TP 13312

•	Foreword
•	Section 1
•	Section 2
•	Neurology
•	Cardiovascular
•	Diabetes
•	Asthma
•	Other Policies
•	Contacts
•	Alternate Formats

Chapter 2: Non-Ischemic Heat Disease

• Valvular Heart Disease
• Aortic Stenosis
• Aortic Regurgitation
• Follow-up Aortic Valve Disease
• Mitral Stenosis
• Mitral Regurgitation
• Mitral Valve Prolapse
• Follow-up for Mitral Valve Disease
• Surgical Repair or Replacement of Valves
• Congenital Heart Disease
• Atrial Septal Defect
• Coarctation of the Aorta
• Pulmonary Stenosis
• Ventricular Septal Defect
• Tetralogy of Fallot
• Transposition of Great Arteries
• Inflammatory Heart Disease
• Cardiomyopathy
• Cardiac Transplantation

Valvular Heart Disease

The significance of valvular heart disease depends primarily on the hemodynamic consequences, functional status and in some cases, the etiology. In the majority of cases, surgical correction will not reduce the risk of sudden incapacitation to acceptable levels; in some cases it may even increase the risk. 

Aortic Stenosis

Moderate or severe stenosis is unacceptable for unrestricted flying. Applicants with mild stenosis of the aortic valve can be considered for licensure if the following conditions are met: 

• The velocity flow across the valve is not less than 3 m/sec. 
• The cross-sectional valve area is not less than 1.2 cm2, taking into account body size.
• There are no related symptoms. 
• Holter monitoring reveals no significant dysrhythmia such as atrial fibrillation or sustained ventricular tachycardia. 
• A satisfactory treadmill exercise test, achieving at least 8.5 METS (end of Stage 3) using the Bruce protocol indicates no ischemia, hypotensive blood pressure response, significant arrhythmia or disabling symptoms. 

Aortic Regurgitation

Pure isolated regurgitation is uncommon; therefore, assessment of applicants with aortic regurgitation will likely include consideration of any associated disorders. Only mild, asymptomatic aortic regurgitation can be considered and only if the following criteria are met:

• The pulse pressure is less than 70 mmHg and the diastolic pressure is greater than 65 mmHg.
• The end-diastolic internal diameter of the left ventricle is less than 57 mm taking into account body size, as measured by two-dimensional echocardiography.
• A satisfactory treadmill exercise test, achieving at least 8.5 METS using the Bruce protocol indicates no ischemia, significant arrhythmia or disabling symptoms. 

Follow-up for Aortic Valve Disease

Because of the increased risk of endocarditis with aortic valve disease, prophylaxis with antibiotics must be strictly followed. Follow-up should include a yearly assessment with at least 2-D and full doppler echocardiography to monitor any progression. 

Mitral Stenosis

In view of its progressive nature and its propensity for thromboembolic complications, mitral stenosis will disqualify most applicants. Only very mild mitral stenosis with a cross sectional mitral valve area > 2.0 cm2 and stable normal sinus rhythm may be considered.

Mitral Regurgitation

The cause of mitral regurgitation can alter the prognosis; therefore, an assessment of this condition should include information about the likely underlying cause, in addition to an estimate of the severity of the lesion. Mild and asymptomatic mitral regurgitation may be acceptable in applicants if the following conditions are met:

• Mitral stenosis is absent.
• The diameter of the left atrium is less than 4.5 cm.
• Atrial dysrhythmia such as fibrillation or other supraventricular tachycardia is absent, as determined by Holter monitoring. 
• There is no history of embolism. 
• Significant coronary artery disease is absent according to the results of a submaximal treadmill exercise test. 

Mitral Valve Prolapse

Mitral valve prolapse has a wide spectrum of severity. Most cases are mild and detectable either by the presence of a midsystolic click and/or a soft murmur. The diagnosis is established by echocardiography. Medical certification may be considered if the following conditions are met: 

• There is no history of embolism or transient cerebral ischemia.
• There is no relevant family history of sudden death.
• Left ventricular size does not exceed 60 mm. 

If the left atrial size is increased or if there is redundancy of the mitral valve leaflets, then a treadmill exercise test and 24 hour Holter-monitoring will be required as these findings can be markers of increased risk.

Follow-up for Mitral Valve Disease 

Annual follow-up for mitral valve stenosis and/or r e g u rgitation should include, in addition to a thorough history and physical examination, 2D and doppler echocardiography and 24 hour Holtermonitoring. The follow-up for mitral valve prolapse will be determined on a case-by-case basis depending on the degree of prolapse and any associated findings.

Surgical repair or replacement of valves 

Following surgical reconstruction (valvuloplasty) of the mitral valve, a licence holder may be considered fit to fly if an assessment after 3 months including an echocardiogram indicates no clinical or significant residual hemodynamic abnormalities.

In view of the risk of thromboembolism, associated cardiac dysfunction, valve failure and bleeding secondary to anticoagulation, prosthetic valvular replacement will disqualify most applicants. Such a level of risk will preclude individuals with a bioprosthetic mitral valve from flying. Where the cumulative risk of incapacitation due to these factors
can be shown to be less than 2% per year in those with a mechanical prosthesis and thus comparable to the acceptable level of risk with other conditions, an applicant may be considered fit. 

Relatively recent surgical procedures including the Ross procedure and homograft valve replacements will be considered on a case by case basis. The former requires a waiting period of at least 12 months to rule out pulmonary stenosis as a complication. 

Congenital Heart Disease

Atrial septal defect

Applicants with a patent foramen ovale or a small sinus venosus or secundum defect (pulmonary/ systemic flow ratio less than 2:1 and normal right heart pressures) as determined by doppler echocardiography or cardiac catheterization and without recurrent atrial arrhythmias need not be restricted from flying. Applicants with partial atrioventricular canal defects (primum type atrial septal defects) cannot have more than mild mitral regurgitation, and they must meet the same
requirements for flow ratios and atrial arrhythmias. 

Those who have undergone a transcutaneous correction or a surgical correction of a larger defect may be medically certified if 3 months after the procedure they meet the same requirements, provided there has not been a significant event associated with their defect. A post-operative follow up echocardiographic evaluation is required to determine the extent of any residual leakage and shunting.

Coarctation of the Aorta

Licence holders with surgically corrected coarctation of the aorta should be considered individually. The age at the time of the surgical correction will be a major determinant in the decision about medical certification of a licence holder since the risk of sudden death and incapacitation due to cerebrovascular accidents is markedly increased in people who undergo surgery after the age of 12 years. In all cases the blood pressure at rest and in response to exercise must be normal. 

Pulmonary Stenosis

The major determinant of risk in applicants with this condition is the severity of the stenosis. Those with mild pulmonary stenosis and normal cardiac output will be considered for licensure provided the following criteria are met:

• The peak systolic pressure gradient across the pulmonary valve is less than 50 mmHg, and the peak systolic right ventricular pressure is less than 75 mmHg, as determined by echocardiography or cardiac catheterization.
• Symptoms are absent.
• The result of a submaximal treadmill exercise test is normal.

Applicants with pulmonic stenosis corrected by surgery or balloon valvuloplasty will be considered fit if there is no dysrhythmia and if the hemodynamic parameters are not worse than those described above. 

Ventricular Septal Defect

An applicant’s eligibility for medical certification will depend on the size of the ventricular septal defect as indicated by the hemodynamic consequences. In the absence of surgical correction an applicant may be considered for licensure if the following conditions are met:

• The heart size is normal.
• The pulmonary/systemic flow ratio is less than 2:1, as determined by echocardiography or cardiac catheterization.
• The pressures in the right heart are normal. 

An applicant with a surgically corrected ventricular septal defect may be considered for medical certification if the same conditions are met as for no surgical intervention, and in addition:

• No dysrhythmias or high-grade conduction disturbances are detected by Holter monitoring.
• The response to a submaximal treadmill exercise test is normal.

Tetralogy of Fallot

The unoperated condition with cyanosis is incompatible with medical certification. Individuals who undergo repair of Tetralogy of Fallot may be considered for medical certification if the following conditions are met:

• Normal arterial oxygen saturation. 
• Normal heart size. 
• Right ventricular systolic pressure less than 75 mmHg and peak RV/PA gradient less than 50 mmHg.
• Residual interventricular shunt not more than 1.5:1.
• No dysrhythmias or high-grade conduction disturbances by Holter monitoring. 
• Normal performance on a treadmill exercise test. 

Transposition of Great Arteries

The unoperated condition is incompatible with medical certification with the sole exception of congenitally corrected transposition without any other associated cardiac abnormalities.

Applicants with atrial switch corrective procedures for transposition of the great arteries are unlikely to be eligible for medical certification because of the increasing propensity to atrial arrhythmias with passing years, even with technically excellent surgery. Applicants who have had arterial switch operations will need to be considered separately when this cohort begins to reach adulthood.

Inflammatory Heart Disease

Active pericarditis and/or myocarditis is medically disqualifying. Medical certification may be considered after satisfactory recovery with no adverse sequelae.

Cardiomyopathy

Obstructive hypertrophic cardiomyopathy poses a significant risk for sudden incapacitation and generally disqualifies an applicant from flying regardless of whether there has been surgical treatment. Applicants with minor asymmetric hypertrophy will be considered individually based on the degree of outflow obstruction and the nature of any arrhythmias.

Nonhypertrophic cardiomyopathies dilated or congestive, in their active phase disqualify an applicant from flying. Symptomatic congestive heart failure even with normal quantification of left ventricular function is incompatible with safe
piloting. Cardiac catheterization is usually required to rule out ischemia as the etiology of the cardiomyopathy. Recertification may be considered after recovery if the following conditions are met:

• Symptoms are absent. 
• A satisfactory exercise tolerance test achieving 8.5 METS (end of Stage 3) using the Bruce protocol indicates no ischemia, significant arrhythmia or disabling symptoms.
• Left ventricular function as determined by echocardiography is satisfactory, i.e. EF > 50%. An ejection fraction between 40% and 50% may be acceptable for restricted flying provided 24 hour Holter monitoring reveals no more than 3 ventricular ectopic beats per hour in the absence of antiarrhythmic medication, with no more than 3 consecutive beats and a cycle length of not less than 500 msec. Nonsustained ventricular tachycardia in someone with an ischemic
  cardiomyopathy is not acceptable.
• The risk of thromboembolism and (if applicable) the risk of hemorrhage secondary to anticoagulation is acceptable.

Cardiac Transplantation 

Due to the cumulative high rate of morbidity including vascular complications and the increasing mortality rate over time, cardiac transplantation disqualifies an applicant from medical certification.