SURGICAL CONSIDERATIONS

MAJOR CRITERIA FOR AORTIC VALVE SELECTION
CLASS I
(1) A mechanical prosthesis is recommended for AVR in patients with a mechanical valve in the mitral or tricuspid position.

(2) A bioprosthesis is recommended for AVR in patients of any age who will not take warfarin or who have major medical contraindications to warfarin therapy.

CLASS IIa
(1) Patient preference is a reasonable consideration in the selection of aortic valve operation and valve prosthesis. A mechanical prosthesis is reasonable for AVR in patients under 65 years of age who do not have a contraindication to anticoagulation. A bioprosthesis is reasonable for AVR in patients under 65 years of age who elect to receive this valve for lifestyle considerations after detailed discussions of the risks of anticoagulation versus the likelihood that a second AVR may be necessary in the future.

(2) A bioprosthesis is reasonable for AVR in patients aged 65 years or older without risk factors for thromboembolism.

(3) Aortic valve re-replacement with a homograft is reasonable for patients with active prosthetic valve endocarditis.

CLASS IIb
(1) A bioprosthesis might be considered for AVR in a woman of child-bearing age.

MYXOMATOUS MITRAL VALVE
CLASS I
(1) MV repair is recommended when anatomically possible for patients with severe degenerative MR who fulfill clinical indications, and patients should be referred to surgeons who are expert in repair.

(2) Patients who have undergone successful MV repair should continue to receive antibiotics as indicated for endocarditis prophylaxis.

(3) Patients who have undergone successful MV repair and have chronic or paroxysmal atrial fibrillation should continue to receive long-term anticoagulation with warfarin.

(4) Patients who have undergone successful MV repair should undergo 2D and Doppler echocardiography before discharge or at the first postoperative outpatient visit.

(5) Tricuspid valve repair is beneficial for severe TR in patients with MV disease that requires MV surgery.

CLASS IIa
(1) Oral anticoagulation is reasonable for the first 3 months after MV repair.

(2) Long-term treatment with low-dose aspirin (75 to 100 mg per day) is reasonable in patients who have undergone successful MV repair and remain in sinus rhythm.

(3) Tricuspid annuloplasty is reasonable for mild TR in patients under- going MV repair when there is pulmonary hypertension or tricuspid annular dilatation.

CLASS IIb
(1) In patients with MR and a history of atrial fibrillation, a Maze procedure may be considered at the time of MV repair.

RHEUMATIC HEART DISEASE
CLASS I
(1) Percutaneous or surgical MV commissurotomy is indicated when anatomically possible for treatment of severe MS, when clinically indicated.

SELECTION OF A MITRAL VALVE PROSTHESIS
CLASS I
(1) A bioprosthesis is indicated for MV replacement in a patient who will not take warfarin, is incapable of taking warfarin, or has a clear contraindication to warfarin therapy.

CLASS IIa
(1) A mechanical prosthesis is reasonable for MV replacement in patients under 65 years of age with long-standing atrial fibrillation.

(2) A bioprosthesis is reasonable for MV replacement in patients 65 years of age or older.

(3) A bioprosthesis is reasonable for MV replacement in patients under 65 years of age in sinus rhythm who elect to receive this valve for lifestyle considerations after detailed discussions of the risks of anticoagulation versus the likelihood that a second MV replacement may be necessary in the future.

TRICUSPID VALVE SURGERY
CLASS I
(1) Severe TR in the setting of surgery for multi-valvular disease should be corrected.

CLASS IIa
(1) Tricuspid annuloplasty is reasonable for mild TR in patients under-going MV surgery when there is pulmonary hypertension or tricuspid annular dilatation.

INTRAOPERATIVE ASSESSMENT
CLASS I
(1) Intraoperative transesophageal echocardiography is recommended for valve repair surgery.

(2) Intraoperative transesophageal echocardiography is recommended for valve replacement surgery with a stentless xenograft, homograft, or autograft valve.

(3) Intraoperative transesophageal echocardiography is recommended for valve surgery for infective endocarditis.

CLASS IIa
(1) Intraoperative transesophageal echocardiography is reasonable for all patients undergoing cardiac valve surgery.



JACC Vol. 52, No. 13, 2008
September 23, 2008: e1-142