|
Abstract
Calcified aortic stenosis is the most frequent valvular heart disease in the Western world. It is a
progressive, degenerative, atherosclerosis-like process that involves aortic valve with increasing
prevalence as the population ages. Surgical aortic valve replacement is relatively low risk operation, but
it has limitations in old patients with high perioperative risk and patients with comorbidities, and it is
contraindicated in patients, who are shocked, who have adjacent malignoma, abnormal pulmonary
function tests or significantly lower left ventricle ejection fraction.
Case report.
A case of a 85-year-old female patient with severe, symptomatic aortic stenosis and in a
septic shock is reported. Due to worsening of clinical picture we have decided for baloon aortic
valvuloplasty. After the procedure improvement in clinical picture has been noted, 3 weeks after it she
was stable and discharged home.
Conclusions.
Our case shows that there are additional therapeutic options for high risk patients with
severe aortic stenosis and comorbidities, which make surgical correction contraindicated. For them
baloon aortic valvuloplasty resembles a possibility for clinical improvement or bridge to appropriate
surgical treatment.
Uvod
Degenerativna stenoza aortne zaklopke je v razvitem svetu najpogostejša pridobljena bolezen srčnih
zaklopk v odraslem obdobju. Najpogosteje je posledica nerevmatičnih degenerativnih sprememb na
zaklopki, ki posnemajo aterosklerozo. Pojavlja se pri 1-9 % odraslih, starejših od 65 let, z višjo starostjo
pa se odstotek še zvišuje
(1, 2)
. Običajno zdravljenje hude stenoze aortne zaklopke pri simptomatskih
235
URGENTNA MEDICINA - IZBRANA POGLAVJA 2010
5.
McLeod CJ, Ommen SR, Ackerman MJ, Weivoda PL, Shen WK, Dearani JA, et al. Surgical septal myectomy
decreases the risk for appropriate implantable cardioverter defibrillator discharge in obstructive hypertrophic
cardiomyopathy. Eur Heart J 2007;28(21):2583–8.
6.
Sorajja P, Valeti U, Nishimura RA, Ommen SR, Rihal CS, Gersh BJ, et al. Outcome of alcohol septal ablation for
obstructive hypertrophic cardiomyopathy. Circulation 2008;118(2): 131–9.
7.
Maron BJ, Nishimura RA, McKenna WJ, Rakowski H, Josephson ME, Kieval RS. Assessment of permanent dual-
chamber pacing as a treatment for drug-refractory symptomatic patients with obstructive hypertrophic
cardiomyopathy. A randomized, double-blind, crossover study (M-PATHY). Circulation 1999;99(22):2927–33.
8.
Fananapazir L, Epstein ND, Curiel RV, Panza JA, Tripodi D, McAreavey D. Long-term results of dual-chamber
(DDD) pacing in obstructive hypertrophic cardiomyopathy. Evidence for progressive symptomatic and
hemodynamic improvement and reduction of left ventricular hypertrophy. Circulation 1994;90(6):2731–42.
9.
Elliott PM, Gimeno Blanes JR, Mahon NG, Poloniecki JD, McKenna WJ. Relation between severity of left-
ventricular hypertrophy and prognosis in patients with hypertrophic cardiomyopathy. Lancet
2001;357(9254):420–4
10. Autore C, Bernabo P, Barilla CS, Bruzzi P, Spirito P. The prognostic importance of left ventricular outflow
obstruction in hypertrophic cardiomyopathy varies in relation to the severity of symptoms. J Am Coll Cardiol
2005;45(7):1076–80.
11. Shakespeare CF, Keeling PJ, Slade AK, McKenna WJ. Arrhythmia and hypertrophic cardiomyopathy.
Arch.Mal.Coeur.Vaiss. 1992;85 Spec No 4:31-36.
12. Maron BJ, Shen WK, Link MS, et al. Efficacy of implantable cardioverter-defibrillators for the prevention of
sudden death in patients with hypertrophic cardiomyopathy. N Engl J Med 2000; 342:365-73.
13. Christiaans I, van Engelen K, van Langen IM, Birnie E, Bonsel GJ, Elliott PM, et al. Risk stratification for sudden
cardiac death in hypertrophic cardiomyopathy: systematic review of clinical risk markers. Europace
2010;12(3):313-21.
14. AJ Marian, Modifier genes for hypertrophic cardiomyopathy. Curr Opin Cardiol. 2002;17(3): 242–252.
234
URGENTNA MEDICINA - IZBRANA POGLAVJA 2010
so bili ti posegi uporavljeni, tudi po večkrat. Število hospitalizacij zaradi srčnega popuščanja se je
pomembno zmanjšalo, kakovost življenja pa bistveno izboljšala
(22).
Do spodbudnih rezultatov je prišla tudi pilotska študijia RADAR, kjer so za preprečevanje restenoz 20
bolnikov povprečne starosti 89 let izpostavili zunanjemu obsevanju. Zapletov povezanih s posegom ni
bilo, po enoletnem spremljanju pa je le v 12 % primerov prišlo do restenoz. Avtorji so menja, da
obsevanje preprečuje nastajanje brazgotin in kalcinacijo po dilataciji
(13).
V Kliničnem centru v Ljubljani smo v zadnjih 12 mesecih opravili 61 balonskih dilatacij aorte zaklopke.
Pri 6 bolnikih je balonska dilatacija omogočila operacijo karcinoma prebavil, pri dveh bolnikih v
septičnem šoku je BAV omogočil bolj optimalno zdravljenje bolnika in izboljšanje kliničnega stanja. Pri
večini bolnikov je BAV izboljšal telesno zmogljivost v povprečju za 0.7 NYHA razreda, zmanjšalo se je
število rehospitalizacij bolnikov (iz 1.6 hospitalizacij/bolnika/6 mesecev na 0.55) (glej tabelo). Pri večini
bolnikov pa je prišlo do ponovne zožitve aortne zaklopke.
Do'stlaringiz bilan baham: |
