The guideline update modifies present
recommendations for open heart surgical aortic valve replacement and transaortic valve replacement (TAVR)
based on the results of clinical studies conducted recently.
‘In transaortic valve replacement (TAVR), damaged aortic valve is replaced by a catheter based procedure, which is less invasive, and recommended for patients who are at high risk for surgery.’
Traditionally symptomatic aortic valve
disease was treated with open heart surgery to replace the abnormal valve.
However in the recently updated guidelines, a set of patients can be managed
with a less invasive catheter based
- Surgical aortic
valve replacement, for example, is recommended for
persons with moderately symptomatic aortic stenosis and are considered low to intermediate risk for
surgery i.e. they are deemed fit to undergo open heart surgery and
unlikely to suffer any major complications due to the procedure.
patients with advanced aortic stenosis who have symptoms, such as
shortness of breath (dyspnea) and fatigue, and considered intermediate to high risk for surgery,
open heart surgery is more likely to be associated with complications and
transaortic valve replacement (TAVR)
is recommended as a safer and viable alternative.
The choice to undergo open heart surgery
or TAVR should be a shared decision
based on the optimal option after taking into consideration the patient's needs
"There have been significant
developments in the treatment of patients with valve disease using open heart
surgery to repair rather than replace leaky valves," said Rick Nishimura,
M.D., a professor of medicine at Mayo Clinic and writing committee co-chair of
the new guideline focused update. "For example, we are now able to replace
abnormal valves using a catheter based approach, so that patients at higher
risk of surgery can be treated less invasively."
The heart valves are 4 in number and
normally allow blood flow from one heart chamber to the next only in the
forward direction. They include the tricuspid
valve, pulmonary valve, mitral or bicuspid valve and the aortic valve
aortic valve regulates blood flow from the left ventricle into the aorta.
Valvular diseases may be present since birth, be acquired due to infection or
damaged following a heart
. They are diagnosed when these damaged valves cause
variations in the blood flow between the various heart chambers resulting in
abnormal sounds (murmurs)
the chest on auscultation
chest sounds using a stethoscope).
The two major types of valvular disease
. Stenosis occurs when
the valvular orifice is narrowed thus reducing blood flow from one chamber to
the next. In an 'incompetent'
the valve permits backflow of blood into the chamber (in aortic valve
incompetence, blood leaks back from
aorta into the left ventricle
). This phenomenon is also referred to as regurgitation
Guideline Updates in Addition to Valvular Replacement Outline
before Dental Treatment
need for antibiotics prior to a
dental procedure in certain patients; and
- Increasing the
age range for choosing tissue valve replacement.
Traditionally antibiotics have been given to reduce risk of infective
life-threatening condition that occurs due to infection of the heart valves.
The bacteria causing infective endocarditis are released into the bloodstream
during dental procedures. As per the latest guidelines, they are recommended in
the following situations
who have had previous valve replacement surgery
with previous history of infection of the heart valve
with certain types of congenital heart
disease and were born with abnormal valves
Prophylactic antibiotics are no longer
recommended for other congenital heart diseases other than those that have been listed in the
the Age-Range for Valve Replacement Surgery
In patients undergoing aortic or mitral
valve replacement, the age range was increased from the existing 60 to 70 years
of age to 50 to 70 years of age for the choice of either a mechanical or tissue valve.
valves last longer than tissue valves but may require taking blood
thinners for life, and were previously recommended for patients younger
than 60 years old.
availability of newer tissue valves that last longer than the earlier
generation of tissue valves, without the need for replacement as often,
give patients between the ages of 50 and 60 more options, Nishimura said.
The current update is meant to help medical
personnel better manage symptoms and prevent complications due to valvular
heart disease (VHD). "A heart murmur often is detected on physical
examination many years before symptoms appear and should prompt further
evaluation with an echocardiogram. Careful periodic monitoring and medical
therapy result in better long term outcomes because patients have valve
replacement at the right time; not too soon and not too late," said
Catherine M. Otto, M.D., co-chair of the writing committee and professor of
Medicine at the University of Washington in Seattle, Washington
- Infective Endocarditis - (http://www.heart.org/HEARTORG/Conditions/CongenitalHeartDefects/TheImpactofCongenitalHeartDefects/Infective-Endocarditis_UCM_307108_Article.jsp#.WMgJW2997IV)