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Sleep-disordered breathing and severe aortic stenosis

Schlafbezogene Atmungsstörungen und schwere Aortenstenose

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Abstract

Background

Aortic stenosis (AS) has been associated with sleep-disordered breathing (SDB), obstructive sleep apnea (OSA), and central sleep apnea (CSA). In patients undergoing transcatheter aortic valve implantation (TAVI), CSA may contribute to sudden cardiac death. Knowledge regarding complications and management of patients with TAVI and CSA is limited. This review defines the clinical manifestations of SDB, especially CSA, associated with AS and TAVI therapy. Prevalence, mechanisms, risk factors, and treatment options are reported.

Methods

Pubmed, Medline, and the Cochrane Database of Systematic Reviews were searched for prospective and retrospective studies, as well as case reports, in which SDB in AS was confirmed by polysomnography. Apnea was defined as a >90% reduction of airflow from baseline for >10 s; hypopnea as a >30% reduction in airflow with ≥4% O2 desaturation; apnea–hypopnea index (AHI) as the number of apnea and hypopnea episodes/h of sleep. AHI >5/h defined SDB. If the recording showed more than 50% central apnea events, this was defined as CSA; otherwise as OSA.

Results

Five studies reporting on 299 patients were included. Patients with severe AS had a high prevalence of SDB (235/299; 78.6%). In AS patients, CSA had a prevalence of 105/251 (41.8%) and OSA of 93/248 (37.5%). Studies reported a strong association with SDB severity. TAVI for severe aortic valve stenosis improved CSA in two studies but had no impact on OSA. Positive airway pressure therapy appears the best treatment for CSA in patients with TAVI. Continuous positive airway pressure (CPAP) may be ineffective in eliminating central apnea or even increase CSA. Adaptive servo ventilation (ASV) and bilevel positive airway pressure (BPAP) ventilation are alternative treatments.

Conclusion

The prevalence of SDB in AS patients ranges from 71 to 95%. The most important risk factor for higher CSA severity in AS patients was heart failure (HF). ASV and CPAP have demonstrated efficacy in treating SDB in patients with HF. Limited data and clinical experience are available for ASV treatment of patients with AS-associated SDB. Prospective studies on quality life and ASV treatment in these patients are needed.

Zusammenfassung

Fragestellung

Die Aortenstenose (AS) ist mit schlafbezogenen Atmungsstörungen (SDB), obstruktiver Schlafapnoe (OSA) und zentraler Schlafapnoe (CSA) assoziiert. Bei Patienten mit Transkatheter-Aortenklappenimplantation (TAVI) stellt eine CSA ein Risiko für plötzlichen Herztod dar. Das Wissen bezüglich der Komplikationen und dem Management von Patienten mit TAVI und CSA ist begrenzt. Diese Übersichtarbeit definiert die klinischen Bilder der SDB, besonders der CSA, im Zusammenhang mit AS und TAVI. Prävalenzen, Mechanismen, Risikofaktoren und Behandlungsoptionen werden erörtert.

Methoden

Es wurde eine Literatursuche bei Pubmed (1986–2016), Medline und der Cochrane-Datenbank systematischer Reviews (Januar 2005–2016) hinsichtlich prospektiver und retrospektiver Studien sowie Fallberichten zu AS mit polysomnographischem Nachweis von SDB durchgeführt. Apnoe war eine Reduktion des Luftflusses um >90 % vom Ausgangswert für >10 s Dauer. Hypopnoe war eine Reduktion des Luftflusses >30 % bei paralleler Sauerstoffentsättigung ≥4 %. Der Apnoe-Hypopnoe-Index (AHI) ist die Anzahl der Apnoen und Hypopnoen je Stunde Schlaf, und bei einem AHI >5/h werden SDB diagnostiziert. Liegen mehr als 50 % zentrale Apnoen vor, wird dies als CSA gewertet, anderenfalls als OSA.

Ergebnisse

Die Literatursuche ergab 5 Studien mit insgesamt 299 Patienten. Patienten mit schwerer AS wiesen eine hohe Prävalenz von SDB auf (235 von 299; 78,6 %). Eine CSA fand sich bei 105 von 251 (41,8 %) Patienten und eine OSA bei 93 von 248 (37,5 %) Patienten. Den Studien zufolge bestand eine enge Assoziation mit dem Schweregrad der SDB. Eine TAVI bei schwerer AS bewirkte eine Besserung der CSA in 2 Studien, hatte aber keinen Effekt auf die OSA. Eine Positivdruckbeatmung scheint die beste Therapie der CSA bei Patienten mit TAVI zu sein. Die kontinuierliche Positivdruckbeatmung mit CPAP erscheint nicht effektiv zur Beseitigung zentraler Apnoen und verstärkt mitunter sogar die CSA. Die adaptive Servoventilation (ASV) und die Bilevel-Positivdruckbeatmung (BPAP) werden als Therapiealternativen in Erwägung gezogen.

Schlussfolgerung

Es zeigte sich eine Prävalenz für SDB bei AS-Patienten zwischen 71 und 95 %. rWichtigste Risikofaktor für schwerere CSA bei den AS-Patienten war das Vorliegen einer Herzinsuffizienz. Bei der Therapie der SDB bei Patienten mit Herzinsuffizienz waren ASV und CPAP erfolgreich. Es liegen jedoch nur wenige Daten und wenig klinische Erfahrung mit der ASV-Behandlung bei Patienten mit SDB und AS vor. Prospektive Studien zur Lebensqualität und zur Behandlung dieser Patienten mit ASV sind erforderlich.

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Abbreviations

SDB:

Sleep-disordered breathing

AS:

Aortic stenosis

OSA:

Obstructive sleep apnea

CSA:

Central sleep apnea

CSR:

Cheyne–Stokes respiration

HF-REF:

Heart failure with reduced left ventricular function

TAVI:

Transcatheter aortic valve implantation

SAVR:

Surgical aortic valve replacement

AVR:

Aortic valve replacement

BAV:

Balloon aortic valvotomy

ASV:

Adaptive servo ventilation

BPAP:

Bilevel positive airway pressure

EPAP:

Expiratory positive airway pressure

T90:

Time spent with oxygen saturation 90%

SU-AVR:

Sutureless aortic valve replacement

CPB:

Cardiopulmonary bypass

HF:

Heart failure

BP:

Blood pressure

CHF:

Chronic heart failure

LV:

Left ventricular

SPAP:

Systolic pulmonary pressure

QoL:

Quality of life

PPM:

Permanent pacemaker

BNP:

Brain natriuretic peptide

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Funding

Funding was provided by National Natural Science Foundation of China (81360016)

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Authors and Affiliations

  1. Department of Respiratory and Critical Care Medicine, Karamay Central Hospital, Karamay, China

    Z. M. He & Z. Ye

  2. Sleep Medicine Center, Charité University Hospital, Luisenstr.13, 10117, Berlin, Germany

    C. Schoebel, T. Penzel & I. Fietze

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  1. Z. M. He
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  2. C. Schoebel
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Correspondence to Z. M. He.

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Z.M. He, C. Schoebel, T. Penzel, I. Fietze, and Z. Ye declare that they have no competing interests.

This article does not contain any studies with human participants or animals performed by any of the authors.

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He, Z.M., Schoebel, C., Penzel, T. et al. Sleep-disordered breathing and severe aortic stenosis. Somnologie 21, 265–272 (2017). https://doi.org/10.1007/s11818-017-0108-6

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