瓣膜病的手术时机选择.ppt

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 BalloonValvotomy,Class I PM

13、BV 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 favorab

14、le 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 a

15、re either not candidates for surgery or are at high risk for surgery. (LOE: C),Indications for Percutaneous Mitral BalloonValvotomy,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 th

16、rombus 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 a

17、s 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 BalloonValvotomy,Class III PMBV is not indicated for patients with mild MS. (LOE: C) PMBV should not be performed in patients

18、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 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 surger