valvular Disease had the task of providing “recommendations in aortic stenosis and regurgitation. for diagnostic testing, treatment and physical activity.” The Surgical intervention has evolved dramatically with identi- CCS primary panel incorporated the ACC/AHA guidelines fication of higher risk groups of patients by refinement of non- where there was agreement and indicated where there was dis- invasive methods for effective risk stratification and agreement (Circulation granted permission to reproduce and uti- appropriate identification of patients, whether symptomatic or lize the ACC/AHA guuidelines). The CCS consensus asymptomatic. Two to three decades ago, surgery was only document addresses only the surgical management of valvular offered to the sickest patients with the most advanced forms of heart disease but considers the overall age spectrum from the valvular heart disease where there was justification for the high neonate to the elderly. The CCS document provides recom- short and long term risks of surgery. Valve replacement or mendations for standards of echocardiographic reporting and repair is now performed safely at much earlier stages of the nat- pathological evaluation. The document also incorporates gener- ural history of the disease process, often in asymptomatic al information, guidelines for classification of valve-related com- patients, with excellent long term results. The earlier inter- plications, prophylaxis against prosthetic valve endocarditis ventions and surgical advances have completely transformed (PVE), antithrombotic management and recommendations for the outlook of patients with valvular heart disease. follow-up strategy for patients with prosthetic heart valves. There still remains the fundamental aspect of decision- The recommendations are assigned classes of support and making in patients with valvular heart disease. Valve replace- levels of evidence according to the classifications of the ACC, ment or repair is still not curative; there is only a shift in the AHA and the CCS. potentially serious problems and conditions. The goal is to offer Class I: Conditions for which there is evidence or general surgery late enough in the natural history to justify the risks of agreement that a given procedure or treatment is intervention but early enough to prevent irreversible ventricu- useful and effective. lar dysfunction, pulmonary hypertension or chronic arrhyth- mias. The risks related to natural history versus the risks related Class II: Conditions for which there is conflicting evidence to surgery may often place the balance in favour of early inter- or a divergence of opinion about the usefulness or vention but one must continue to consider the anticipated early efficacy of a procedure or treatment. and late outcomes of surgical procedures against the expected IIa: Weight of evidence or opinion is in outcome of isolated medical management. favour of usefulness and efficacy. The purpose of the Consensus Conference on Surgical Management of Valvular Heart Disease is to provide consensus IIb: Usefulness and efficacy is less well for decision-making based on both objective
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