cardiovascular disorders
Aortic Stenosis
Treatment of Aortic Stenosis
Sometimes aortic valve replacement Nothing has yet been proved to slow the progression of aortic stenosis ( Treatment references ). Statins have been ineffective ( Medications that can cause hypotension (eg, nitrates) should be used cautiously, althoughnitroprussidehas been used as a temporizing measure to reduce afterload in patients with decompensated heart failure in the hours before valve replacement. Patients who develop heart failure but are too high risk for valve intervention benefit from cautious treatment withdigoxin, diuretics, and angiotensin-converting enzyme (ACE) inhibitors. The benefits of intervention do not outweigh the risks until patients develop symptoms and/or meet certain echocardiographic criteria. Thus, patients should have periodic clinical evaluations, including echocardiography and sometimes exercise testing, to determine the optimal time for valve replacement. Valve replacement is recommended when aortic stenosis is severe and there is any one of the following: Symptoms Exercise testing causing symptoms or showing reduced effort tolerance or a fall in blood pressure ≥ 10 mm Hg below baseline) LV EF < 50% In addition, if surgical risk is low, then surgery may also be considered if there is any one of: Very severe AS (aortic velocity > 5 m/second) Brain (B-type) natriuretic peptide (BNP) is > 3 times normal Severe pulmonary hypertension without other explanation Decline in EF to<60% Severe valve calcification with rapid progression of stenosis (reduction in aortic valve area ≥ 0.3 m/second/year) Studies are ongoing to determine whether earlier surgical intervention may be warranted as the risks of surgical valve replacement and percutaneous valve replacement decline. When cardiac surgery is being done for other reasons, concomitant aortic valve surgery is indicated regardless of symptoms if the AS is moderate or greater. Balloon valvotomyis used primarily in children and very young adults with congenital AS. In older patients who are not candidates for surgery,balloon valvuloplastyhas been used as a bridge to valve replacement, but this procedure has a high complication rate and provides only temporary relief. Transcatheter valve implantation, which can be done with similar procedural risk, even in sick, high-risk patients is more commonly being performed. Surgical aortic valve replacement(SAVR) usually involves replacement with a mechanical or bioprosthetic valve. In younger patients, the patient’s own pulmonic valve can be used, with a bioprosthesis then used to replace the pulmonic valve (Ross procedure). The advantage of the Ross procedure rather than SAVR to replace the aortic valve only is increased durability of the procedure. The valve exposed to systemic pressure is the patient's own pulmonic valve, and this lasts longer than other replacement valves. The bioprosthesis in the pulmonary position tends to also last a long time. Transcatheter (percutaneous) aortic valve implantation (TAVI)(sometimes called transcatheter aortic valve replacement, or TAVR) is a less invasive method of aortic valve replacement. TAVI valves are constructed differently than SAVR valves; TAVI valves are inserted through an artery in a collapsed configuration to the aortic valve site and are then deployed/expanded to replace the stenotic aortic valve. 10 years. In patients aged 65 to 80 years whose arteries are suitable for transfemoral TAVI, the decision regarding SAVR or TAVI is determined based on individual patient characteristics ( Treatment references ). If the patient’s arteries are not suited to the transfemoral route, then SAVR is preferred as long as surgical risk is not prohibitive. In patients with a life expectancy of<1 year even with a successful procedure, intervention is not recommended. Compared with SAVR, transfemoral TAVI has lower short-term mortality, and less risk of stroke, major bleeding, and atrial fibrillation. TAVI also requires a shorter hospital stay, causes less pain, and permits more rapid return to activity; however, it also increases vascular complications and paravalvular regurgitation and increases the need for permanent pacemaker implantation and early repeat valve intervention. Preoperative evaluation for CAD is indicated so that coronary artery bypass grafting (CABG) and valve replacement, if indicated, can be done during the same procedure. . Direct-acting oral anticoagulants (DOAC) are ineffective and should not be used (see also Anticoagulation for patients with a prosthetic cardiac valve ). 1.Otto CM, Nishimura RA, Bonow RO, et al: 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.Circulation143(5):e35–e71, 2021. doi: 10.1161/CIR.0000000000000932 2.Thiago L, Tsuji SR, Nyong J, et al: Statins for aortic valve stenosis.Cochrane Database Syst Rev9(9):CD009571, 2016. doi:10.1002/14651858.CD009571.pub2 