Guidelines and surgical timing for aortic regurgitation

Linee guida e timing chirurgico dell’Insufficienza Aortica : che cosa attende migliore definizione Dr. Antonio Federico “ L’Insufficienza Valvolare Aortica” Villa Maria Cecilia Hospital 15 – 16 Maggio 2009

Natural History of Aortic Regurgitation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],ACC/AHA VHD Guidelines: 2008 Focused Update Incorporated JACC Vol. 52, No. 13, 2008 e1–142

Indici di performance ventricolare sinistra + + + + + + + + + + + S.F. (v.n. 25%-45%) + + + + + + + + + 0 + Dimens. sistoliche + + + + + + + + 0 + + + VCF (SF/ET) (v.n.>1,1circ./sc) + + + + + + + + + + + + dP/dt + + + + + + + + + + + + F.E. fattibilità Dipendenza Massa/vol. Dipendenza da postcarico Dipendenza da precarico Sensibilità a inotropismo

Indici di performance ventricolare sinistra ,[object Object],[object Object]

[object Object],Am. J. Cardiol. 2003;92:755-758

Diagnostic and prognostic value of N-terminal pro B-type natriuretic peptide in patients with chronic aortic regurgitation ,[object Object],[object Object],[object Object],[object Object],[object Object],International Journal of Cardiology 2008 Vol. 127 (3): 321-327

BNP e timing CCH nella SVA severa JACC 2006 (47), 11:2141 - 2151

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EF 54 % EF 51 % Rest Exercise Sv 5.4 cm/s Sv 6.1 cm/s Delay 60 ms F UP:Acute HF EF 34% Sv 2.4 cm/s “ Stress testing could be useful for the early detection of latent systolic failure”

Proposta flow chart per timing chirurgico in I. Ao DTD 55-70 mm + DTS 45/55 mm DTD > 70 mm + DTS > 55 mm F.E. > 55% F.E. < 55% dP/dt + BNP = < > + stress ECO = < Follow up CCH

Quale ruolo per la terapia medica ?

Quale ruolo per la terapia medica ? JACC 2005;45:1205-30

Quale ruolo per la terapia medica ? ,[object Object],[object Object],[object Object],JACC 2005;45:1205-30

Quale ruolo per la terapia medica ? ,[object Object],[object Object],[object Object],N Engl J Med 2005;353:1342-9 .

[object Object],Circulation 2004;110:1477 - 1483

Quale ruolo per la terapia medica ? ,[object Object],[object Object],[object Object],[object Object],J. Am. Coll. Cardiol. 2008;52;e1-e142

Quale ruolo per la terapia medica ? ,[object Object],[object Object],JACC 2008;52;e1-e142

Quando intervenire su I. Ao. associata ad altra valvulopatia ? ,[object Object],JACC 2005;45:1205-30

Insufficienza aortica + stenosi mitralica severa ,[object Object],[object Object],[object Object],[object Object],[object Object],JACC 2005;45:1205-30

Insufficienza aortica + insufficienza mitralica severe ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Quando operare una I. Ao. moderata ,[object Object],[object Object],[object Object],[object Object],[object Object],European Heart Journal (2007) 28, 230–268 1. AVR may be considered in patients with moderate AR while undergoing surgery on the ascending aorta. (IIb evidence: C) 2. AVR may be considered in patients with moderate AR while undergoing CABG. (II b evidence: C) JACC 2005;45:1205-30

La riparabilità della valvola modifica il timing chirurgico ? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],ACC/AHA VHD Guidelines: 2008 Focused Update Incorporated JACC Vol. 52, No. 13, 2008 e1–142

CONCLUSIONI ,[object Object],[object Object],[object Object],[object Object]

CONCLUSIONI ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Guidelines and surgical timing for aortic regurgitation

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Guidelines and surgical timing for aortic regurgitation