Die asymptomatische Aortenstenose

Zusammenfassung

Patienten mit symptomatischer hochgradiger Aortenstenose (AS) wird der Aortenklappenersatz dringend empfohlen. In asymptomatischer AS ist die klinische Strategie noch kontrovers. Prospektive Studien empfehlen ein abwartendes Vorgehen und Verlaufskontrollen. Vor allem bei älteren und komorbiden Patienten kann die Zuordnung des symptomatischen Status zur Erkrankung schwierig sein. Die robuste Messung des Stenosegrades ist daher notwendig, zumal auch Patienten mit asymptomatischer AS von frühem Klappenersatz profitieren. Dieser Übersichtsartikel stellt relevante klinische Studien und Richtlinien zum Management von Patienten mit asymptomatischer AS dar.

Abstract

In patients with symptomatic severe aortic stenosis (AS) therapeutic decision is straightforward and aortic valve replacement is strongly recommended. In asymptomatic AS patients clinical strategy is controversial and challenging. Prospective studies suggest a watchful waiting approach in the majority of patients with regular follow-up exams. Defining symptomatic status related to the disease can be particularly difficult in the elderly and patients with comorbidities. A robust measurement of AS severity is mandatory in this context. Nevertheless some patients with asymptomatic AS benefit from early valve replacement and reliable risk stratification for identification of high-risk patients is of importance. This review article will outline relevant clinical studies and guidelines on management of asymptomatic AS patients.

asymptomatische Aortenstenose - Echokardiographie - Risikostratifikation

asymptomatic aortic stenosis - echocardiography - risk stratification

Literatur

• 1 Bahlmann E, Cramariuc D, Gerdts E. et al . Impact of pressure recovery on echocardiographic assessment of asymptomatic aortic stenosis: a SEAS substudy.  J Am Coll Cardiol Img. 2010;  3 555-562
• 2 Bonow R O, 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 e523-e661
• 3 Cramariuc D, Cioffi G, Rieck A. et al . Low-flow aortic stenosis in asymptomatic patients valvular-arterial impedance and systolic function from the SEAS substudy.  J Am Coll Cardiol Img. 2009;  2 390-399
• 4 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
• 5 Hachicha Z, Dumesnil J G, Bogaty P, Pibarot P. Paradoxical low-flow, low-gradient severe aortic stenosis despite preserved ejection fraction is associated with higher afterload and reduced survival.  Circulation. 2007;  115 2856-2864
• 6 Jander N, Minners J, Holme I. et al . Outcome of patients with low gradient „severe” aortic stenosis and preserved ejection fraction.  Circulation. 2011;  123 887-895
• 7 Minners J, Allgeier M, Gohlke-Baerwolf C, Kienzle R P, Neumann F J, Jander N. Inconsistencies of echocardiographic criteria for the grading of aortic valve stenosis.  Eur Heart J. 2008;  29 1043-1048
• 8 Otto C M. Valvular aortic stenosis. Disease severity and timing of intervention.  J Am Coll Cardiol. 2006;  47 2141-2151
• 9 Otto C M, Burwash I G, Legget M E. et al . Prospective study of asymptomatic valvular aortic stenosis: clinical, echocardiographic and exercise predictors of outcome.  Circulation. 1997;  95 2262-2270
• 10 Pellikka P A, Sarano M E, Nishimura R A. et al . Outcome of 622 adults with asymptomatic, hemodynamically significant aortic stenosis during prolonged follow-up.  Circulation. 2005;  111 3290-3295
• 11 Pibarot P, Dumesnil J G. Low-flow, low-gradient, normal ejection fraction aortic stenosis.  Curr Cardiol Rep. 2010;  12 108-115
• 12 Rafique A M, Biner S, Ray I, Forrester J S, Tolstrup K, Siegel R J. Prognostic value of stress testing in patients with asymptomatic aortic stenosis.  Am J Cardiol. 2009;  104 972-977
• 13 Rosenhek R, Binder T, Porenta G. et al . Predictors of outcome in severe, asymptomatic aortic stenosis.  N Engl J Med. 2000;  343 611-617
• 14 Rosenhek R, Klaar U, Schemper M. et al . Mild and moderate aortic stenosis. Natural history and risk stratification by echocardiography.  Eur Heart J. 2004;  25 199-205
• 15 Rosenhek R, Zilberszak R, Schemper M. et al . Natural history of very severe aortic stenosis.  Circulation. 2010;  121 151-156
• 16 Ross J, Braunwald E. Aortic stenosis.  Circulation. 1968;  38 61-67
• 17 Rossebo A B, Pedersen T R, Boman K. et al . Intensive lipid lowering with Simvastatin and Ezetimibe in aortic stenosis.  N Engl J Med. 2008;  359 1-14
• 18 Vahanian A, Alfieri O, Al-Attar N. 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
• 19 Vahanian A, Baumgartner H, Bax J. 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