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American Association for Thoracic Surgery (AATS)/ American College of Cardiology Foundation (ACCF): Heart Valve Summit 2014
Bicuspid valve surgical management in rapid flux
CHICAGO – Surgical management of leaky bicuspid valves is rapidly evolving from replacement to repair of any purely insufficient bicuspid valve with enough leaflet surface area.
“We’re coming to the point like with mitral valves 20 years ago, that we don’t have to replace every blessed bicuspid valve. We can repair a lot of these valves,” Dr. Joseph Bavaria, vice chief of cardiovascular surgery, University of Pennsylvania, Philadelphia, said.
A valve-sparing root procedure in a patient with bicuspid aortic valve (BAV) disease and aortic insufficiency (AI) provides excellent results, no matter if the aortic root is abnormal or not. Many patients with BAV, however, have leaky valves without a root aneurysm.
Thus, the “great dilemma” facing surgeons now is whether they can continue to justify doing a root procedure, which is a much bigger operation, when the root is normal diameter, Dr. Bavaria said at Heart Valve Summit 2014.
“It may be inappropriate in today’s world to take a normal physiological valve and just take it out and consign someone who’s in their 30s and 40s to a mechanical or bioprosthetic valve for life,” he said in an interview. “That has anticoagulation issues, structural deterioration issues, infection issues.”
The alternative is a valve repair operation, but that’s complicated by the growing understanding that BAV AI has three distinct phenotypic presentations:
• BAV with AI with relatively normal root diameters.
• BAV with AI and relatively normal root diameters, with an ascending aortic aneurysm.
• BAV with AI and root dilation.
“The problem we have is there’s probably a different therapeutic procedure for each of these three presentations,” Dr. Bavaria said.
The goals for any bicuspid repair are to equalize the free margin lengths with plication or resection of the redundant leaflet, reduce the annulus by 10%-15%, and stabilize it with either reimplantation or a subannular technique, and to increase the height of the free margin, if the leaflet belly falls below the annular plane.
In the university’s current surgical management algorithm, patients who have an aortic annulus dilated to 28 mm or more undergo root reimplantation if they have an aneurysmal root or receive external annuloplasty rings plus a valve repair if their aortic annulus is dilated and they have a nonaneurysmal root. The Dacron ring is placed subcoronary and subannular and is generally sized 5-7 mm larger than the desired end-procedural annular diameter, he said.
For patients with a normal aortic annulus (27 mm or less), root reimplantation or remodeling is used for those with an aneurysmal root, while subcommissural annuloplasty is reserved only for those with a normal aortic annulus and a nonaneurysmal root.
Subcommissural annuloplasty had been used for many BAV patients with AI who were candidates for repair, but emerging data over the last 2 years from Dr. Bavaria’s group (Annals Thor. Surg. 2014;97:1227-34) and others show it results in a lot of midterm failures and reoperations, compared with root reimplantation. Some groups continue to use this procedure routinely, but “It doesn’t work,” Dr. Bavaria said.
His team recently compared postoperative outcomes among BAV repairs and the more commonly performed tricuspid repair between 2004 and 2014. Overall, the outcomes were the same between the two groups including mortality, stroke, freedom from AI grade +1, and aortic reoperation for bleeding (P = NS). Notably, all 41 BAV patients required concomitant primary leaflet repair, compared with only 7% of the 99 patients who underwent tricuspid valve repair (P < .01), he said.
Dr. Bavaria reported consultant fees and honoraria from St. Jude Medical and research grants from Edwards Lifesciences and Sorin Group.
CHICAGO – Surgical management of leaky bicuspid valves is rapidly evolving from replacement to repair of any purely insufficient bicuspid valve with enough leaflet surface area.
“We’re coming to the point like with mitral valves 20 years ago, that we don’t have to replace every blessed bicuspid valve. We can repair a lot of these valves,” Dr. Joseph Bavaria, vice chief of cardiovascular surgery, University of Pennsylvania, Philadelphia, said.
A valve-sparing root procedure in a patient with bicuspid aortic valve (BAV) disease and aortic insufficiency (AI) provides excellent results, no matter if the aortic root is abnormal or not. Many patients with BAV, however, have leaky valves without a root aneurysm.
Thus, the “great dilemma” facing surgeons now is whether they can continue to justify doing a root procedure, which is a much bigger operation, when the root is normal diameter, Dr. Bavaria said at Heart Valve Summit 2014.
“It may be inappropriate in today’s world to take a normal physiological valve and just take it out and consign someone who’s in their 30s and 40s to a mechanical or bioprosthetic valve for life,” he said in an interview. “That has anticoagulation issues, structural deterioration issues, infection issues.”
The alternative is a valve repair operation, but that’s complicated by the growing understanding that BAV AI has three distinct phenotypic presentations:
• BAV with AI with relatively normal root diameters.
• BAV with AI and relatively normal root diameters, with an ascending aortic aneurysm.
• BAV with AI and root dilation.
“The problem we have is there’s probably a different therapeutic procedure for each of these three presentations,” Dr. Bavaria said.
The goals for any bicuspid repair are to equalize the free margin lengths with plication or resection of the redundant leaflet, reduce the annulus by 10%-15%, and stabilize it with either reimplantation or a subannular technique, and to increase the height of the free margin, if the leaflet belly falls below the annular plane.
In the university’s current surgical management algorithm, patients who have an aortic annulus dilated to 28 mm or more undergo root reimplantation if they have an aneurysmal root or receive external annuloplasty rings plus a valve repair if their aortic annulus is dilated and they have a nonaneurysmal root. The Dacron ring is placed subcoronary and subannular and is generally sized 5-7 mm larger than the desired end-procedural annular diameter, he said.
For patients with a normal aortic annulus (27 mm or less), root reimplantation or remodeling is used for those with an aneurysmal root, while subcommissural annuloplasty is reserved only for those with a normal aortic annulus and a nonaneurysmal root.
Subcommissural annuloplasty had been used for many BAV patients with AI who were candidates for repair, but emerging data over the last 2 years from Dr. Bavaria’s group (Annals Thor. Surg. 2014;97:1227-34) and others show it results in a lot of midterm failures and reoperations, compared with root reimplantation. Some groups continue to use this procedure routinely, but “It doesn’t work,” Dr. Bavaria said.
His team recently compared postoperative outcomes among BAV repairs and the more commonly performed tricuspid repair between 2004 and 2014. Overall, the outcomes were the same between the two groups including mortality, stroke, freedom from AI grade +1, and aortic reoperation for bleeding (P = NS). Notably, all 41 BAV patients required concomitant primary leaflet repair, compared with only 7% of the 99 patients who underwent tricuspid valve repair (P < .01), he said.
Dr. Bavaria reported consultant fees and honoraria from St. Jude Medical and research grants from Edwards Lifesciences and Sorin Group.
CHICAGO – Surgical management of leaky bicuspid valves is rapidly evolving from replacement to repair of any purely insufficient bicuspid valve with enough leaflet surface area.
“We’re coming to the point like with mitral valves 20 years ago, that we don’t have to replace every blessed bicuspid valve. We can repair a lot of these valves,” Dr. Joseph Bavaria, vice chief of cardiovascular surgery, University of Pennsylvania, Philadelphia, said.
A valve-sparing root procedure in a patient with bicuspid aortic valve (BAV) disease and aortic insufficiency (AI) provides excellent results, no matter if the aortic root is abnormal or not. Many patients with BAV, however, have leaky valves without a root aneurysm.
Thus, the “great dilemma” facing surgeons now is whether they can continue to justify doing a root procedure, which is a much bigger operation, when the root is normal diameter, Dr. Bavaria said at Heart Valve Summit 2014.
“It may be inappropriate in today’s world to take a normal physiological valve and just take it out and consign someone who’s in their 30s and 40s to a mechanical or bioprosthetic valve for life,” he said in an interview. “That has anticoagulation issues, structural deterioration issues, infection issues.”
The alternative is a valve repair operation, but that’s complicated by the growing understanding that BAV AI has three distinct phenotypic presentations:
• BAV with AI with relatively normal root diameters.
• BAV with AI and relatively normal root diameters, with an ascending aortic aneurysm.
• BAV with AI and root dilation.
“The problem we have is there’s probably a different therapeutic procedure for each of these three presentations,” Dr. Bavaria said.
The goals for any bicuspid repair are to equalize the free margin lengths with plication or resection of the redundant leaflet, reduce the annulus by 10%-15%, and stabilize it with either reimplantation or a subannular technique, and to increase the height of the free margin, if the leaflet belly falls below the annular plane.
In the university’s current surgical management algorithm, patients who have an aortic annulus dilated to 28 mm or more undergo root reimplantation if they have an aneurysmal root or receive external annuloplasty rings plus a valve repair if their aortic annulus is dilated and they have a nonaneurysmal root. The Dacron ring is placed subcoronary and subannular and is generally sized 5-7 mm larger than the desired end-procedural annular diameter, he said.
For patients with a normal aortic annulus (27 mm or less), root reimplantation or remodeling is used for those with an aneurysmal root, while subcommissural annuloplasty is reserved only for those with a normal aortic annulus and a nonaneurysmal root.
Subcommissural annuloplasty had been used for many BAV patients with AI who were candidates for repair, but emerging data over the last 2 years from Dr. Bavaria’s group (Annals Thor. Surg. 2014;97:1227-34) and others show it results in a lot of midterm failures and reoperations, compared with root reimplantation. Some groups continue to use this procedure routinely, but “It doesn’t work,” Dr. Bavaria said.
His team recently compared postoperative outcomes among BAV repairs and the more commonly performed tricuspid repair between 2004 and 2014. Overall, the outcomes were the same between the two groups including mortality, stroke, freedom from AI grade +1, and aortic reoperation for bleeding (P = NS). Notably, all 41 BAV patients required concomitant primary leaflet repair, compared with only 7% of the 99 patients who underwent tricuspid valve repair (P < .01), he said.
Dr. Bavaria reported consultant fees and honoraria from St. Jude Medical and research grants from Edwards Lifesciences and Sorin Group.
EXPERT OPINION FROM HEART VALVE SUMMIT 2014
Spotlight falls on rising levels of tricuspid valve surgery
CHICAGO – Ten times as many papers were published on the mitral valve as were published on the tricuspid valve during the 1990s, based on a literature review.
Things have picked up over the past decade, however, for the “forgotten,” little-respected “Rodney Dangerfield” valve, with surgeons writing more about tricuspid regurgitation and doing more tricuspid surgery than ever before, Dr. Patrick McCarthy said at Heart Valve Summit 2014.
Tricuspid interventions more than doubled from 1999 to 2008, although overall hospital mortality was substantial at 10.6%. (J. Thorac. Cardiovasc. Surg. 2012;143:1043-9).
A Society of Thoracic Surgeons risk model containing intraoperative variables showed that multiple-valve surgery mortality is more than twice that of single-valve surgery, but that performance of arrhythmia ablation and atrioventricular valve repair are protective for mortality (Ann. Thorac. Surg. 2013;95:1484-90).
“There isn’t any data that the tricuspid per se is actually the reason that the operation is higher risk,” said Dr. McCarthy, director of the Bluhm Cardiovascular Institute and chief of cardiac surgery, Northwestern University in Chicago.
The new American Heart Association/American College of Cardiology (AHA/ACC) guideline on valvular heart disease, published earlier this year, reflects the changing attitudes about mitral valve surgery and the need for earlier intervention.
A class I indication for surgery remains in place for severe tricuspid regurgitation (TR) with mitral valve disease. However, what had been a class IIb indication in the 2006 guidelines for primary TR with symptoms is now a class I indication in the 2014 guidelines.
“Don’t wait for right ventricular failure in primary TR. Plan for earlier intervention, and think of it more like we do mitral regurgitation,” Dr. McCarthy said.
The recommendation for more moderate TR has also changed. The class IIb recommendation for patients with less than severe TR during mitral valve repair with pulmonary hypertension, right heart failure, or tricuspid dilation is now class IIa, indicating a lower threshold for surgery for these patients, he said.
Asymptomatic primary TR with right ventricle dilation or reoperations for TR with symptoms and prior left heart surgery had been a class III indication against surgery in 2006, but are now in sync with the European valvular guidelines with a class IIb indication, suggesting surgery may be considered.
The move toward earlier surgery is supported by results showing that TR only gets worse if left untreated, Dr. McCarthy said. Among patients with annular dilation greater than 70 mm as the only criterion for tricuspid valve repair (TVR), TR was shown to increase by more than 2 grades after 2 years in just 2% of patients who underwent TVR during mitral valve repair (MVR), versus 48% without TVR (Ann. Thorac. Surg. 2005;79:127-32).
Another study showed that prophylactic tricuspid annuloplasty in patients with dilated tricuspid annulus undergoing MVR reduces the rate of TR progression, improves right ventricular remodeling, and improves functional outcomes on the 6-minute walk test (J. Thorac. Cardiovasc. Surg. 2012;143:632-8).
Not all data, however, have been viewed through the same lens, with the “Mayo Clinic and Cleveland Clinic finding the same thing but drawing different conclusions,” Dr. McCarthy observed.
A Cleveland Clinic analysis involving 1,833 patients with degenerative mitral valve disease reported that MVR alone improved TR and right ventricular function in patients with severe TR (grade 3+/4+), but that improvements were incomplete and temporary. In contrast, MVR with concomitant TVR eliminated severe TR and improved RV function toward normal, “supporting an aggressive approach to important functional tricuspid regurgitation” (J. Cardiovasc Surg. 2013;146:1126-32).
An 11-year review by the Mayo Clinic in Rochester, Minn., involving 699 patients with functional TR and degenerative mitral valve leaflet prolapse also showed that MVR alone significantly reduced TR within the first year in all patients and produced significant decreases until the third year in those with severe regurgitation. Only one patient required tricuspid reoperation 4.5 years after mitral repair. The authors argued for a selective approach to TR, concluding that “tricuspid valve surgery is rarely necessary for most patients undergoing repair of isolated mitral valve prolapse.”
“While both Cleveland and Mayo Clinic found that untreated TR persisted, Mayo interpreted the rare need for reoperation and no decrease in 5-year survival as evidence that it need not be repaired, while Cleveland suggested with the evidence of improved RV function that it should be repaired,” Dr. McCarthy said in an interview. “The European Society of Cardiology and AHA/ACC guidelines would support the approach from the Cleveland Clinic.”
Dr. McCarthy disclosed inventing the Edwards MC3 tricuspid valve repair ring.
Dr. Hossein Almassi, FCCP,comments: Historically, cardiac surgeons have been reluctant to operate on the tricuspid valve, mainly because of poor outcome and a high mortality rate. The excellent results with mitral valve repair and the emerging experience on tricuspid valve surgery have led to a welcome shift in the attitude of cardiac surgeons and cardiologists in adopting an earlier and more proactive approach in treating patients with significant tricuspid valve regurgitation, either alone or in conjunction with other valvular operations, as evidenced by changes in the 2014 AHA/ACC guidelines.
Dr. Almassi is with the Cardiothoracic Surgery Division at the Medical College of Wisconsin in Milwaukee, WI.
Dr. Hossein Almassi, FCCP,comments: Historically, cardiac surgeons have been reluctant to operate on the tricuspid valve, mainly because of poor outcome and a high mortality rate. The excellent results with mitral valve repair and the emerging experience on tricuspid valve surgery have led to a welcome shift in the attitude of cardiac surgeons and cardiologists in adopting an earlier and more proactive approach in treating patients with significant tricuspid valve regurgitation, either alone or in conjunction with other valvular operations, as evidenced by changes in the 2014 AHA/ACC guidelines.
Dr. Almassi is with the Cardiothoracic Surgery Division at the Medical College of Wisconsin in Milwaukee, WI.
Dr. Hossein Almassi, FCCP,comments: Historically, cardiac surgeons have been reluctant to operate on the tricuspid valve, mainly because of poor outcome and a high mortality rate. The excellent results with mitral valve repair and the emerging experience on tricuspid valve surgery have led to a welcome shift in the attitude of cardiac surgeons and cardiologists in adopting an earlier and more proactive approach in treating patients with significant tricuspid valve regurgitation, either alone or in conjunction with other valvular operations, as evidenced by changes in the 2014 AHA/ACC guidelines.
Dr. Almassi is with the Cardiothoracic Surgery Division at the Medical College of Wisconsin in Milwaukee, WI.
CHICAGO – Ten times as many papers were published on the mitral valve as were published on the tricuspid valve during the 1990s, based on a literature review.
Things have picked up over the past decade, however, for the “forgotten,” little-respected “Rodney Dangerfield” valve, with surgeons writing more about tricuspid regurgitation and doing more tricuspid surgery than ever before, Dr. Patrick McCarthy said at Heart Valve Summit 2014.
Tricuspid interventions more than doubled from 1999 to 2008, although overall hospital mortality was substantial at 10.6%. (J. Thorac. Cardiovasc. Surg. 2012;143:1043-9).
A Society of Thoracic Surgeons risk model containing intraoperative variables showed that multiple-valve surgery mortality is more than twice that of single-valve surgery, but that performance of arrhythmia ablation and atrioventricular valve repair are protective for mortality (Ann. Thorac. Surg. 2013;95:1484-90).
“There isn’t any data that the tricuspid per se is actually the reason that the operation is higher risk,” said Dr. McCarthy, director of the Bluhm Cardiovascular Institute and chief of cardiac surgery, Northwestern University in Chicago.
The new American Heart Association/American College of Cardiology (AHA/ACC) guideline on valvular heart disease, published earlier this year, reflects the changing attitudes about mitral valve surgery and the need for earlier intervention.
A class I indication for surgery remains in place for severe tricuspid regurgitation (TR) with mitral valve disease. However, what had been a class IIb indication in the 2006 guidelines for primary TR with symptoms is now a class I indication in the 2014 guidelines.
“Don’t wait for right ventricular failure in primary TR. Plan for earlier intervention, and think of it more like we do mitral regurgitation,” Dr. McCarthy said.
The recommendation for more moderate TR has also changed. The class IIb recommendation for patients with less than severe TR during mitral valve repair with pulmonary hypertension, right heart failure, or tricuspid dilation is now class IIa, indicating a lower threshold for surgery for these patients, he said.
Asymptomatic primary TR with right ventricle dilation or reoperations for TR with symptoms and prior left heart surgery had been a class III indication against surgery in 2006, but are now in sync with the European valvular guidelines with a class IIb indication, suggesting surgery may be considered.
The move toward earlier surgery is supported by results showing that TR only gets worse if left untreated, Dr. McCarthy said. Among patients with annular dilation greater than 70 mm as the only criterion for tricuspid valve repair (TVR), TR was shown to increase by more than 2 grades after 2 years in just 2% of patients who underwent TVR during mitral valve repair (MVR), versus 48% without TVR (Ann. Thorac. Surg. 2005;79:127-32).
Another study showed that prophylactic tricuspid annuloplasty in patients with dilated tricuspid annulus undergoing MVR reduces the rate of TR progression, improves right ventricular remodeling, and improves functional outcomes on the 6-minute walk test (J. Thorac. Cardiovasc. Surg. 2012;143:632-8).
Not all data, however, have been viewed through the same lens, with the “Mayo Clinic and Cleveland Clinic finding the same thing but drawing different conclusions,” Dr. McCarthy observed.
A Cleveland Clinic analysis involving 1,833 patients with degenerative mitral valve disease reported that MVR alone improved TR and right ventricular function in patients with severe TR (grade 3+/4+), but that improvements were incomplete and temporary. In contrast, MVR with concomitant TVR eliminated severe TR and improved RV function toward normal, “supporting an aggressive approach to important functional tricuspid regurgitation” (J. Cardiovasc Surg. 2013;146:1126-32).
An 11-year review by the Mayo Clinic in Rochester, Minn., involving 699 patients with functional TR and degenerative mitral valve leaflet prolapse also showed that MVR alone significantly reduced TR within the first year in all patients and produced significant decreases until the third year in those with severe regurgitation. Only one patient required tricuspid reoperation 4.5 years after mitral repair. The authors argued for a selective approach to TR, concluding that “tricuspid valve surgery is rarely necessary for most patients undergoing repair of isolated mitral valve prolapse.”
“While both Cleveland and Mayo Clinic found that untreated TR persisted, Mayo interpreted the rare need for reoperation and no decrease in 5-year survival as evidence that it need not be repaired, while Cleveland suggested with the evidence of improved RV function that it should be repaired,” Dr. McCarthy said in an interview. “The European Society of Cardiology and AHA/ACC guidelines would support the approach from the Cleveland Clinic.”
Dr. McCarthy disclosed inventing the Edwards MC3 tricuspid valve repair ring.
CHICAGO – Ten times as many papers were published on the mitral valve as were published on the tricuspid valve during the 1990s, based on a literature review.
Things have picked up over the past decade, however, for the “forgotten,” little-respected “Rodney Dangerfield” valve, with surgeons writing more about tricuspid regurgitation and doing more tricuspid surgery than ever before, Dr. Patrick McCarthy said at Heart Valve Summit 2014.
Tricuspid interventions more than doubled from 1999 to 2008, although overall hospital mortality was substantial at 10.6%. (J. Thorac. Cardiovasc. Surg. 2012;143:1043-9).
A Society of Thoracic Surgeons risk model containing intraoperative variables showed that multiple-valve surgery mortality is more than twice that of single-valve surgery, but that performance of arrhythmia ablation and atrioventricular valve repair are protective for mortality (Ann. Thorac. Surg. 2013;95:1484-90).
“There isn’t any data that the tricuspid per se is actually the reason that the operation is higher risk,” said Dr. McCarthy, director of the Bluhm Cardiovascular Institute and chief of cardiac surgery, Northwestern University in Chicago.
The new American Heart Association/American College of Cardiology (AHA/ACC) guideline on valvular heart disease, published earlier this year, reflects the changing attitudes about mitral valve surgery and the need for earlier intervention.
A class I indication for surgery remains in place for severe tricuspid regurgitation (TR) with mitral valve disease. However, what had been a class IIb indication in the 2006 guidelines for primary TR with symptoms is now a class I indication in the 2014 guidelines.
“Don’t wait for right ventricular failure in primary TR. Plan for earlier intervention, and think of it more like we do mitral regurgitation,” Dr. McCarthy said.
The recommendation for more moderate TR has also changed. The class IIb recommendation for patients with less than severe TR during mitral valve repair with pulmonary hypertension, right heart failure, or tricuspid dilation is now class IIa, indicating a lower threshold for surgery for these patients, he said.
Asymptomatic primary TR with right ventricle dilation or reoperations for TR with symptoms and prior left heart surgery had been a class III indication against surgery in 2006, but are now in sync with the European valvular guidelines with a class IIb indication, suggesting surgery may be considered.
The move toward earlier surgery is supported by results showing that TR only gets worse if left untreated, Dr. McCarthy said. Among patients with annular dilation greater than 70 mm as the only criterion for tricuspid valve repair (TVR), TR was shown to increase by more than 2 grades after 2 years in just 2% of patients who underwent TVR during mitral valve repair (MVR), versus 48% without TVR (Ann. Thorac. Surg. 2005;79:127-32).
Another study showed that prophylactic tricuspid annuloplasty in patients with dilated tricuspid annulus undergoing MVR reduces the rate of TR progression, improves right ventricular remodeling, and improves functional outcomes on the 6-minute walk test (J. Thorac. Cardiovasc. Surg. 2012;143:632-8).
Not all data, however, have been viewed through the same lens, with the “Mayo Clinic and Cleveland Clinic finding the same thing but drawing different conclusions,” Dr. McCarthy observed.
A Cleveland Clinic analysis involving 1,833 patients with degenerative mitral valve disease reported that MVR alone improved TR and right ventricular function in patients with severe TR (grade 3+/4+), but that improvements were incomplete and temporary. In contrast, MVR with concomitant TVR eliminated severe TR and improved RV function toward normal, “supporting an aggressive approach to important functional tricuspid regurgitation” (J. Cardiovasc Surg. 2013;146:1126-32).
An 11-year review by the Mayo Clinic in Rochester, Minn., involving 699 patients with functional TR and degenerative mitral valve leaflet prolapse also showed that MVR alone significantly reduced TR within the first year in all patients and produced significant decreases until the third year in those with severe regurgitation. Only one patient required tricuspid reoperation 4.5 years after mitral repair. The authors argued for a selective approach to TR, concluding that “tricuspid valve surgery is rarely necessary for most patients undergoing repair of isolated mitral valve prolapse.”
“While both Cleveland and Mayo Clinic found that untreated TR persisted, Mayo interpreted the rare need for reoperation and no decrease in 5-year survival as evidence that it need not be repaired, while Cleveland suggested with the evidence of improved RV function that it should be repaired,” Dr. McCarthy said in an interview. “The European Society of Cardiology and AHA/ACC guidelines would support the approach from the Cleveland Clinic.”
Dr. McCarthy disclosed inventing the Edwards MC3 tricuspid valve repair ring.
EXPERT ANALYSIS FROM HEART VALVE SUMMIT 2014
Mitral valve guidelines stress early intervention at experienced centers
CHICAGO – Early repair and greater reliance on experienced surgical centers are key to the new guidelines on the management of mitral valve disease.
It’s been 8 years since the last American Heart Association/American College of Cardiology guideline on valvular heart disease in 2006, with little change in the 2008 update.
The 2014 guidelines, however, have substantiative changes, including the decision to begin talking about valvular disease and at-risk patients much as we do for heart failure, guideline committee member Robert Bonow said at the Heart Valve Summit 2014.
The 2014 guidelines, published earlier this year, include four stages of valvular heart disease:
Stage A, for people at risk of valvular disease such as those with bicuspid valves, a history of rheumatic heart disease, or mitral valve prolapse without regurgitation.
Stage B, for mild to moderate, asymptomatic disease.
Stage C, for severe, asymptomatic disease, including those with normal left ventricular function (stage C1) or depressed LV function (stage C2).
Stage D, for severe, symptomatic valve disease.
The new guidelines also drive home the point that primary and secondary mitral regurgitation (MR), while they can be difficult to distinguish, are separate diseases with different pathophysiologies, natural histories, management strategies, and outcomes, said Dr. Bonow, director of the Center for Cardiovascular Innovation, Northwestern University, Chicago.
Class 1 surgical indications for primary MR, or diseases of the valve, are symptomatic patients and asymptomatic patients with LV systolic dysfunction. This continues to be defined as an ejection fraction of < 60% or an end-systolic dimension > 40 mm, although new data have suggested that even smaller systolic dimensions may have prognostic importance, he noted.
Pulmonary hypertension and atrial fibrillation are class IIa indications for surgery in asymptomatic, primary MR.
Critics would argue that patients shouldn’t be allowed to develop these indications because they may be irreversible, but the reality is that many patients arrive in your office with one or more indications already in place, Dr. Bonow said. The real issue is whether mitral valve repair is feasible and can improve survival in patients who have normal LV function and none of these indications, with the guidelines clearly tipping in favor of early surgery for asymptomatic MR patients.
Dr. Bonow highlighted recent long-term outcomes data from Dr. Tirone David’s group (Circulation 2013;127:1485-92) showing that overall survival among patients undergoing mitral valve repair for degenerative diseases is 75% at 20 years for those with functional class (FC) I disease, 66% with FC II, 52% with FC III, and only 32% for those with FC IV.
“I think these data, along with many other series, are quite important in identifying the risks we have for our patients for waiting too long, and if we can refer our patients to an expert surgical team for these valves to be repaired, their outcomes will be much better,” Dr. Bonow said.
The guidelines include the class I indication that repair is better than mitral valve replacement for primary MR and that patients should be referred to “centers experienced in repair.” Instead of stating that there should be a 90% or greater likelihood of a durable repair without residual MR for a patient undergoing elective surgery at that center, the 2014 threshold is now set at more than 95%.
“We really want to make sure patients are going to an experienced center,” he said.
Despite the emphasis on a heart team approach and referral to experienced centers, the term “experienced” has not been fully defined, Dr. Bonow acknowledged.
“Our medical and surgical societies need to be working together to start defining what we mean by ‘experienced,’ what we mean by ‘centers of excellence,’ and that process is already underway,” he added.
Dr. David H. Adams, chair of cardiovascular surgery at Mount Sinai Hospital, New York City, said that there’s no question asymptomatic patients need to be treated in experienced repair centers, but questioned whether the 95% threshold is realistic. Although repair rates are increasing worldwide, Society of Thoracic Surgery published data show a wide disparity in mitral repair that would be troublesome in an asymptomatic population. Mandatory reporting data from New York State, home to several experienced heart programs, also show that 45% of the latest 4,325 mitral valves with interventions were replaced, rather than repaired. Dr. Adams added that data are similar across the world.
He also urged caution about an “asymptomatic surgery for all” attitude, emphasizing judgment is necessary, particularly in elderly patients or in those who are very early in the course of severe regurgitation with no evidence of ventricular dilation or declining systolic function.
Finally, the new guidelines include recommendations for using transcatheter valves and the mitral clip to treat patients with secondary MR with LV dysfunction. This is not yet an approved indication from the Food and Drug Administration, pending the results of three ongoing trials, but in Europe, more than 70% of patients getting a mitral clip do so for secondary MR rather than primary mitral valve prolapse, Dr. Bonow said. The European guidelines came out 2 years ahead of the new AHA/ACC guidelines because writing was delayed until these devices were approved in the United States.
Secondary MR, or disease of the heart muscle, remains “problematic” because of a lack of outcomes data indicating that surgery leads to a better outcome than medical management in patients with LV dysfunction and because of questions raised by the Cardiothoracic Surgical Network about whether these valves should be repaired rather than replaced, he said.
What remains is a solid class 1 recommendation for guideline-directed medical therapy for heart failure including cardiac resynchronization therapy (CRT).
The surgical indications in secondary MR are class IIa for patients with severe MR undergoing coronary artery bypass grafting or aortic valve replacement and class IIb for those not undergoing such surgeries, but with severe MR and persistent symptoms, despite medical therapy, including CRT.
“There’s no data we’re going to improve survival ... but clearly some patients will have a dramatic improvement in symptoms,” Dr. Bonow said.
Dr. Bonow disclosed reviewing grant applications for the Gilead (Sciences) Scholars Program. Dr. Adams disclosed royalties as an inventor for Edwards Lifesciences and Medtronic, and serving as a Medtronic national coprimary investigator for the CoreValve Trial.
CHICAGO – Early repair and greater reliance on experienced surgical centers are key to the new guidelines on the management of mitral valve disease.
It’s been 8 years since the last American Heart Association/American College of Cardiology guideline on valvular heart disease in 2006, with little change in the 2008 update.
The 2014 guidelines, however, have substantiative changes, including the decision to begin talking about valvular disease and at-risk patients much as we do for heart failure, guideline committee member Robert Bonow said at the Heart Valve Summit 2014.
The 2014 guidelines, published earlier this year, include four stages of valvular heart disease:
Stage A, for people at risk of valvular disease such as those with bicuspid valves, a history of rheumatic heart disease, or mitral valve prolapse without regurgitation.
Stage B, for mild to moderate, asymptomatic disease.
Stage C, for severe, asymptomatic disease, including those with normal left ventricular function (stage C1) or depressed LV function (stage C2).
Stage D, for severe, symptomatic valve disease.
The new guidelines also drive home the point that primary and secondary mitral regurgitation (MR), while they can be difficult to distinguish, are separate diseases with different pathophysiologies, natural histories, management strategies, and outcomes, said Dr. Bonow, director of the Center for Cardiovascular Innovation, Northwestern University, Chicago.
Class 1 surgical indications for primary MR, or diseases of the valve, are symptomatic patients and asymptomatic patients with LV systolic dysfunction. This continues to be defined as an ejection fraction of < 60% or an end-systolic dimension > 40 mm, although new data have suggested that even smaller systolic dimensions may have prognostic importance, he noted.
Pulmonary hypertension and atrial fibrillation are class IIa indications for surgery in asymptomatic, primary MR.
Critics would argue that patients shouldn’t be allowed to develop these indications because they may be irreversible, but the reality is that many patients arrive in your office with one or more indications already in place, Dr. Bonow said. The real issue is whether mitral valve repair is feasible and can improve survival in patients who have normal LV function and none of these indications, with the guidelines clearly tipping in favor of early surgery for asymptomatic MR patients.
Dr. Bonow highlighted recent long-term outcomes data from Dr. Tirone David’s group (Circulation 2013;127:1485-92) showing that overall survival among patients undergoing mitral valve repair for degenerative diseases is 75% at 20 years for those with functional class (FC) I disease, 66% with FC II, 52% with FC III, and only 32% for those with FC IV.
“I think these data, along with many other series, are quite important in identifying the risks we have for our patients for waiting too long, and if we can refer our patients to an expert surgical team for these valves to be repaired, their outcomes will be much better,” Dr. Bonow said.
The guidelines include the class I indication that repair is better than mitral valve replacement for primary MR and that patients should be referred to “centers experienced in repair.” Instead of stating that there should be a 90% or greater likelihood of a durable repair without residual MR for a patient undergoing elective surgery at that center, the 2014 threshold is now set at more than 95%.
“We really want to make sure patients are going to an experienced center,” he said.
Despite the emphasis on a heart team approach and referral to experienced centers, the term “experienced” has not been fully defined, Dr. Bonow acknowledged.
“Our medical and surgical societies need to be working together to start defining what we mean by ‘experienced,’ what we mean by ‘centers of excellence,’ and that process is already underway,” he added.
Dr. David H. Adams, chair of cardiovascular surgery at Mount Sinai Hospital, New York City, said that there’s no question asymptomatic patients need to be treated in experienced repair centers, but questioned whether the 95% threshold is realistic. Although repair rates are increasing worldwide, Society of Thoracic Surgery published data show a wide disparity in mitral repair that would be troublesome in an asymptomatic population. Mandatory reporting data from New York State, home to several experienced heart programs, also show that 45% of the latest 4,325 mitral valves with interventions were replaced, rather than repaired. Dr. Adams added that data are similar across the world.
He also urged caution about an “asymptomatic surgery for all” attitude, emphasizing judgment is necessary, particularly in elderly patients or in those who are very early in the course of severe regurgitation with no evidence of ventricular dilation or declining systolic function.
Finally, the new guidelines include recommendations for using transcatheter valves and the mitral clip to treat patients with secondary MR with LV dysfunction. This is not yet an approved indication from the Food and Drug Administration, pending the results of three ongoing trials, but in Europe, more than 70% of patients getting a mitral clip do so for secondary MR rather than primary mitral valve prolapse, Dr. Bonow said. The European guidelines came out 2 years ahead of the new AHA/ACC guidelines because writing was delayed until these devices were approved in the United States.
Secondary MR, or disease of the heart muscle, remains “problematic” because of a lack of outcomes data indicating that surgery leads to a better outcome than medical management in patients with LV dysfunction and because of questions raised by the Cardiothoracic Surgical Network about whether these valves should be repaired rather than replaced, he said.
What remains is a solid class 1 recommendation for guideline-directed medical therapy for heart failure including cardiac resynchronization therapy (CRT).
The surgical indications in secondary MR are class IIa for patients with severe MR undergoing coronary artery bypass grafting or aortic valve replacement and class IIb for those not undergoing such surgeries, but with severe MR and persistent symptoms, despite medical therapy, including CRT.
“There’s no data we’re going to improve survival ... but clearly some patients will have a dramatic improvement in symptoms,” Dr. Bonow said.
Dr. Bonow disclosed reviewing grant applications for the Gilead (Sciences) Scholars Program. Dr. Adams disclosed royalties as an inventor for Edwards Lifesciences and Medtronic, and serving as a Medtronic national coprimary investigator for the CoreValve Trial.
CHICAGO – Early repair and greater reliance on experienced surgical centers are key to the new guidelines on the management of mitral valve disease.
It’s been 8 years since the last American Heart Association/American College of Cardiology guideline on valvular heart disease in 2006, with little change in the 2008 update.
The 2014 guidelines, however, have substantiative changes, including the decision to begin talking about valvular disease and at-risk patients much as we do for heart failure, guideline committee member Robert Bonow said at the Heart Valve Summit 2014.
The 2014 guidelines, published earlier this year, include four stages of valvular heart disease:
Stage A, for people at risk of valvular disease such as those with bicuspid valves, a history of rheumatic heart disease, or mitral valve prolapse without regurgitation.
Stage B, for mild to moderate, asymptomatic disease.
Stage C, for severe, asymptomatic disease, including those with normal left ventricular function (stage C1) or depressed LV function (stage C2).
Stage D, for severe, symptomatic valve disease.
The new guidelines also drive home the point that primary and secondary mitral regurgitation (MR), while they can be difficult to distinguish, are separate diseases with different pathophysiologies, natural histories, management strategies, and outcomes, said Dr. Bonow, director of the Center for Cardiovascular Innovation, Northwestern University, Chicago.
Class 1 surgical indications for primary MR, or diseases of the valve, are symptomatic patients and asymptomatic patients with LV systolic dysfunction. This continues to be defined as an ejection fraction of < 60% or an end-systolic dimension > 40 mm, although new data have suggested that even smaller systolic dimensions may have prognostic importance, he noted.
Pulmonary hypertension and atrial fibrillation are class IIa indications for surgery in asymptomatic, primary MR.
Critics would argue that patients shouldn’t be allowed to develop these indications because they may be irreversible, but the reality is that many patients arrive in your office with one or more indications already in place, Dr. Bonow said. The real issue is whether mitral valve repair is feasible and can improve survival in patients who have normal LV function and none of these indications, with the guidelines clearly tipping in favor of early surgery for asymptomatic MR patients.
Dr. Bonow highlighted recent long-term outcomes data from Dr. Tirone David’s group (Circulation 2013;127:1485-92) showing that overall survival among patients undergoing mitral valve repair for degenerative diseases is 75% at 20 years for those with functional class (FC) I disease, 66% with FC II, 52% with FC III, and only 32% for those with FC IV.
“I think these data, along with many other series, are quite important in identifying the risks we have for our patients for waiting too long, and if we can refer our patients to an expert surgical team for these valves to be repaired, their outcomes will be much better,” Dr. Bonow said.
The guidelines include the class I indication that repair is better than mitral valve replacement for primary MR and that patients should be referred to “centers experienced in repair.” Instead of stating that there should be a 90% or greater likelihood of a durable repair without residual MR for a patient undergoing elective surgery at that center, the 2014 threshold is now set at more than 95%.
“We really want to make sure patients are going to an experienced center,” he said.
Despite the emphasis on a heart team approach and referral to experienced centers, the term “experienced” has not been fully defined, Dr. Bonow acknowledged.
“Our medical and surgical societies need to be working together to start defining what we mean by ‘experienced,’ what we mean by ‘centers of excellence,’ and that process is already underway,” he added.
Dr. David H. Adams, chair of cardiovascular surgery at Mount Sinai Hospital, New York City, said that there’s no question asymptomatic patients need to be treated in experienced repair centers, but questioned whether the 95% threshold is realistic. Although repair rates are increasing worldwide, Society of Thoracic Surgery published data show a wide disparity in mitral repair that would be troublesome in an asymptomatic population. Mandatory reporting data from New York State, home to several experienced heart programs, also show that 45% of the latest 4,325 mitral valves with interventions were replaced, rather than repaired. Dr. Adams added that data are similar across the world.
He also urged caution about an “asymptomatic surgery for all” attitude, emphasizing judgment is necessary, particularly in elderly patients or in those who are very early in the course of severe regurgitation with no evidence of ventricular dilation or declining systolic function.
Finally, the new guidelines include recommendations for using transcatheter valves and the mitral clip to treat patients with secondary MR with LV dysfunction. This is not yet an approved indication from the Food and Drug Administration, pending the results of three ongoing trials, but in Europe, more than 70% of patients getting a mitral clip do so for secondary MR rather than primary mitral valve prolapse, Dr. Bonow said. The European guidelines came out 2 years ahead of the new AHA/ACC guidelines because writing was delayed until these devices were approved in the United States.
Secondary MR, or disease of the heart muscle, remains “problematic” because of a lack of outcomes data indicating that surgery leads to a better outcome than medical management in patients with LV dysfunction and because of questions raised by the Cardiothoracic Surgical Network about whether these valves should be repaired rather than replaced, he said.
What remains is a solid class 1 recommendation for guideline-directed medical therapy for heart failure including cardiac resynchronization therapy (CRT).
The surgical indications in secondary MR are class IIa for patients with severe MR undergoing coronary artery bypass grafting or aortic valve replacement and class IIb for those not undergoing such surgeries, but with severe MR and persistent symptoms, despite medical therapy, including CRT.
“There’s no data we’re going to improve survival ... but clearly some patients will have a dramatic improvement in symptoms,” Dr. Bonow said.
Dr. Bonow disclosed reviewing grant applications for the Gilead (Sciences) Scholars Program. Dr. Adams disclosed royalties as an inventor for Edwards Lifesciences and Medtronic, and serving as a Medtronic national coprimary investigator for the CoreValve Trial.
AT THE HEART VALVE SUMMIT 2014
