Aortic stenosis surgery: Difference between revisions
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==[[Aortic stenosis surgery videos|Videos]]== | ==[[Aortic stenosis surgery videos|Videos]]== | ||
==Mechanical and device based therapy== | ==Mechanical and device based therapy== | ||
Revision as of 16:22, 12 November 2011
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Aortic stenosis surgery | |
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Treatment | |
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Aortic stenosis surgery On the Web | |
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American Roentgen Ray Society Images of Aortic stenosis surgery | |
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Risk calculators and risk factors for Aortic stenosis surgery | |
For the WikiPatient page for this topic, click here; For the main page of aortic stenosis, click here
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Mohammed A. Sbeih, M.D.[2]; Claudia P. Hochberg, M.D. [3]; Abdul-Rahman Arabi, M.D. [4]; Keri Shafer, M.D. [5]; Priyamvada Singh, MBBS [6]; Assistant Editor-In-Chief: Kristin Feeney, B.S. [7]
Overview
Indications
Preoperative Evaluation
Procedure
Recovery
Outcomes & Prognosis
Complications
Videos
Mechanical and device based therapy
Aortic stenosis requires aortic valve replacement if medical management does not successfully control symptoms. According to a prospective, single-center, nonrandomized study of 25 patients, percutaneous implantation of an aortic valve prosthesis in high risk patients with aortic stenosis results in marked hemodynamic and clinical improvement when successfully completed.[1]
Bileaflet mechanical aortic valve <googlevideo>4541951625687665949&hl=en</googlevideo>
Aortic valvuloplasty
Patient selection and treatment choices
- Surgical Aortic valve replacement is the treatment of choice for aortic stenosis but many patients are not good candidates due to advanced age and multiple co-morbidities
- Percutaneous aortic valve replacement is in its infancy and thus aortic valvuloplasty can offer palliation of symptoms and potentially prolong survival for these high risk patients in class III-IV heart failure
- It can be performed emergently in patients with end-stage heart failure due to aortic stenosis: patients in cardiogenic shock, as a bridge to aortic valve replacement, patients with critical aortic stenosis needing emergent non-cardiac surgery, poor surgical candidates and nonagenerians, patients with congenital or rheumatic aortic stenosis
- Results usually last 6 months up to 2 years (with repeat procedures possible if aortic regurgitation is not severe)
- Valvuloplasty tends to alleviate heart failure symptoms and improve hemodynamics but rarely does it alleviate angina
Technique
The retrograde technique is the most commonly used technique.
- 8 French femoral sheath can usually accommodate a 20 mm balloon and minimizes vascular complications
- Alternatively two 6 Fr sheath from bilateral femoral approach and two smaller balloons can be used
- The letter may be necessary in female elderly patients with concomitant peripheral vascular disease
- 0.035” straight wire is commonly used to cross the valve and advance via pig-tail or Amplatz catheter; Right heart catheterization is done and transaortic gradient is typically measured pre-procedure
- The 0.035” wire is then exchanged for a stiffer 0.038”Amplatz exchange length wire with the tip shaped into a pig-tail shape so as not to injure the LV
- The 20-23 mmX 6 cm balloon is advance over the wire and positioned to straddle the aortic valve
- The balloon is manually inflated with a 60 cc syringe containing diluted contrast (slowly)
- Meticulous control of balloon position must be maintained at all times by backward traction on the balloon to prevent jumping forward and injuring/perforating the LV apex
Complications
Complications stemming from aortic stenosis surgical therapies primarily involve vascular complications.
The most preferable surgical closure method for this tenuous patient population is a perclose or angioseal closure. This particular closure method calls for a mandatory attention to the meticulous access technique. An antegrade approach may be a viable method in some patient populations. An example of such would be the venuous access with transseptal approach. This particular procedure can be done in a select population of patients. Many patients experience an adverse response to the hemodynamic effect of mitral valve incompetence. In this situation, the rigidity of the wire traveling across the mitral valve can directly result in mitral valve injury. It is, therefore, not an advisable treatment method for most populations.
External Links
- ↑ Grube E, Laborde JC, Gerckens U; et al. (2006). "Percutaneous implantation of the CoreValve self-expanding valve prosthesis in high-risk patients with aortic valve disease: the Siegburg first-in-man study". Circulation. 114 (15): 1616–24. doi:10.1161/CIRCULATIONAHA.106.639450. PMID 17015786.