Severe left ventricular dysfunction and valvular heart disease: should we operate?

Transcription

1 Severe left ventricular dysfunction and valvular heart disease: should we operate? Laurie SOULAT DUFOUR Hôpital Saint Antoine Service de cardiologie Pr A. COHEN JESFC 16 janvier 2016

2 Disclosure : No conflict

3 1. STS National Database Risk Calculator Roques et al.j Cardiothorac Surg 1999;15: Nashef et al.eur J Cardiothorac Surg 2012;41: Vahanian et al. European Heart Journal 2012;33: Background LVEF : important prognostic factor, included in current operative risk scores : STS score (1), EuroScore (2), Euroscore II (3) Clinical question remains whether it is too late to operate when the EF is severely depressed Clinical guidelines doesn t focus on this question (4) Operative mortality

4 Background Severe left ventricular dysfunction Medical treatment Overall mortality Valvular heart disease AR AS : low flow low gradient MR : primary/secondary Conventional surgery Percutaneous intervention Operative/ perioperative mortality Overall Mortality Symptoms : NYHA, CHF Echocardiography : LVEF

5 Aortic regurgitation

6 Severe left ventricular dysfunction and aortic regurgitation : should we operate? Vahanian et al. European Heart Journal 2012;33: Nishimura et al. Circulation. 2014;129:e521-e643.

7 Severe left ventricular dysfunction and aortic regurgitation : should we operate? Retrospective study. 450 patients / AVR for isolated AR ( ) EF <35% (LoEF, n=43) / EF 35% to 50% (MedEF, n=134) /EF 50% (Nl EF, n=273). Operative mortality rate : LoEF : 14%, MedEF: 6.7%, and Nl EF: 3.7% (p=0.02). CHF after AVR EF after AVR Survival after AVR Chaliki et al. Circulation 2002;106:

8 Severe left ventricular dysfunction and aortic regurgitation : should we operate? Retrospective cohort. 785 patients with severe AR. 166 patients had severe LV dysfunction (=EF 35%). 69% of these were men, age 65±16 years, and LVEF was 23±8% AVR (n=53) (32%) Clinical characteristics Survival curves in patients with EF 35% There is a clear reluctance to offer AVR in a large number of patients with severe AR associated with LV dysfunction. Kamath et al. Circulation. 2009;120:S134 S138

9 Aortic stenosis

10 Severe left ventricular dysfunction and aortic stenosis : should we operate? Vahanian et al. European Heart Journal 2012;33:

11 Severe left ventricular dysfunction and aortic stenosis: should we operate? Nishimura et al. Circulation. 2014;129:e521-e643.

12 Severe left ventricular dysfunction and aortic stenosis : should we operate? 2017 patients AS (AVA<1 cm², MG 40 mmhg, or IAVA<0.6 cm²/m²)/ AVR (1995 to June 2009) 4 groups : LVEF<50% in 300 [15%] patients, 50% 59% in 331 [17%], 60% 69% in 908 [45%], and 70% in 478 [24%] Overall survival as a function of LVEF. Dahl et al. Circ Cardiovasc Imaging. 2015;8:e002917

13 Severe left ventricular dysfunction and aortic stenosis : should we operate? Multicenter series, 217 patients (168 men, 77%) with severe AS (area <1 cm²), low EF ( 35%), and low MG ( 30 mm Hg) who AVR (1990 and 2005) NYHA functional class III or IV : pre-operatively 79%, compared with 16% after AVR (p = ). LVEF from 28±5% pre-operatively to 41±13% after AVR (p= ) Patients operated in the 1990 to 1999 era (n =112) and in the 2000 to 2005 era (n = 105) : operative mortality was lower in the recent era (10% vs. 20%, p = 0.04) 5-Year overall survival curve after RVA in the total population Levy et al. J Am Coll Cardiol 2008;51:

14 Severe left ventricular dysfunction and aortic stenosis : should we operate? Predictors of overall mortality In view of the very poor prognosis of unoperated patients, the current operative risk, and the long-term outcome after surgery, AVR is the treatment of choice in the majority of cases of LF/LGAS. Levy et al. J Am Coll Cardiol 2008;51:

15 Severe left ventricular dysfunction and aortic stenosis : should we operate? 384 patients : TAVI 2 groups: group A (50 patients) with left ventricular ejection fraction (LVEF) 35%, and group B (334 patients) with LVEF >35% Changes in LVEF In Hospital Outcome /Events Fraccaro et al. Circ Cardiovasc Interv 2012;5:

16 Mitral regurgitation

17 Severe left ventricular dysfunction and mitral regurgitation : should we operate? SMR Surgery should be considered in symptomatic patients with severe MR, LVEF <30%, option for revascularization, and evidence of viability (Iia, C) Vahanian et al. European Heart Journal 2012;33:

18 Severe left ventricular dysfunction and mitral regurgitation : should we operate? Nishimura et al. Circulation. 2014;129:e521-e643.

19 Severe left ventricular dysfunction and mitral regurgitation : should we operate? MIDA Registry patients / Mitral regurgitation (flail leaflets)/ Sinus rhythm 65±13 years; median EF, 66% [60% 71%] Mitral valve surgery : 1443 patients (77%), 85% valve repair Severe LV dysfunction : EF <30% 5 patients (0.3%); 438 patients with EF of 45% to 60%, 53 patients with EF <45%. Kaplan Meier : all-cause mortality according to EF in patients under conservative management. Tribouilloy et al. Circ Cardiovasc Imaging. 2014;7:

20 Severe left ventricular dysfunction and mitral regurgitation : should we operate? Curves are adjusted for sex, comorbidity index, symptoms, and coronary artery disease. Outcome in EF subsets of compared between surgical and medical management. Patients with EF <45% have severe LV dysfunction, catastrophic outcome under medical management, and should not be denied surgery. Tribouilloy et al. Circ Cardiovasc Imaging. 2014;7:

21 Severe left ventricular dysfunction and mitral regurgitation : should we operate? Retrospective (databases from Duke University ) 1441 patients : moderate or severe functional MR + severe LV dysfunction (LVEF 30% or LV end-systolic diameter >55 mm) Baseline characteristics Samad et al. European Heart Journal :

22 Severe left ventricular dysfunction and mitral regurgitation : should we operate? In patients with moderate or severe MR and severe LV dysfunction, mortality was substantial, and among those selected for surgery, MV surgery, though performed in a small number of patients, was independently associated with higher event-free survival. Samad et al. European Heart Journal :

23 Severe left ventricular dysfunction and mitral regurgitation : should we operate? 59 patients with reduced EF and severe MR/ MitraClip Subgroup of patients showing severely reduced LVEF <30% (EF 23+2%; n=25) Thirty-day mortality was 2.9% Mitral valve regurgitation (MR) class NYHA functional class LA volume, LVESD,EF Percutaneous MV repair using MitraClip TM is a safe technique in high-risk surgical patients, causing significant 1 year reduction of MR which results in structural cardiac reverse remodelling and an increased LVEF. The present data encourage percutaneous MV repair in heart failure patients. Pleger et al. Eur J Heart Fail Aug;15:

24 Conclusion The management of patients with severe left ventricular dysfunction and valvular heart disease is complex Cohort study/ no randomized trials Poor prognostic under medical treatment Improvement EF, NHYA after surgery Evolution of surgical therapy improvement of prognosis Patients should not be denied surgery Future : percutaneous techniques?