Khuyến cáo mới về bệnh van tim của hội tim mạch châu âu và hoa kỳ

What’s New in ACC/AHA Valve Guidelines 2014: Mitral Regurgitation A/Prof Yeo Khung Keong MBBS, ABIM (Internal Medicine, Cardiology, Interventional Cardiology), ABVM (Vascular Medicine, Endovascular), FAMS, FACC, FSCAI Senior Consultant, Cardiology National Heart Centre Singapore Adjunct Associate Professor Duke-NUS Graduate Medical School Valve Guidelines First guidelines in 1996 revised in 1998 2nd major revision 2006 with minor revision 2008 ESC guidelines 2013 Major changes Stage system • • • Reflects valve severity, effect on LV and symptoms Valve specific changes Adds the role of expertise and “Heart Valve Centre of Excellence” Reviewers official reviewers: ACC and the AHA reviewer each from the American Association for Thoracic Surgery, ASE, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and STS 39 individual content reviewers (which included representatives from the following ACC committees and councils: Adult Congenital and Pediatric Cardiology Section, Association of International Governors, Council on Clinical Practice, Cardiovascular Section Leadership Council, Geriatric Cardiology Section Leadership Council, Heart Failure and Transplant Council, Interventional Council, Lifelong Learning Oversight Committee, Prevention of Cardiovascular Disease Committee, and Surgeon Council) Approved for publication by ACC and AHA and endorsed by the AATS, ASE, SCAI, Society of Cardiovascular Anesthesiologists, and STS Intervention Indication for intervention is dependent on: • Presence or absence of symptoms; • The severity of VHD; • Response of the LV and/or RV to the volume or pressure overload caused by VHD; • The effect on the pulmonary or systemic circulation; and • A change in heart rhythm Stages Rationale • The purpose of valvular intervention is to improve symptoms and/or prolong survival, as well as to minimize the risk of VHD-related complications such as asymptomatic irreversible ventricular dysfunction, pulmonary hypertension, stroke, and atrial fibrillation (AF) Heart Valve Team • Management best achieved by a Heart Valve Team composed primarily of a cardiologist and surgeon (including a structural valve interventionist if a catheter-based therapy is being considered) • Multidisciplinary; including cardiologists, structural valve interventionalists, cardiovascular imaging specialists, cardiovascular surgeons, anesthesiologists, and nurses • Optimize patient selection through a comprehensive understanding of the risk–benefit ratio of different treatment strategies • Shared informed, decision-making approach with patient and family Heart Valve Centres of Excellence • Composed of experienced healthcare providers with expertise from multiple disciplines • Offer all available options for diagnosis and management, including complex valve repair, aortic surgery, and transcatheter therapies • Participate in regional or national outcome registries; • Demonstrate adherence to national guidelines • Participate in continued evaluation and quality improvement processes to enhance patient outcomes • Publicly report their available mortality and success rates Mitral Regurgitation 3 3 39 40 42 43 Secondary (Functional MR) • • • • Optimal medical tx first Biventricular pacing first if indicated MV surgery if going for cardiac surgery (eg CABG) Limited utility of surgery (IIB) 45 Optimal Timing of Intervention: Stage C • Current approaches to identifying the optimal timing of intervention in patients with progressive valve disease are suboptimal • Symptom onset is a subjective measure and may occur too late in the disease course for optimal long-term outcomes • Recommendations rely only on simple linear dimensions used in published series with data that may not reflect contemporary clinical outcomes • However, LV enlargement and dysfunction are late consequences of valve dysfunction Better Options for Intervention: Stage D • Moderate-to-severe VHD is present in 2.5% of the U.S population a • 4% and 9% of those 65 to 75 years of age • 12% to 13% of those >75 years of age • However, even with intervention, overall survival is lower than expected, and the risk of adverse outcomes due to VHD is high, both because of limited options for restoring normal valve function and failure to intervene at the optimal time point in the disease course Summary • • • • • • • • New staging system New valve criteria Symptoms Cardiac dysfunction Repair better than Replacement Heart valve surgery outcomes Percutaneous option for first time Heart teams and Heart valve centres of excellence [...]... 42 43 4 Secondary (Functional MR) • • • • Optimal medical tx first Biventricular pacing first if indicated MV surgery if going for cardiac surgery (eg CABG) Limited utility of surgery (IIB) 45 Optimal Timing of Intervention: Stage C • Current approaches to identifying the optimal timing of intervention in patients with progressive valve disease are suboptimal • Symptom onset is a subjective measure... of limited options for restoring normal valve function and failure to intervene at the optimal time point in the disease course 5 Summary • • • • • • • • 5 New staging system New valve criteria Symptoms Cardiac dysfunction Repair better than Replacement Heart valve surgery outcomes Percutaneous option for first time Heart teams and Heart valve centres of excellence ... approaches to identifying the optimal timing of intervention in patients with progressive valve disease are suboptimal • Symptom onset is a subjective measure and may occur too late in the disease course for optimal long-term outcomes • Recommendations rely only on simple linear dimensions used in published series with data that may not reflect contemporary clinical outcomes • However, LV enlargement and dysfunction