Aktuelle Aspekte der herznahen Aortenchirurgie

Zusammenfassung

Erkrankungen der thorakalen Aorta erfordern je nach Komplexität der Pathologie eine interdisziplinäre Behandlungsstrategie und -planung. Der Zeitpunkt der operativen Sanierung ist dabei entscheidend. Während bei dem potenziell letalen Pathologienkomplex des akuten Aortensyndroms in Bezug auf die Notfallindikation Konsens besteht, beruht die Entscheidung bei degenerativen Aortenaneurysmen auf verschiedenen Faktoren, die von den unterschiedlichen Fachgesellschaften teilweise divergent beurteilt werden und folglich geografisch unterschiedliche Leitlinien und Empfehlungen bedingen. Grundlage der Indikationsstellung bildet bis dato immer noch der maximale Aortendiameter sowie dessen jährliche Zunahme, evaluiert in der Computer- oder Magnetresonanztomografie. Zudem müssen ätiologische Einflussgrößen wie das Marfan-Sydrom berücksichtigt werden. Die chirurgische Therapie orientiert sich grundsätzlich an Lokalisation und Ausmaß des Aneurysmas, wobei man in den letzten Jahren v. a. bei komplexen Pathologien zu einer einzeitigen und vollständigen Sanierung tendiert. Konservative Ansätze umfassen Veränderungen des Lebensstils und die Behandlung mit β-Blockern oder Losartan, auch postoperativ. Voraussetzung für eine umfassende und optimale Behandlung von komplexen Aortenerkrankungen ist allerdings die frühzeitige Anbindung an ein spezialisiertes Aortenzentrum.

Abstract

Depending on the complexity of the pathology, thoracic aortic diseases require interdisciplinary treatment strategies. Optimal timing of surgical intervention is essential. Acute aortic syndromes are potentially lethal and require emergency surgery. In cases of degenerative aortic aneurysms several factors contribute to the indication for surgery which tend to be judged diversely by different associations resulting in varying guidelines and recommendations. So far, the indication for surgery is still based on the maximum aortic diameter and its annual progress, based on computed or magnetic resonance tomography imaging. Additional contributing criteria are etiological factors such as Marfanʼs syndrome. Surgical therapy is based on localization and extent of the aneurysm. Recently, single-stage procedures resulting in repair of the whole pathology especially in complex cases are preferred. Conservative approaches comprise lifestyle changes and medical treatment with beta-blockers and losartan both of which is indicated post-operatively as well. In order to achieve comprehensive and optimal treatment of aortic pathologies, referral to specialized centers is necessary.

Schlüsselwörter

Aortenchirurgie - akutes Aortensyndrom - Aortenaneurysma - Leitlinien Aortenchirurgie - Marfan-Syndrom - bikuspide Aortenklappe - Hybrid-Technik

Key words

aortic surgery - acute aortic syndrome - aortic aneurysm - guidelines aortic surgery - Marfanʼs syndrome - bicuspid aortic valve - frozen elephant trunk

• Literatur

• 1 Erbel R, Alfonso F, Boileau C et al. Diagnosis and management of aortic dissection. Eur Heart J 2001; 22: 1642-1681
• 2 Hiratzka LF, Bakris GL, Beckman JA et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology,American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons,and Society for Vascular Medicine. J Am Coll Cardiol 2010; 55: e27-e129
• 3 Booher AM, Eagle KA, Bossone E. Acute aortic syndromes. Herz 2011; 36: 480-487
• 4 Ahmad F, Cheshire N, Hamady M. Acute aortic syndrome: pathology and therapeutic strategies. Postgrad Med J 2006; 82: 305-312
• 5 Coady MA, Rizzo JA, Hammond GL et al. What is the appropriate size criterion for resection of thoracic aortic aneurysms?. J Thorac Cardiovasc Surg 1997; 113: 476-491 discussion 489–491
• 6 Booher AM, Eagle KA. Diagnosis and management issues in thoracic aortic aneurysm. Am Heart J 2011; 162: 38-46.e1
• 7 Danyi P, Elefteriades JA, Jovin IS. Medical therapy of thoracic aortic aneurysms: are we there yet?. Circulation 2011; 124: 1469-1476
• 8 Lavall D, Schäfers JH, Böhm M et al. Aneurysms of the ascending aorta. Dtsch Arztebl Int 2012; 109: 227-233
• 9 Kallenbach K, Schwill S, Karck M. [Modern aortic surgery in Marfan syndrome–2011]. Herz 2011; 36: 505-512
• 10 Elefteriades JA, Farkas EA. Thoracic aortic aneurysm clinically pertinent controversies and uncertainties. J Am Coll Cardiol 2010; 55: 841-857
• 11 Braverman AC. Medical management of thoracic aortic aneurysm disease. J Thorac Cardiovasc Surg 2013; 145 (Suppl. 03) S2-S6
• 12 Beller CJ, von Tengg-Kobligk H. Computermodellierung und multimodale 4D-Bildgebung für Risikostratifizierung und Operationsplanung bei Erkrankungen der thorakalen Aorta. Z Herz-Thorax-Gefäßchir 2012; 26: 316-321
• 13 Wang Y, Barbacioru CC, Shiffman D et al. Gene expression signature in peripheral blood detects thoracic aortic aneurysm. PLoS One 2007; 2: e1050
• 14 Davies RR, Goldstein LJ, Coady MA et al. Yearly rupture or dissection rates for thoracic aortic aneurysms: simple prediction based on size. Ann Thorac Surg 2002; 73: 17-27 discussion 27–28
• 15 Patel HJ, Deeb GM. Ascending and arch aorta: pathology, natural history, and treatment. Circulation 2008; 118: 188-195
• 16 Haverich A, Hagl C. Organ protection during hypothermic circulatory arrest. J Thorac Cardiovasc Surg 2003; 125: 460-462
• 17 Hagl C, Pichlmaier M, Khaladj N. Elephant trunks in aortic surgery: fresh and frozen. J Thorac Cardiovasc Surg 2013; 145 (Suppl. 03) S98-S102
• 18 Vallabhajosyula P, Szeto W, Desai N et al. Type I and Type II hybrid aortic arch replacement: postoperative and mid-term outcome analysis. Ann Cardiothorac Surg 2013; 2: 280-287
• 19 Groenink M, den Hartog AW, Franken R et al. Losartan reduces aortic dilatation rate in adults with Marfan syndrome: a randomized controlled trial. Eur Heart J 2013; 34: 3491-3500
• 20 Braverman A, Harris K, Pyeritz R et al. Aortic dissection during pregnancy: results from the International Registry of Acute Aortic Dissection (IRAD). J Am Coll Cardiol 2012; 59?A: A467
• 21 Beckmann A, Funkat AK, Lewandowski J et al. Cardiac surgery in Germany during 2012: a report on behalf of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiovasc Surg 2014; 62: 5-17
• 22 Mao SS, Ahmadi N, Shah B et al. Normal thoracic aorta diameter on cardiac computed tomography in healthy asymptomatic adults: impact of age and gender. Acad Radiol 2008; 15: 827-834
• 23 Suzuki T, Bossone E, Sawaki D et al. Biomarkers of aortic diseases. Am Heart J 2013; 165: 15-25