瓣膜病的手术时机选择

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 IndicationsforAorticValveReplacementinptswithAS ClassIAVRisindicatedforsymptomaticpatientswithsevereAS LOE B AVRisindicatedforpatientswithsevereASundergoingCABG LOE C AVRisindicatedforpatientswithsevereASundergoingsurgeryontheaortaorotherheartvalves LOE C AVRisrecommendedforpatientswithsevereASandLVsystolicdysfunction EF 0 50 LOE C ClassIIaAVRisreasonableforptswithmoderateASundergoingCABGorsurgeryontheaortaorotherheartvalves LOE B IndicationsforAorticValveReplacementinptswithAS ClassIIbAVRmaybeconsideredforasymptomaticptswithsevereASandabnormalresponsetoexercise e g developmentofsymptomsorasymptomatichypotension LOE C AVRmaybeconsideredforadultswithsevereasymptomaticASifthereisahighlikelihoodofrapidprogression age calcification andCAD orifsurgerymightbedelayedatthetimeofsymptomonset LOE C IndicationsforAorticValveReplacementinptswithAS ClassIIbAVRmaybeconsideredinptsundergoingCABGwhohavemildASwhenthereisevidence suchasmoderatetoseverevalvecalcification thatprogressionmayberapid LOE C AVRmaybeconsideredforasymptomaticptswithextremelysevereAS AVA 0 6cm2 MPG 60mmHg andjetvelocity 5 0m sec whenthepatient sexpectedoperativemortalityis 1 0 LOE C IndicationsforAorticValveReplacementinptswithAS ClassIIIAVRisnotusefulforthepreventionofsuddendeathinasymptomaticpatientswithASwhohavenoneofthefindingslistedundertheclassIIa IIbrecommendations LOE B IndicationsforAorticValveReplacementinptswithAR ClassIAVRisindicatedforsymptomaticptswithsevereARirrespectiveofLVsystolicfunction LOE B AVRisindicatedforasymptomaticptswithchronicsevereARandLVsystolicdysfunction EF 0 50 atrest LOE B AVRisindicatedforptswithchronicsevereARwhileundergoingCABGorsurgeryontheaortaorotherheartvalves LOE C ClassIIaAVRisreasonableforasymptomaticptswithsevereARwithnormalLVsystolicfunction EF 0 50 butsevereLVdilatation EDD 75mmorESD 55mm LOE B IndicationsforAorticValveReplacementinptswithAR ClassIIbAVRmaybeconsideredinptswithmoderateARwhileundergoingsurgeryontheascendingaorta LOE C AVRmaybeconsideredinptswithmoderateARwhileundergoingCABG LOE C AVRmaybeconsideredforasymptomaticptswithsevereARandnormalLVsystolicfunctionatrest EF 0 50 whenEDD 70mmorESD 50mm whenthereisevidenceofprogressiveLVdilatation decliningexercisetolerance orabnormalhemodynamicresponsestoexercise LOE C IndicationsforAorticValveReplacementinptswithAR ClassIIIAVRisnotindicatedforasymptomaticpatientswithmild moderate orsevereARandnormalLVsystolicfunctionatrest EF 0 50 whenEDD 70mmorESD 50mm LOE B ClassI ClassIIb Clinicalevalevery6moEchoevery6mo ChronicSevereAorticRegurgitation No Clinicalevaluation Echo Yes Equivocal Exercisetest EFborderlineofuncertain NormalEF EFof50 orless RVGorMRI SD45 50mmorDD60 70mm Nosymptoms SD50 55mmorDD70 75mm SD 45mmorDD 60mm Symptoms Yes Yes No orinitialstudy ReevaluateandEcho3mo Clinicalevalevery6 12moEchoevery12mo Yes Reevaluation Considerhemodynamicresponsetoexercise ClassIIa SD 55mmorDD 75mm Abnormal Normal ClassI AVR ClassI IndicationsforPercutaneousMitralBalloonValvotomy ClassIPMBViseffectiveforsymptomaticpts NYHAfunctionalclassII III orIV withmoderateorsevereMSandvalvemorphologyfavorableforitintheabsenceofLAthrombusormoderatetosevereMR LOE A PMBViseffectiveforasymptomaticptswithmoderateorsevereMSandvalvemorphologyfavorableforitwhohavepulmonaryhypertension PPP 50mmHgatrestor60mmHgwithexercise intheabsenceofLAthrombusormoderatetosevereMR LOE C ClassIIaPMBVisreasonableforptswithmoderateorsevereMS whohaveanonpliablecalcifiedvalve areinNYHAfunctionalclassIII IV andareeithernotcandidatesforsurgeryorareathighriskforsurgery LOE C IndicationsforPercutaneousMitralBalloonValvotomy ClassIIbPMBVmaybeconsideredforasymptomaticptswithmoderateorsevereMS andvalvemorphologyfavorableforitwhohavenewonsetofAFintheabsenceofLAthrombusormoderatetosevereMR LOE C PMBVmaybeconsideredforsymptomaticpts NYHAfunctionalclassII IV withMVA 1 5cmifthereisevidenceofheamodynamicallysignificantMSbasedonPPP 60mmHg PAWP 25mmHg ormeanMVgradient 15mmHgduringexercise LOE C PMBVmaybeconsideredasanalternativetosurgeryforptswithmoderateorsevereMSwhohaveanonpliablecalcifiedvalveandareinNYHAclassIII IV LOE C ndicationsforPercutaneousMitralBalloonValvotomy ClassIIIPMBVisnotindicatedforpatientswithmildMS LOE C PMBVshouldnotbeperformedinpatientswithmoderatetosevereMRorleftatrialthrombus LOE C IndicationsforSurgeryforMitralStenosis ClassIMVsurgery repairifpossible isindicatedinptswithsymptomatic NYHAIII IV moderateorsevereMS when1 PMBVisunavailable 2 PMBViscontraindicatedbecauseofLAthrombusor3 thevalvemorphologyisnotfavorableforPMBVinptswithacceptableoperativerisk LOE B SymptomaticptswithmoderatetosevereMS whoalsohavemoderatetosevereMRshouldreceiveMVreplacement unlessvalverepairispossibleatthetimeofsurgery LOE C IndicationsforSurgeryforMitralStenosis ClassIIaMVreplacementisreasonableforptswithsevereMS andseverepulmonaryhypertension PASP 60 withNYHAfunctionalclassI IIsymptomswhoarenotconsideredcandidatesforPMBVorsurgicalMVrepair LOE C ClassIIbMVrepairmaybeconsideredforasymptomaticptswithmoderateorsevereMS whohavehadrecurrentemboliceventswhilereceivingadequateanticoagulationandwhohavevalvemorphologyfavorableforrepair LOE C IndicationsforSurgeryforMitralStenosis ClassIIIMVrepairforMSisnotindicatedforpatientswithmildMS LOE C ClosedcommissurotomyshouldnotbeperformedinpatientsundergoingMVrepair opencommissurotomyisthepreferredapproach LOE C MitralStenosis Symptoms History PhysicalexamCXR ECG 2Decha Doppler Asymptomatic Symptomatic seeFigures6and7 MildstenosisMVA 1 5cm2 Moderateorseverestenosis MVA 1 5cm2 ValvemorphologyfavorableforPMBV PASP 50mmHg Exercise Class Class Yes No PoorexercisetoleranceorPASP 60mmHgorPAWP 25mmHg Yes No New onsetAF Class b Yes Yes No Yearlyfollow upHistory PhysicalexamCXR ECG No ConsiderPMBV ExcludeLAclot 3 to4 MR ExcludeLAclot 3 to4 MR No Yes Lookforothercauses PSAP 60mmHgPAWP 25mmHgMVG 15mmHg Class b MitralvalverepairorMVR Class No Yes Class a ConsiderPMBV ExcludeLAclot 3 to4 MR No Class Yes IndicationsforSurgeryforMR ClassIMVsurgeryisrecommendedforthesymptomaticptswithacutesevereMR LOE B MVsurgeryisbeneficialforptswithchronicsevereMR andNYHAfunctionalclassII III orIVsymptomsintheabsenceofsevereLVdysfunction EF 0 30 and orESD 55mm LOE B MVsurgeryisbeneficialforasymptomaticptswithchronicsevereMR andmildtomoderateLVdysfunction EF0 30to0 60 and orESD 40mm LOE B MVrepairisrecommendedoverMVreplacementinthemajorityofptswithseverechronicMR whorequiresurgery andptsshouldbereferredtosurgicalcentersexperiencedinMVrepair LOE C IndicationsforSurgeryforMR ClassIIaMVrepairisreasonableinexperiencedsurgicalcentersforasymptomaticptswithchronicsevereMR withpreservedLVfunction EF 0 60and 40mm inwhomthelikelihoodofsuccessfulrepairwithoutresidualMRis 90 LOE B MVsurgeryisreasonableforasymptomaticptswithchronicsevereMR preservedLVfunction andnewonsetofAF LOE C MVsurgeryisreasonableforasymptomaticptswithchronicsevereMR preservedLVfunction andpulmonaryhypertension PPP 50mmHgatrestor 60mmHgwithexercise LOE C IndicationsforSurgeryforMR ClassIIaMVsurgeryisreasonableforptswithchronicsevereMR duetoaprimaryabnormalityofthemitralapparatusandNYHAfunctionalclassIII IVsymptomsandsevereLVdysfunction EF 0 30and orESD 55mm inwhomMVrepairishighlylikely LOE C ClassIIbMVrepairmaybeconsideredforptswithchronicsever