Aortic Valvular Stenosis
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1 Aortic Valvular Stenosis How to Assess the Four Variables for Management Low Flow / Low Gradient / Normal EF / Low EF Patrick T. O Gara, MD, MACC Brigham and Women s Hospital Harvard Medical School No Disclosures
2 Stages of Valvular Heart Disease Stage A At Risk of VHD Stage B Progressive VHD Stage C Asx Severe VHD Stage D Sx Severe VHD C1 Normal LV or RV C2 Abnormal LV or RV
3 Stages of Chronic AS Stage D Sx Severe Stage D1 HF/HG/NL EF Stage D2 LF/LG/Low EF Stage D3 LF/LG/NL EF Mean Δ P = AVA
4 Low Flow Low Gradient Severe AS LF LG AS SVi < 35 ml/m 2 MPG < 40 mm Hg Evaluation TTE DSE CT Aortic Valve Catheterization Low EF < 0.50 Pibarot P, Dumesnil JG. JACC 2012; 60:145-53
5 LF/LG AS with Reduced EF Flow Reserve > 20% SVi Clavel M-A et al EHJ 2016; 37:
6 DSE Baseline Dobutamine Vmax 3.5 m/s Mean ΔP 32 mm Hg Vmax 4.9 m/s Mean ΔP 56 mm Hg Picano E et al. JACC 2009;54:
7 Hemodynamics Mean Gradient 22 Mean Gradient 48 Courtesy of Rick Nishimura, MD
8 AHA/ACC 2014 Guideline Aortic Stenosis (D2): Timing of Intervention Recommendation COR LOE AVR is reasonable in patients with LF/LG severe AS with reduced EF (stage D2) with a dobutamine stress study that shows an aortic velocity 4 m/s (or mean ΔP 40 mm Hg) with an AVA 1.0 cm 2 at any dobutamine dose IIa B
9 ESC/EACT 2017 Guideline Aortic Stenosis: Timing of Intervention Recommendations COR LOE AVR is indicated in symptomatic patients with severe LF/LG AS and reduced EF with flow reserve excluding I C pseudo-severe stenosis AVR should be considered in symptomatic patients with LF/LG AS and reduced EF without flow reserve if CT calcium scoring confirms severe AS IIa C
10 Poor Outcomes After AVR Classical LF/LG AS NYHA 3+, 6MWT, high STS score EF < 0.35; reduced GLS; lack of flow reserve; low gradient (< 20 mm Hg) Multi-vessel CAD Markedly elevated NT-BNP LGE
11 PARTNER Trial LG/LG Severe AS with Low EF Mortality Rate (%) B - TAVR n=17 B - Std Rx n=25 Prohibitive surgical risk Log Rank P= % 47.1% Time (days) Herrmann 13H et al, Circulation ;127: Courtesy of RO Bonow
12 PARTNER Trial LF/LG Severe AS with low EF Mortality Rate (%) A - TAVR n=56 Surgery n=49 B - TAVR n=17 B - Std Rx n=25 High surgical risk Prohibitive surgical risk Log Rank P= % 47.1% 42.9% 37.1% Time (days) Herrmann 13 et al, Circulation ;127: Courtesy of RO Bonow
13 Low Flow Low Gradient Severe AS LF LG AS SVi < 35 ml/m 2 MPG < 40 mm Hg Evaluation TTE DSE CT Aortic Valve Catheterization NL EF > 0.50 Pibarot P, Dumesnil JG. JACC 2012; 60:145-53
14 Development of Severe AS Sorin V Pislaru, and Patricia A Pellikka Heart doi: /heartjnl
15 Assessment of Total LV Afterload Valvulo-Arterial Impedance: Z VA Z va = SBP + Mean ΔP SVi Hachicha Z et al. Circulation 2007;115:
16 LFLG Severe AS with NL EF Sorin V Pislaru and Patricia A Pellikka Heart doi: /heartjnl
17 LF/LG AS with Normal EF STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 Check for Measurement Errors Assess Symptoms Identify and Treat HTN Repeat Echo, Cath CT Calcium Score STEP 6 >1200 AU (Women) >2000 AU (Men) <1200 AU (Women) <2000 AU (Men) True Severe AS Pseudo-Severe AS Adapted from Clavel M-A et al EHJ 2016; 37:
18 Effect of AVR on Survival Adjusted, Propensity Analysis Ozkan A et al. Circulation 2013;128:622-28
19 AHA/ACC 2014 Guideline Aortic Stenosis (D3): Timing of Intervention Recommendation COR LOE AVR is reasonable in patients with LF/LG severe AS (stage D3) who are normotensive and have an EF 50% if clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms IIa C
20 ESC/EACT 2017 Guideline Aortic Stenosis: Timing of Intervention Recommendation COR LOE AVR should be considered in symptomatic patients with LF/LG AS and normal EF after careful confirmation of severe AS IIa C
21 Poor Outcomes After AVR Paradoxical LF/LG AS LGE Moderate/severe diastolic dysfunction Reduced GLS Very low SVi
22 Clavel M-A et al EHJ 2016; 37:
23 82 y/o woman PAF, HTN Fatigue, dyspnea Grade 3 murmur No LVH on ECG
24 Mean gradient 28 mmhg AVA 0.8 cm2 SVI 35 ml/m2 DVI 0.23
25 Mean gradient 17 Valve area 0.9cm2 PCWP 14 CO 3.4 Aortic BP 160/63 Mean gradient 19 Valve area 1.2cm2 PCWP 28 CO 6.7 Aortic BP 201/ Rest -25 Peak Courtesy Mayo Clinic Fellows
26 <
27
28 Biomarkers in LF/LG AS TOPAS Study JACC Imag 2017
29 Survival Hachicha Z et al. Circulation 2007;115:
30 82 yo F History Progressive fatigue and dyspnea for the last year Can now walk only a block before limited No edema, chest pain, syncope No orthopnea, PND
31 PMH Paroxysmal AF Borderline HTN Home Meds Aspirin
32 Exam BP 119/55, HR 70, BMI JVP normal Carotid upstroke 1+ parvus and tardus Heart: LV impulse slightly sustained and localized Normal S1, single S2. 2/6 SEM RUSB with early to mid peak Lungs: Clear No edema
33
34 Paradoxical Low flow, low gradient severe AS TAVR? SAVR? Observe?
35 225 Rest
36 Exercise
37 DIAGNOSIS HFpEF Moderate AS
38 Stages of Chronic AS Stage D Sx Severe Stage D1 NF/HG/NL EF Stage D2 LF/LG/Low EF Stage D3 LF/LG/NL EF Stage D4 NF/LG/NL EF
39 LF/LG Severe AS with Low EF Pibarot P, Dumesnil JG. JACC 2012; 60:145-53
40 Eleid M F et al. Circulation 2013;128:
41 Anatomic/Doppler Assessment of AS Lindman BR et al. Nat Rev Dis Prim 2016
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