Shahbudin H. Rahimtoola MB, FRCP, MACP, MACC, FESC, D.Sc. (Hon.)
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1 Shahbudin H. Rahimtoola MB, FRCP, MACP, MACC, FESC, D.Sc. (Hon.) DISCLOSURE As Editor, Current Problems in Cardiology Elsevier Honoraria for educational lectures from: American College of Cardiology Foundation; American College of Physicians; University of California, Los Angeles; University of California, Irvine; Cornell University; Creighton University; Thomas Jefferson University; Cedars-Sinai Medical Center; Harvard Medical School; University of Wisconsin; Wake Forest University; University of Hawaii; Cardiologist s Association, Hong Kong, China; Beverly Hospital Medical Center; North Florida Cardiovascular Association; San Bernardino Medical Center; ATS, St. Jude Medical, Carbomedics, Edwards Life Sciences, Merck, Pfizer,
2 ESC, Paris, 2011 Session: Controversies in Asymptomatic Valvular Disease 8:30-10:00 Severe Aortic Stenosis Should be Operated Before Symptom Onset: PRO Shahbudin H. Rahimtoola Los Angeles, USA Monday 29 August 2011; 09:15-09:30 Pres. No Berne-Zone E
3 Symptom (simp tŏm). Any morbid phenomenon or departure from the normal in structure, function, or sensation, experienced by the patient and indicative of disease. (1) Symptom (simp təm). [L. symptoma; Gr. symptōma anything that has befallen one]. Any subjective evidence of disease or of a patient s condition, i.e., such evidence as perceived by the patient; a noticeable change in a patient s condition indicative of some bodily or mental state. (2) (1) Stedman s Medical Dictionary 25 th Edition, page 1718, Williams & Wilkins 1995 (2) Dorland s Illustrated Medical Dictionary 31 st Edition, page 1843, Saunders, Elsevier 2007
4 Predictors of Outcome in Severe, Asymptomatic Aortic Stenosis Patients with moderate or severe valve calcification and those with rapid increase in aortic jet velocity have an event rate of 79% at 2 years. Conclusions:.... However, outcomes vary widely.... These patients should be considered for early valve replacement rather than have surgery delayed until symptoms develop. R. Rosenhek, MD..... Helmut Baumgartner, MD N Engl J Med 2000;343:611-7
5 AVR for Patients with Severe AS Guidelines Recommendations CLASS I ACC/AHA Level of Evidence ESC Level of Evidence Symptomatic B B Undergoing CABG or Surgery on Aorta or Other Heart Valves C C LV Systolic Dysfunction (LVEF <0.50) C B Abnormal Ex Test with Symptoms - C Bonow RO et al. Circulation 2006;114:e Vahanian A et al. Eur Heart J 2007;28:
6 AVR for Patients with Severe AS Recommendations CLASS IIa ACC/AHA Level of Evidence Guidelines ESC Level of Evidence Moderate AS Undergoing Surgery for CAD, Aorta, other Valve Disease B C Severe AS Ex. Test Positive plus Symptoms or Fall of BP - C Mod-Severe Valve Calcification, and Ao Vel >0.35 m/sec/year Low gradient (<40mmHg) and LV dysfunction plus contractile reserve Bonow RO et al. Circulation 2006;114:e Vahanian A et al. Eur Heart J 2007;28: C - C
7 A SUGGESTED GRADING OF THE DEGREE OF AORTIC STENOSIS Aortic Stenosis AVA, cm 2 AVA Index, cm 2 /m 2 Mild >1.5 >0.9 Moderate >1.0 to 1.5 >0.6 to 0.9 Severe <1.0 <0.6 Very Severe / <0.7 <0.4 ( Critical ) *Patients with AVA s that are borderline values between the moderate and severe grades ( cm 2 ; cm 2 /m 2 ) should be individually considered. Update from Rahimtoola SH. JACC 1989;14:1-23 Rahimtoola SH. EHJ 2008;29:
8 Severe AS Clinical Evaluation plus Mean Gradient >50 mm Hg * and/or AVAI * <0.6 cm 2 /m 2 ELI ELI = Energy Loss Index [(AVA x A A ) / A A AVA] Doppler/Echo at Sino-tubular Junction * Cardiac Cath Bahlmann E. et al. JACC Img 2010;3: Garcia D et al. Circulation 2000;101: Rahimtoola SH JACC Img 2010;3:
9 Asymptomatic Patients with AS Event Rate At 1 Year 2 Years Otto * 30% 79 ± 18% Rosenhek ** 33 ± 5% 44 ± 5% Amato 43 ± 6% 62 ± 6% Lancellotti 20% - Das 29% - Pellikka ** 20% 37% Rosenhek 36 ± 6% 64 ± 5% Stewart RAH <1.0 cm 2 ~58%+ Otto CM et al. Circulation 1997;95: Rosenheck R et al. NEJM 2000;343: Amato MCM et al Heart 2001; 86: Lancellotti P. et.al. Circulation 2005;112 (Suppl II): Das P et al. Eur Heart J 2005;26: Pellikka PA et al Circulation 2005; 111: Rosenhek el al. Circulation 2010;121: Range: 1.5 to 3% per month * >4 m/s <1.0 cm2 ** >4 m/s cardiac death <1.2 cm2 symptoms + symptoms
10 At Start: 622 Asymptomatic Pts. Peak Velocity >4.0 m/s; AVA 0.9 ± 0.2 Survival Free of Cardiac Events (%) Survival Free of Symptoms (%) cm 2 * Symptoms AVR or Cardiac Death 1 yr 18% 20% 3 yrs 33% 37% 5 yrs 67% 75% 7 yrs >80% Years No. at risk Pellikka P et al. Circulation 2005;111: * Available in 293 (47%)
11 Event-Free Survival (%) Rosenhek R et al. Circulation 2010;121: Vienna Study AVA > < 0.6 cm 22 AVA P = > 0.6 cm Years Pts at risk AVA >0.6 cm AVA <0.6 cm
12 Symptom deterioration-free survival New Zealand Study A B A. AV peak vel <350 cm/s B. 350 cm/s < AV peak vel <400 cm/s C. AV peak vel > 400 cm/s C A. B. C S S Follow-up time (years) Judge DP EHJ 2010;31:
13 Sudden Death (SD) in AS Pts. No. SD Rosenhek R et.al % Amato MCM et.al %* Lancellotti P et.al %* Pellikka PA et.al % Rosenhek R et.al % Hartzell M et al % Stewart RAH et al % (3+1) Lund O. et al. 99 7% Maron BJ % Razavi M et.al % Rosenhek R et al. NEJM 2000;343: Amato MCM et al. Heart 2001;86: Lancellotti P. et.al. Circulation 2005;112 (Suppl II): Pellikka PA et al Circulation 2005; 111: Maron BJ. NEJM 2003;349: Razavi M et al, ACC Anaheim, March 2000 Rosenhek R et al. Circulation 2010;121: Haratzell M et al. AJC 2011;107: Stewart RAH EHJ 2010;31: Lund O et al.jtcvs 1996;44: * All pts. had positive exercise test SD in athletes Pathologic specimens at Mayo C
14 183 Asymptomatic Severe AS: New Zealand FOLLOW-UP (at 6 mos. Intervals)» In clinic» Clinical evaluation and ECHO/DOPPLER» 31 mos (IQR 14 40)» Symptomatic: 106 (58%) 103 (81%) at least 12 mos F-U (means 19% did not do so) Increasing SOB and/or angina on exertion 3 sudden deaths, 1 CA with resuscitation 95 referred for surgery At baseline had smaller AVA and higher Ao Peak Vol. On follow-up: Greater decrease of AVA and greater increase of Ao Peak Vel. No data on coronary arteriography autopsy? Stewart RAH et al EJH 2010;31:
15 Predictors of Outcome in Severe, Asymptomatic Aortic Stenosis Patients with moderate or severe valve calcification and those with rapid increase in aortic jet velocity have an event rate of 79% at 2 years. Conclusions:.... However, outcomes vary widely.... These patients should be considered for early valve replacement rather than have surgery delayed until symptoms develop. R. Rosenhek, MD..... Helmut Baumgartner, MD N Engl J Med 2000;343:611-7
16 Mild and moderate aortic stenosis Natural history and risk stratification by echocardiography Multivariate analysis of clinical and echocardiographic predictors of outcome Multivariate Variable P Risk Ratio AV Calcification (score 3 or 4) R. Rosenhek....Helmut Baumgartner Eur Heart J 2004;25: ( ) Coronary artery disease ( ) AV Peak Velocity >3 m/s ( )
17 Aortic Stenosis: Asymptomatic Peak Aortic Velocity >4 m/s Pts. No. 26 Age 63 ± 16 yrs EVENTS (AVR and/or Death):» At 2 yrs: 79 ± 18%* All Patients 123 Coro. Art. 52/123 (42%) SIGNIFICANT CAD 26/52 (50%) LMCAD 7/26 (27%) 3 VD 5/26 (20%) 2 VD 4/26 (15%) 1 VD 10/26 (38%) * By actuarial analysis Otto C et al. Circulation 1997;95:
18 Isolated AVR Incidence of Associated CAD Pts. No. CAD (%) VA Co-op Study Mayo Clinic MGH (>80 yrs. old) Aachen & Mannheim, DE Mayo Clinic ( ) 1, additional papers * 41, 50, 65 Sethi GK et al. JTCVS 93:844;1987 Mullany CJ et al. JACC 10:66;1987 Greason KL et al. ATS 2011;91: Levinson JR et al. Circulation 80:I-49,1987 Kaden JJ et al. JHVD 2006;15: * Reviewed by Iung Heart 2000;84:347-52
19 Initially Asymptomatic Severe AS 622 did NOT have AVR Initially Remained Asymptomatic (325; 52.3%) Mortality»145 (45%) AVR 28%»180 (55%) No AVR 57% Pellikka PA et al. Circulation 2005;111:3290-5
20 All Patients with Severe AS Should be Considered for AVR
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