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Reconstruction of the Aortic Valve and Root A practical approach
Sebastian Ewen
Klinik für Innere Medizin III
Kardiologie, Angiologie und Internistische Intensivmedizin
Universitätsklinikum des Saarlandes
Homburg/Saar
Direktor: Prof. Dr. Michael Böhm
Aortic regurgitation and aneurysm
– epidemiology and guidelines
Distribution of valvular disease
5001 patients
native valve disease
AS
(33%)
AR
(11%)
MS
(10%)
MR
(25%)
Multiple
(20%)
RH
(1%)
Iung et al. Eur Heart J 2003
European Heart Survey
Patient characteristics
Iung et al. Eur Heart J 2003
European Heart Survey
Age
(years)
>1 comorbidity
(%)
AS 69 ± 12 36
AR 58 ± 16 26
MS 58 ± 13 22
MR 65 ± 14 42
Prevalence of valvular disease
Singh et al. Am J Cardiol 1999
Framingham Heart Study: 5 out of 10,000 people
MEN:
WOMEN:
Etiology
Iung et al. Eur Heart J 2003
European Heart Survey
Etiology
Iung et al. Eur Heart J 2003
European Heart Survey
Prognosis in asymptomatic patients
Bonow et al. JACC 2013
Prognosis depends on symptoms
Dujardin et al. Circulation 1999
n=246 patients, conservative management
Prognosis depends on LVESV
Dujardin et al. Circulation 1999
n=246 patients, conservative management
Stages of chronic AR
Stage Consequences Symptoms
A At risk of AR - -
B Progressive AR EF >50%
LVESD 50
LVESD 25mm/m²)
D Symptomatic severe AR
EF50mm
(LVESD >25mm/m²)
Dyspnea or more
severe HF symptoms
Nishimura et al. JACC 2014
AHA/ACC guidelines 2014
Echocardiograms in asymptomatic patients
Nishimura et al. JACC 2014
AHA/ACC guidelines 2014
Severe aortic regurgitation
ESC guidelines aortic regurgitation
Vahanian et al. Eur Heart J 2012
AHA/ACC guidelines aortic regurgitation
Nishimura et al. JACC 2014
AHA/ACC guidelines aortic regurgitation
Nishimura et al. JACC 2014
Medical therapy aortic regurgitation
• Stringent control of hypertension with CCB and/or ACEIs/ARBs (IB)
• CHF treatment including BB and ACEIs/ARBs in symptomatic severe
AR when surgery is not an option (IIa, B)
• No routine vasodilator therapy in chronic asymptomatic AR with
normal LV function (III)
Vahanian et al. Eur Heart J 2012
No routine vasodilator therapy in AR
Evangelista et al. NEJM 2005
n=95 patients with asymptomatic severe AR and EF>50%
Prognosis after AVR
Tornos et al. JACC 2006
Transapical TAVI in AR
Seiffert et al. JACC 2014
n=31 patients with pure severe AR from 9 German centers 76 years, EuroSCORE 24%
Transfemoral TAVI in AR
Roy et al. JACC 2013
n=43 patients with pure severe AR from 14 European centers 78 years, STSS 27%
Thoracic aortic aneurysm & dissection
• TAA: 10.4 per 100.000 per year (m:f ̴ 1.7:1)
• TAD: 2.9 per 100.000 per year (m:f ̴ 4:1 to 1:1)
Incidence
• Congenital connective tissue disorders
• Bicuspid aortic valve
• Aortitis
• Hypertension
• Atherosclerosis
Causes
Ramanath et al. Mayo Clin Proc. 2009
Normal size aortic root
Roman et al. Am J Cardiol 1989
Current AHA/ACC valvular disease guidelines 2014 do not
recommend adjustments of aortic diameter for body size!
Risk of rupture of thoracic aortic aneurysms
Davies et al. Ann Thorac Surg 2006
Surgery recommended with aortic diameter ≥2.75 cm/m²
ESC guidelines aortic aneurysm
Vahanian et al. Eur Heart J 2012
*risk factors: >2 mm/year progression, family history
Medical therapy thoracic aortic aneurysms
• Stringent control of hypertension (IB), statins (IIa, A), and smoking
cessation (IB)
• BB in Marfan´s syndrome (IB)
• ARBs (losartan) in Marfan´s syndrome (IB)
• BB and ACEIs/ARBs in all patients with thoracic aortic aneurysms
(IIa, B)
Vahanian et al. Eur Heart J 2012
No difference between ARB and BB
Lacro et al. NEJM 2014
n=608 patients with Marfan´s syndrome, randomized 1:1, age 11y
Subpopulation: Marfan´s syndrome
Jondeau et al., Circulation 2012
ESC guidelines aortic aneurysm
Vahanian et al. Eur Heart J 2012
*risk factors: >2 mm/year progression, family history
ESC guidelines aortic aneurysm
Vahanian et al. Eur Heart J 2012
*risk factors: >2 mm/year progression, family history
Subpopulation: bicuspid aortic valve
1 Tutar et al. Am Heart J 2005, 2 Nistri et al. Am J Cardiol 2005
Echo screening in neonates (n=1075)1
• BAV 4.6/1000 live births
• 7.1/1000 boys
• 1.9/1000 girls
Echo screening in military recruits (n=20.946)2
• BAV in 0.8% (possibly underestimate)
Subpopulation: BAV predicts aortic dilatation
Keane et al. Circulation 2000
Associated aortopathy in BAV
Verma and Siu. NEJM 2014
Mean increase 0.66 ± 0.05 mm/yr
Dilatation of the aortic root and
asymmetric dilatation of the tubular ascending aorta Dilatation of the aortic arch
Aortic surgery in patients with BAV
Michelena et al. JAMA 2011
416 cohort patients with BAV
Subpopulation: bicuspid aortic valve (BAV)
Erbel et al. ESC guidelines aortic diseaes 2014
*risk factors: >2 mm/year progression, family history
Subpopulation: bicuspid aortic valve (BAV)
Erbel et al. ESC guidelines aortic diseaes 2014
*risk factors: >2 mm/year progression, family history
Subpopulation: bicuspid aortic valve (BAV)
Erbel et al. ESC guidelines aortic diseaes 2014
*risk factors: >2 mm/year progression, family history
Dr. med. Sebastian Ewen
Klinik für Innere Medizin III
Universitätsklinikum des Saarlandes
Homburg/Saar, Germany
Tel. 06841-16-21346
Fax. 06841-16-21415
Thank you!