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Presentation transcript:

Aortic Valve and Ascending Aorta Guidelines for Management and Quality Measures Lars G. Svensson, MD, PhD, David H. Adams, MD, Robert O. Bonow, MD, Nicholas T. Kouchoukos, MD, D. Craig Miller, MD, Patrick T. O'Gara, MD, David M. Shahian, MD, Hartzell V. Schaff, MD, Cary W. Akins, MD, Joseph E. Bavaria, MD, Eugene H. Blackstone, MD, Tirone E. David, MD, Nimesh D. Desai, MD, PhD, Todd M. Dewey, MD, Richard S. D'Agostino, MD, Thomas G. Gleason, MD, Katherine B. Harrington, MD, Susheel Kodali, MD, Samir Kapadia, MD, Martin B. Leon, MD, Brian Lima, MD, Bruce W. Lytle, MD, Michael J. Mack, MD, Michael Reardon, MD, T. Brett Reece, MD, G. Russell Reiss, MD, Eric E. Roselli, MD, Craig R. Smith, MD, Vinod H. Thourani, MD, E. Murat Tuzcu, MD, John Webb, MD, Mathew R. Williams, MD The Annals of Thoracic Surgery Volume 95, Issue 6, Pages S1-S66 (June 2013) DOI: 10.1016/j.athoracsur.2013.01.083 Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Options for minimally invasive J incision. The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 (A) Relationship of late survival to years after aortic valve insertion in 13,258 patients, divided by aortic valve prosthesis. (B) Survival by age. The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Survival by age groups: (A) younger patients; (B) middle-aged patients; (C) elderly patients. Note that differences disappear. The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Average annual valve procedures for STS sites (left axis) and busy practice (right axis) over time. (AVR = aortic valve replacement; CAB = coronary artery bypass; CCF = Cleveland Clinic Foundation; MV = mitral valve repair.) The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Coronary artery bypass and percutaneous coronary intervention volume trends. The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Trends in volume for STS sites and a large center with increasing valve and thoracic aorta numbers. (AVR = aortic valve replacement; CAB = coronary artery bypass; CAD = coronary artery disease; CCF = Cleveland Clinic Foundation; MV = mitral valve; O/E = observed to expected mortality ratio at CCF.) The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 7 Predicted global trends for transcatheter aortic valve replacement (TAVR). The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 8 Predicted trends for transcatheter aortic valve replacement (TAVR) in the United States. The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 9 Targeted market and likely population of transcatheter aortic valve replacement (TAVR). The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 10 Trends for in-hospital mortality for coronary artery bypass graft surgery (CABG) in Pennsylvania. Note the decline. Source: Cardiac Surgery in Pennsylvania 2008–2009. Used with permission of PA Health Care Cost Containment Council. The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 11 Trends for in-hospital mortality for valve procedures in Pennsylvania. Note the decline. Source: Cardiac Surgery in Pennsylvania 2008–2009. Used with permission of PA Health Care Cost Containment Council. The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 12 (A) Seven-day readmission after valve surgery (note increasing trend) for Pennsylvania. (B) Thirty-day readmission after valve surgery. Source: Cardiac Surgery in Pennsylvania 2008–2009. Used with permission of PA Health Care Cost Containment Council. The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 13 Readmission costs and Medicare payments for Pennsylvania. (CABG = coronary artery bypass graft surgery.) Source: Cardiac Surgery in Pennsylvania 2008–2009. Used with permission of PA Health Care Cost Containment Council. The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 14 Average number of heart procedures performed by Pennsylvania hospitals (solid line) and surgeons (stippled line). Source: Cardiac Surgery in Pennsylvania 2008–2009. Used with permission of PA Health Care Cost Containment Council. The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 15 Hospital infections after cardiac surgery in Pennsylvania. Note the 37% at surgical site. Source: Cardiac Surgery in Pennsylvania 2008–2009. Used with permission of PA Health Care Cost Containment Council. The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 16 Outcomes after hospital infections, increase in cost, and estimated Medicare reimbursement. (CABG = coronary artery bypass graft surgery; HAI = hospital acquired infection.) Source: Cardiac Surgery in Pennsylvania 2008–2009. Used with permission of PA Health Care Cost Containment Council. The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 17 Material decline in coronary artery bypass surgery (CAB) by STS sites from an average of approximately 400 cases per annum. The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 18 (A) Survival for 3,624 Medicare patients treated in 2003 for isolated aortic valve stenosis. The 5% random sample showed 31% were treated medically, 651 were categorized as high-risk medically treated. The associated variables in the 651 medically treated high-risk patients were central nervous system or psychiatric disease 53%, unstable angina 43%, prior surgery 40%, peripheral vascular disease 28%, chronic pulmonary disease 22%, pulmonary hypertension 20%, and cancer 18%. These variable likely influenced the decision not to operate. The curves show the 5-years survivals. (HR = high risk; MM = medically managed; NHR = not high risk; ST = surgical treatment.) (B) Cost of care over 5 years for those operated on or treated in 2003. Costs are Medicare payments for Parts A, B, and schedule beneficiary cost sharing. The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 19 Management strategy for severe aortic stenosis. Preoperative coronary angiography should be performed routinely as determined by age, symptoms, and coronary risk factors. Cardiac catheterization and angiography may also be helpful when there is discordance between clinical findings and echocardiography. (AVA = aortic valve area; BP = blood pressure; CABG = coronary artery bypass graft; LV = left ventricular; Vmax = maximal velocity across aortic valve by Doppler echocardiography.) Reprinted with permission from Ref. 19 [Bonow RO, et al. Circulation. 2008;118:e523–e661. ©2008 American Heart Association, Inc.] The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 20 Management strategy with chronic severe aortic regurgitation. Preoperative coronary angiography should be performed routinely as determined by age, symptoms, and coronary risk factors. Cardiac catheterization and angiography may also be helpful when there is discordance between clinical findings and echocardiography. “Stable” refers to stable echocardiographic measurements. In some centers, serial follow-up may be performed with radionuclide ventriculography (RVG) or magnetic resonance imaging (MRI) rather than echocardiography to assess left ventricular (LV) volume and systolic function. (AVR = aortic valve replacement; DD = end-diastolic dimension; Echo = echocardiography; EF = ejection fraction; SD = end-systolic dimension. Reprinted with permission from Ref. 19 [Bonow RO, et al. Circulation. 2008;118:e523–e661. ©2008 American Heart Association, Inc.] The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 21 Surgical evaluation of patients for aortic valve replacement (AVR) or transcatheter aortic valve replacement (TAVR). (AS = aortic stenosis; AVI = aortic valve implantation; BAV = balloon aortic valvuloplasty; Cath = catheterization; LA = left atrium; LVEF = left ventricular ejection fraction; LV = left ventricle; PET = positron emission tomography; PFTs = pulmonary function tests; TA = transapical; TAVI = transcatheter aortic valve implantation; TF = transfemoral; Vel = velocity.) The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 22 Relationship between age of patient for pericardial or homograft valve and the risk of reoperation within 12 years of surgery. (SVD = structural valve deterioration). This graph is useful for discussing with patients the risk of reoperation for biological aortic valve replacement. The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 23 Survival for aortic valve repair, matched age and sex US life population, and matched biological aortic valve replacement (AVR). The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 24 Survival by bicuspid valve or Marfan syndrome aortic valve repair, US matched patients, degenerative root aneurysm/valve repairs of the aorta by tailoring, biological aortic valve replacement (AVR), and aortic dissection with valve repair. The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 25 Survival by remodeling, reimplantation, US life, biologic aortic valve replacement (AVR), and tailoring. The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 26 Hazard curves showing increasing risk of biological aortic valve replacement (AVR) failure after approximately 7 years but declining risk with repair. The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 27 Risk of reoperation by biological aortic valve replacement (AVR), tricuspid valve repair, mostly by modified David reimplantation, and for bicuspid valves. The Annals of Thoracic Surgery 2013 95, S1-S66DOI: (10.1016/j.athoracsur.2013.01.083) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions