Bicuspid Aortic Valve Guidelines

Updated: Jan 15, 2019
  • Author: Duraisamy Balaguru, MBBS, MRCP, FACC, FAAP, FSCAI; Chief Editor: Syamasundar Rao Patnana, MD  more...
  • Print
Guidelines

Guidelines Summary

Guidelines for the management of bicuspid aortic valve (BAV) repair have been issued by the following organizations:

  • American Heart Association/American College of Cardiology (AHA/ACC)
  • European Society of Cardiology (ESC)
  • Society of Thoracic Surgeons (STS)

In 2015, the AHA/ACC released a guideline clarification statement addressing indications for early surgical intervention for associated enlargement or aneurysm of the ascending aorta in patients with bicuspid aortic valve. Repair or replacement of the aortic sinuses or replacement of the ascending aorta is indicated in the following [43] :

  • Symptomatic patients with diameter of the aortic sinuses or ascending aorta ≥5.5cm (class I)
  • Symptomatic patients if the diameter of the aortic root or ascending aorta is ≥5.0 cm and an additional risk factor for dissection is present, or if the patient is at low surgical risk and the surgery is performed by an experienced aortic surgical team in a center with established expertise in these procedures (class IIa)
  • Patients undergoing aortic valve surgery for severe aortic stenosis or aortic regurgitation with diameter of the ascending aorta >4.5cm (class IIa)

The 2014 ESC guidelines on the diagnosis and treatment of aortic diseases provide a class I recommendation to all three AHA/ACC recommendations, and include the following additional guidance: [44]

  • Serial measurement of the aortic root and ascending aorta in every patient with BAV, with an interval determined by aortic size, increase in size and family history (class I)
  • Annual measurement of aortic diameter in patients with a diameter of the aortic root or the ascending aorta >4.5 cm or an increase >3.0cm/year measured by echocardiography (class I)
  • In patients with aortic diameter >5.0 cm or an increase >3.0 cm/year measured by echocardiography, confirm measurement with CT or MR (class I)
  • Consider beta-blockers in patients with BAV and dilated aortic root >40 mm (class IIb)
  • Screening of first-degree relatives should be considered (class IIa)

The 2013 Society of Thoracic Surgeons (STS) guidelines for the management of aortic valve disease concur with the AHA/ACC recommendations while also providing the following additional class I recommendations [45] :

  • Prophylactic antibiotics for both gram-negative and gram-positive coverage for the operative procedure.

  • Intraoperative transesophageal echocardiogram (TEE)

  • Postoperative beta-blockers

  • ACE inhibitor therapy should be considered in patients with low ejection fraction postoperatively

  • Patients should be given prophylactic antibiotics at any time that an invasive procedure is done, including dental procedures

Infective Endocarditis

Both the AHA/ACC and ESC released updated guidelines for the management of infective endocarditis (IE) in 2015. Major recommendations for the management of IE are summarized below. [46, 47] :

Class I

The Modified Duke Criteria should be used in evaluating a patient with suspected IE (level of evidence: B)

At least 3 sets of blood cultures from different venipuncture sites should be obtained, with the first and last samples drawn at least 1 hour apart (level of evidence: A)

Transthoracic echocardiogram (TTE) should be performed in all cases of suspected IE (level of evidence: B)

TEE should be done if initial TTE images are negative or inadequate in patients for whom there is an ongoing suspicion for IE or when there is concern for intracardiac complications in patients with an initial positive TTE (level of evidence: B)

If there is a high suspicion of IE despite an initial negative TEE, then a repeat TEE in 3 to 5 days or sooner if clinical findings change (level of evidence: B)

Repeat TEE should be done after an initially positive TEE if clinical features suggest a new development of intracardiac complications (level of evidence: B)

Patients with IE should first be evaluated and stabilized in the hospital before being considered for outpatient therapy (level of evidence: C)

Appropriate antibiotic therapy should be initiated and continued after blood cultures are obtained with guidance from antibiotic sensitivity data and infectious disease consultants (level of Evidence: B)

Patients selected for outpatient parenteral antibiotic therapy (OPAT) should be at low risk for the complications of IE, the most frequent of which are heart failure and systemic emboli (level of evidence: C)

Surgery should be performed before completion of a full therapeutic course of antibiotics in patients with the following:

  • IE and valve dysfunction resulting in symptoms of HF (level of evidence: B)
  • IE caused by fungi or highly resistant organisms (eg, vancomycin-resistant Enterococcus, multidrug-resistant Gram-negative bacilli) (level of evidence: B)
  • IE complicated by heart block, annular or aortic abscess, or destructive penetrating lesions (level of evidence: B)
  • Persistent bacteremia or fevers lasting longer than 5 to 7 days after onset of appropriate antimicrobial therapy (level of evidence: B)

Valve repair rather than replacement should be performed when feasible (level of evidence: C)

Months to years after completion of medical therapy for IE, patients should have ongoing observation for and education about recurrent infection and delayed onset of worsening valve dysfunction (level of evidence: C)

Class III

Patients should not receive antibiotics before blood cultures are obtained for unexplained fever (level of evidence: C)

Antimicrobial therapy should not be initiated for the treatment of undefined febrile illnesses unless the patient’s condition (eg, sepsis) warrants it (level of evidence: C)

Prophylaxis against infective endocarditis (IE)

The 2014 AHA/ACC guidelines for management of valvular diseases recommend (class IIa) prophylaxis against infective endocarditis (IE) before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa for patients at highest risk for adverse outcomes from IE including the following [48] :

  • Patients with prosthetic cardiac valves
  • Patients with previous IE
  • Patients with congenital heart disease with completely repaired congenital heart defect repaired with prosthetic material or device, whether placed by surgery or catheter intervention, during the first 6 months after the procedure

The indication for antibiotic prophylaxis for endocarditis has also been significantly reduced in the 2012 European Society of Cardiology/European Association for Cardio-Thoracic Surgery (ESC/EACTS) guidelines for the management of valvular diseases, although they recommend considering antibiotic prophylaxis for high-risk procedures in high-risk patients. [44]