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Updated Guidelines for Valvular Heart Disease

Updated Guidelines for Valvular Heart Disease

According to recent estimates, just less than 3% of Americans have moderate-to-severe valvular heart disease (VHD), a condition that increases in prevalence with age. The disease affects between 4% and 9% of those aged 65 to 75 and 12% to 13% of those aged 75 and older. Many of these patients require surgical or interventional procedures, but even with these treatments, the overall survival rates associated with VHD are lower than expected. The risk of adverse outcomes due to VHD is high because of limited options for restoring normal valve function and because of failures to intervene at the optimal time point in the disease course. A Welcome Update In 2008, the American College of Cardiology (ACC) and American Heart Association (AHA) released an updated guideline for diagnosing and managing adult patients with VHD. In 2014, the ACC/AHA updated these guidelines in an effort to facilitate access to concise, relevant information at the point of care when clinical knowledge is needed the most. “In the past 5 years, we have accumulated new evidence and a better understanding of earlier research surrounding VHD,” explains Paul Sorajja, MD, FACC, FAHA, FSCAI, who was a member of the ACC/AHA writing group that developed the most recent guideline update. “Our goal was to provide clinicians with concise, evidence-based recommendations and the supporting documentation to encourage their use.” Restructured Definitions The 2014 guidelines include restructured definitions of VHD severity into four classifications—at risk, progressive, asymptomatic severe, and symptomatic severe (Table 1). “These categories were created to help clinicians determine the optimal timing of interventions,” Dr. Sorajja says. The stages consider the degree of valve...

The Emergence of Transcatheter Aortic Valve Replacement

Aortic valve stenosis (AVS) involves thickening and progressive immobility of the aortic valve. This restricts blood flow from the left ventricle to the aorta. AVS most frequently involves an anatomically normal three-leaflet aortic valve and is less frequently due to either a congenitally abnormal bicuspid aortic valve or to the late consequence of rheumatic fever. Since AVS predominantly afflicts the elderly, its prevalence is increasing. In fact, AVS currently ranks among the top five Medicare cardiac diagnoses. AVS is slowly progressive and has a long asymptomatic period. However, the prognosis turns grim once the cardinal triad of symptoms occur, including: Progressive shortness of breath. Anginal-like chest discomfort. Lightheaded or fainting spells. In such cases, the average survival without aortic valve replacement (AVR) is between 1 and 2 years. Improved Surgical Treatments for AVS Until recently, the only treatment for AVS has been surgical AVR. Unfortunately, the morbidity and mortality related to this open-heart surgery in elderly patients can be prohibitive and has prompted the development of less invasive non-surgical, catheter-based technologies to replace the aortic valve. Recently, the FDA has approved a new balloon-expandable stent-mounted bovine pericardial valve (SAPIEN, Edwards Life Sciences) for the treatment of symptomatic severe AVS in patients who are considered to be at either high or prohibitive risk for surgical AVR. The valve represents a significant advance in that it’s delivered via femoral arterial access and does not require cardiopulmonary bypass. “There is hope that TAVR will continue to emerge as a viable alternative to surgical AVR in patients at high surgical risk.” In the Placement of Aortic Transcatheter Valves (PARTNER) trial, transcatheter AVR (TAVR)...

ACC.12 Highlights for Surgeons

New research was recently presented at ACC.12, the annual scientific meeting of the American College of Cardiology, from March 24-27 in Chicago. The features below highlight just some of the studies that emerged from the meeting that pertain specifically to the surgeon audience.  >> Positive Outcomes Observed With TAVI >> Assessing the Safety of On- & Off-Pump CABG >> TAVR Comparable to Open-Heart Surgery at 2 Years >> Bariatric Surgery Yields Big Rewards for Obese Diabetics >> Underweight Patients at Increased Risk During ICD Procedures >> Improving the Quality of ACS Care       Positive Outcomes Observed With TAVI The Particulars: Transcatheter aortic valve implantation (TAVI) involves insertion of a bioprosthetic valve into a diseased native aortic valve and represents a potentially less invasive option than surgical replacement. Currently, TAVI has been used mostly in non-operable patients. Data Breakdown: A study was conducted in high-risk patients with severe aortic stenosis who underwent TAVI at 44 centers. Major adverse cardiac and cerebrovascular events at 30-days follow-up occurred in 8.3% of patients receiving TAVI. Total mortality, cardiac mortality, stroke, and life-threatening or disabling bleeding rates were 4.5%, 2.2%, 2.9%, and 4.9%, respectively. Persistent, significant improvements in aortic valve function were also observed. Take Home Pearl: In high operative risk and non-operable patients, TAVI appears to be safe and effective. Assessing the Safety of On- & Off-Pump CABG The Particulars: CABG is one of the most commonly performed cardiac operations, but small randomized trials and meta-analyses have yet to determine conclusively if less-invasive off-pump CABG has better outcomes than on-pump CABG. Data Breakdown: A trial of nearly 5,000 patients with coronary artery disease...
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