Aortic stenosis surgery
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Aortic Stenosis Microchapters |
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Diagnosis |
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Treatment |
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Percutaneous Aortic Balloon Valvotomy (PABV) or Aortic Valvuloplasty |
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Transcatheter Aortic Valve Replacement (TAVR) |
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Case Studies |
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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 |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editors-In-Chief: Claudia P. Hochberg, M.D. [2]; Abdul-Rahman Arabi, M.D. [3]; Keri Shafer, M.D. [4]; Priyamvada Singh, MBBS [[5]]
Assistant Editor-In-Chief: Kristin Feeney, B.S. [[6]]
Overview
Surgical intervention may be a necessary component of treatment. Intervention methods may include mechanical and devise based therapies such as bileaflet mechanical aortic valves. An alternative treatment method includes aortic valvuloplasty.
Surgery
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
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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
References
- ↑ 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.