2014 acc/aha guideline for the management of patients with valvular heart disease
DESCRIPTION
Dr. İlham Tokatlı Dilmen sunumuAmerikan Hastanesi 13/03/2015Credits:AHA,ACC,JACCTRANSCRIPT
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2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease
Dr. İLHAM TOKATLI DİLMEN
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Erişkinlerde Kalp Kapak Hastalıklarının Teşhis ve Tedavisinde Rehber Olmak
● Teşhis ve takip● Medikal tedavi● Girişimsel tedavi
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Hastalık Evreleri
● A : Risk grubu● B : Progressive (Hafif-Orta)● C : Asemptomatik ileri
C1: LV/RV fonksiyonları N
C2: LV/RV fonksiyonları bozulmuş
● D : Semptomatik ileri
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Romatizmal Ateş Profilaksisi
● RA+cardit+KKH ise 10 yıl / 40 yaşa kadar● RA+cardit ise 10 yıl / 21 yaş● RA ise 5 yıl / 21 yaş, hangisi uzunsa
Penisilin G benzatin 1,2 MU/ IM /4 hafta Sulfadiazine 1gr oral/gün
Allerjik ise macrolid.
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Asemptomatik hastaların rutin EKO takibi
● Hafif (B) AS,AR,MS,MR 3-5 yıl● Orta (B) 1-2 yıl● İleri (C) 6-12 ay
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Operasyon / Girişim Riskinin Değerlendirilmesi
● STS● Euroscore
Limitation: Derive from surgical patients● Frailty: Günlük aktivite, 5 m yürüme< 6 sn● Major organ yetersizliği● Prosedüre spesifik engel
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Girişim Nafile (futile)
● Yaşam beklentisi < 1 yıl, başarılı olsa da,● Yaşam+fayda (survival with benefit) %25/
2 yıl
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Heart Valve TeamHeart Valve Center of Excellence
● İleri kapak hastalarıbu merkezlerde değerlendirilmeli
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Aort Stenozu
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Asemptomatik İleri AS (C)
● C1: Vmax ≥ 4 m/s or mean gradiyent ≥40mmHg
AVA ≤1 cm² (AVAI ≤ 0,6 cm²/m²)LV sistolik fonsiyonları normal
– Very severe AS: Vmax ≥5 m/s veya mean gradiyent ≥ 60 mmHg
– Egzersiz testi yapılabilir!
● C2: EF %50 den az
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Semptomatik İleri AS (D)
● D1: Yüksek gradiyentli AS● D2: Low flow/low gradient AS, EF<%50
-Dobutamine eko yapılabilir (Class 2a)
● D3: Low gradient, normal EF, paradoksik low-flow
-LVH, Küçük LV, Stroke volüm index <35 ml/m²
-Ölçüm normotansif (sistolik TA<140 mmHg) iken yapılmalı!
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Girişim Zamanlaması
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Girişim Seçimi AVR/TAVR?
● TAVR endikasyonları:
-Kalp kapak takımı karar vermeli
-Yüksek op riskli (STS PROM %8-15) ve post-TAVR yaşam beklentisi>1 yıl (Class 1, LOE:B)
-Anatomik engeller
-Frailty● Tablo 10
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Aort Yetersizliği
● Akut AY : İE veya diseksiyon
Erken cerrahi, özellikle hipotansiyon, pulmoner ödem veya düşük akım bulguları varsa!
● Kronik AY: Neden en sık biküspit aorta veya kalsifik kapak,
● Yavaş ilerler,● Tablo 11 Kronik AR evreleri
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Kronik AY de AVR Endikasyonları
● Fig 2● Tablo 12 özet tavsiyeler
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Biküspit Aort Kapak ve Aortopati
● Biküspit aortluların çoğunda yaşamı boyunca AS ve/veya AR gelişir!
● Genellikle Aort dilatasyonu ile birlikte (RC+NC füzyonunda daha çok)
● Aort çapı > 4,5 cm ise senelik EKO,CT, MR
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Girişim Zamanı?
● Class 1, LOE:B
Aort çapı (sinüs veya asc aorta seviyesinde) > 5,5 cm * (5 cm idi)
● Class 2a, LOE:C
- Çap 5,1-5,5 cm +ailede aort diseksiyonu öyküsü veya hızlı ilerleme(≥ 0,5 cm/yıl)
- İleri AS/AR nedeniyle op olacaksa, aort çapı> 4,5 cm
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Mitral Darlığı
● Romatik ya da nonromatik (senil kalsifik)● Planimetrik ve PHT ile ölçüm (Kalp hızı
önemli) genellikle yeterli.
--MVA ≤ 1,5 cm² ileri MD● Kapak morfolojisi: Wilkins skoru● PMBC yapılacaksa, LA trombus ve MY >2+
?araştırması için TEE şart
Romatik MD Evreleri: Tablo 13
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Romatizmal MS 'da Girişim Endikasyonları
● Fig3 >>>
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Antikoagülan Tedavi(VKA veya Heparin) Kimlere?
1-MS ve AF(Paroksismal, Persistent, Permanent)
2-MS ve embolik olay
3-MS ve LA trombus
Class1, LOE B
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● Sinüs ritminde de olsa yeterli antikoagülana rağmen tekrarlayan embolileri olanlarda
LAA excisionu, ligasyona göre tercih edilmeli
COE 2b, LOE C
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Mitral Yetmezliği
● Akut MY :İE, MI(inf), dejeneratif kordal rüptür
Tedavi: Erken cerrahi (tamir)● Kronik MY
1-Primer (dejeneratif):MVP en sık
2-Sekonder (fonksiyonel): LV disfonksiyonu
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Primer MY Evreleri
● Tablo 15 >>>
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Sekonder MY Evreleri
● Tablo 16 >>>
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Primer MY de Özet Öneriler
● Tablo 17 >>>
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Triküspit Yetersizliği
● %80 fonksiyonel● Anüler dilatasyon: Preop TTE/TEE ile
diastolik çap>40 mm(veya>21mm/m²);veya direct intraop ölçüm>70 mm
● RV sistolik fonksiyonu:TAPSE >16 mm, S'>10 cm/sn, RV end sistolik alanı<20 cm² veya fraksiyonel alan değişimi >%35
● Tablo 19: TY evreleri● Fig 5 Cerrahi tedavi endikasyonları
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Protez Kapaklar
● Hâlâ kapak hastası!● İlk TTE postop. 6 hafta-3 ay içinde mutlaka● Semptom ve bulgularda değişiklik olursa
tekrar● Bioprotezde ilk 10 yıldan sonra rutin
senelik TTE, asemptomatik de olsa● TEE mitral protezlerde daha üstün
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Protez Kapaklarda Antitrombotik Tedavi
● Sürekli, hedef INR de VKA● Ek risk faktörleri:AF, tromboemboli öyküsü,
LV disfonksiyonu, hiperkoagülasyon)● Mitralde tromboemboli daha sık● Aspirin 75-100 mg/gün tüm protez
kapaklılara● Yeni antikoagülanların mekanik kapaklarda
kullanımı kontrendike(Class:3, LOE: B)
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Bridging Therapy for Prosthetic Valves
● Minör prosedürlerde (diş çekimi, katarakt)VKA ya ara verme,
● AVR de kısa (2-4 gün) ara ver, heparine gerek yok,
● Mekanik MVR, Mekanik AVR+ek risk, eski jenerasyon mekanik AVR ise UFH veya LMWH ile bridging
● Acil durumlarda VKA altındaysa TDP veya protrombin komplex konsantresi verilebilir.
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INR Yüksekliği ve Kanamalar
● INR 5-10: İlacı kes ve bekle● INR >10: İlacı kes, oral vit K1
(phytonadione) 1-2,5 mg ver● Kontrol edilemez kanama varsa TDP veya
protrombin komplex konsantresi ver.
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Protez Kapaklılarda Tromboembolik Olaylar
● INR hedef değerde olsa bile risk yüksek,● Subterapötik hasta %30-40● Olursa INR hedefini yükselt (AVR ise 2,5
dan 3'e, MVR ise 3 den 4 'e)● Bioprotez ise VKA 'e başla.
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Protez Kapak Trombozu
● TEE sensitivitesi daha yüksek, özellikle mitralde,
● Pannusa göre trombus daha büyük, yoğunluğu az ve daha mobil,
● Trombus büyüklüğü (TEE ile ölçülen alan) trombolize cevabı etkileyen bağımsız prediktör (<0,8 cm² düşük risk)
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Gelecekte Neler Var?
● RCT ler artmalı, kanıt düzeyi C to A● Heart Valve Center of Excellence verileri
değerlendirilmeli● Koruyucu sağlık: RF aşı? Biküspitleri
saptamak, genetik çalışmalar● Op riski düştükçe, transkateter yaklaşımlar
geliştikçe girişim zamanı erkene çekilebilecek
● Yeni antikoagülanlar
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Teşekkürler
Dr. İlham Tokatlı Dilmen
MedAmerikan Polikliniği
2015