La patologia valvolare dell anziano: problemi decisionali complessi. Ottavio Alfieri S.Raffaele University Hospital Milan
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1 La patologia valvolare dell anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61 CONGRESSO NAZIONALE SIGG, Napoli, 2016
2 Bulk of Population Growth The Economist, May 14 th 2011
3 Longevity
4 Nkomo, Lancet 2006
5 Survival (%) The Burden of Valve Disease Survival 100 Treament of severe valve desease has a favorable impact on survival at any age Expected Observed P < Years European Heart Journal doi: /eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery doi: /ejcts/ezs455).
6 Frailty is a Phenotype Comorbidity (>2 conditions) 66% Frailty 25% Disability (>1 ADL) Weakness Muscle Wasting Physical Function Fatigue Cognition Depression 27% Limited Life Space Isolation Nutrition Weight Loss Courtesy Karen Alexander
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8 Surgical Risk vs Benefit Optimum Value Limited? Value Surgical Risk Poor value: Patient Purchaser Physician Clinical Benefit Increasing age, comorbidities,lv dysf,frailty
9 European Heart Journal doi: /eurheartj/ehs109 Guidelines on the management of valvular heart disease (version 2012) The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Authors/Task Force Members: Alec Vahanian (Chairperson) (France), Ottavio Alfieri (Chairperson) (Italy), Felicita Andreotti (Italy), Manuel J. Antunes (Portugal), Gonzalo Barón-Esquivias (Spain), Helmut Baumgartner (Germany), Michael Andrew Borger (Germany),Thierry P. Carrel (Switzerland), Michele De Bonis (Italy), Arturo Evangelista (Spain), Volkmar Falk (Switzerland), Bernard Iung (France), Patrizio Lancellotti (Belgium), Luc Pierard (Belgium), Susanna Price (UK), Hans-Joachim Schäfers (Germany), Gerhard Schuler (Germany), Janina Stepinska (Poland), Karl Swedberg (Sweden), Johanna Takkenberg (The Netherlands), Ulrich Otto Von Oppell (UK), Stephan Windecker (Switzerland), Jose Luis Zamorano (Spain), Marian Zembala (Poland) ESC Committee for Practice Guidelines (CPG): Jeroen J. Bax (Chairperson) (The Netherlands), Helmut Baumgartner (Germany), Claudio Ceconi (Italy), Veronica Dean (France), Christi Deaton (UK), Robert Fagard (Belgium), Christian Funck-Brentano (France), David Hasdai (Israel), Arno Hoes (The Netherlands), Paulus Kirchhof (United Kingdom), Juhani Knuuti (Finland), Philippe Kolh (Belgium), Theresa McDonagh (UK), Cyril Moulin (France), Bogdan A. Popescu (Romania), Željko Reiner (Croatia), Udo Sechtem (Germany), Per Anton Sirnes (Norway), Michal Tendera (Poland), Adam Torbicki (Poland), Alec Vahanian (France), Stephan Windecker (Switzerland) Document Reviewers: Bogdan A. Popescu (ESC CPG Review Coordinator) (Romania), Ludwig Von Segesser (EACTS). Review Coordinator) (Switzerland), Luigi P. Badano (Italy), Matjaž Bunc (Slovenia), Marc J. Claeys (Belgium), Niksa Drinkovic (Croatia), Gerasimos Filippatos (Greece), Gilbert Habib (France), A. Pieter Kappetein (The Netherlands), Roland Kassab (Lebanon), Gregory Y.H. Lip (UK), Neil Moat (UK), Georg Nickenig (Germany), Catherine M. Otto (USA), John Pepper, (UK), Nicolo Piazza (Germany), Petronella G. Pieper (The Netherlands), Raphael Rosenhek (Austria), Naltin Shuka (Albania), Ehud Schwammenthal (Israel), Juerg, Schwitter (Switzerland), Pilar Tornos Mas (Spain), Pedro T.Trindade (Switzerland), Thomas Walther (Germany). European Heart Journal doi: /eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery doi: /ejcts/ezs455).
10 The «Heart Team» SURGEONS CARDIOLOGISTS Anesthesiologists Treatment of Valve disease Other specialists: Geriatricians Imaging specialists (Echo, CT, MRI)
11 Heart Team Complexity of the disease Complexity of the patient Expansion of the therapeutic options
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13 Essential questions in the evaluation of a patient for valvular intervention Is valvular heart disease severe? Does the patient have symptoms? Are symptoms related to valvular disease? What are patient life expectancy and expected quality of life? Do the expected benefits of intervention (versus spontaneous outcome) outweigh its risks? What are the patient's wishes? Are local resources optimal for planned intervention? European Heart Journal doi: /eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery doi: /ejcts/ezs455).
14 Aetiologies of Single Valvular Heart Diseases in the Euro Heart Survey 100% 43% 13% 32% 12% 80% 60% 40% 20% Other Ischemic Congenital Inflammatory Endocarditis Rheumatic Degenerative 0% AS AR MR MS Iung et al. Eur Heart J 2003;24: European Heart Journal doi: /eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery doi: /ejcts/ezs455).
15 Patient Characteristics in the Euro Heart Survey Age (years) 70 years (%) 1 comorbidity (%) AS 69± AR 58± MS 58± MR 65± Iung et al. Eur Heart J 2003;24: European Heart Journal doi: /eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery doi: /ejcts/ezs455).
16 Patient Characteristics in the Euro Heart Survey Age (years) 70 years (%) 1 comorbidity (%) AS 69± AR 58± MS 58± MR 65± Iung et al. Eur Heart J 2003;24: European Heart Journal doi: /eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery doi: /ejcts/ezs455).
17 Current Management of Severe Symptomatic AS in the Elderly Aortic Stenosis 75 years (n=398) No Severe AS (n=114) Severe AS (n=284) No Symptoms (n=68) Symptoms (n=216) No Intervention (n=72) 33% Intervention (n=144) 67% Iung et al. Eur Heart J 2005;26: European Heart Journal doi: /eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery doi: /ejcts/ezs455).
18 Current Management of Severe MR Isolated MR > 75 years (n=887) No Severe MR (n=347) Severe MR (n=540) No Symptoms (n=144) Symptoms (n=396) No Intervention (n=193) 49% Intervention (n=203) 51% Mirabel et al. Eur Heart J 2007;28: European Heart Journal doi: /eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery doi: /ejcts/ezs455).
19 Aortic stenosis is life-threatening and progresses rapidly Survival Percent Latent Period (Increasing Obstruction, Myocardial Overload) Onset severe symptoms Angina Syncope Failure Avg. survival Years Age Years Sources: 1 S.J. Lester et al., The Natural History and Rate of Progression of Aortic Stenosis, Chest C.M. Otto, Valve Disease: Timing of Aortic Valve Surgery, Heart 2000 Chart: Ross J Jr, Braunwald E. Aortic stenosis. Circulation. 1968;38 (Suppl 1):61-7.
20 LIFE EXPECTANCY AFTER AVR Life expectancy for men in normal populations versus life expectancy after implantation of a prosthetic valve Life expectancy (yrs) LE normal BC population LE normal Dutch population LE normal UK population LE normal US population LE (US) with MECH LE (US) with BIO Age (yrs) Patient outcome after AVR with mechanical or bioprostheses: weighing lifetime anticoagulant-related event risk against reoperation risk Martijn W.A. van Ge ldorp 1, W.R. Eric Jamieson 2, Jian Ye 2, Guy J. Fradet 2, A. Pieter Kappetein 1, Marinus J.C. Eijkemans 3, Gary L. Grunkemeier 4, Ad J.J.C. Bogers 1, Johanna J.M. Takkenberg 1
21 Aortic Valve Implantation The Evolving Process Invasiveness Conventional through midline sternotomy Surgical through minimal incision On pump, arrested heart sutureless valve replacement Surgical apico-aortic valved conduit Transaortic delivery Transapical delivery Transaxillary delivery Transcarotid delivery Percutaneous transfemoral TAVI
22 TAVI OPTIONS Ruiz et al. J Am Coll Cardiol. July 14, 2015,66(2):
23 Indications for transcatheter aortic valve implantation TAVI should only be undertaken with a multidisciplinary heart team including cardiologists and cardiac surgeons and other specialists if necessary. Class I Level C TAVI should only be performed in hospitals with cardiac surgery on-site. I C TAVI is indicated in patients with severe symptomatic AS who are not suitable for AVR as assessed by a heart team and who are likely to gain improvement in their quality of life and to have a life expectancy of more than 1 year after consideration of their comorbidities. TAVI should be considered in high risk patients with severe symptomatic AS who may still be suitable for surgery, but in whom TAVI is favoured by a heart team based on the individual risk profile and anatomic suitability. I IIa B B European Heart Journal doi: /eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery doi: /ejcts/ezs455).
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25 Published April 2012
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27 Published April 2012
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29 US CoreValve High-Risk Trial 2014
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31 All-Cause Mortality STS 7%
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35 Transfemoral rather than Transapical
36 Procedural Recovery Non-procedure related Gaudiani et al. presented at the AATS, 2016
37 Alec Vahanian MD, Bichat Hospital, Paris, University Paris VII Performance Safety (mortality,stroke) Vascular complications Perivalvular leaks Conduction defects Durability
38 Alec Vahanian MD, Bichat Hospital, Paris, University Paris VII Surgical AVR will be limited to contraindications to and to pts requiring combined cardiac or aortic sur
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41 Degenerative MR If a good and durable repair is carried out before symptoms, LV dysfunction, LA dilatation, PH and AF, normal life expectancy is expected at any age Detaint, et al. Circulation. 2006;114:
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43 Neochord Inc.
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45 Mitra Clip
46 MitraClip Therapy Current Global Adoption commercial investigational special access
47 Transcatheter Annuloplasty Coronary sinus remodeling SL dimensions cinching RF/Ultrasound remodeling External compression Direct annuloplasty
48 How Does Cardioband Work? 48
49 Fully Percutaneous Mitral Repair
50 Transcatheter Mitral Valve Replacement CardiAQ Tendyne Tiara Twelve Fortis Cephe Cardiovalve High Life
51 Tiara case done in San Raffaele Fully successful case perform in less than 40 min
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53 The complementary role of transcatheter techniques replacement annuloplasty mitraclip Stand-alone annuloplasty: early treatment FMR /symmetric tethering Stand-alone Mitraclip: FMR with asymmetric tethering (IMR) DMR with little annular dilatation Combined Annuloplasty and MitraClip: DMR with important annular dilatation and advanced FMR MV Replacement: advanced organic MR and advanced FMR /
ESC / EACTS Guidelines for the Management of Valvular Heart Disease. Management of Aortic Regurgitation
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ESSENTIAL MESSAGES FROM
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