Aortic Stenosis.

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Stephany Hicks
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1 Aortic Stenosis

2 Common causes Normal Rheumatic (Rim or Commissures) Calcific Degenerative Bicuspid Adapted from C. Otto, Principles of Echocardiography, 2007

3 Rare causes Congenital Aortic stenosis Severe artherosclerosis of aorta and aortic valve (In Hyperlipoproteinemia type II) Rheumatoid arthritis with aortic valve involvement

4 Aortic disease Bicuspid aortic valve Fish mouth opening

5 Distribution by age group of BAV versus TAV In patients undergoing AVR for aortic stenosis. TAV BAV Age Circulation 2005;111:

6 Aortic disease Calcific Aortic Valve Disease Aortic Stenosis VS Aortic Sclerosis Paget s disease Age-related calcific Genetic polymorphism ESRD CV risks factor (DM, HT, LDL,smoking)

7 Aortic Stenosis Aortic Sclerosis Defined as calcification and thickening of the aortic valve without significant outflow obstruction (gradient < 20 to 25 mmhg)

8 Aortic disease Calcific Aortic Valve Disease Can Statins Slow progression of disease? SEAS study(n 1800) ASTONOMER study(n 269) Simvastatin + Ezetimibe VS Placebo Rosuvastatin VS Placebo No Statistically Significant (Mortality, time to AVR)

9 Rheumatic Aortic Stenosis Developing Country Frequently combined AS + AR Usually combined with Rheumatic Mitral Valve Involvement

10 Pathophysiology AS LV outflow obstruction LV systolic P LV EjectionTime LV diastolic P Aortic P LV mass O2 consumption Blood supply ischemia LV failure & myocardial ischemia

11 Aortic pressure gradient & AVA correlation S Severe : Remember : 4-40 (Vmax 4 m/sec, AV mean PG 40 mmhg) AVA 1.0 cm2 Moderate : (Vmax 3-4 m/sec, AV mean PG mmhg) AVA cm2

European Heart Journal Jul 2013, 34 (25) 1906-1914 Aortic pressure gradient & AVA

12 European Heart Journal Jul 2013, 34 (25) Aortic pressure gradient & AVA correlation AV mean PG 20 mmhg correlate with AVA 1.0 cm2 AV mean PG 40 mmhg correlate with AVA 0.8 cm2

13 Hemodynamic SBP LV diameter 2 LV wall thickness LV wall stress

$Ejection fraction and wall stress relationship EF & LV wall stress are correlate and predictable If not Poor outcome Carabello BA, Green LH, Grossman W, et al:$

14 Ejection fraction and wall stress relationship EF & LV wall stress are correlate and predictable If not Poor outcome Carabello BA, Green LH, Grossman W, et al: Hemodynamic determinants of prognosis of aortic valve replacement in critical aortic stenosis and advanced congestive heart failure. Circulation 1980;62:

15 Hemodynamic LA pressure Atrial fibrillation LVEDP

16 Hemodynamic Heart rate Systolic ejection time Cardiac output in response to exercise Rise in blood pressure < 10 mmhg (Severe obstruction)

17 Hemodynamic High LVEDP & Low Aortic Pressure P P Subendocardium Myocardial Ischemia

18 Clinical manifestation Dyspnea on exertion Angina 5 yrs. Syncope 3 yrs. Heart failure 2 yrs. Bicuspid AS onset year-old Tricuspid AS > 70 year-old

19 Heydes syndrome Aortic stenosis + LGIB (Angiodysplasia : most common Rt. side colon)

20 Physical examination Pulsus parvus et tardus Severity SEM radiate to neck Gallavardin phenomenon Single S2 or paradoxical S2

21 Physical examination Heavy calcified and immobility A2 delayed closure (esp. LBBB) S2 Single S2 or Paradoxical split S2 S1 A2 P2 S4 due to LV stiffness S1 A2 P2

22 Dynamic Auscultation Aortic Stenosis All soft Valsava ( Decrease Preload Decrease aortic blood flow) Hand grip ( Increase afterload Decrease aortic blood flow)

23 ECG

24 CXR Poststenotic dilatation Roundening of apex

25 Prognosis Asymptomatic Gradient Prognosis Hemodynamic progression AVA cm2/year AV Vmax 0.32 m/sec/year AV mean PG 7 mmhg/year <3.0 m/s m/s > 4.0 m/s

26 Classification of Aortic stenosis severity based on ACC/AHA guideline

27 Classification of Aortic stenosis severity based on ACC/AHA guideline

28 Progression from Aortic sclerosis Severe aortic stenosis Mean about 7 years Arch Intern Med. 2002;162(20):

29 From Unicuspid to Quadricuspid Unicuspid Bicuspid Tricuspid Quadricuspid Associate with AS Associate with AR>AS Associate with AR

30 Unicuspid Unicommissural Acommissural a lateral attachment of the valve orifice to the aorta estimated incidence of 0.02% eccentric teardrop opening may also be associated with dilation of the ascending aorta.

31 Bicuspid AV and Aortic root dilatation (Aortopathy + flow disturbance)

Patterns of bicuspid aortopathy TYPE 1 Dilatation of tubular ascending aorta primarily along convexity of aorta, with mild to moderate root dilatation RCC-LCC fusion TYPE 2 Arch dilatation with

32 Patterns of bicuspid aortopathy TYPE 1 Dilatation of tubular ascending aorta primarily along convexity of aorta, with mild to moderate root dilatation RCC-LCC fusion TYPE 2 Arch dilatation with involvment of tubular ascending aorta, with relative sparing of root RCC-NCC fusion TYPE 3 Isolated aortic root involvment with normal tubular ascending aorta and arch dimensions Younger age & genetic

33 Bicuspid AV and Coarctation of aorta 10% 50% Bicuspid AV 10% Coarctation of aorta Coarctation of aorta 50% Bicuspid AV

34 Savino K, Quintavalle E, Ambrosio G. Quadricuspid aortic valve: A case report and review of the literature. J Cardiovasc Echography 2015;25:72-6 Quadricuspid subtype Most common

35 Medical management and Follow up Mild AS F/U echo q 3-5 years Moderate AS F/U echo q 1-2 year(s) Rx Systemic hypertension Diuretics use with caution (may cause hypotension) ACEI should be used with caution in LV systolic dysfunction. Avoid Betablocker (worsening LV function)

36 Management in critical AS Vasodilator Nitroprusside (decrease afterload) Inotropic agent Preload optimization Atrial arrhythmia Abrupt decompensation Cardioversion is recommended

37 Nishimura et al. JACC Vol. 63, No. 22, AHA/ACC Valvular Heart Disease Guideline Summary of Recommendations for AS: Timing of Intervention

39 Low flow Low gradient AS Calcium score > 1650 Lack of contractile reserve has been associated with lower operative survival rate (6% vs. 33% ) Circulation: Cardiovascular Imaging.2014; 7:

40 The relationship between transvalvular flow and transvalvular gradient Am Heart J 1951;41: 1-29

3 cm2 In hospital Mortality rate 10% Pre PBAV Post PBAV No benefit long term

41 Balloon valvulotomy Acute hemodynamic effect 50% gradient reduction AVA increase cm2 In hospital Mortality rate 10% Pre PBAV Post PBAV No benefit long term outcome N Engl J Med. 1991; 325: Circulation. 1991; 84: J Intervent Cardiol. 2006; 19( 3): J Am Coll Cardiol. 1995; 26( 6):

42 TAVR (Transcatheter aortic valve replacement) SAPIEN CoreValve

44 PARTNER (Placement of AoRtic TraNscathetER valves) F/U 2 yrs. F/U 2 yrs. Cohort A : High risk but operable N Engl J Med 2011; 364: Cohort B : Inoperable N Engl J Med 2010; 363:

45 PARTNER (Placement of AoRtic TraNscathetER valves) Death from any cause or stroke Death from any cause Cohort A : High risk but operable N Engl J Med 2011; 364: Cohort B : Inoperable 40% RRR N Engl J Med 2010; 363:

46 PARTNER (Placement of AoRtic TraNscathetER valves) Atrial fibrillation, Bleeding SAVR > TAVR Vascular complication, Stroke or TIA TAVR > SAVR N Engl J Med 2011; 364:

47 PARTNER 2 Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients Symptomatic Severe AS (N=2032),mean age 81 ±6.7 yo. STS 4 and 10 (mean 5.8) Assessment by Heart Valve team Intermediate risk for AVR Inoperable Y Transfemoral access? Transfemoral Transapical N Y Transfemoral access? N 1:1 Randomization 1:1 Randomization Not in study TAVR (Sapien XT) Surgical AVR TAVR (Sapien XT) TAVR Sapien Primary Outcome : All Cause Mortality+Major Stroke at 2 year (Non-inferiority) Primary Outcome : All Cause Mortality+Major Stroke at 1 year (Non-inferiority)

48 PARTNER 2 Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients N Engl J Med 2016; 374:

49 PARTNER 2 (Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients ) Atrial fibrillation, Major Bleeding SAVR > TAVR Vascular complication, TIA TAVR > SAVR N Engl J Med 2016; 374:

50 Recommendations for AS: Surgical AVR or TAVR Nishimura et al. JACC Vol. 63, No. 22, AHA/ACC Valvular Heart Disease Guideline

51 Surgical AVR

Estimates of freedom from structural valve deterioration (SVD) for patients undergoing porcine aortic valve Slower valve deterioration in elderly

52 Estimates of freedom from structural valve deterioration (SVD) for patients undergoing porcine aortic valve Slower valve deterioration in elderly Cohn LH, Collins JJ Jr, Rizzo RJ, et al: Twenty-year follow-up of the Hancock modified orifice porcine aortic valve. Ann Thorac Surg 66:S30, 1998

53 Summary of Recommendations for Prosthetic Valve Choice Bioprosthetic (if anticoagulant is contraindicated) (I) Mechanical valve (IIa) Ross procedure (IIb) Bioprosthetic or Mechanical (IIa) Bioprosthetic (IIa) 60 year 70 year

54 Ross Procedure

55 Hemodynamic in Aortic stenosis

56 Gorlin formula Flow across the valve Constant x PG AVA = CO x 1000 / (systolic time x HR) 43.3 x AV mean PG MVA = CO x 1000 / (diastolic time x HR) 37.7 x MV mean PG

57 Pressure gradient in AS Ao LV Peak to peak gradient = 70% of Peak instantaneous gradient

58 AS VS HOCM

59 Pressure recovery phenomenon Echocardiography may over estimate true gradient Aortic root size < 3 cm Pressure recovery (small aortic root size)

60 Pressure Volume Loop

Change in transvalvular flow decrease aortic valve area Jen s J.

61 Hypertension and Aortic Stenosis Trojan Horse (Blood flow) Ejection flow Gate (Aortic stenosis) Resistance Army (Hypertension) Resistance Systemic hypertension Change in transvalvular flow decrease aortic valve area Jen s J. Kaden, Dariusch Haghi Hypertension in aortic valve stenosis a Trojan horse European Heart Journal Jun 2008,

62 References

63 Thankyou

Aortic Stenosis: UPDATE Anjan Sinha, MD Krannert Institute of Cardiology

Aortic Stenosis: UPDATE Anjan Sinha, MD Krannert Institute of Cardiology Aortic Stenosis: UPDATE 2010 Anjan Sinha, MD Krannert Institute of Cardiology None Disclosures 67-Year-Old Male Dyspnea and angina Class III heart failure No PND or orthopnea 3/6 late peak SEM Diminished