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1 Potential Conflicts of Interest ESC Stockholm 2010 Bernard Iung, MD Speaker s fee / Consultancy: St. Jude Medical Edwards Lifesciences Sanofi-Aventis Servier Boehringer Ingelheim

2 Acute Decompensation of Chronic Valve Disease Bernard Iung Groupe Hospitalier Bichat - Claude Bernard Paris, France

3 Background Valvular disease may cause acute heart failure 7% of patients with acute heart failure had aortic stenosis (Euro Heart Survey on Heart Failure Eur Heart J 2003;24:442-63) Heterogeneity of mechanisms AS / chronic organic regurgitations / functional MR Contribution of valvular disease and LV dysfunction Triggering factors Difficulties in diagnosis Particularities of medical therapy Indications for surgery

4 Diagnosis of Valvular Disease Clinical examination Valvular disease revealed by acute heart failure Low-intensity cardiac murmur Echocardiographic analysis Pitfalls in quantitation due to low-output (gradients, severity indices of regurgitation) Fluctuations in the severity of regurgitations (medical therapy, functional MR ) Interaction with triggering factors (tachyarrhythmia )

5 Euro Heart Survey LV Function and Heart Failure 5001 pts included 3547 patients with native valve disease (Iung et al. Eur Heart J 2003;24: ) LVEF (%) p< I II III IV NYHA Class European Society of Cardiology Euro Heart Survey

6 Aortic Stenosis

7 Medical Therapy in Decompensated AS Nitroprusside 25 patients with AS 1 cm², LVEF 35%, cardiac index 2.2 l/min/m² and heart failure (Khot et al. N Engl J Med 2003;348: ) Dobutamine (mean 27 µg/kg/min in 27 pts) (Lin et al. Am Heart J 1998; 136:1010-6)

8 Natural History of AS Median survival 2 years if congestive heart failure (Ross and Braunwald Circulation 1968;38(Suppl.V):61-7) Median survival < 1 year if heart failure and LVEF < 50% (Aronow et al. Am J Cardiol 1993;72:846-8)

9 AVR for AS with LV Dysfunction Connolly et al. (Circulation 1997) Powell et al. (Arch Intern Med 2000) Pereira et al. (J Am Coll Cardiol 2002) Sharony et al. (Ann Thorac Surg 2003) Rothenburger at al. (Eur J Cardiothorac Surg 2003) Vaquette et al. (Heart 2005) Levy et al. (J Am Coll Cardiol 2008) Selection n= Prev. MI (%) CABG (%) LVEF (%) Op.Death (%) EF 35% ±6 9 EF 30% ±6 18 EF 35% and P 30 mmhg ±6 8 EF 40% EF 30% ±4 17 EF 30% ±5 12 EF 35% and P 30 mmhg ±6 16

10 Spontaneous Prognosis Natural History of Aortic Stenosis 205 patients aged 70 yrs, 94 pts (46%) operated on Stratification of spontaneous prognosis - LV dysfunction (RR=4.8) - mitral regurgitation (RR=2.0) 3 risks groups - class III or IV (RR=1.6) (Bouma et al. Heart 1999;82:143-8)

11 AS with LV Dysfunction Surgery vs. Natural History 159 pts with AS, LV EF 35% and mean gradient 30 mmhg Subgroup of 95 propensity-matched patients : 39 underwent AVR 56 were medically treated (Pereira et al. J Am Coll Cardiol 2002;39: )

12 Aortic Valve Disease and LV Dysfunction Clinical Features EF 40% (n=986) EF<40% (N=416) Age (years) 67±0.5 69± Previous cardiac surgery (%) <0.001 Previous MI (%) <0.001 Diabetes (%) Renal disease (%) <0.001 Peripheral vascular disease (%) CHF (%) <0.001 Urgent / Emergent surgery (%) <0.001 p (Sharony et al. Ann Thorac Surg 2003;75: )

13 Indications for Surgery in Symptomatic Aortic Stenosis Patients with severe AS and any symptoms Patients with severe AS undergoing coronary artery bypass surgery, surgery of the ascending aorta, or on another valve Patients with moderate AS* undergoing CABG, surgery of the ascending aorta or another valve AS with low gradient (< 40 mmhg) and LV dysfunction with contractile reserve AS with low gradient (< 40 mmhg) and LV dysfunction without contractile reserve Class IB IC IIaC IIaC IIbC * Moderate AS is defined as valve area 1.0 to 1.5 cm² (0.6 cm²/m² to 0.9 cm²/m² BSA) or mean aortic gradient 30 to 50 mmhg in the presence of normal flow conditions. VHD Guidelines Slide-set 2007 European Society of Cardiology

14 Balloon Aortic Valvuloplasty in Cardiogenic Shock n Mortality (%) Secondary AVR (%) FU (mo) Survival (%) Moreno Cribier Smedira Losordo Desnoyers Friedman Balloon valvulopalsty can be considered as a bridge to surgery in haemodynamically unstable patients who are at high risk for surgery (IIbC). (ESC Guidelines 2007)

15 TAVI in High-Risk Patients with AS 345 procedures in 339 patients (6 centres) 30-day mortality 10.4% Transfemoral Transapical Predictors of late mortality procedural sepsis, hemodynamic support, pulmonary hypertension, chronic kidney disease, COPD (Rodés-Cabau et al. J Am Coll Cardiol 2010;55: )

16 Aortic Regurgitation

17 AR with LV Dysfunction 166 patients with AR with LVEF 35% (53 patients operated on) After adjustment on propensity analysis RR of intervention 0.59 [ ] (p=0.04) (Kamath et al. Circulation 2009;120[suppl.I]:S134-8)

18 Indications for Surgery in Aortic Regurgitation Severe AR Symptomatic patients (dyspnoea NYHA class II, III, IV or angina) Asymptomatic patients with resting LV EF 50% Patients undergoing CABG or surgery of ascending aorta, or on another valve Asymptomatic patients with resting LV EF > 50% with severe LV dilatation: End diastolic dimension > 70 mm or End systolic dimension > 50 mm (or > 25 mm/m² BSA)* Class IB IB IC IIaC IIaC * Changes in sequential measurements should be taken into account. VHD Guidelines Slide-set 2007 European Society of Cardiology

19 Organic Mitral Regurgitation

20 Impact of LV Function on Operative Mortality Predictors of operative mortality in 409 patients operated on for organic MR Age (p=0.0003) Date of intervention (p=0.003) Functional class (p=0.016) (Enriquez-Sarano et al. Circulation 1994;90:830-7) Low operative mortality reported in patients with MR and severe LV dysfunction 2.1% in 46 pts with organic MR and LVEF <45% (Shah et al. Ann Thorac Surg 2005;80: ) 5.4% in 727 pts with LVEF 30% vs. 3.1% in pts with LVEF >30% (univariate p=0.01, multivariate p=0.09) (Haan et al. Ann Thorac Surg 2004;78:820-5)

21 Impact of LV Function on Late Survival After Surgery 488 patients undergoing valve repair for organic MR 61 ± 6% survival at 15 years Multivariate predictors RR [95% CI] p Age (per 5 yrs). 1.2 [ ] NYHA class III/IV 3.0 [ ] COPD 3.1 [ ] LVEF <40% 2.7 [ ] Prior stroke 3.2 [ ] Redo surgery 4.6 [1.4-15] 0.01 (David et al. J Thorac Cardiovasc Surg 2003;125: )

22 Indications for Surgery in Severe Chronic Organic Mitral Regurgitation Symptomatic patients with LV EF > 30% and ESD < 55 mm* Asymptomatic patients with LV dysfunction (ESD > 45 mm* and /or LV EF 60%) Asymptomatic patients with preserved LV function and AF or pulmonary hypertension (spap >50 mmhg at rest) Patients with severe LV dysfunction (LV EF < 30% and/or ESD > 55 mm*) refractory to medical therapy with high likelihood of durable repair and low comorbidity Asymptomatic patients with preserved LV function, high likelihood of durable repair, and low risk for surgery Patients with severe LV dysfunction (LV EF < 30% and/or ESD > 55 mm*) refractory to medical therapy with low likelihood of repair and low comorbidity * Lower values can be considered for patients of small stature. Class IB IC IIaC IIaC IIbB IIbC VHD Guidelines Slide-set 2007 European Society of Cardiology

23 Ischaemic / Functional Mitral Regurgitation

24 Acute Decompensation of Ischaemic MR Mechanisms Underlying LV systolic dysfunction Transient increase in functional MR May cause acute pulmonary oedema Exercise-induced changes in the severity of MR, LVEF, and PAP (Pierard et al. N Engl J Med 2004;351: ) (ESC Textbook)

25 Acute Decompensation of Ischaemic MR Therapeutic Issues Optimal treatment of LV systolic dysfunction (medical therapy ± CRT) Efficacy on heart failure Decrease of regurgitant volume Surgical correction of MR ± CABG Decrease of MR, but risk of late recurrence after repair (Gelsomino et al. Eur Heart J 2008;29:231-40) Left ventricular reverse remodelling in 60% of patients (Braun et al. Eur J Cardiothorac Surg 2005;27:847-53) No proven benefit on late survival (Wu et al. J Am Coll Cardiol 2005;45:381-7)

26 Impact of Surgery of Ischaemic MR CABG With or Without Valve Repair 2 groups of 54 patients with ischaemic MR 3/4 matched according to a propensity score 54 had isolated CABG 54 had CABG + valve repair No significant difference in survival and NYHA class III-IV during follow-up (Mihajlevic et al. J Am Coll Cardiol 2007;49: )

27 Surgery for Functional MR vs. Medical Therapy 682 patients with functional MR and severe LV dysfunction 126 had valve repair, 556 were treated medically Predictors of cardiac event Hazard Ratio [95% CI] p Sodium (1mMol/l increase) 0.93 [ ] < Coronary artery disease 1.80 [ ] Mean arterial pressure (1 mm increase) 0.98 [ ] Blood urea nitrogen (1 mg/dl increase) 1.01 [ ] Cancer 2.77 [ ] Beta-blockers use 0.59 [ ] Digoxin use 1.66 [ ] ACE-inhibitor use 0.65 [ ] 0.03 Mitral annuloplasty was not a predictor of late cardiac events (death, ventricular assistance, or transplantation) (Wu et al. J Am Coll Cardiol 2005;45:381-7)

28 Indications for Surgery in Ischaemic / Functional MR Chronic Ischaemic MR Patients with severe MR, LV EF > 30% undergoing CABG Patients with moderate MR undergoing CABG if repair is feasible Symptomatic patients with severe MR, LV EF < 30% and option for revascularization Patients with severe MR, LVEF > 30%, no option for revascularization, refractory to medical therapy, and low comorbidity Class IC IIaC IIaC IIbC Functional MR: surgery can be considered only in selected patients with severe symptoms despite optimal medical therapy VHD Guidelines Slide-set 2007 European Society of Cardiology

29 Percutaneous Mitral Valve Repair Edge-to-Edge Technique Coronary Sinus Annuloplasty

30 Mitral Stenosis

31 Mitral Stenosis Left ventricular function is preserved in > 90% of patients Decompensation is often favoured by tachycardia Supraventricular tachycardia Fever Anemia Pregnancy (high risk of pulmonary edema) Medical therapy: rhythm control (beta-blockers++), diuretics Consider percutaneous mitral commissuromy according to patient characteristics (pregnancy)

32 Treatment of Associated Conditions Atrial fibrillation Improvement of haemodynamics vs. risk of recurrence Hypertension In particular for regurgitations Renal failure Impact on loading conditions Sepsis Need to reevaluate promptly the severity and consequences of valvular disease

33 Conclusions (I) The possibility of underlying valvular disease should be considered in acute heart failure All medical resources should be used in patients with aortic stenosis and acute heart failure Short-term prognosis of medically treated patients is poor Surgery carries a high operative mortality but late results favour intervention in most cases as compared with natural history

34 Conclusions (II) Patients should not be denied surgery on the basis of acute heart failure or LV dysfunction When indicated, intervention should be not be delayed until the need for urgent surgery The results of transcatheter procedures should be assessed in high-risk patients with AS or MR Importance of early evaluation of valvular diseases

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