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1
Cardiology 2008 Innovations Challenges
Evidence-Based Management of Valvular Heart
Disease
Robert O. Bonow, M.D. Bluhm Cardiovascular
Institute Northwestern Memorial Hospital
Northwestern University Feinberg School of
Medicine
Consultant Edwards Lifesciences
2
Journal of the American College of Cardiology _at_
2006 byt the American College of Cardiology and
the American Heart Association, Inc. Published
by Elsevier, Inc.
Vol. 48, No. 3, 2006 ISSN 0735-1097/06/32.00
doi10.1016/j.jacc.2006.05.021
ACC/AHA PRACTICE GUIDELINES
ACC/AHA 2006 Guidelines for the Management of
Patients With Valvular Heart Disease A Report of
the American College of Cardiology/American
Heart Association Task Force on Practice
Guidelines (Writing Committee to Revise the 1998
Guidelines for the Management of Patients With
Valvular Heart Disease Developed in Collaboration
With the Society of Cardiovascular
Anesthesiologists Endorsed by the Society of
Cardiovascular Angiography and Interventions and
the Society of Thoracic Surgeons
WRITING
COMMITTEE MEMBERS
Robert O. Bonow, MD, FACC, FAHA, Chair
Blase A. Carabello, MD, FACC, FAHA Bruce Whitney
Lytle, MD, FACC Kanu Chatterjee, MD, FACC,
FAHA Rick A. Nishimura, MD, FACC, FAHA
Antonio C. De Leon, Jr, MD, FACC, FAHA Patrick
T. OGara, MD, FACC, FAHA David P. Faxon, MD,
FACC, FAHA Robert A. ORourke, MD, MACC,
FAHA Michael D. Freed, MD, FACC, FAHA Catherine
M. Otto. MD, FACC, FAHA William H. Gaasch, MD,
FACC, FAHA Pravin M. Shah, MD, MACC, FAHA

Jack A. Shanewise, MD
www.acc.org www.americanheart.org
3
Journal of the American College of Cardiology _at_
2006 byt the American College of Cardiology and
the American Heart Association, Inc. Published
by Elsevier, Inc.
Vol. 48, No. 3, 2006 ISSN 0735-1097/06/32.00
doi10.1016/j.jacc.2006.05.021
ACC/AHA PRACTICE GUIDELINES
ACC/AHA 2006 Guidelines for the Management of
Patients With Valvular Heart Disease
Key recommendations

• Quantification of valve severity
• Indications for mitral valve repair
• Ischemic mitral regurgitation
• Indications for aortic valve replacement
• Low gradient, low output aortic stenosis
• Bicuspid valves with aortic root dilatation
• Endocarditis prophylaxis

4
Mitral Regurgitation
Mitral regurgitation Severe Regurgitant
volume (ml) gt60 Regurgitant fraction
() gt50 Regurgitant orifice (cm2) gt0.4
5
Aortic Stenosis
Aortic stenosis Severe Jet velocity
(m/sec) gt4.0 Mean gradient (mmHg) gt40 Valve area
(cm2) lt1.0 Valve area (cm2/m2) lt0.6
6
Journal of the American College of Cardiology _at_
2006 byt the American College of Cardiology and
the American Heart Association, Inc. Published
by Elsevier, Inc.
Vol. 48, No. 3, 2006 ISSN 0735-1097/06/32.00
doi10.1016/j.jacc.2006.05.021
ACC/AHA PRACTICE GUIDELINES
ACC/AHA 2006 Guidelines for the Management of
Patients With Valvular Heart Disease
Mitral regurgitation and aortic stenosis

• Quantification of valve severity
• Indications for mitral valve repair
• Ischemic mitral regurgitation
• Indications for aortic valve replacement
• Low gradient, low output aortic stenosis
• Bicuspid valves with aortic root dilatation
• Endocarditis prophylaxis

7
Chronic Severe Mitral Regurgitation - 2006

• Indications for operation
• Symptoms class I
• LV systolic dysfunction class I
• EF lt60 or serial ?EF
• LVSD gt40mm or serial ?ESD
• Pulmonary Hypertension class IIa
• RV dysfunction class IIa
• Atrial fibrillation class IIa
• Severe MR with repair feasible?
  

ACC/AHA Guidelines 2006
8
Contemporary Use of Mitral Valve Repair
5000
MV Replacement
4000
3000
Procedures
MV Repair
2000
1000
0
1993
2003
1994
1995
1996
1997
1998
1999
2000
2001
2002
Year
Society of Thoracic Surgeons Database, 2005
9

• Should all asymptomatic patients
• with chronic severe MR undergo
• mitral valve repair?

if you are certain it will be repaired?
10
Mitral RegurgitationSurvival of Patients With
Flail Leaflets
Expected
55
Survival (percent)
Observed
Time (years)
from Ling et al, N Engl J Med 1996
11

• 456 patients with MR
• Evaluated 1991-2000
• Initially asymptomatic with normal LVEF
• Management by individual patients physician
• Follow-up information collected in 2002

12
Mitral RegurgitationNatural History of
Asymptomatic Chronic MR
ERO lt20 mm2
ERO 20-39 mm2
Cardiac Survival ()
ERO gt40 mm2
0
1
2
3
4
5
Time (years)
from Sarano et al. N Engl J Med 2005352875-883
13
Valvular Heart Disease
Outcome of Watchful Waiting in Asymptomatic
Severe Mitral Regurgitation
Raphael Rosenhek, MD Florian Rader, MD Ursala
Klaar, MD Harald Gabriel, MD Marcel Krejc,
PhD Daniel Kalbeck, PhD Michael Schemper, PhD
Gerald Maurer, MD Helmut Baumgartner, MD
Circulation 20061132238-2244

• 132 patients
• 62 month follow-up
• Indications for surgery
• Symptoms
• LV dilatation (ESD gt45mm)
• LV dysfunction (EF lt60)
• Atrial fibrillation
• PA pressure gt 50 mmHg

41 patients with events 21 symptoms 10 LV
criteria 10 PA criteria 7 Atrial
fibrillation 1 SBE
2 deaths in patients who refused surgery
14
Mitral RegurgitationNatural History of
Asymptomatic Severe MR
Rosenhek

Alive, Asymptomatic without Surgery ()
Sarano
Rosen
0
1
2
3
4
5
6
7
8
9
10
Time (years)
from Rosen et al. Am J Cardiol 1994 74
374-380 Sarano et al. N Engl J Med
2005352875-883 Rosenhek et al. Circulation
20061132238-2244
15
www.acc.org www.amaericanheart.org
ACC/AHA TASK FORCE REPORT
ACC/AHA 2006 Guidelines for the Management of
Patients With Valvular Heart Disease
Chronic Mitral Regurgitation
Indications for surgery MV repair is
reasonable in experienced surgical centers for
asymptomatic patients with chronic severe MR with
preserved LV function in whom the likelihood of
successful repair without residual MR is greater
than 90. MV repair is recommended over MV
replacement in the majority of patients who
require surgery, and patients should be referred
to surgical centers experienced in MV repair.
Class IIa
Class I
www.acc.org www.americanheart.org
16
Cardiovascular Surgery
Influence of Hospital Procedural Volume on Care
Process and Mortality for Patients Undergoing
Elective Surgery for Mitral Regurgitation
James S. Gammie, MD Sean OBrien, PhD Bartley
P. Griffith, MD T. Bruce Ferguson, MD Eric D.
Peterson, MD
Circulation 2007115881-887
STS Database 2000-2003
13,674 patients 575 NA hospitals
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INTERVENTIONAL CARDIOLOGY AND SURGERY
Mitral repair best practice proposed standards
B Bridgewater, T Hooper, C Munsch, S Hunter, U
von Oppell, S Livesty, B Keogh, F Wells, M
Patrick, J Kneeshaw, J Chambers, N Masani, S Ray
Heart 200692939-944

• 19 criteria for best practice
• Surgical training
• Intraoperative echocardiography
• Volume thresholds
• Audit
• Cardiology and imaging

Surgeon gt25/yr Hospital gt50/yr
Operative mortality lt1 5 year reoperation lt5
18
Journal of the American College of Cardiology _at_
2006 byt the American College of Cardiology and
the American Heart Association, Inc. Published
by Elsevier, Inc.
Vol. 48, No. 3, 2006 ISSN 0735-1097/06/32.00
doi10.1016/j.jacc.2006.05.021
ACC/AHA PRACTICE GUIDELINES
ACC/AHA 2006 Guidelines for the Management of
Patients With Valvular Heart Disease
Mitral regurgitation and aortic stenosis

• Quantification of valve severity
• Indications for mitral valve repair
• Ischemic mitral regurgitation
• Indications for aortic valve replacement
• Low gradient, low output aortic stenosis
• Bicuspid valves with aortic root dilatation
• Endocarditis prophylaxis

19
Carpentiers Functional Classification
Type IIIb
Restricted Leaflet Motion
Carpentier. J Thorac Cardiovasc Surg
198386323-337
20
Ischemic MR
Effect of MR on Survival Post-MI
100
80
ERO 0
61
60
ERO 1-19
Survival (percent)
47
ERO 20
40
29
p0.001
20
0
1
2
3
4
5
0
Time (years)
Grigioni et al. Circulation 20011031759-1764
21
Ischemic MR
Development of Heart Failure
100
p0.001
80
68
ERO 20
60
Onset of Heart Failure ()
46
ERO 1-19
40
ERO 0
20
18
0
1
2
3
4
5
0
Time (years)
Grigioni et al. Circulation 20011031759-1764
22
Ischemic Mitral Regurgitation

• Should it be repaired ?
• Moderate MR in a patient
• undergoing CABG ?
• How should it be repaired
• (or replaced)?

23
Ischemic Mitral Regurgitation
Moderate MR in a CABG patient

• Untreated MR persists and often progresses
• Even moderate MR has a poor prognosis
• in a patient undergoing CABG
• Late survival and functional class are more
• favorable with CABG plus mitral repair

compared to CAGB alone compared to CABG plus MVR
Unlike repair of myxomatous MR, recurrent
ischemic MR is common
24
www.acc.org www.amaericanheart.org
ACC/AHA TASK FORCE REPORT
ACC/AHA Guidelines for the Management of
Patients With Valvular Heart Disease
3.6.5. Ischemic Mitral Regurgitation
CABG alone is usually insufficient and leaves
many patients with significant residual MR, and
these patients would benefit from concomitant MV
repair at the time of CABG.
7.3.1. Mitral Valve Repair
7.3.1.3. Ischemic Mitral Valve Disease When
functional MR is severe, it may be corrected by
placement of an annuloplasty ring that decreases
annular circumference, shortens the intertrigonal
distance, reduces the septal-lateral annular
diameter and restores the geometry of the
annulus,thereby allowing the leaflets to coapt.
www.acc.org www.americanheart.org
25
Journal of the American College of Cardiology _at_
2006 byt the American College of Cardiology and
the American Heart Association, Inc. Published
by Elsevier, Inc.
Vol. 48, No. 3, 2006 ISSN 0735-1097/06/32.00
doi10.1016/j.jacc.2006.05.021
ACC/AHA PRACTICE GUIDELINES
ACC/AHA 2006 Guidelines for the Management of
Patients With Valvular Heart Disease
Mitral regurgitation and aortic stenosis

• Quantification of valve severity
• Indications for mitral valve repair
• Ischemic mitral regurgitation
• Indications for aortic valve replacement
• Low gradient, low output aortic stenosis
• Bicuspid valves with aortic root dilatation
• Endocarditis prophylaxis

26
Aortic Stenosis
Symptomatic Patients

• Aortic valve replacement
• Improves symptoms
• Improves LV function
• Improves survival

27
Journal of the American College of Cardiology _at_
2006 byt the American College of Cardiology and
the American Heart Association, Inc. Published
by Elsevier, Inc.
Vol. 48, No. 3, 2006 ISSN 0735-1097/06/32.00
doi10.1016/j.jacc.2006.05.021
ACC/AHA PRACTICE GUIDELINES
ACC/AHA 2006 Guidelines for the Management of
Patients With Valvular Heart Disease
Severe Aortic Stenosis
Indications for aortic valve replacement
Symptomatic patients Patients undergoing
CABG or surgery on the aorta or another
valve Patients with LV systolic
dysfunction
class I
class I
class I
28
Aortic Stenosis
Are asymptomatic patients really asymptomatic?
29
Aortic StenosisPredictive Value of Exercise
Testing
No symptoms n79
Limiting symptoms n46
Symptom-Free Survival (percent)
plt0.001
Time (months)
Das et al Eur Heart J 2005261309-1313
30
www.acc.org www.amaericanheart.org
ACC/AHA TASK FORCE REPORT
ACC/AHA 2006 Guidelines for the Management of
Patients With Valvular Heart Disease
Aortic Stenosis
Exercise Testing Exercise testing in
asymptomatic patients with AS may be considered
to elicit exercise-induced symptoms and abnormal
blood pressure responses. Indications for Aortic
Valve Replacement AVR may be considered for
asymptomatic patients with severe AS and abnormal
exercise response (e.g., development of symptoms
or asymptomatic hypotension).
Class IIb
Class IIb
www.acc.org www.americanheart.org
31
Aortic Stenosis
Are asymptomatic patients at risk of sudden death?
32
Sudden Death in Asymptomatic Aortic Stenosis
Follow-up SD without n (years)
symptoms Chizner 1980 8 5.7
0 Turina 1987 17 2.0 0 Horstkötte 1988
35 years 3 Kelley 1988 51
1.5 0 Faggiano 1992 37 2.0
0 Otto 1997 123 2.5 0 Rosenhek 2000 106
2.3 1 Amato 2001 66 1.3
4 Das 2005 125 1.0 0 Pellikka 2005 622 5.4
11 Total 1190 3.7 19
33
Natural History of Asymptomatic AS
Vmax lt 3.0
Asymptomatic without AVR ()
Vmax 3.0 - 4.0
n123 Age 63?16
Vmax gt 4.0
0
1
2
3
4
5
Time (years)
from Otto et al. Circulation 1997952262-2270
34
Natural History of Asymptomatic AS
Patients with Severe AS (Vmax
gt4 m/s)
Pellikka
Asymptomatic without AVR ()
Rosenhek
Otto
0
1
2
3
4
5
Time (years)
from Otto et al. Circulation 1997952262-2270 Ros
enhek et al. N Engl J Med 2000343611 Pellikka
et al. Circulation 20051113290-2395
35
Natural History of Asymptomatic AS
No or mild calcification
Severe AS
Asymptomatic without AVR ()
Moderate or severe calcification
plt0.001
Time (years)
Rosenhek et al. N Engl J Med 2000343611
36
www.acc.org www.amaericanheart.org
ACC/AHA TASK FORCE REPORT
ACC/AHA 2006 Guidelines for the Management of
Patients With Valvular Heart Disease
Aortic Stenosis

• Indications for Aortic Valve Replacement
• AVR may be considered for adults with severe
  asymptomatic AS if there is a high likelihood of
  rapid progression (age, calcification, and CAD)
  or if surgery might be delayed at the time of
  symptom onset.

Class IIb
37
Aortic Valve ReplacementHospital Mortality
Medicare data

• Average hospital mortality 8.8
• Low volume centers 13.0
• High volume centers 6.0

Data from national Medicare database
1994-1999 684 hospitals 142,488 AVRs
Goodney et al, Ann Thorac Surg 2003761131-1337
38
Identifying Risk of AVR

• STS risk calculator
• 24 variables
• validated in 210,000 patients
• www.sts.org
• euroSCORE
• 17 variables
• validated in gt500,000 patients
• www.euroscore.org

• Valve-specific risk calculator
• 13 variables
• validated in gt16,000 patients

Shroyer et al. Ann Thorac Surg 2003751856-1865 N
ashef et al. Eur J Cardiovasc Surg
1999169-13 Ambler et al. Circulation
2005112224-231
39
Conclusion Surgery was denied in 33 of elderly
patients with severe, symptomatic AS. Older age
and LV dysfunction were the most striking
characteristics of patients who were denied
surgery, whereas comorbidity played a less
important role.
40
Journal of the American College of Cardiology _at_
2006 byt the American College of Cardiology and
the American Heart Association, Inc. Published
by Elsevier, Inc.
Vol. 48, No. 3, 2006 ISSN 0735-1097/06/32.00
doi10.1016/j.jacc.2006.05.021
ACC/AHA PRACTICE GUIDELINES
ACC/AHA 2006 Guidelines for the Management of
Patients With Valvular Heart Disease
Mitral regurgitation and aortic stenosis

• Quantification of valve severity
• Indications for mitral valve repair
• Ischemic mitral regurgitation
• Indications for aortic valve replacement
• Low gradient, low output aortic stenosis
• Bicuspid valves with aortic root dilatation
• Endocarditis prophylaxis

41
www.acc.org www.americanheart.org
ACC/AHA TASK FORCE REPORT
ACC/AHA 2006 Guidelines for the Management of
Patients With Valvular Heart Disease
Bicuspid Aortic Valve

• Indications for surgery
• Aortic root dilatation
• Ao diameter gt50 mm or
• rate of increase gt5 mm/yr
• Patients with criteria for AVR
• Ao diameter gt45 mm

class I
class I
www.acc.org www.americanheart.org
42
Journal of the American College of Cardiology _at_
2006 byt the American College of Cardiology and
the American Heart Association, Inc. Published
by Elsevier, Inc.
Vol. 48, No. 3, 2006 ISSN 0735-1097/06/32.00
doi10.1016/j.jacc.2006.05.021
ACC/AHA PRACTICE GUIDELINES
ACC/AHA 2006 Guidelines for the Management of
Patients With Valvular Heart Disease
Mitral regurgitation and aortic stenosis

• Quantification of valve severity
• Indications for mitral valve repair
• Ischemic mitral regurgitation
• Indications for aortic valve replacement
• Low gradient, low output aortic stenosis
• Selection of aortic valve prostheses
• Endocarditis prophylaxis

43
Endocarditis Prophylaxis Does It Make Sense?

• No randomized trials
• Few observational studies
• some positive
• most negative
• Lots of expert opinion
• No cost-effectiveness studies

44
Endocarditis Prophylaxis Does It Make Sense?
Risk of endocarditis versus Risk from endocarditis

45
AHA Guideline
Prevention of Infectious Endocarditis
Guidelines From the American Heart Association
A Guideline from the American Heart
Association Rheumatic Fever, Endocarditis, and
Kawasaki Disease Committee, Council
on Cardiovascular Disease in the Young, and the
Council on Clinical Cardiology, Council on
Cardiovascular Surgery and Anesthesia, and the
Quality of Care and Outcomes Research
Interdisciplinary Working Group
Walter Wilson MD, Chair Kathryn A. Taubert, PhD,
FAHA Michael Green, MD, FAHA Peter B. Lockhart,
DDS Larry M. Baddour MD Matthew Levison, MD
Ann Bolger, MD, FAHA Christopher H. Cabell, MD,
MHS Masato Takahashi, MD, FAHA Robert S.
Baltimore, MD Jane W. Newburger, MD MPH, FAHA
Brian L. Strom, MD Lloyd Y. Tani, MD Michael
Gerber, MD Robert O. Bonow, MD, FAHA Thomas
Pallasch, DDS, MS Stanford T. Shulman, MD, FAHA
Anne H. Rowley, MD Jane C. Burns, MD Patricia
Ferrien, MD Timothy Gardner, MD, FAHA David
Goff, MD, PhD, FAHA David T. Durack, MD, PhD
Circulation 20071161736-1754
www.americanheart.org
46
AHA Guideline
Prevention of Infectious Endocarditis
Guidelines From the American Heart Association
Indications for antibiotic prophylaxis

• Patients with
• Prosthetic heart valves
• Previous infectious endocarditis
• Cyanotic congenital heart disease
• Congenital heart disease with indwelling shunts
• Cardiac transplantation with valvular
  abnormalities

www.americanheart.org