Aortic regurgitation and aneurysm. epidemiology and guidelines
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1 Reconstruction of the Aortic Valve and Root A practical approach Aortic regurgitation and aneurysm epidemiology and guidelines Sebastian Ewen Klinik für Innere Medizin III Kardiologie, Angiologie und Internistische Intensivmedizin Universitätsklinikum des Saarlandes Homburg/Saar Direktor: Prof. Dr. Michael Böhm
2 Distribution of valvular disease European Heart Survey 5001 patients native valve disease AS (33%) AR (11%) MS (10%) MR (25%) Multiple (20%) RH (1%) Iung et al. Eur Heart J 2003
3 Patient characteristics European Heart Survey Age (years) >1 comorbidity (%) AS 69 ± AR 58 ± MS 58 ± MR 65 ± Iung et al. Eur Heart J 2003
4 Prevalence of valvular disease Framingham Heart Study: 5 out of 10,000 people MEN: WOMEN: Singh et al. Am J Cardiol 1999
5 Etiology European Heart Survey Iung et al. Eur Heart J 2003
6 Etiology European Heart Survey Iung et al. Eur Heart J 2003
7 Prognosis in asymptomatic patients Bonow et al. JACC 2013
8 Prognosis depends on symptoms n=246 patients, conservative management Dujardin et al. Circulation 1999
9 Prognosis depends on LVESV n=246 patients, conservative management Dujardin et al. Circulation 1999
10 Stages of chronic AR AHA/ACC guidelines 2014 Stage Consequences Symptoms A At risk of AR - - B Progressive AR EF >50% LVESD <50mm - C1 C2 Compensated severe AR Decompensated severe AR EF>50 LVESD <50mm EF<50% or LVESD >50mm (LVESD >25mm/m²) Dyspnea during exercise D Symptomatic severe AR EF<50% LVESD >50mm (LVESD >25mm/m²) Dyspnea or more severe HF symptoms Nishimura et al. JACC 2014
11 Echocardiograms in asymptomatic patients AHA/ACC guidelines 2014 Nishimura et al. JACC 2014
12 Severe aortic regurgitation
13 ESC guidelines aortic regurgitation Vahanian et al. Eur Heart J 2012
14 AHA/ACC guidelines aortic regurgitation Nishimura et al. JACC 2014
15 AHA/ACC guidelines aortic regurgitation Nishimura et al. JACC 2014
16 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
17 No routine vasodilator therapy in AR n=95 patients with asymptomatic severe AR and EF>50% Evangelista et al. NEJM 2005
18 Prognosis after AVR Tornos et al. JACC 2006
19 Transapical TAVI in AR n=31 patients with pure severe AR from 9 German centers 76 years, EuroSCORE 24% Seiffert et al. JACC 2014
20 Transfemoral TAVI in AR n=43 patients with pure severe AR from 14 European centers 78 years, STSS 27% Roy et al. JACC 2013
21 Thoracic aortic aneurysm & dissection Incidence TAA: 10.4 per per year (m:f 1.7:1) TAD: 2.9 per per year (m:f 4:1 to 1:1) Causes Congenital connective tissue disorders Bicuspid aortic valve Aortitis Hypertension Atherosclerosis Ramanath et al. Mayo Clin Proc. 2009
22 Normal size aortic root Current AHA/ACC valvular disease guidelines 2014 do not recommend adjustments of aortic diameter for body size! Roman et al. Am J Cardiol 1989
23 Risk of rupture of thoracic aortic aneurysms Surgery recommended with aortic diameter 2.75 cm/m² Davies et al. Ann Thorac Surg 2006
24 ESC guidelines aortic aneurysm *risk factors: >2 mm/year progression, family history Vahanian et al. Eur Heart J 2012
25 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
26 No difference between ARB and BB n=608 patients with Marfan s syndrome, randomized 1:1, age 11y Lacro et al. NEJM 2014
27 Subpopulation: Marfan s syndrome Jondeau et al., Circulation 2012
28 ESC guidelines aortic aneurysm *risk factors: >2 mm/year progression, family history Vahanian et al. Eur Heart J 2012
29 ESC guidelines aortic aneurysm *risk factors: >2 mm/year progression, family history Vahanian et al. Eur Heart J 2012
30 Subpopulation: bicuspid aortic valve 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) 1 Tutar et al. Am Heart J 2005, 2 Nistri et al. Am J Cardiol 2005
31 Subpopulation: BAV predicts aortic dilatation Keane et al. Circulation 2000
32 Associated aortopathy in BAV Dilatation of the aortic root and asymmetric dilatation of the tubular ascending aorta Dilatation of the aortic arch Mean increase 0.66 ± 0.05 mm/yr Verma and Siu. NEJM 2014
33 Aortic surgery in patients with BAV 416 cohort patients with BAV Michelena et al. JAMA 2011
34 Erbel et al. ESC guidelines aortic diseaes 2014 Subpopulation: bicuspid aortic valve (BAV) *risk factors: >2 mm/year progression, family history
35 Erbel et al. ESC guidelines aortic diseaes 2014 Subpopulation: bicuspid aortic valve (BAV) *risk factors: >2 mm/year progression, family history
36 Erbel et al. ESC guidelines aortic diseaes 2014 Subpopulation: bicuspid aortic valve (BAV) *risk factors: >2 mm/year progression, family history
37 Thank you! Dr. med. Sebastian Ewen Klinik für Innere Medizin III Universitätsklinikum des Saarlandes Homburg/Saar, Germany Tel Fax
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