Die asymptomatische Aortenklappenstenose

Abstract

Aortic stenosis is the most frequent type of valvular heart disease in Europe and North America. Calcific aortic valve disease is the leading etiology in industrialized countries. Doppler echocardiography plays a key role in the grading of aortic valve stenosis. Symptomatic patients with severe aortic stenosis have a very poor prognosis and indication for valve replacement. It is often difficult, particularly in older patients with comorbidities to be confident about the origin of symptoms which might lead to operation in a patient with a low chance of symptomatic and prognostic improvement. Management of asymptomatic severe aortic stenosis is controversial and challenging. Reliable risk stratification is helpful for identification of asymptomatic patients at high risk who would benefit from early aortic valve replacement with the goal to reduce mortaility. Assessment of valve calcification, hemodynamic progression and LV function, clinical parameters, exercise testing and cardiac biomarkers have been reported as major predictors of clinical outcome.

Kernaussagen

• Bei asymptomatischen Patienten mit hochgradiger Aortenklappenstenose ist das perioperative Mortalitätsrisiko und das jährliche Risiko der Prothesenkomplikation größer als das Risiko der wachsamen Verlaufsbeobachtung. Dennoch müssen diese Patienten engmaschig durch klinische und echokardiografische Nachsorge überwacht werden und über die Symptome aufgeklärt werden. Belastungstests sollten bei unklarem Symptomstatus hinzugezogen werden.

• Ein frühzeitiger Aortenklappenersatz erscheint bei Patienten mit höherem Risikoprofil (ausgeprägte Aortenklappenkalzifizierung, schnelle Aorten-Jet-Progression in Verlaufskontrollen, gleichzeitige KHK, LV-Dsyfunktion, erhöhte BNP-Spiegel und in einzelnen Fällen vor Zuweisung großer elektiver nicht kardialer chirurgischer Eingriffe) vernünftig.

• Ein präventiver Aortenklappenersatz könnte sich bei reduziertem Operations- oder Interventionsrisiko als das Verfahren der Wahl herausstellen. Eine solche Strategie setzt allerdings die verbesserte Beurteilbarkeit der Prognose durch nicht invasive Testverfahren und Fortschritte bei prothetischen Aortenklappen und perkutanen Klappen voraus.

Literatur

• 1 Stewart B F, Siscovick D, Lind B K, Gardin J M. et al . Clinical factors associated with calcific aortic valve disease. Cardiovascular Health Study.  J Am Coll Cardiol. 1997;  29 630-634
• 2 Nkomo V T, Gardin J M, Skelton T N, Gottdiener J S. et al . Burden of valvular heart diseases: a population-based study.  Lancet. 2006;  368 1005-1011
• 3 Otto C M, Lind B K, Kitzman D W, Gersh B J, Siscovick D S. Association of aortic-valve sclerosis with cardiovascular mortality and morbidity in the elderly.  N Engl J Med. 1999;  341 142-147
• 4 Dare A J, Veinot J P, Edwards W D, Tazelaar H D, Schaff H V. New observations on the etiology of aortic disease: a surgical pathologic study of 236 cases from 1990.  Hum Pathol. 1993;  24 1330-1338
• 5 Agmon Y, Khandheira B K, Meissner I, Sicks J R. et al . Aortic valve sclerosis and aortic atherosclerosis: different manifestations of te same disease? Insights from a population-based study.  J Am Coll Cardiol. 2001;  28 827-834
• 6 Rosenhek R, Raer F, Loho N, Gabriel H. et al . Statins but not angiotensin-converting enzyme inhibitors delay progression of aortic stenosis.  Circulation. 2004;  110 1291-1295
• 7 Moura L M, Ramos S F, Zamorano J L, Barros I M. et al . Resuvastatin affecting aortic valve endothelium to slow the progression of aortic stenosis.  J Am Coll Cardiol. 2007;  49 554-561
• 8 Rossebo A B, Pedersen T R, Boman K, Brudi P h. et al . Intensive Lipid Lowering with Simvastatin and Ezitimibe in Aortic Stenosis.  N Engl J Med. 2008;  359 1-14
• 9 Cosmi J E, Kort S, Tunick P A, Rosenzweig B P. et al . The risk of the development of aortic stenosis in ptients with „benign” aortic valve thickening.  Arch Intern Med. 2002;  162 2345-2347
• 10 Rosenhek R, Klaar U, Schemper M, Scholten C. et al . Mild and moderate aortic stenosis Natural history and risk stratification by echocardiography.  Eur Heart J. 2004;  25 199-205
• 11 Rosenhek R, Binder T, Porenta G, Lang I. et al . Predictors of outcome in severe, asymptomatic aortic stenosis.  N Engl J Med. 2000;  343 611-617
• 12 Otto C M, Burnwash I G, Legget M E, Munt B I. et al . Prospective study of asymptomatik valvular aortic stenosis: clinical, echocardiographic and exercise predictors of outcome.  Circulation. 1997;  95 2262-2270
• 13 Beppu S, Suzuki S, Matsuda H, Ohmori F. et al . Rapidity of progression of aortic stenosis in patients with congenital bicuspid aortic valves.  Am J Cardiol. 1993;  71 322-327
• 14 Ross J, Braunwald E. Aortic stenosis.  Circulation. 1968;  38 61-67
• 15 Pelikka P A, Nihimura R A, Bailey K R, Tajik A J. The natural history of adults with asymptomatic, hemodynamically significant aortic stenosis.  J Am Coll Cardiol. 1990;  15 1012-1017
• 16 Baumgartner H. Aortic stenosis: medical and surgical management.  Heart. 2005;  91 1483-1488
• 17 Pellikka P A, Sarano M E, Nishimura R A, Malouf J F. et al . Outcome of 622 adults with asymptomatic, hemodynamically significant aortic stenosis during prolonged follow-up.  Circulation. 2005;  111 3290-3295
• 18 Dal-Bianco J P, Khandheira B K, Mookadam F, Gentile F, Sengupta P P. Management of asymptomatic aortic stenosis.  J Am Coll Cardiol. 2008;  52 1279-1292
• 19 Kelly T A, Rothbart R M, Cooper C M, Kaiser D L. et al . Comparison of outcome of asymptomatic to symptomatic patients older than 20 years of age with valvular aortic stenosis.  Am J Cardiol. 1988;  61 123-130
• 20 Turina J, Hess O, Sepulcri F, Krayenbuehl H P. Spontanous course of aortic valve disease.  Eur Heart J. 1988;  8 471-483
• 21 Chizner M A, Pearle L D, eLeon A C. The natural history of aortic stenosis in adults.  Am Heart J. 1980;  99 419-424
• 22 Ivivanainen A M, Lindroos M, Tilvis R, Heikkila J, Kupari M. Natural history of aortic valve stenosis of varying severity in the elderly.  Am J Cardiol. 1996;  78 97-101
• 23 Bonow R O, Blase A, Carabello B A, Chatterjee K. et al . Focused update incorporated into the ACC/AHA 2006 Guidelines for the Management of Patients with Valvular Heart Disease: A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients with Valvular Heart Disease): Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions and Society of Thoracic Surgeons.  Circulation. 2008;  118 523-661
• 24 Lindblom D, Lindblom U, Qvist J, Lundstrom H. Long-term relative survival rates after heart valve replacement.  J Am Coll Cardiol. 1990;  15 566-573
• 25 Vahanian A, Baumgartner H, Bax J, Butchart E. et al . Guidelines on the management of valvular heart disease. The task force on the management of valvular heart disease of the European Society of Cardiology.  Eur Heart J. 2007;  28 230-268
• 26 Otto C M. Valvular aortic stenosis. Disease severity and timing of intervention.  J Am Coll Cardiol. 2006;  47 2141-2151
• 27 Rosenhek R, Maurer G, Baumgartner H. Should early elective surgery be performed in patients with severe but asymptomatic aortc stenosis?.  Eur Heart J. 2002;  23 1417-1421
• 28 Lund O. Preoperative risk evaluation and stratification of long-term survival after valve replacement for aortic stenosis: reasons for earlier operative intervention.  Circulation. 1990;  82 124-139
• 29 Carabello B A. Clinical practice. Aortic stenosis.  N Engl J Med. 2002;  346 677-682
• 30 Minners J, Allgeier M, Gohlke-Baerwolf C, Kienzle R P. et al . Inconsistencies of echocardiographic criteria for the grading of aortic valve stenosis.  Eur Heart J. 2008;  29 1043-1048
• 31 Jander N, Minners J, Holme I, Gerdts E. et al . Outcome of Asymptomatic Patients With Low Gradient „Severe” Aortic Valve Stenosis and Preserved Ejection Fraction – Results From the Prospective SEAS Study.  Circulation. 2009;  120 371
• 32 Quinones M A, Otto C M, Stoddard M, Waggoner A, Zoghbi W A. Recommendations for quantification of Doppler echocardiography: a report from the Doppler Quantification Task Force of the Nomenclature and Standards Committee f the American Society of Echocardiography.  J Am Soc Echocardiog. 2002;  15 167-184
• 33 Garcia D, Dumesnil J, Durand L G, Kadem L, Pibarot P. Discrepancies between catheter and Doppler estimates of valve effective orifice area can be predicted from the pressure recovery phenomenon.  J Am Coll Cardiol. 2003;  41 435-442
• 34 Baumgartner H, Stefanelli T, Niederberger J, Schima H, Maurer G. „Overestimation” of catheter gradients by Doppler ultrasound in patients with aortic stenosis: a predictable manifestation of pressure recovery.  J Am Coll Cardiol. 1999;  33 1655-1661
• 35 Garcia D, Pibarot P, Dumesnil J, Sakr F, Durand L G. Assessment of aortic valve stenosis severity: a new Index based on the Energy Loss Concept.  Circulation. 2000;  101 765-771
• 36 Bahlmann E, Cramariuc D, Gerdts E, Gohlke-Baerwolf C. et al . Impact of Pressure Recovery on Diagnosis of Severe Aortic Stenosis in Asymptomatic Patients. (A SEAS Substudy).  Circulation. 2008;  118 931
• 37 Gorlin R, Gorlin S G. Hydraulic formula for calculation of the area of the stenotic mitral valve, other cardiac valves and central circulatory shunts.  Am Heart J41. 1951;  1-29
• 38 Heinrich R S, Fontaine A A, Grimes R Y, Sidhaye A. et al . Experimental analysis of fluid mechanical energy losses in aortic valve stenosis: importance of pressure recovery.  Ann Biomed Eng. 1996;  24 685-694
• 39 Goland S, Trento A, Iida K, Czer L S. et al . Assessment of aortic stenosis by three-dimensional echocardiography: an accurate and novel approach.  Heart. 2007;  93 801-807
• 40 Pouleur A C, le Polain de Waroux J B, Pasquet A, Vanoverschelde J L, Gerber B L. Aortic valve area assessment: multidetector CT compared with cine MR imaging and transthoracic and transesophageal echocardiography.  Radiology. 2007;  244 745-754
• 41 Malyar N M, Schlosser T, Barkhausen J, Gutersohn A. et al . Assessment of aortic valve area in aortic stenosis using cardiac magnetic resonance tomography: comparison with echocardiography.  Cardiology. 2008;  109 126-134
• 42 Krayenbuehl H P, Hess O M, Ritter M, Monrad E S, Hoppeler H. Left ventricular systolic function in aortic stenosis.  Eur Heart J. 1988;  100 361-368
• 43 Stuber M, Scheidegger M B, Fischer S E, Nagel E, Steinemann F. et al . Alterations in the local myocardial motion patterns in patients suffering from pressure overload due to aortic stenosis.  Circulation. 1999;  100 361-368
• 44 Wachtell K. Left ventricular systolic performance in asymptomatic aortic stenosis.  Eur Heart J. 2008;  10 (Suppl.) 16-22
• 45 Cramariuc D, Cioffi G, Rieck A. et al . Low-Flow Aortic Stenosis in symptomatic Patients Valvular-Arterial Impedance and Systolic Function from the SEAS Substudy.  J Am Coll Cardiol: Cardiovascular Imaging. 2009;  2 390-399
• 46 Steine K, Rossebø A B, Stugaard M, Pedersen T R. Left ventricular systolic and diastolic function in asymptomatic patients with moderate aortic stenosis.  Am J Cardiol. 2008;  102 897-901
• 47 Peterson K L. Severe calcific aortic stenosis left ventricular afterload and its quantification.  J Am Coll Cardiol. 2005;  46 299-301
• 48 Kupari M, Turto H, Lommi J. Left ventricular hypertrophy in aortic valve stenosis: preventive or promotive of systolic dysfunction and heart failure?.  Eur Heart J. 2005;  26 1790-1796
• 49 Aurigemma G P, Silver K H, McLaughlin M, Mauser J, Gaasch W H. Impact of chamber geometry and gender of left ventricular systolic function in patients > 60 years of age wit aortic stenosis.  Am J Cardiol. 1994;  74 794-798
• 50 Romhilt D W, Estes E H. A point score system for the ECG diagnosis of left ventricular hypertrophy.  Am Heart J. 1968;  75 752-758
• 51 Das P, Rimington H, Chambers J. Exercise testing to stratify risk in aortic stenosis.  Eur Heart J. 2005;  26 1309-1313
• 52 Bergler-Klein J, Klaar U, Heger M, Rosenhek R. et al . Natriuretic peptides predict symptom-free survival and postoperative outcome in severe aortic stenosis.  Circulation. 2004;  109 2302-2308
• 53 Monin J L, Lancellotti P, Monchi M, Lim P. et al . Risk score for predicting outcome in patients with asymptomatc aortic stenosis.  Circulation. 2009;  120 69-75
• 54 Monin J L, Quéré J P, Monchi M, Petit H. et al . Low-gradient aortic stenosis: operative risk stratification and predictors for long-term outcome: a multicenter study using dobutamine stress hemodynamics.  Circulation. 2003;  108 319-324
• 55 Salomon S D, Anavekar N, Skali H, McMurray J JV. et al., for the Candesartan in Heart Failure Reduction in Mortality (CHARM) Investigators. . Influence of ejection fraction on cardiovascular outcomes in a broad spectrum of heart failure patients.  Circulation. 2005;  112 3738-3744
• 56 de Simone G, Devereux R B, Koren M J, Mensah G A. et al . Midwall left ventricular mechanics: an independent pedictor of cardiovascular risk in arterial hypertension.  Circulation. 1996;  93 259-265
• 57 Liao Y, Cooper R S, McGee D L, Mensah G A, Ghali J K. The relative effects of left ventricular hypertrophy, cornary artery disease and ventricular dysfunction on survival among black adults.  JAMA. 1995;  273 1592-1597
• 58 Lancellotti P, Lebois F, Simon M, Tomeux C. et al . Prognostic importance of quantitative exercise Doppler echocardiography in asymptomatic valvular aotic stenosis.  Circulation. 2005;  112 377-382
• 59 Amato M C, Moffa P J, Werner K E, Ramires J A. Treatment decision in asymptomatic aortic valve stenosis: role of exercise testing.  Heart. 2001;  86 381-386
• 60 Peidro R, Brion G, Angelino A. Exercise testing in asymptomatic aortic stenosis.  Cardiology. 2007;  108 258-264
• 61 Marechaux S, Ennezat P V, LeJemetel T H, Polge A S. et al . Left ventricular response to exercise in aortic stenosis: an exercise echocardiographic study.  Echocardiography. 2007;  24 955-959
• 62 Rafique A M, Biner S, Ray I, Forrester J S. et al . Prognostic value of stress testing in patients with asymptomatic aortic stenosis.  Am J Cardiol. 2009;  104 972-977
• 63 Messika-Zeitoun D, Aubry M C, Detaint D, Bielak L F. et al . Evaluation and clinical implications of aortic valve calcification measured by electron-beam computed tomography.  Circulation. 2004;  110 356-362
• 64 Feuchtner G M, Müller S, Grander W, Alber H F. et al . Aortic valve calcification as quantified with multislice computed tomography predicts short-term clinical outcome in patients with asymptomatic aortic stenosis.  J Heart Valve Dis. 2006;  15 494-498
• 65 Bergler-Klein J, Mundigler G, Pibarot P, Burwash I. et al . B-Type Natriuretic Peptide in Low-Flow, Low-Gradient Aortic Stenosis – Relationship to Hemodynamics an Clinical Outcome: Results from the Multicenter Truly or Pseudo-Severe Aortic Stenosis (TPAS) Study.  Circulation. 2007;  115 2848-2855
• 66 Horstkotte D, Loogen F. The natural history of aortic valve stenosis.  Eur Heart J. 1988;  9 (Suppl.) 57-64
• 67 Antonini-Canterin F, Huang G, Cervesato E, Faggiano P. et al . Symptomatic aortic stenosis: does systemic hypertension play an additional role?.  Hypertension. 2003;  41 1268-1272
• 68 Iung B, Baron G, Butchart E G, Delahaye F. et al . A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease.  Eur Heart J. 2003;  24 1231-1243
• 69 Goodney P P, O'Connor G T, Wennberg D E, Birkmeyer J D. Do hospitals with low mortality rates in coronary artery bypass also perform well in valve replacement?.  Ann Thorac Surg. 2003;  76 1131-1136
• 70 Kolh P, Kerzmann A, Honore C, Comte L, Limet R. Aortic valve surgery in octogenarians: predictive factors for operative and long-term results.  Eur J Cardiothorac Surg. 2007;  31 600-606
• 71 Kolh P, Lahaye L, Gerard P, Limet R. Aortic valve replacement in the octogenarians: perioperative outcome and clinical follow-up.  Eur J Cardiothorac Surg. 1999;  16 68-73
• 72 Vahanian A, Alfieri O, Al-Attar N, Antunes M. et al . Transcatheter valve implantation for patients with aortic stenosis: a position statement from the European Association of Cardio-Thoracic Surgery (EACTS), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI).  Eur Heart J. 2008;  29 1463-1470