AORTIC VALVE STENOSIS – CURRENT VIEW ON DIAGNOSTICS AND TREATMENT Edited by Petr Šantavý Aortic Valve Stenosis – Current View on Diagnostics and Treatment Edited by Petr Šantavý Published by InTech Janeza Trdine 9, 51000 Rijeka, Croatia Copyright © 2011 InTech All chapters are Open Access articles distributed under the Creative Commons Non Commercial Share Alike Attribution 3.0 license, which permits to copy, distribute, transmit, and adapt the work in any medium, so long as the original work is properly cited After this work has been published by InTech, authors have the right to republish it, in whole or part, in any publication of which they are the author, and to make other personal use of the work Any republication, referencing or personal use of the work must explicitly identify the original source Statements and opinions expressed in the chapters are these of the individual contributors and not necessarily those of the editors or publisher No responsibility is accepted for the accuracy of information contained in the published articles The publisher assumes no responsibility for any damage or injury to persons or property arising out of the use of any materials, instructions, methods or ideas contained in the book Publishing Process Manager Alenka Urbancic Technical Editor Teodora Smiljanic Cover Designer Jan Hyrat Image Copyright Floris Slooff, 2011 Used under license from Shutterstock.com First published September, 2011 Printed in Croatia A free online edition of this book is available at www.intechopen.com Additional hard copies can be obtained from orders@intechweb.org Aortic Valve Stenosis – Current View on Diagnostics and Treatment, Edited by Petr Šantavý p cm 978-953-307-628-7 free online editions of InTech Books and Journals can be found at www.intechopen.com Contents Preface VII Chapter Congenital Aortic Stenosis in Childhood David Crespo and Nagib Dahdah Chapter Geriatric Aspects of Aortic Stenosis 35 Fatih Tufan, Fahrettin Öz, Ömer A Sayın and Hüseyin Oflaz Chapter Anaesthetic Considerations for Patients with Severe Aortic Stenosis 67 Subhamay Ghosh, Lajos Bogar and Ahmed Sabry Chapter Operative Management – Patient-Prosthesis Mismatch Koji Tsutsumi Chapter Patient-Prosthesis Mismatch After Aortic Valve Replacement 95 Pierre Wauthy and Sophie G Malekzadeh-Milani Chapter Pharmacologic and Non-Pharmacologic Treatment of Chronic Atrial Fibrillation – With Special Reference to Valvular Atrial Fibrillation in Rheumatic Heart Disease 113 Mohan Nair, Sanjeeb Patra and Vanita Arora Chapter Trends in Degenerative Aortic Disease: Novel Alternative Therapies for the Treatment of Severe Aortic Stenosis 129 Javier Gualis, Alejandro Diego, Antonio de Miguel and Mario Castaño 85 Preface Aortic stenosis is a major health problem with large personal and economic impact In the last decades there has been a trend of worldwide aging, and diseases which are common in elderly people will take an important place in clinical practice Aortic stenosis affects 3-5 percent of persons older than 65 years and leads to greater morbidity and mortality than other cardiac valve diseases Currently, aortic stenosis is the most frequent heart valve disease in industrialized countries and its prevalence increases with age Thus with the prolongation of life expectancy, the population of patients with aortic stenosis is expected to grow in the future The etiology of this disease is changing and is more precisely specified Diagnostics is changing with new trends and technical developments in echocardiography Guidelines and indications for aortic valve replacement are changing thanks to new trends in anesthesiology, surgery and mini-invasive approaches Patients previously considered too old or ill are now indicated for aortic valve replacement procedures The approach and management of isolated aortic valve stenosis between fetal life and late adolescence is discussed in the first chapter Bicuspid aortic valve as a most common form of congenital valve stenosis, is also described Since approximately 2% of people over the age of 65, 3% of people over the age of 75, and 4% of people over the age of 85 have the disorder, important geriatric aspects of aortic stenosis are discussed in the second chapter Highly accurate indications are extremely important in future treatment decisions Abnormal left ventricular response to exercise and change in the hemodynamic severity of the valvular disease add to the prognostic value of clinical symptoms Therefore stress testing is debated in the third chapter Successful valve replacement surgery in elderly and often polymorbid patients with congestive heart failure would not be possible without properly aimed modern anesthesia and monitoring Patients formerly considered inoperable are now profiting from valve replacement procedures Challenges in anesthesia and post-surgical care are described in chapter four The only mode of treatment of highly calcified degenerated native aortic valve is its replacement In chapter five types of surgical approaches and valve prostheses are discussed Currently, there is no artificial aortic valve prosthesis hemodynamically equal to native healthy aortic valve The condition, where the prosthesis orifice is distinctly smaller for a given patient than natively appropriate is defined as patient-prosthesis VIII Preface mismatch Clinical importance of this phenomenon is the subject of chapter six Atrial fibrillation is the most common concurrent arrhythmia associated with heart valve diseases and is very poorly tolerated by patients Sinus rhythm restitution contributes to hemodynamic heart output increase and clinical status improvement Atrial fibrillation treatment modalities are debated in chapter seven Despite increasing safeness of standard aortic valve replacement surgery, it is still greatly complex procedure connected with possible adverse complications especially in polymorbid elderly patients Therefore an effort to decrease extensiveness of surgery has led to development of mini-invasive approaches and procedures These principles and techniques, which are still evolving, are discussed in the final chapter Limited volume of this book cannot substitute comprehensiveness of textbooks, but tries to depict current advances in aortic valve stenosis evaluation and treatment Petr Šantavý, M.D., Ph.D Dept of Cardiac Surgery, Palacky Universtity Teaching Hospital, Olomouc, Czech Republic 132 Aortic Valve Stenosis – Current View on Diagnostics and Treatment The Core Valve The new Edwards Lifescience device, the Sapien-XT valve, can be delivered by an arterial or venous access site (anterograde or retrograde technique) as well as by a transapical approach; it has the CE mark since 2007 and has the FDA investigational device exemption for the PARTNER US trial Like the CoreValve system, more than 10.000 devices have been implanted all around the world with promising initial results It is constructed with a bovine pericardium valve sewed to a balloon expandable chromium-cobalt stent to be anchored to the calcified native aortic annulus Three sizes are commercialized: 23mm (for aortic annulus between 18 and 21mm), 26mm (for aortic annulus between 21 and 25mm) and the recently added 29mm size for annulus over 25mm The femoral sheath is 18F for the smaller size and 19F for the 26, and the transapical sheath is 22F for the smaller, 24F for the 26mm size and 26F for the 29mm No femoral system has been designed yet for the 29mm valve The Edwards Sapien XT valve 3.1 Indications Initially, these devices were only approved as compassionate therapy for non operable patients with severe symptoms (NYHA class IV dyspnea or angina), but after the initial results achieved, the indications of these proceedings are extending to any patient with symptomatic severe aortic stenosis and specific contraindication for cardiac surgery or very high perioperative risk profile It is reasonable to think that, as the technique is consolidating, the screening of patients for TAVI should follow the general Trends in Degenerative Aortic Disease: Novel Alternative Therapies for the Treatment of Severe Aortic Stenosis 133 recommendations for the management of patients with degenerative aortic stenosis reported by the scientific societies (Vahanian A et al., 2007,2008) 3.1.1 General indications of aortic valve replacement for aortic stenosis following the European Society of Cardiology clinical guidelines Patients with severe aortic stenosis and presence of any symptoms (Recommendation class IB) Asymptomatic patients with severe aortic stenosis and systolic dysfunction (LVEF 0,3m/s per year (IIaC) Patients with low gradient severe aortic stenosis (