Aortic Stenosis: UPDATE Anjan Sinha, MD Krannert Institute of Cardiology
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1 Aortic Stenosis: UPDATE 2010 Anjan Sinha, MD Krannert Institute of Cardiology
2 None Disclosures
3 67-Year-Old Male Dyspnea and angina Class III heart failure No PND or orthopnea 3/6 late peak SEM Diminished A 2 Parvus et tardus PCI of LAD in the past
4
5 LVEF: 15% Severe Aortic Stenosis
6 What Next Aortic Valve Surgery Medical Therapy Balloon Aortic Valvuloplasty Balloon Aortic Valvuloplasty followed by AVR if improvement
7 Etiology of Aortic Stenosis Calcific Bicuspid Rheumatic Misc Dare et al. Hum Pathol 1993;24:
8
9 Classification of Severity of AS Indicator Mild Moderate Severe Jet velocity (m/s) Mean gradient (mm Hg) Valve Area (cm 2 ) Valve area index (cm 2 / m 2 ) < > 4 < > 40 > < 1.0 < 0.6 Bonow et al: ACC/AHA Practice guidelines. J Am Coll Cardiol 2006
10 Rate of hemodynamic progression Aortic jet velocity by 0.32 m/s per year Mean gradient by 7 mm Hg per year AVA by 0.12 cm 2 per year Rate of progression not significantly different for bicuspid and trileaflet valves Otto et al. Circulation 1997;95:
11 Progression of AS D-gradient/yr D-AVA/yr Series No. (mm Hg) (cm 2 ) Otto, Fagiano, Brener, Bahler, Palta,
12 Pathophysiology Hypertrophy Systolic dysfunction Subendocardial ischemia Dilated LV cavity Diastolic dysfunction Low output low gradient AS Afterload mismatch
13 Classic symptoms Exertional angina Subendocardial ischemia Exertional syncope Cerebral hypoperfusion Baroreceptor malfunction Exertional dyspnea progressing to frank heart failure Pulmonary venous hypertension
14 Circulation Jul;38(1 Suppl):61-7.
15 Survival (%) Valvular Aortic Stenosis in Adults 100 Average Course (Post Mortem Data) Latent period (increasing obstruction, myocardial overload) Clinical presentation Onset severe symptoms Age (yr) Average death age (male) Angina Syncope Failure Avg survival (yr) Ross, Bruanwald: Circulation 1968: 38 (Supp V):61
16 Natural History of Valvular AS Symptomatic Patients Study Criteria n F/U Survival O Keefe,1987 Vmax > y 37% at 2 y Turina, 1987 MG > y 12% at 5 y Horstkotte, 1988 AVA < y 18% at 5 y
17 Aortic Stenosis The Truth-For Now In the vast majority of adults, AVR(aortic valve replacement ) is the only effective treatment for severe aortic stenosis ACC/AHA guidelines Bonow RO,1998 Carabello NEJM 2002
18 Operative mortality with AVR
19 Predictors of outcome after AVR Age Concomitant CAD LV dysfunction / HF Atrial fibrillation Concurrent MVR Renal failure
20 Survival after AVR by preop NYHA class Kvidal et al. J Am Coll Cardiol 2000;35:747-56
21 Severe AS with LV dysfunction Patients with LVEF < 30% have threefold higher mortality (15% vs. 6%) 1 Outcome is even worse without surgical interventions (Survival 20-50% at 12 m) 2 Fremes et al. Circulation 1989;80: Otto et al. Circulation 1994;89:642-50
22 Decision to operate according to LV systolic function Operate Not operate n < >60 LV Ejection Fraction (%) Lung B et al. Eur Heart J 2005;26:
23 Aortic Stenosis with Ventricular systolic dysfunction
24 157 patients, mean age 70 years Mean AVA 0.62 cm 2 Mean gradient 25mm Hg Mean LVEF 22% 68 pts had AVR, 89 treated medically Mean follow-up 2.7 ± 1.3 years J Am Coll Cardiol 2002;39:
25 Improved survival Surgically treated 82% at 1 year 78% at 4 years Medically treated 41% at 1 year 15% at 4 years Pereira et al. J Am Coll Cardiol 2002;39:
26 Improvement in symptoms Pereira et al. J Am Coll Cardiol 2002;39:
27 Improvement in LV systolic function Connolly et al. Circulation 2000;101:
28 Representative hemodynamic tracings from 3 patients representing 3 different responses to dobutamine Nishimura, R. A. et al. Circulation 2002;106: Copyright 2002 American Heart Association
29 Response of mean aortic valve gradient (MG; top) and aortic valve area (AVA; bottom) at baseline (1) and during peak dobutamine infusion (2) Nishimura, R. A. et al. Circulation 2002;106: Copyright 2002 American Heart Association
30 Clinical outcome of the patients (pt) with low-output aortic stenosis (AS) who underwent AVR Nishimura, R. A. et al. Circulation 2002;106: Copyright 2002 American Heart Association
31 Decision Making in Low-Flow, Low-Gradient AS Picano, E. et al. J Am Coll Cardiol 2009;54: Copyright 2009 American College of Cardiology Foundation. Restrictions may apply.
32 Probability of Survival in LF/LGAS Patients Without CR on DSE Tribouilloy, C. et al. J Am Coll Cardiol 2009;53: Copyright 2009 American College of Cardiology Foundation. Restrictions may apply.
33 Prognostic Impact of AVR in LF/LGAS Patients Without CR on DSE Tribouilloy, C. et al. J Am Coll Cardiol 2009;53: Copyright 2009 American College of Cardiology Foundation. Restrictions may apply.
34 Influence of MPG and CAD on Survival in LF/LGAS Patients Without CR on DSE Tribouilloy, C. et al. J Am Coll Cardiol 2009;53: Copyright 2009 American College of Cardiology Foundation. Restrictions may apply.
35
36
37 Viability assessment: There is limited area of improved contractility (mainly in the lateral and anterior segments) at 20mcg/Kg/min dobutamine infusion. Aortic valve assessment with Dobutamine: At 20 mcg/ kg/min Dobutamine infusion there is a 23% relative increase in LVOT TVI compared to rest. Rest: LVOT/AV = 0.13, peak AV velocity 2.8m/sec, mean AV gradient 14mmHg, valve area 0.8cm2 Peak (20mcg/Kg/min dob): LVOT/AV = 0.16, peak AV 3.27m/sec, mean AV gradient 22mmHg, valve area 0.89cm2.
38 What Next Aortic Valve Surgery Medical Therapy Balloon Aortic Valvuloplasty Balloon Aortic Valvuloplasty followed by AVR if improvement
39 Cumulative Survival Repeat Valvuloplasty for Aortic Stenosis (59 to 104 yr) Multiple BAV n= Single BAV n= yr 2 yr 3 yr Agarwal A et al, Am J Cardiol Jan 1;95(1):43-7.
40 Aortic Balloon Valvuloplasty Post-PAV AVA Failure 3% Post-PAV AI 2 Grade 2% 0.7 cm2 38% 1.0 cm2 27% cm2 38% < 1 Grade 28% No Changes 65% Palacios et al Cribier et al
41 Balloon Aortic Valvuloplasty Hemodynamic Follow-up Pre BAV Post BAV 6m f/u AVA cm m AVG mmhg P-P AVG mmhg LV EF % LVeDP mmhg ±3.3 months n = 95 Mansfield Registry Bashore JACC 1991:1188
42 What Next Aortic Valve Surgery Medical Therapy Balloon Aortic Valvuloplasty Balloon Aortic Valvuloplasty followed by AVR if improvement
43
44 LVEF: 29% AVA: 0.17 cm2 by VTI, 0.22 by PV RVSP: mmhg
45
46
47 Patient characteristics Medical Co-morbidities Coronary Artery Disease 50% of patients Inadequate residual valve area < 1 cm 2 in most patients post procedure Start with AS end with AS The procedure Fracture of calcific nodules Commissural splitting Annular stretching
48 Underwent Aortic Valve Replacement Last seen by cardiologist on Oct 26 th 2010 History of Present Illness: pt. feels good and remains active, played some golf, walking 1 mile qod, mild dry nonproductive cough slowly getting better, mild dizziness /orhtostasis occ Currently Functional Class I.
49 Conclusion Decision regarding whether to operate or not still has to be made on a case-by- case basis. Despite significantly higher peri-operative mortality, AVR markedly improves the longterm outcome of patients with LV systolic dysfunction
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