Severe Asymptomatic Aortic Stenosis
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1 Severe Asymptomatic Aortic Stenosis The Clinician s Perspective Robert O. Bonow, MD, MS Northwestern University Feinberg School of Medicine Bluhm Cardiovascular Institute Northwestern Memorial Hospital No Relationships to Disclose
2 Severe Asymptomatic Aortic Stenosis The Clinician s Perspective Are asymptomatic patients with severe AS really asymptomatic?
3 Severe Aortic Stenosis Indications for valve replacement Exercise test: Symptoms Hypotension class I class I
4 Severe Aortic Stenosis Indications for valve replacement Exercise test: Symptoms Hypotension class I class I Should asymptomatic patients with severe AS undergo AVR? when they are really asymptomatic?
5 Vmax: 4.6 m/s Mean : 52 mmhg AVA: 0.7 sq cm Severe AS: >4.0 m/s >40 mmhg <1.0 sq cm
6 Aortic Stenosis 84 year old man with severe AS Watchful waiting? * More data (more testing)? Aortic valve replacement? * Wait until he develops symptoms in 5-6 years and then recommend TAVR?
7 Natural History of Severe Asymptomatic AS Event-Free Survival (%) Medicare 80 data Vmax > 4.0 m/s Average hospital mortality: 8.8% Low volume centers: 13.0% High volume centers: 6.0% Otto Time (years) Otto et al. Circulation 1997;95:
8 Natural History of Severe Asymptomatic AS Event-Free Survival (%) Medicare 80 data Vmax > 4.0 m/s Average hospital mortality: 8.8% Low volume centers: 13.0% High volume centers: 6.0% Otto Rosenhek Time (years) Otto et al. Circulation 1997;95: Rosenhek et al. N Engl J Med 2000;343:
9 Natural History of Severe Asymptomatic AS Event-Free Survival (%) Medicare 80 data Vmax > 4.0 m/s Average hospital mortality: 8.8% Low volume centers: 13.0% High volume centers: 6.0% Otto Rosenhek Pellikka Time (years) Otto et al. Circulation 1997;95: Rosenhek et al. N Engl J Med 2000;343: Pellikka et al. Circulation 2005;111:
10 Natural History of Severe Asymptomatic AS Event-Free Survival (%) Medicare 80 data Vmax > 4.0 m/s Average hospital mortality: 8.8% Low volume centers: 13.0% Stewart High volume centers: 6.0% Otto Rosenhek Pellikka Time (years) Otto et al. Circulation 1997;95: Rosenhek et al. N Engl J Med 2000;343: Pellikka et al. Circulation 2005;111: Stewart et al. Eur Heart J 2010;31:
11 Natural History of Severe Asymptomatic AS Event-Free Survival (%) Medicare 80 data Vmax > 4.0 m/s Average hospital mortality: 8.8% Low volume centers: 13.0% Stewart High volume centers: 6.0% Otto Time (years) Rosenhek Pellikka Nistri Otto et al. Circulation 1997;95: Rosenhek et al. N Engl J Med 2000;343: Pellikka et al. Circulation 2005;111: Stewart et al. Eur Heart J 2010;31: Nistri et al. Am J Cardiol 2012;109;
12 Natural History of Severe Asymptomatic AS Event-Free Survival (%) Medicare 80 data Vmax > 4.0 m/s Average hospital mortality: 8.8% Low volume centers: 13.0% Rosenhek High n=128 volume centers: 6.0% Time (years) Rosenhek et al. N Engl J Med 2000;343:
13 Natural History of Severe Asymptomatic AS Event-Free Survival (%) Medicare 80 data Average hospital mortality: 8.8% Low volume centers: 13.0% High n=128 volume centers: 6.0% p<0.001 No or mild calcification Moderate or severe calcification Time (years) Rosenhek et al. N Engl J Med 2000;343:
14 Natural History of Severe Asymptomatic AS Event-Free Survival (%) Medicare 80 data Average hospital mortality: 8.8% Low volume centers: 13.0% High n=198 volume centers: 6.0% p< Time (years) Vmax m/s Vmax m/s Vmax >5.5 m/s Rosenhek et al. Circulation 2010;121:
15 Asymptomatic Aortic Stenosis Indications for valve replacement: Very severe AS: Vmax 5 m/s
16 Asymptomatic Aortic Stenosis Indications for valve replacement: Very severe AS: Vmax 5 m/s Rapid progression and low surgical risk class IIb
17 Asymptomatic Aortic Stenosis Indications for valve replacement: Very severe AS: Vmax 5 m/s Rapid progression and low surgical risk class IIb Very severe AS: Vmax >5.5 m/s
18 Asymptomatic Aortic Stenosis Indications for valve replacement: Very severe AS: Vmax 5 m/s Rapid progression and low surgical risk class IIb Very severe AS: Vmax >5.5 m/s Severe valve calcification and rate of progression 0.3 m/s / year
19 Asymptomatic Aortic Stenosis Indications for valve replacement: Very severe AS: Vmax 5 m/s Rapid progression and low surgical risk class IIb Very severe AS: Vmax >5.5 m/s Severe valve calcification and rate of progression 0.3 m/s / year Markedly elevated BNP Increase in gradient with exercise >20 mmhg Excessive LVH class IIb
20 Aortic stenosis The ACC/AHA guidelines have lowered the threshold for surgery in asymptomatic patients with AS Severity of AS Severity of calcification Left ventricular function Exercise response
21 Aortic stenosis The ACC/AHA guidelines have lowered the threshold for surgery in asymptomatic patients with AS Severity of AS Severity of calcification Left ventricular function Exercise response BNP?
22 Aortic stenosis The ACC/AHA guidelines have lowered the threshold for surgery in asymptomatic patients with AS Survival (percent) BNP ratio < Severity of AS Severity of calcification Left ventricular function Exercise response BNP? Time (years) Clavel et al, J Am Coll Cardiol 2014;63:
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