Priv.-Doz. Dr. med. Michael Kindermann CaritasKlinikum Saarbrücken, St. Theresia Interventionelle Kardiologie und Angiologie Aortic Regurgitation and Aneurysm: Epidemiology and Guidelines Homburg, Wednesday, May 14 th , 2014 Workshop: Reconstruction of the Aortic Valve and Root cts CaritasKlinikum Saarbrücken St. Theresia
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Priv.-Doz. Dr. med. Michael Kindermann
CaritasKlinikum Saarbrücken, St. Theresia Interventionelle Kardiologie und Angiologie
Aortic Regurgitation and Aneurysm:
Epidemiology and Guidelines
Homburg, Wednesday, May 14th, 2014
Workshop: Reconstruction of the
Aortic Valve and Root
cts CaritasKlinikum Saarbrücken St. Theresia
cts Some numbers - on aortic regurgitation
• Prevalence: 5 out of 10,000 people
• Third most frequent single left-sided valve disease (13%) in
patients admitted to medical or surgical cardiology departments
• Among single native left-sided valve disease, pure AR accounts
for 13% of all valve interventions
Iung B.: Eur Heart J;2003:24:1231.
Aortic valve replacement
with mechanical or bioprosthesis 94.1%
Replacement by homograft 02.5%
Replacement by autograft 01.7%
Aortic valve repair 01.7%
Interventions on AR in 2001 (Euro Heart Survey on Valvular Heart Disease):
cts Aortic regurgitation - Etiology
Abnormalities of the cusps Abnormalities of the aortic root Abnormalities of cusps & root
cts Valvular Heart Disease – International Guidelines
20
14
20
10
2
01
2
cts
Vahanian A.: Eur Heart J;2012:33:2451.
Management of AR – ESC Guidelines 2012
Significant enlargement of ascending aorta
No Yes
Other cardiac surgery (IC) LVEF 50% (IB) or LVEDD > 70 mm (IIaC) or LVESD > 50 mm (IIaC) or LVESD/BSA > 25 mm/m² (IIaC)
No
No Yes
Whatever the severity of AR
Cutoff for surgery dependent on maximal ascending aortic diameter
• Marfan syndrome - without risk factors 50 mm (IC) - with risk factors 45 mm (IIaC)
• Bicuspid aortic valve
- without risk factors 55 mm (IIaC)
- with risk factors 50 mm (IIaC)
• Others 55 mm (IIaC)
AR severe
No
Follow-Up Surgery
Yes
Symptoms
Yes
(IB)
cts
Bicuspid aortic valve with significant enlargement of ascending aorta
No Yes
Other cardiac surgery (IC) LVEF < 50% (IB) or LVESD > 50 mm (IIaB) or LVESD/BSA > 25 mm/m² (IIaB) or LVEDD > 65 mm & low risk (IIbC)
No
No Yes
Whatever the severity of AR - Without risk factors* 55 mm (IB) - With risk factors* 50 mm (IIaC) With severe AS or AR - No risk factors required 45 mm (IIaC)
*Risk factors:
Family history of aortic dissection
Increase rate ≥ 5 mm per year
AR severe
No
Follow-Up Surgery
Yes
Symptoms
Yes
(IB)
Management of AR – AHA/ACC Guidelines 2014
Nishimura RA.: Circulation 2014.
moderate AR & other cardiac surgery (IIaC)
cts AHA/ACC Guidelines 2010
Indications for aortic root repair in Marfan syndrome (IIaC):
Maximal aortic diameter 50 mm
Hiratzka LF.: Circulation;2010:121:e266.
unless - family history of aortic dissection at < 5 cm
- rapid expanding aneurysm (> 5 mm/year)
- significant valvular regurgitation
cts AHA/ACC Guidelines 2010
Indications for aortic root repair in Marfan syndrome (IIaC):
Maximal aortic diameter 50 mm
Hiratzka LF.: Circulation;2010:121:e266.
unless
Indications for aortic repair in Loeys-Dietz syndrome (IIaC)*:
Maximal aortic inner diameter (TEE measure) 42 mm Maximal aortic external diameter (CT, MRI) 44 - 46 mm *same recommendation for familial TAAD syndrom with TGFBR-mutations
Maximal aortic cross sectional area (d²/4) in cm² divided by height in meters > 10 applicable also to other genetic diseases or bicuspid aortic valves
- family history of aortic dissection at < 5 cm
- rapid expanding aneurysm (> 5 mm/year)
- significant valvular regurgitation
Prophylactiv aortic repair in women contemplating pregnancy if aortic diameter > 40 mm
NB.: Current AHA/ACC Valvular Disease Guidelines 2014 do not
recommend adjustments of aortic diameter for body size!
cts
Neither genetic syndrom, nor bicuspid valve:
Indications (IC) for aortic root repair or
replacement of the ascending aorta
(Class IC recommendations):
Diameter or aortic root or ascending aorta > 55 mm
Rate of diameter increase 5 mm/year
or
If AVR is indicated anyway,
cutoff diameter for aortic root/ascending aorta is > 45 mm
or
AHA/ACC Guidelines 2010
Hiratzka LF.: Circulation;2010:121:e266.
cts Medical therapy – AHA/ACC Guidelines 2010 & 2014
Thoracic aortic aneurysms
Stringent control of hypertension (IB), statins (IIaA), smoking
cessation (IB)
ß-blockers in Marfan syndrome (IB)
ARBs (losartan) in Marfan syndrome (IIaB)
ß-blockers and ACEIs/ARBs in all patients with thoracic aortic