Update Guidelines : Management of Valvular Heart Disease
เรี ยบเรี ยงโดย นพ.วิรุฬ นภาอัมพร
รศ.นพ.ธีรวิทย์ พันธุ์ชัยเพชร
ESC/EACTS2012
Echocardiographic criteria for the definition of severe valve stenosis
AS
MS
TS
Valve area (cm2)
< 1.0
< 1.0
-
Indexed valve area
(cm2/m2 BSA)
Mean gradient (mmHg)
< 0.6
-
-
>40a
>10b
≥5
Max jet velocity (m/s)
>40a
-
-
Velocity ratio
<0.25
-
-
BSA = body surface area.
a
In patients with normal cardiac output/transvalvular flow.
b
Useful in patients in sinus rhythm. to be interpreted according to heart rate.
Echocardiographic criteria for the definition of severe valve regurgitation :
an integrative approach
Qualitative
Valve morphology
Colour flow
regurgitant jet
Aortic
regurgitation
Mitral regurgitation
Tricuspid regurgitation
Abnormal/flail/
large coaptation
defect
Large in central
jets, variable in
eccentric jetsa
Flail leaflet/ruptured
papillary muscle/large
coaptation defect
Very large central jet
or eccentric jet
adhering, swirling, and
reaching the posterior
wall of the left atrium
Dense/triangular
Abnormal/flail/large
coaptation defect
Very large central jet
or eccentric wall
impinging jeta
CW signal of
regurgitant jet
Dense
Other
Holodiastolic
flow reversal in
Descending aorta
(EDV >20 cm/s)
Large flow
convergence zonea
>6
≥ (>8 for biplane)b
≥7a
-
Systolic pulmonary
vein flow reversal
E-wave dominant ≥
1.5 m/sd
TVI mitral/TVI
aortic >1.4
Primary Secondary
≥40
≥20
≥60
≥30
LV,LA
Systolic hepatic vein
reversal
E-wave dominant ≥ 1
m/se
PISA radius >9 mm
Semlquantitative
Vena contracta
width (mm)
Upstream vein
flow
Inflow
Other
Quantitative
EROA(mm2)
R Vol (ml/beat)
+ enlargement of
cardiac
chamers/vessels
Pressure halftime < 200 msf
≥30
≥60
LV
Dense/triangular with
early peaking (peak <2
m/s in massive TR)
-
≥40
≥45
RV, RA, Inferior vena
cava
CW = continuous wave; EDV = end –diastolic velocity; EROA = effective regurgitant orifice area;
LA= left ventricle; PISA = proximal isovelocity surface area; RA = right atrium; RV = right
ventricle; R Vol = regurgitant volume; TR = tricuspid regurgitatant; TVI= time – velocity integral.
aAt a Nyquist limit of 50-60 cm/s.
b For average between apical four and two-chamber views.
C Unless other reasons for systolic blunting (atrial fibrillation, elevated atrial pressures).
d In the absence of other causes of elevated left atrial pressures and of mitral stenosis.
e In the absence of other causes of elevated left atrial pressures.
f Pressure half-time is shortened with increasing left ventricular diastolic pressure, vasodilator
therapy, and in patients with a dilated compliant aorta, or lengthened in chronic aortic regurgitation.
g Baseline Nyquist limit shift of 28 cm/s.
h Different thresholds are used in secondary MR where an EROA> 20mm2 and regurgitant volume
> 30 ml identify a subset of patients at increased risk of cardiac events.
Adapted from Lancellotti et al.
Management of coronary artery disease in patients with
valvular heart disease
Diagnosis of coronary artery disease
1. CAG is recommended before valve surgery :
- history of CAD
- suspected myocardial ischaemia
- LV systolic dysfunction
- in men aged over 40 y and > I cardiovascular risk factor (I,C)
2. CAG recommended in the evaluation of secondary
mitral regurgitation. (I,C)
Indications for myocardial revascularization:
aortic/ diameter stenosis ≥ 70% (I,C), ≥ 50-70% (IIa,C)
mitral valve surgery and coronary artery disease
Severe AR, Aortic root disease (ESC/EACT2012)
Indication for surgery
Severe AR or Aortic root disease
1.1 Symptomatic (I,B)
1.2 Asymptomatic with resting LVEF  50% (I,B)
1.3 With other cardiac surgery (I,C)
1.4 Asymptomatic with resting EF > 50% with severe LV dilatation
(LVEDD > 70 mm, LVESD > 50 mm. LVESD > 25 mm/m 2 BSA (IIa,C)
1.5 Aortic root disease : size ≥ 55 mm (IIa, C)
- Marfan syndrome aortic root size ≥ 50 mm (I, C)
size ≥ 45 mm with risk factor * (IIa, C)
- Bicuspid valve with risk factor (IIa, C)
* risk factor : Family history of aortic dissection and/or aortic size increase > 2
mm/year (on repeated measurements using technique, measured at the same aorta
level with severe AR or mitral regurgitation, despite of pregnancy.
Severe AS : ESC/EACT 2012
1. Symptomatic Severe AS (I,B)
2. With other cardiac surgery (I,C)
3. Asymptomatic severe AS and systolic LV dysfunction (LVEF < 50%) or
symptomatic on exercise test.
4. High risk symptomatic AS (Suitable for TAVI) (Ia,B)
5. Asymptomatic severe AS with Hypotension on exercise test (IIa,C)
6. Moderate AS with other cardiac surgery (IIa,C)
7. Symptomatic low flow, low gradient (< 40 mmHg) with normal EF or
reduce EF and flow or contractile reserve ( IIa, C) without flow reserve
(IIb, C)
8. Asymptomatic, normal EF, low surgical risk
- Very severe AS peak trans valvular velocity > 5.5 m/s
- Severe Calcified Valve peak trans valvular velouty progression ≥ 0.3
m/s per year (IIa,C)
- Marked elevate natriuretic peptide levels (IIb, C)
- Mean pressure gradient increase with exercise > 20 mmHg (IIb,C)
- Excessive LV hypertrophy without hypertension (IIb,C)
TAVI Indication
1.
พิจารณารักษาโดย Heart team (I,C)
2. Severe Symptomatic AS expect better qualify of life and life expectancy
> 1 y (I,B)
3. High risk severe symptomatic AS suitable for surgery favoured by heart
team (IIa,B)
TAVI Absolute Contra indication
1. Estimated life expectancy unlikely to improving the quality of life
- major symptom form other valve disease
2. Annulus < 18 or > 29 mm
3. Thrombus in LV
4. Active endocarditis
5. Risk of coronary ostium obstruction (asymmetric, valve calcification,
short distance between annulus and coronary ostium, small aortic sinuses)
6. Inadequate vascular assess ( small size, calcification, tortuosity )
Relative contraindications
Bicuspid or non-calcified valves
Untreated coronary artery disease requiring revascularization
Hemodynamic Instability
LVEF < 20%
For trans apical approach : severe pulmonary disease, LV apex not
accessible
Severe MR : ESC/EACT 2012
Indications for surgery in severe primary mitral regurgitation
Mitral valve repair (I,C)
Symptomatic LVEF > 30% and LVESD < 55 mm. (I,B)
Asymptomatic with LV dysfunction (LVESD ≥ 45 mm and/or LVEF 
60%) (I,C)
Asymptomatic preserved LV function and new onset of AF or pulmonary
hypertension (SPAP at rest > 50 mmHg) (IIa,C)
Asymptomatic with preserved LV function, high likelihood of durable
repair low surgical risk and flail leaflet and LVESD > 40 mm. (IIa,C)
Severe LV dysfunction (LVEF < 30% and/or LVESD > 55 mm) refractory
to medical therapy with
 high likelihood of durable repair and low comorbidity (IIa,C)
 low likelihood of durable repair and low comorbidity (IIb,C)
Asymptomatic with preserved LV function. High likelihood of durable
repair, low surgical risk, and
 Left atrial dilatation (volume index ≥ 60 ml/m2 BSA) and sinus
rhythm. or
 Pulmonary hypertension on exercise (SPAP ≥ 60 mmHg at
exercise). (IIb,C)
Indications for mitral valve surgery in chronic secondary mitral
regurgitation
Severe MR undergoing CABG. and LVEF > 30% (I,C)
Moderate MR undergoing CABG
(IIa,C)
Symptomatic severe MR, LVEF < 30%, option for revascularization, and
evidence of viability (IIa, C)
symptomatic despite optimal medical management (Including CRT* If
Indicate) Severe MR, LVEF > 30% and low comorbidity, when
revascularization is not indicated. (IIb,C)
* CRT = Cardiac resynchronization therapy
Severe MS : ACC/AHA 2008
Indications for Surgery for Mitral Stenosis
1. MV surgery (repair if possible) symptomatic (NYHA class III-IV)
moderate or severe MS when percutaneous mitral balloon
valvotomy is unavailable or contra indication (I,B)
2. Symptomatic moderate to severe MS and moderate to severe MR
should receive MV replacement, unless valve repair is possible.
(I,C)
3. MV replacement for severe MS and severe PHT (PAP> 60 mmHg)
with NYHA class I-II (I,C)
4. MV repair for asymptomatic moderate or severe MS who have had
recurrent embolic events while receiving adequate anticoagulation
(IIb, C)
5. MV repair for MS is not indicated for patients with mild MS.
(III,C)
6. Closed commissurotomy should not be performed in patients
undergoing MV repair; open commissurotomy is the preferred
approach. (III,C)
Tricuspid valve disease : ESC/EACT 2012
Indications for tricuspid valve surgery
Symptomatic severe TS
(I,C)
Severe TS undergoing left-sided valve intervention (I,C)
Severe primary or secondary TR undergoing left-sided valve surgery
(I,C)
Symptomatic severe isolated primary TR without severe right RV
dysfunction. (I,C)
Moderate primary TR undergoing left-sided valve surgery (IIa,C)
Mild or moderate secondary TR with dilated annulus (≥40 mm or >21
mm/m2) undergoing left-sided valve surgery. (IIa,C)
Asymptomatic or mildly symptomatic severe isolated primary TR and
progressive RV dilatation or deterioration of RV function.
(IIa,C)
After left-sided valve surgery, severe TR who are symptomatic or have
progressive RV dilatation/dysfunction in the absence of left-sided valve
dysfunction , severe right or left ventricular dysfunction and severe
pulmonary vascular disease. (IIa,C)
Reference
1. 2012 ESC/EACTS Guidelines on Valvular Heart Disease
2. 2008 ACC/AHA Guideline Update on Valvular Heart Disease