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of the risk of thromboembolism (assuming sinus rhythm) but its survival may be shorter than that of the
porcine valve, particularly in younger individuals. In the certification of subjects of professional aircrew
age, it is likely that a mechanical valve will be recommended on the grounds of its long-term performance
and this will disbar from certification to fly. Mitral valve repair due to prolapse of either or both cusps has
a survival of 88 per cent at eight years in one review with a 93 per cent freedom from thromboembolic
events at six years. The majority maintained NYHA class I status as well as sinus rhythm.
Certification may be considered in the best-risk subjects who have undergone aortic valve replacement
with a bioprosthesis / mitral valve repair at least six months previously and who:
• are free of symptoms
• are in sinus rhythm and do not require treatment with warfarin
• have no significant left ventricular hypertrophy on echocardiography (> 1.3 cm, septum and free
wall) or dilation (> 6. 0 cm end diastole / 4.1 cm end systole), nor dilation of the aortic root
(> 4.5 cm)
• have no abnormality of wall motion on echocardiography (except that due to left bundle branch
block)
• have no significant (un-grafted) coronary artery disease
• have no significant rhythm disturbance on Holter monitoring
• are restricted to fly on multi-crew operations only
• undergo annual cardiological review.
In the case of aortic valve replacement, only a cadaver homograft or possibly a Carpentier-Edwards or
similar xenograft may be considered for certification. Following mitral valve repair, only subjects who are
in sinus rhythm may be considered for certification. Amputation of the left atrial appendage may be an
advantage. Mitral valve replacement is disbarring. Any history of thrombo-embolism will be
disqualifying. Precautions are needed for the antibiotic cover of dental and urinary tract procedures.
PERICARDITIS, MYOCARDITIS AND ENDOCARDITIS
II Mild symptoms and slight limitation during ordinary activity.
Comfortable at rest.
III Marked limitation in activity due to symptoms, even during less-than-ordinary
activity.
Comfortable only at rest.
IV Severe limitations. Experiences symptoms even while at rest.
ICAO Preliminary Unedited Version — October 2008 III-1-34
Pericarditis involves inflammation of the fibrous sac in which the heart lies; it has a number of
pathological causes. Acute benign aseptic pericarditis is the condition most likely to be encountered in
aircrew. It is also the condition most likely to be associated with full recovery and eventual unrestricted
certification to fly. Identifiable causes of pericarditis include the following:
• idiopathic (acute benign aseptic)
• viral: Coxsackie B, echovirus 8, Epstein-Barr virus, varicella, mumps
• bacterial: Staphylococcus, Pneumococcus, Meningococcus, Gonococcus
• mycobacterial: tuberculosis
• filamentous bacterial: actinomycoses, nocardia
• fungal: candidiasis, Histoplasma
• protozoal: Toxoplasma, Entamoeba
• immunological: Dressler1, rheumatoid arthritis, systemic lupus erythematosus, scleroderma,
polyarteritis
• neoplastic
• traumatic
• metabolic
• post-irradiation.
Acute benign aseptic pericarditis
Acute benign aseptic pericarditis is a self-limiting illness. It is often associated with a systemic
disturbance resembling influenza, a friction rub, and characteristic midsternal discomfort which may be
worsened by inspiration. It is commonly relieved by bending forward. It is sometimes misdiagnosed as a
coronary syndrome. Spontaneous recovery is to be expected, with supportive treatment such as aspirin.
The identification of a viral infective agent may or may not be possible. The characteristic ECG changes
seen are widespread concave ST segment elevation, with later diffuse ST-T changes which may be
persistent and raise the possibility of myocardial involvement — so-called myopericarditis. The QRS
voltages may be reduced if signification pericardial fluid has accumulated. This justifies subsequent
monitoring until there is confidence that myocardial function remains unimpaired.
Three to six months should elapse before restricted certification is permitted which is contingent upon the
subject being asymptomatic with a normal echocardiogram, 24-hour ambulatory ECG and exercise ECG.
Follow-up for at least two years is required. Coronary angiography or stress thallium MPI may be
needed to resolve doubt surrounding non-invasive investigations. Relapse following idiopathic
pericarditis is not uncommon, particularly in the first year. The pain of such an episode may be
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Manual of Civil Aviation Medicine 1(94)
