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Ann Thorac Surg 1995;59:1264-1271
© 1995 The Society of Thoracic Surgeons

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Report

Practice Guidelines in Cardiothoracic Surgery

Ad Hoc Committee for Cardiothoracic, Surgical Practice Guidelines

	Introduction

Top Introduction Footnotes References:

 
Since 1989 the Ad Hoc Committee for Cardiothoracic Surgical Practice Guidelines has been developing and publishing cardiothoracic surgical practice guidelines. This committee includes representatives from The American Association for Thoracic Surgery, The Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, and the Western Thoracic Surgical Association. It was decided that these guidelines would be procedure-oriented according to organ system diseases. The details of the method of construction of the guidelines have been published previously and are described in the introduction to the first three sets of guidelines. Nine sets of practice guidelines have been published: Chest Wall, Diaphragm, Mediastinum, Pericardium (Ann Thorac Surg 1992;53:729–37), Ischemic Heart Disease (Ann Thorac Surg 1992;53:930–9), Esophageal Disease (Ann Thorac Surg 1992;53:1138–46), Bronchopulmonary Disease (Ann Thorac Surg 1993;56:1203–13), Congenital Heart Disease (Ann Thorac Surg 1993;56:1434–7), Video-Assisted Thoracic Surgery (Ann Thorac Surg 1994;58:596–602), Transplantation (Heart, Lung, Heart-Lung) and Heart Assist Devices (Ann Thorac Surg 1994;58:903–10), and Thoracic Aortic Disease (Ann Thorac Surg 1994;58:1207–11).

Following are practice guidelines concerning Valvular Heart Disease. Practice guidelines for Cardiac Electrical Problems will be published in the June issue of The Annals of Thoracic Surgery. Publication of the practice guidelines for Cardiac Electrical Problems will conclude the first complete cycle of guidelines as planned. To have these references readily available in one place, they will be collated and republished as a supplement to The Annals.

These practice guidelines have been approved by The American Association for Thoracic Surgery, The Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, and the Western Thoracic Surgical Association.

These practice guidelines have been generated through the extensive effort of the members of the Ad Hoc Committee and its subcommittees. They deserve the gratitude of the cardiothoracic surgical community for their commitment to this project. I personally am grateful to all of them for their continued diligence and cooperation.

Practice Guidelines

Valvular Heart Disease: I (Aortic Valve)

Diagnosis:

395.0 Rheumatic aortic stenosis

395.1 Rheumatic aortic insufficiency, incompetence, or regurgitation

395.2 Rheumatic aortic stenosis with insufficiency

424.1 Aortic valvular incompetence, insufficiency, regurgitation, or stenosis (nonrheumatic)

396.0 Aortic valve stenosis and mitral valve stenosis

396.1 Aortic valve insufficiency and mitral valve stenosis

396.2 Aortic valve stenosis and mitral valve insufficiency

396.3 Aortic valve insufficiency and mitral valve insufficiency

969.02 Aortic prosthesis malfunction

Procedure:

33400 Valvuloplasty, aortic valve

33405 Replacement, aortic valve with prosthetic valve other than homograft

33406 with homograft

33411 Replacement, aortic valve with aortic annulus enlargement

33412 Replacement, aortic valve (Konno procedure)

33413 Replacement, aortic valve (Ross procedure)

Indication:

1) Aortic stenosis or regurgitation with symptoms (syncope, angina, or congestive heart failure)

2) Aortic stenosis with a significant pressure gradient (>40 mm Hg) with normal cardiac output or a lower gradient with low cardiac output

3) Aortic stenosis with aortic valve area <1.0 cm²

4) Aortic stenosis with progression of left ventricular hypertrophy by electrocardiography

5) Aortic stenosis or regurgitation with progressive deterioration of left ventricular function

6) Aortic regurgitation or stenosis with progressive enlargement of left ventricle

7) Aortic prosthesis dysfunction due to clot, tissue ingrowth, or prosthesis deterioration leading to stenosis or insufficiency

8) Aortic valvular or prosthesis infection not cleared by appropriate antibiotic therapy and/or causing significant aortic stenosis or regurgitation

9) Recurrent systemic emboli from an aortic prosthesis despite adequate anticoagulation therapy

10) Recurrent mycotic embolization despite adequate antibiotic therapy

11) Recurrent embolic episodes from a calcified aortic valve

Confirmation of Indication:

1) Cardiac catheterization demonstrating valve area <1 cm² and/or a valve gradient of 40 to 50 mm Hg with relatively normal cardiac output or lower with reduced cardiac output

2) Aortic root aortography or echocardiogram showing valvular insufficiency 3+ (of 1 to 4+) or greater

3) Serial noninvasive studies showing progressive deterioration in left ventricular function and/or increase in left ventricular size or wall thickness

4) In males <40 years, females <50 years, echo demonstration of 40 to 50 mm Hg gradient or severe aortic regurgitation

Contraindications:

1) Inability to benefit from the procedure due to other chronic illness or malignant disease

Actions Prior to Procedure:

1) Treatment of congestive heart failure

2) Treatment of pulmonary, renal, or hepatic dysfunction

3) Treatment of cardiac dysrhythmias

4) Restoration of normal coagulation function, possibly requiring hospitalization for heparinization while anticoagulation with oral agents is discontinued

5) Treatment of infection (subacute bacterial endocarditis), if possible

6) Coronary arteriography in all male patients over age 40 years, all female patients over age 50 years, or any patient with electrocardiographic or historical evidence suggesting ischemic heart disease

Actions During Procedure:

1) Transesophageal echocardiography may confirm appropriate function of the prosthesis or repaired valve if necessary

2) Arrhythmia monitoring

3) Meticulous myocardial preservation

4) Meticulous efforts to avoid embolization of calcific or other debris

5) Pulmonary artery catheter to monitor cardiac output and left ventricular function after coronary bypass

Actions Following Procedure:

1) Monitor blood loss and ongoing evaluation of clotting function

2) Monitor cardiac activity and peripheral perfusion

3) Arrhythmia monitoring and assessment of drug treatment

4) Ventilatory support assessment on an ongoing basis including the effect on cardiac output and perfusion

5) Ongoing assessment of renal function

6) Assessment of central nervous system function in relationship to anesthetic agents, analgesic agents, and perfusion

Outcome:^*

1) Operative mortality <4%, 7% to 10% if a patient >74 years of age

2) Absence of complications

3) Discharge <10 days

Practice Guidelines:

Valvular Heart Disease: II (Mitral Valve)

Diagnosis:

394.0 Rheumatic mitral obstruction or stenosis

394.1 Rheumatic mitral insufficiency, incompetence, or regurgitation

394.2 Mitral valve stenosis with incompetence or regurgitation

424.0 Mitral valve incompetence, insufficiency or regurgitation (nonrheumatic)

396.0 Mitral valve stenosis and aortic valve stenosis

396.1 Mitral valve stenosis and aortic valve insufficiency

396.2 Mitral valve insufficiency and aortic valve stenosis

396.3 Mitral valve insufficiency and aortic valve insufficiency

996.02 Mitral prosthesis malfunction

Procedure:

33425 Mitral valve repair

33426 with prosthetic ring

33427 radical reconstruction, with or without ring

33430 Replacement, mitral valve

Indication:

1) Mitral stenosis or regurgitation with symptoms due to valvular heart disease (New York Heart Association functional class III or IV)

2) Mitral stenosis or regurgitation with moderate symptoms (New York Heart Association functional class II) with new onset atrial fibrillation that cannot be converted to sinus rhythm with medical therapy and/or decreasing cardiac function manifested by enlarging heart size or decreasing left ventricular ejection fraction by serial noninvasive studies

3) Mitral stenosis with a valve area index of 1.5 cm²/m² body surface area

4) Recurrent systemic emboli from the native mitral valve or left atrium despite adequate anticoagulation therapy

5) Mitral prosthetic dysfunction due to clot, tissue ingrowth, or prosthetic deterioration leading to significant mitral stenosis or regurgitation

6) Mitral valvular or prosthetic infection not resolved with appropriate antibiotic regimen or causing mycotic emboli despite appropriate antibiotic therapy

7) Alternative to septal myotomy in patient with idiopathic hypertrophic subaortic stenosis

8) Mitral regurgitation secondary to myocardial infarction with papillary muscle dysfunction or rupture and unremitting congestive heart failure

Confirmation of Indication:

Valve index <1.5 cm²/m² or significant regurgitation by cardiac catheterization or echocardiography

Contraindications:

1) Left ventricular ejection fraction <0.2

2) Inability to benefit from the procedure due to other chronic illness or malignant disease

Actions Prior to Procedure:

1) Treatment of congestive heart failure

2) Treatment of other organ system dysfunction (renal, pulmonary, hepatic)

3) Treatment of cardiac dysrhythmias

4) Restoration of normal coagulation function, possibly requiring hospitalization for heparinization while oral agent anticoagulation is discontinued

5) Control infection if possible (subacute bacterial endocarditis)

6) Coronary angiography should be performed in all male patients over age 40 years, all females over age 50 years, and any patient with clinical or electrocardiographic evidence of ischemic heart disease

Actions During Procedure:

1) Transesophageal echocardiography may confirm appropriate function of the prosthesis or repaired valve if necessary

2) Monitor left atrial pressure and pressure trace curve to confirm absence of V wave and for assistance with separation from cardiopulmonary bypass in patients with pulmonary hypertension, obstructive lung disease, or when serious ventricular dysfunction is present

Actions Following Procedure:

1) Monitor blood loss and ongoing evaluation of clotting function

2) Monitor cardiac activity and peripheral perfusion

3) Arrhythmia monitoring and assessment of drug treatment

4) Ventilatory support respiratory function assessment on an ongoing basis

5) Ongoing assessment of renal function

6) Assessment of central nervous system function in relationship to anesthetic agents, analgesic agents, and perfusion

7) Treatment with antibiotics in accordance with previous bacteriologic studies if done for subacute bacterial endocarditis on protocol for elective open heart surgery

Outcome: ^*

1) Operative mortality <10%

2) Absence of complications

3) Discharge <10 days

Practice Guidelines:

Valvular Heart Disease: III (Tricuspid Valve)

Diagnosis:

397.0 Insufficiency, obstruction, regurgitation, or stenosis of tricuspid valve (rheumatic)

424.4 Incompetence, insufficiency, regurgitation, or stenosis of tricuspid valve (nonrheumatic)

Procedure:

33460 Valvectomy, tricuspid valve

33463 Valvuloplasty, tricuspid valve; without ring insertion

33464 with ring insertion

33465 Replacement, tricuspid valve

33468 Tricuspid valve repositioning and plication for Ebstein anomaly

Indication:

1) Tricuspid stenosis or regurgitation with significant symptoms due to the valve disease (New York Heart Association class III or IV)

2) Marked regurgitation of the tricuspid valve by preoperative or intraoperative echocardiography

3) Repeated positive blood cultures with echocardiographic evidence or vegetative growth on the valve combined with either right-sided congestive heart failure or failure of appropriate antibiotic regimen to clear the infection

4) Moderate tricuspid valve regurgitation due to left-sided valve lesions treated when doing mitral or aortic valve surgery

Confirmation of Indication:

1) Cardiac catheterization to confirm tricuspid stenosis with a gradient >4 mm Hg

2) Cardiac catheterization with right atrial V wave in excess of right atrial A wave

3) Echocardiography to confirm tricuspid regurgitation

Contraindications:

1) Tricuspid regurgitation of recent onset in a patient in whom left-sided valve repair is likely to lead to a significant decrease in pulmonary artery pressure and subsequent improvement or elimination of tricuspid regurgitation

2) Inability to benefit from the procedure due to other chronic illness or malignant disease

Actions Prior to Procedure:

1) Treatment of congestive heart failure

2) Cardiac catheterization to evaluate the function of other valves, possible pulmonary hypertension, and possible coronary artery disease

3) Coronary angiography should be performed in all male patients over age 40 years, all females over age 50 years, and any patients with clinical or electrocardiographic evidence of ischemic heart disease

4) Treatment of cardiac dysrhythmias

5) Restoration of normal coagulation function possibly requiring hospitalization for heparinization while anticoagulation with oral agents is discontinued

6) Treatment of infection (subacute bacterial endocarditis)

7) Treatment to improve nutritional status

8) Evaluation of liver function

Actions During Procedure:

1)Transesophageal echocardiography may confirm appropriate function of the prosthesis or repaired valve if necessary

Actions Following Procedure:

1) Monitor blood loss and ongoing evaluation of clotting function

2) Monitor cardiac activity and peripheral perfusion

3) Arrhythmia monitoring and assessment of drug treatment

4) Ventilatory support assessment on an ongoing basis including the effect on cardiac output and perfusion

5) Ongoing assessment of renal function

6) Assessment of central nervous system function in relationship to anesthetic agents, analgesic agents, and perfusion

7) Treatment with antibiotics in accordance with previous bacteriologic studies for subacute bacterial endocarditis

Outcome: ^*

1) Mortality 10%

2) Absence of complications

3) Hospital discharge <15 days

	Footnotes

Top Introduction Footnotes References:

 
^* Not derived from formal outcomes analyses with risk stratification.

^* Not derived from formal outcomes analyses risk stratification.

	References:

Top Introduction Footnotes References:

 

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This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): George C. Kaiser Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Kaiser, G. C. Search for Related Content PubMed PubMed Citation Articles by Kaiser, G. C.