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aircrew age; coexisting pathology or congenital abnormality are likely to disbar from flying duty. Antitachycardia
devices and implantable defibrillators are disbarring.
The subject should:
• have no other disqualifying condition, including unsuppressed atrial or ventricular rhythm
disturbance
• have bipolar lead systems
• have a normal echocardiogram, Holter recording and satisfactory exercise ECG
• not be pacemaker-dependent (however defined)
• be restricted to Class 1 OML/Class 2
• undergo regular cardiological/pacemaker review.
1 After Anton Jervell and Frederik Lange-Nielsen, Norwegian cardiologists (20th century).
2 Bazett’s formula: formula for calculating the heartrate-corrected QT interval QTc. QTc = QT : /R-R, measured in
seconds. After Henry Cuthbert Bazett, English-American physiologist (1885-1950).
ICAO Preliminary Unedited Version — October 2008 III-1-31
HEART MURMURS AND VALVAR HEART DISEASE
Heart murmurs are very common, particularly in the young and the slim. Most are innocent flow
murmurs, which, by definition, will be brief and early systolic. Although a harsher murmur is more likely
to be of significance, it may still be unimportant and reflect turbulence in the left and/or right ventricular
outflow tracts. In older people, this may reflect thickening (sclerosis) of the aortic valve. Pan-systolic, late
systolic or continuous murmurs are always abnormal.
When any murmur is found at the initial examination for the issuance of a Medical Assessment, a
cardiological opinion should be sought. Usually a single consultation, with or without echocardiography,
will be sufficient to identify the few people in whom further review is justified. The remainder can be
reassured. A previously unidentified murmur discovered in later years should also be reviewed.
Aortic valve disease
Bicuspid aortic valve
Bicuspid aortic valve is one of the most common congenital cardiac malformations and affects at least
one per cent of the population. A significant percentage of subjects with such an anomaly will progress in
later years to aortic stenosis and/or regurgitation. For this reason at least biennial (every two years) review
is required. It may be associated with aortic root disease which, when present, needs to be followed
closely and eventually will disbar on account of risk of dissection and/or rupture. Finally it may also be
associated with patent ductus arteriosus or coarctation of the aorta. Any increase in the aortic root
diameter needs ongoing echocardiographic follow-up; if this exceeds 5.0 cm, certification is no longer
possible. There is a small but finite risk of endocarditis, which underscores the need for antibiotic cover
for dental and urinary tract manipulation, although the need for this has recently been challenged.
As an isolated finding, following cardiological review, bicuspid aortic valve may be consistent with
unrestricted certification to fly. Many aircrew developing aortic stenosis are likely to have a bicuspid
valve, although calcification of a tricuspid aortic valve is more common with age. Isolated rheumatic
involvement is rare in Western countries. Aortic regurgitation, if mild or moderate, is well tolerated over
many years, the exception being if it is associated with root disease. Mild non-rheumatic aortic
regurgitation (arbitrarily < 1/6) not associated with aortic root disease or other potentially disqualifying
condition may be permissible for unrestricted certification to fly.
Aortic Stenosis
Mild aortic stenosis (Doppler peak aortic velocity 2.5 m/s) may be acceptable for unrestricted
certification, but 2.5 - 3.0 m/s will restrict to multi-crew operation subject to annual cardiological review.
A velocity >3.0 m/s needs very close cardiological supervision in the regulatory context. Evidence of
valvar calcification should restrict the licence to multi-crew operations. Attributable symptoms will
disbar. Any increase in left ventricular wall thickness (> 1.1 cm) or history of cerebral embolic event will
also be disqualifying.
Aortic regurgitation
There should be no significant increase in the left ventricular end systolic diameter of the heart
(arbitrarily >6.0 cm) and no increase of the left ventricular end diastolic diameter (> 4.1 cm) measured
on echocardiography. There should be no significant arrhythmia, and the effort performance should be
normal. An aortic root diameter >5 . 0 cm will disqualify. Significant increase in the end-systolic
(> 4.4 cm) and/or end-diastolic (> 6.5 cm) diameters of the left ventricle, with or without evidence of
ICAO Preliminary Unedited Version — October 2008 III-1-32
impairment of systolic/diastolic function will also disqualify. Annual cardiological follow-up with
　
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