Paradoxical low flow-low gradient severe aortic stenosis: where are we?
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1 Journées Européennes de la SFC Paris, 15 janvier 2016 Paradoxical low flow-low gradient severe aortic stenosis: where are we? Nicolas Mansencal Hôpital Ambroise Paré, Boulogne Centre de Réf ce pour les M dies Card ques Héréditaires INSERM U-1018, CESP, EpReC Université de Versailles Saint-Quentin France
2 Conflits d intérêts J'ai actuellement, ou j'ai eu au cours des deux dernières années, une affiliation ou des intérêts financiers ou intérêts de tout ordre avec une société commerciale ou je reçois une rémunération ou des redevances ou des octrois de recherche d'une société commerciale : I currently have, or have had over the last two years, an affiliation or financial interests or interests of any order with a company or I receive compensation or fees or research grants with a commercial company : Affiliation/Financial Relationship Grant/Research Support Consulting Fees/Honoraria Major Stock Shareholder/Equity Royalty Income Ownership/Founder Intellectual Property Rights Congress Company N.A. AstraZeneca, Edwards Lifesciences, GSK, MSD, Novartis N.A. N.A. N.A. N.A. Bayer, MSD, Lilly
3 Classical AS N al flow, high gradient: Normal LVEF SVi > 35 ml/m² AVA < 1 cm² (0.6 cm²/m²) Mean gradient > 40 mmhg Low flow, low gradient: Depressed LVEF SVi 35 ml/m² AVA < 1 cm² (0.6 cm²/m²) Mean gradient 40 mmhg Pibarot JACC 2012
4 Pibarot JACC 2012
5 Definition of paradoxical low flowlow gradient severe aortic stenosis Aortic valve area 1.0 cm² ( 0.6 cm²/m²) Vmax < 4 m/s or mean gradient < 40 mmhg LVEF > 50% Stroke volume index < 35 ml/m² Measured when patient is normotensive (systolic BP < 140 mmhg) Nishimura JACC 2014
6 Several important questions What is the prevalence of LF/LG AS? What are the characteristics of this subpopulation? Is it possible to make some mistakes?????? What is the prognosis of LF/LG AS? Is surgery of interest?
7 Retrospective study 512 patients with AS and LVEF 50% Prevalence of paradoxal LF/LG AS: 35% Hachicha Circulation 2007
8 What is the prevalence of LF/LG AS? What are the characteristics? Uncertain Contradictory data (3-35%) # 10% (or < 10%) of AS Majority of women Older Mohty Circulation 2013, Triboulloy JACC 2015
9 Factors contributing to low-flow state more advanced stage of AS poorer prognosis Hachicha Circulation 2007, Pibarot Circulation 2013
10 Advanced state of AS? LF/LG AS have larger AVA, less LVH and similar focal fibrosis Barone-Rochette Circ Cardiovasc Imaging 2013
11 59 patients with 2 echo FU MDG (8 mmhg/y; 86%), V (0.36 m/s/y), AVA (0.04 cm²/y), LVEF 41% acquired the features of classical HG AS LG/LF AS is an intermediate stage between moderate AS and HG AS rather than an advanced form of the disease AJC 2015
12 LF/LG AS and measurement Echocardiographic errors Diameter of the LV outflow tract Velocity time integral of the LV outflow tract: PW Doppler Body size area Hypertension errors/pitfalls Inconsistencies of echocardiographic criteria for the grading of AS % depending on which echo criterion was used Minners EHJ 2008
13 LF/LG AS and hypertension 18 patients with LF/LG AS and hypertension Use of Na+ nitroprusside AVA Mean Gt Eleib Circulation 2013
14 LVOTd & VTI of the LVOT Calculation of aortic area V1 A1 V2 A2 Calculation of stroke volume A1 x V1 = A2 x V2 A2 = (A1 x V1) / V2 with A1 = π x diam²/4 Stroke volume = VTI1 x A1 with A1 = π x diam²/4 Need of several measurements
15 Issues of LVOTd Michelena Heart 2013 Underestimation of LVOT diameter Underestimation of aortic valve area False diagnosis of severe AS Underestimation of stroke volume False diagnosis of low flow, 83 years, BSA: 1.8, Vmax: 3 m/s, mean gradient: 24 mmhg LVOT diameter: 18 mm AVA: 0.90 cm² Svi: 28 ml/m² LVOT diameter: 20 mm AVA: 1.09 cm² Svi: 36 ml/m²
16 Complete assessment Multidetector CT Stress echo Strain echo Stress echo MDCT 33% with pseudosevere AS MDCT Aortic valve calcification score >2065 in >1274 in Clavel JACCi 2012, Adda Circi 2012, Clavel JACC 2013, Kamperidis EHJ 2015
17 What is the prognosis of LF/LG AS? Hachicha Circ 2007, Jander Circulation 2011, Lancellotti JACC 2012, Eleid Circ 2013, Mohty Circ 2013
18 Medical management Medical & surgical management Triboulloy JACC 2015
19 Is surgery of interest? American recommendations European recommendations 18 studies Improved outcome after AVR Dayan JACC 2015
20 LF/LG AS Adjusted for age, sex, body surface area, comorbidity, symptoms, coronary artery disease, atrial fibrillation, and ejection fraction HG AS the outcome of severe LG/LF aortic stenosis with preserved EF was not favorably influenced by aortic surgery Triboulloy JACC 2015
21 Magne Heart 2015
22 Take Home Message Controversial medical entity/contradictory data Definition of LF/LG AS: AVA 1.0 cm² ( 0.6 cm²/m²), Vmax < 4 m/s or MDG < 40 mmhg Svi < 35 ml/m², LVEF > 50%, normotensive pts False diagnosis (LVOTd, VTI of the LVOT) Adequate and complete assessment of AS Advanced state of AS or an intermediate stage between moderate AS and HG AS? Poorer prognosis or better prognosis? AVR or medical treatment?
23
24 Clavel JACC 2012 Eleib Circ 2013
25 Characterization of 512 consecutive patients with severe AS (AVAi <0.6 cm2/m2) and preserved ejection fraction (>0.50) based on for SVi > or 35 ml/m2 and mean pressure gradient > or 40 mmhg (data taken from Hachicha et al.2). Jean G. Dumesnil et al. Eur Heart J 2010;31: Published on behalf of the European Society of Cardiology. All rights reserved. The Author For permissions please journals.permissions@oxfordjournals.org.
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