Linee guida e timing chirurgico insufficienza aortica

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Linee guida e timing chirurgico dell’insufficienza valvolare aortica: che cosa attende migliore definizione. Dr. Antonio Federico - Villa Maria Cecilia Hospital - Maggio 2009

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Linee guida e timing chirurgico insufficienza aortica

  1. 1. Linee guida e timing chirurgico dell’Insufficienza Aortica : che cosa attende migliore definizione Dr. Antonio Federico “ L’Insufficienza Valvolare Aortica” Villa Maria Cecilia Hospital 15 – 16 Maggio 2009
  2. 3. Natural History of Aortic Regurgitation <ul><li>1) Asymptomatic patients with normal LV systolic Function: </li></ul><ul><li>Progression to symptoms and/or LV Dysfunction: < 6%/y </li></ul><ul><li>Progression to asymptomatic LV dysfunction: < 3.5%/y </li></ul><ul><li>Sudden death < 0.2%/y </li></ul><ul><li>2) Asymptomatic patients with LV dysfunction </li></ul><ul><li>Progression to cardiac symptoms > 25%/y </li></ul><ul><li>3) Symptomatic patients: </li></ul><ul><li>Mortality rate > 10%/y </li></ul>ACC/AHA VHD Guidelines: 2008 Focused Update Incorporated JACC Vol. 52, No. 13, 2008 e1–142
  3. 4. Indici di performance ventricolare sinistra + + + + + + + + + + + S.F. (v.n. 25%-45%) + + + + + + + + + 0 + Dimens. sistoliche + + + + + + + + 0 + + + VCF (SF/ET) (v.n.>1,1circ./sc) + + + + + + + + + + + + dP/dt + + + + + + + + + + + + F.E. fattibilità Dipendenza Massa/vol. Dipendenza da postcarico Dipendenza da precarico Sensibilità a inotropismo
  4. 5. Indici di performance ventricolare sinistra <ul><li>La valutazione dello strain e strain rate globali del V.S. possono essere utili indicatori per definire il timing chirurgico e la prognosi dei Pazienti con insufficienza aortica severa, specie dopo sostituzione valvolare </li></ul><ul><li>(J. Am. Coll. Cardiol. Img. 2011;4;223-230) </li></ul>
  5. 6. <ul><li>.. in the present study, which predominantly included asymptomatic patients with ejection fractions of 50%, many patients had natriuretic peptide levels similar to those seen in age- and gender-matched controls despite increased LV volumes. This suggests that an increased LV volume alone is not the stimulus for release of natriuretic peptides . Natriuretic peptide levels may increase in patients with AR with LV decompensation even when the ejection fraction is within the normal range. In conclusion, measurement of natriuretic peptide levels may provide information on LV function in addition to echocardiography in patients with chronic AR </li></ul>Am. J. Cardiol. 2003;92:755-758
  6. 7. Diagnostic and prognostic value of N-terminal pro B-type natriuretic peptide in patients with chronic aortic regurgitation <ul><li>NT-proBNP is linked to disease severity in patients with </li></ul><ul><li>chronic aortic regurgitation reflecting hemodynamic stress </li></ul><ul><li>due to volume overload. </li></ul><ul><li>It provides prognostic information for the clinical outcome </li></ul><ul><li>and thus might be a useful biomarker for risk stratification. </li></ul>International Journal of Cardiology 2008 Vol. 127 (3): 321-327
  7. 8. BNP e timing CCH nella SVA severa JACC 2006 (47), 11:2141 - 2151
  8. 9. <ul><li>Although the role of exercise stress testing in aortic </li></ul><ul><li>regurgitation has not yet been demonstrated, it is considered reasonable (class IIA) in the US guidelines for assessment of functional capacity and symptomatic response in patients with: </li></ul><ul><li>a history of equivocal symptoms (evidence: B) </li></ul><ul><li>before participation in athletic activities (evidence: C). </li></ul>
  9. 10. <ul><li>Which parameters? </li></ul><ul><li>Left ventricular end-diastolic and end-systolic volumes </li></ul><ul><li>ejection fraction should be assessed at rest and during the test. </li></ul><ul><li>Annular systolic velocities and indices of longitudinal function could be measured using tissue Doppler imaging </li></ul>
  10. 11. EF 54 % EF 51 % Rest Exercise Sv 5.4 cm/s Sv 6.1 cm/s Delay 60 ms F UP:Acute HF EF 34% Sv 2.4 cm/s “ Stress testing could be useful for the early detection of latent systolic failure”
  11. 12. Proposta flow chart per timing chirurgico in I. Ao DTD 55-70 mm + DTS 45/55 mm DTD > 70 mm + DTS > 55 mm F.E. > 55% F.E. < 55% dP/dt + BNP = < > + stress ECO = < Follow up CCH
  12. 13. Quale ruolo per la terapia medica ?
  13. 14. Quale ruolo per la terapia medica ? JACC 2005;45:1205-30
  14. 15. Quale ruolo per la terapia medica ? <ul><li>Unloading therapy with nifedipine in </li></ul><ul><li>asymptomatic patients with AR represents a pharmacologic strategy capable of delaying the need for surgery by prolonging the asymptomatic period while preservingLVEF. </li></ul><ul><li>This treatment allows one to indicate AVR at the appearance of reduced LVEF with a low operative mortality and with significant improvement of long-term postoperative survival . </li></ul>JACC 2005;45:1205-30
  15. 16. Quale ruolo per la terapia medica ? <ul><li>Long-term vasodilator therapy with nifedipine or enalapril did not reduce or delay the </li></ul><ul><li>need for aortic-valve replacement in patients with asymptomatic severe aortic regurgitation </li></ul><ul><li>and normal left ventricular systolic function. Furthermore, such therapy did not reduce the aortic regurgitant volume, decrease the size of the left ventricle, or improve left ventricular function. </li></ul>N Engl J Med 2005;353:1342-9 .
  16. 17. <ul><li>“ ...metoprolol treatment had a significant beneficial global effect on LV remodeling anf function. These results suggest that…. adrenergic-blocking agents may play a role in the treatment of this disease.” </li></ul>Circulation 2004;110:1477 - 1483
  17. 18. Quale ruolo per la terapia medica ? <ul><li>CLASS I </li></ul><ul><li>1. Vasodilator therapy is indicated for chronic therapy in patients with severe AR who have symptoms or LV dysfunction when surgery is not recommended because of additional cardiac or noncardiac factors. (Level of Evidence: B) </li></ul><ul><li>CLASS IIa </li></ul><ul><li>1. Vasodilator therapy is reasonable for short-term therapy to improve the hemodynamic profile of patients with severe heart failure symptoms and severe LV dysfunction before proceeding with AVR. </li></ul>J. Am. Coll. Cardiol. 2008;52;e1-e142
  18. 19. Quale ruolo per la terapia medica ? <ul><li>CLASS IIb </li></ul><ul><li>Vasodilator therapy may be considered for long-term therapy in asymptomatic patients with severe AR who have LV dilatation but normal systolic function. (Level of Evidence: B) </li></ul>JACC 2008;52;e1-e142
  19. 20. Quando intervenire su I. Ao. associata ad altra valvulopatia ? <ul><li>Other than recommending evaluation with physical examination, echocardiography and cardiac catheterization as clinically indicated for patient evaluation and management, the committee has developed no specific recommendations in this section. </li></ul>JACC 2005;45:1205-30
  20. 21. Insufficienza aortica + stenosi mitralica severa <ul><li>Ridotto riempimento V. Sx. </li></ul><ul><li>ridotto o nullo incremento della gittata anterograda </li></ul><ul><li>non segni obbietti di I. Ao. </li></ul><ul><li>assenza di dilatazione V. Sx </li></ul><ul><li>inaccuratezza del PHT per AVM </li></ul>JACC 2005;45:1205-30
  21. 22. Insufficienza aortica + insufficienza mitralica severe <ul><li>..surgery should considered in asymptomatic patients </li></ul><ul><li>meeting any criteria for AR or MR alone </li></ul><ul><li>Circulation 2003; 108:2432 – 2438 </li></ul><ul><li>...when surgery is required, AVR plus MV repair is the </li></ul><ul><li>preferred strategy when MV repair is possible </li></ul><ul><li>JACC 2005;45:1205-30 </li></ul>
  22. 23. Quando operare una I. Ao. moderata <ul><li>Patients who have aortic root disease with </li></ul><ul><li>- maximal aortic diameter 45 mm for patients with </li></ul><ul><li>Marfan’s syndrome (IC) </li></ul><ul><li>- 50 mm for patients with bicuspid valves ( IIa evidence: C ) </li></ul><ul><li>- 55 mm for other patients (IIa: evidence C ) </li></ul>European Heart Journal (2007) 28, 230–268 1. AVR may be considered in patients with moderate AR while undergoing surgery on the ascending aorta. (IIb evidence: C) 2. AVR may be considered in patients with moderate AR while undergoing CABG. (II b evidence: C) JACC 2005;45:1205-30
  23. 24. La riparabilità della valvola modifica il timing chirurgico ? <ul><li>The surgical options for treating AR are expanding, with </li></ul><ul><li>growing experience in aortic homografts, pulmonary autografts, </li></ul><ul><li>unstented tissue valves, and aortic valve repair . </li></ul><ul><li>If these techniques are ultimately shown to improve long-term </li></ul><ul><li>survival or reduce postoperative valve complications, it is </li></ul><ul><li>conceivable that the thresholds for recommending AVR </li></ul><ul><li>may be reduced . </li></ul>ACC/AHA VHD Guidelines: 2008 Focused Update Incorporated JACC Vol. 52, No. 13, 2008 e1–142
  24. 25. CONCLUSIONI <ul><li>Le attuali linee guida lasciano aperte alcune questioni non secondarie nella gestione del Paziente con insufficienza aortica severa: </li></ul><ul><li>1) La valutazione della disfunzione sistolica V. Sx. si può avvalere di altri markers oltre a quelli ecocardiografici ? </li></ul><ul><li>Vi sono numerose evidenze che sia lo stress eco che il dosaggio del BNP possano essere utili nel monitoraggio </li></ul><ul><li>della disfunzione sistolica latente del V. Sx. </li></ul>
  25. 26. CONCLUSIONI <ul><li>Quale ruolo ha la terapia medica nel follow up dell’Insufficienza aortica severa asintomatica e con normale F.E.V.Sx ? </li></ul><ul><li>Non vi sono evidenze che la T.M. (calcioantagonisti, aceinibitori, betabloccanti) sia utile nel ritardare l’intervento o nel migliorare la prognosi nel periodo postoperatorio. </li></ul><ul><li>Essa resta indicata perciò solo come bridge alla CCH o quando vi siano controindicazioni ad essa </li></ul><ul><li>Resta ancora da chiarire quale ruolo possa avere in quest’ultimo caso la procedura di impianto percutaneo di bioprotesi </li></ul>
  26. 27. CONCLUSIONI <ul><li>La riparabilità della valvola modifica il timing chirurgico ? </li></ul><ul><li>No ! (al momento attuale) </li></ul><ul><li>In quali casi si può considerare SVA nell’I. Ao. Moderata ? </li></ul><ul><li>Se il Paziente deve essere sottoposto a CCH per: </li></ul><ul><li>patologia dell’aorta ascendente </li></ul><ul><li>rivascolarizzazione coronarica </li></ul><ul><li>altra valvulopatia </li></ul>
  27. 28. CONCLUSIONI <ul><li>Come comportarsi in caso di SM critica (con indicazione a CCH) e I. Ao severa ? </li></ul><ul><li>Se possibile valvuloplastica mitralica e SVA solo se persistono sintomi. </li></ul><ul><li>Altrimenti SVM e SVA. </li></ul><ul><li>Come comportarsi in caso di IM severa (candidata a CCH) </li></ul><ul><li>ed I.Ao. Severa ? </li></ul><ul><li>Se possibile plastica mitralica e SVA. </li></ul><ul><li>Altrimenti SVM e SVA </li></ul>

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