aortic regurgitation and aneurysm epidemiology and guidelines · 2016. 4. 27. · medical therapy...

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



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



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


AHA/ACC guidelines 2014

Severe aortic regurgitation

ESC guidelines aortic regurgitation

Vahanian et al. Eur Heart J 2012

AHA/ACC guidelines aortic regurgitation


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)


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


*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)


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



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


Dr. med. Sebastian Ewen

Klinik für Innere Medizin III

Universitätsklinikum des Saarlandes

Homburg/Saar, Germany

Tel. 06841-16-21346

Fax. 06841-16-21415

[email protected]

Thank you!

aortic regurgitation and aneurysm epidemiology and guidelines · 2016. 4. 27. · medical therapy...

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