2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease

[AZ Don]

New guidelines are out: http://content.onlinejacc.org/article.aspx?articleid=1838843, but not final yet:

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
our customers we are providing this early version of the manuscript. The manuscript will undergo
copyediting, typesetting, and review of the resulting proof before it is published in its final form.

So far the only significant change that I have noticed is that the surgical intervention criteria for aortic aneurysm in those with a BAV has changed from from 5.0 to 5.5cm. I doubt that all Dr's agree with this but I think this document is now the new standard.

Operative intervention to repair the aortic sinuses or replace the ascending aorta is indicated in
patients with a bicuspid aortic valve if the diameter of the aortic sinuses or ascending aorta is
greater than 5.5 cm (113, 268, 269). (Level of Evidence: B)

Previous ACC/AHA guidelines have recommended surgery when the degree of aortic dilation is >5.0 cm at any level,
including sinuses of Valsalva, sinotubular junction, or ascending aorta. The current writing committee considers
the evidence supporting these previous recommendations very limited and anecdotal and endorses a more
individualized approach. Surgery is recommended with aortic dilation of 5.1 cm to 5.5 cm only if there is a
family history of aortic dissection or rapid progression of dilation. In all other patients, operation is indicated if
there is more severe dilation (5.5 cm). The writing committee also does not recommend the application of
formulas to adjust the aortic diameter for body size.

 

[ottagal]

New guidelines are out: http://content.onlinejacc.org/article.aspx?articleid=1838843, but not final yet:

So far the only significant change that I have noticed is that the surgical intervention criteria for aortic aneurysm in those with a BAV has changed from from 5.0 to 5.5cm. I doubt that all Dr's agree with this but I think this document is now the new standard.

Thanks AZ Don.
Very interesting re: changes in recommendations for surgery with ascending aortic aneurysm! In particular, I wonder why they changed the previous recommendation of indexing to body size? With this new information, it appears I won't be needing surgery for this aneurysm for a long time (hopefully and with fingers crossed!) even though I am very small framed.

I also found this information interesting from the 2014 ACC guidelines regarding drug therapy for aneurysm. Not sure what to make of that....

5.1.2. Medical Therapy
There are no proven drug therapies that have shown to reduce the rate of progression of aortic dilation in
patients with aortopathy associated with bicuspid aortic valve. In patients with hypertension, control of BP with
any effective antihypertensive medication is warranted. Beta blockers and ARBs have conceptual advantages to
reduce rate of progression but have not been shown to be beneficial in clinical studies.

 

[AZ Don]

Beta blockers and ARBs have conceptual advantages to reduce rate of progression but have not been shown to be beneficial in clinical studies.

Beta blockers are often prescribed with the intent to reduce risk of aneurysm but I have read that studies do not support this. ARBs, which I think includes Losartan show promise to reduce or slow the rate of aneurysm, but there is limited and possibly mixed data supporting this. More studies are needed and there are a couple being done now.

 

[DavesMom]

Thanks so much for the link! I also find it very interesting that they're not recommending indexing to body size. I'm only 4'10", weigh very little and have a 4.5cm aneurysm. It just makes sense to me that a 4.5 cm on someone my size would be more substantial than on someone 5'10"

However, would LOVE to avoid surgery as long as possible so this could be good news. : )

Again, this is very interesting and thanks for the link.

 

[AZ Don]

There are a couple formula's that do index the aortic aneurysm to body size. I would be surprised if the Dr's that developed those formula's stopped using them because of a decision by committee, even if it is the new guideline. Dr's don't always agree so I'm sure some will be more aggressive in recommending surgery, perhaps particularly in healthy individuals that have lower risks in surgery. I think I read that Cedars Sinai was using 4.5cm as the criteria for those with a BAV.

 

[ottagal]

There are a couple formula's that do index the aortic aneurysm to body size. I would be surprised if the Dr's that developed those formula's stopped using them because of a decision by committee, even if it is the new guideline. Dr's don't always agree so I'm sure some will be more aggressive in recommending surgery, perhaps particularly in healthy individuals that have lower risks in surgery. I think I read that Cedars Sinai was using 4.5cm as the criteria for those with a BAV.

I agree that these are only "guidelines"; hence, surgeons and cardiologists can deviate from them if their expert opinion deems it should be otherwise.

It still find it very interesting that the writing committee is not recommending ANY formulas to index to body size. I wish I had been a fly on the wall during the writing committee's deliberation on this one.

 

[tjay]

Well, everyone in medical community did seem to go along together for over a decade. This new guidance is based on data and new understanding in that period. If certain group of surgeons still want to go their way, which they probably once recommended based on certain assumptions (e.g. BAV=Marfan etc), they sure can.

We always ask clinical trials to back-up any big claims. When they dropped to 5mm criteria for BAV back then, was it based on actual BAV data, or certain assumptions? A decade later, can those assumptions be proven by those taking aggressive stance? Or did they base their previous guideline based on a few isolated cases here and there? Were those cases have any other indication e.g. familial genetics, predispositioned to dissections? Marfan?? There are stories in this very forum of folks who discovered their aneurysms in high 5s or even 6s. But then there are stories of unfortunate dissections at a much smaller no as well (<5). May be latter are far fewer than former (who knows), but we still don't know the reality because a large BAV population probably went thru elective procedures around 5mm during this decade.

When those details lacked, it made sense to lump together certain attributes together (e.g. BAV=Marfan), but perhaps they feel confident in raising the bar now. I don't think surgeons will like this new criteria very much, afterall they do surgeries for living. This new guideline may translate fewer surgeries or delayed surgeries. On the contrary, they sure had a lot of interest in setting up agressive schedule (of 5mm, or take Ceder Sinai's 4.5mm) not too long ago. The onus is also on them to back-up their claims to continue to push for 5mm or 4.5mm after more than a decade.

Time will tell. In the mean time, I wish all of us in the global BAV comminity a safe and fulfilling life.

 

[AZ Don]

But then there are stories of unfortunate dissections at a much smaller no as well (<5). May be latter are far fewer than former (who knows), but we still don't know the reality because a large BAV population probably went thru elective procedures around 5mm during this decade.

In fact observations from the International Registry of Acute Aortic Dissection (IRAD) have indicated that more dissections happen at < 5.5cm than above, and a large number occur at 5.0cm and lower. See figure 13 in the document linked below. Also, see figure 11 which shows the risk of rupture, dissection, and death is uncomfortably high despite aneurysm size at < 6.0cm, and extremely dangerous above. From what I know of the supporting studies behind the new guidelines, in my mind it is not enough to outweigh the risks I see in these figures, but maybe I'm missing something.

http://content.onlinejacc.org/article.aspx?articleid=1140497#bib15

 

[workmonkey]

I think the primary change in these new guidelines (though there are many) is that they are no longer treating BAV patients more aggressively than everyone else. For the past decade, they stated that patients with BAV had a higher rate of aortic aneurysms than the general public; this seems to remain true. What seems to have changed is the suspicion that patients with BAV have a higher rate of dissections or ruptures than the general public. BAV tissue may be more prone to dilate, but not dissect (unlike Marfan's patients, which are well-established to have a higher rate of dissection/rupture). Thus, the dissection risk with BAV (2 patients out of 416 in their trial dissected) isn't high enough to suggest surgery at a lower threshold than the population at large (which has always been 5.5 cm).

I faced this decision myself. When I learned about my 5.1 cm aortic aneurysm last November (with a highly functioning BAV), I visited two top surgeons in NYC. One told me to wait until it reached 5.5 cm. The other told me 5.0 cm was the trigger. So I had a choice. What's interesting is that these new guidelines don't take into account the psychic/emotional consequences of finding out you have an aneurysm. It isn't fear of dissection; it is the knowledge that the aneurysm will inevitably grow and inevitably you will have surgery. I could never shake this notion and wanted it to be gone; I started to view the aneurysm like a tumor. I wanted to be "full-strength" and shovel snow, move furniture, etc without fear that I was constantly at risk or that my time was coming.

In the end, these are guidelines. The paper advises an individual approach to each patient, and I couldn't agree more. Had I wanted to wait until 5.5 cm, I had an option ... Likewise, if I wanted to be more aggressive, I had that option as well. This surgery has become exceedingly safe, which is one reason I'd imagine they've been more aggressive this past decade, particularly with younger patients. However, it is good to know the doctors are constantly evaluating what's best for us and tweaking their advice. For those of us on this site, these new guidelines become food for thought; we know have more options than before and may not feel "forced" into the OR. Apparently, one size does not fit all - This seems to be a good development.

 

[DavesMom]

You hit the nail on the head as far as I'm concerned, workmonkey. Just the thought that the aneurysm is there makes me anxious and I really want it OUTTA there.

On the other hand, the thought of another operation makes me equally anxious. This would be my third OHS and, according to my cardio, very complicated. I know I've got lots of scar tissue (my right ventricle is stuck to my sternum) so I would NOT be as calm about number three as I was about numbers one and two.

So as my grandpa used to say, "it's six of one, half-dozen of another." : ) I have my yearly tests and cardio visit coming up in May and June so we'll see if there's been any change.

Hope everyone is well. Take care!

 

[skeptic49]

I think the primary change in these new guidelines (though there are many) is that they are no longer treating BAV patients more aggressively than everyone else. .

Agreed. BAVers are lumped in with everyone else when it comes to timing for surgical intervention, even though one would think that the rate of progression of AS may be faster in those with bicuspid valves. Are any studies on this?

 

[Lynlw]

You hit the nail on the head as far as I'm concerned, workmonkey. Just the thought that the aneurysm is there makes me anxious and I really want it OUTTA there.

On the other hand, the thought of another operation makes me equally anxious. This would be my third OHS and, according to my cardio, very complicated. I know I've got lots of scar tissue (my right ventricle is stuck to my sternum) so I would NOT be as calm about number three as I was about numbers one and two.

So as my grandpa used to say, "it's six of one, half-dozen of another." : ) I have my yearly tests and cardio visit coming up in May and June so we'll see if there's been any change.

Hope everyone is well. Take care!

I don't know if it helps you but we knew going into both Justin's 4th and 5th OHS that his heart was fused to his sternum, actually it was one of the main things I discussed w/ various surgeons when we were deciding who to "let" operate on Justin., Granted we talked to the top CHD surgeons, but not one refused to operate or said it was too risky, mainly we talked about what they would do to open him the safest,
I think the fact they know your heart is fused before hand is good as the make their plans. They WERE a little surprised before the 5th OHS how much scar tissue he build in a little under 2 years.
Anyone I ever heard of personally who ran into problems because their heart was fused to their chest happened in kids they didnt realize it was fused until they opened them.

Hopefully your anuerysm behaves and you dont need another surgery for a long time IF at all, but if you do need another surgery, I would ask the surgeon how many people they've operated on that were multiple REDOs (over 3 or 4) The ones with the most experience probably have hundreds if not thousands, and even then the heart fused to the sternum is pretty rare, so I would ask how many of them they did too.
PS the surgeons who have done multiple REDOs for the most part w/ be CHD surgeons who operate on children and adults, since many need 3 before they are in kindergarden

 

[DavesMom]

Hi Lyn,

Thanks for your insight. I don't think the surgeon was aware of the scar tissue before my second operation so I'm sure he opened me up and went "oopsie!" : ) At least next time they'll know and that's a good thing.

I think the location of the aneurysm is another reason a third OHS would be complicated so I'm definitely going to get the best and most experienced surgeon I can. IF it happens. As I mentioned in another post, it was 4.5cm last year so we'll see in a couple of months if it's changed.

Thanks again and my very best to you and Justin. What a brave young man and how lucky he is to have you.

Take care.