Với người hở van động mạch chủ phẫu thuật thay van, thay van qua da hay điều trị nội khoa

Thomas Tu, MD FACC FSCAI Vietnam National Congress of Cardiology Da Nang, Vietnam October 13, 2014 Aortic Regurgitation  Etiology  Assessment of Severity  Natural History  Prognosis  Surgical Treatment  TAVI for AR Aortic Regurgitation: Etiology  Any conditions resulting in incompetent aortic leaflets  Congenital  Bicuspid valve  Aortopathy  Cystic medial necrosis  Collagen disorders (e.g Marfan’s)  Ehler-Danlos  Osteogenesis imperfecta  Pseudoxanthoma elasticum  Acquired  Rheumatic heart disease  Dilated aorta (e.g hypertension )  Degenerative  Connective tissue disorders  E.g ankylosing spondylitis, rheumatoid arthritis, Reiter’s syndrome, Giant-cell arteritis )  Syphilis (chronic aortitis)  Acute AI: aortic dissection, infective endocarditis, trauma Aortic Regurgitation: Symptoms  Dyspnea, orthopnea, PND  Chest pain  Nocturnal angina >> exertional angina  ( diastolic aortic pressure and increased LVEDP thus  coronary artery diastolic flow)  With extreme reductions in diastolic pressures (e.g < 40) may see angina Assessing Severity of AR  Assess severity by impact on peripheral signs and LV   peripheral signs =  severity   LV =  severity  S3  Austin -Flint  LVH  radiological cardiomegaly Aortic Regurgitation: Natural History Asymptomatic  Normal LV function (~good prognosis)  Progression to symptoms or LV dysfunction  Progression to asymptomatic LV dysfunction %/Y 10 TX: Medical  Surgery BEFORE LV dysfunction Bonow RO, et al, JACC 1998;32:1486 Case Series  43 patients in 14 centers treated with Corevalve TAVI for Aortic Stenosis > Aortic Regurgitation  Surgery of AS is 4x more likely than surgery for AI  Most patients with AR are young and therefore more likely to be low surgical risk  AR often associated with aortic root pathology, requiring surgical approach Discussion  TAVI for high risk patients with AR is feasible  79% had residual AR 1+ or less  VARC-defined success rate 74%  TAVI complication rates (stroke, bleeding) low compared with typical TAVI for AS (lower risk patient subset) Two-valve Procedures  8/43 patients required valves  All of this occurred in patients without aortic calcification  Causes:  Poor fixation of the annular portion of the prosthesis  Movement of the prosthesis in the regurgitant jet  Highly variable anatomy of the aortic root and ascending aorta with AR Aortic Aneurysm  High six-month mortality (3/4)  TAVI likely doesn’t change prognosis of aneurysmal disease Conclusions  Aortic regurgitation is primarily a surgical disease  Severe AR should be treated surgically when patients     develop symptoms or have LV enlargement or reduced LV systolic function Valve replacement is typical, though repair is possible in experienced hands TAVI represents a possible alternative for those patients who are high risk subsets Technical limitations include lack of stabilizing annular calcification and challenging aortic root anatomy Clinical outcomes of patients with aneurysms of the ascending aorta not seem to improve after TAVI