Aortic stenosis in octogenarians and comorbidities. Constantinos Evdoridis, MD Elpis General Hospital, Athens
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1 Aortic stenosis in octogenarians and comorbidities Constantinos Evdoridis, MD Elpis General Hospital, Athens
2 Decision to operate according to age range European Heart Journal (2005) 26,
3 Fitness & Health Fit & Healthy Frailty Score: 0-1 No Major organ compromise with comorbidities Frailty Score: 2 Major organ compromise Procedure at risk
4 Risk assessment for Intervention Procedure at risk
5 Comobirdities in the Elderly
6 Charlson Comorbidity Scoring System One Point MI,HF, PVD, Dementia, CORD, Peptic ulcer, Mild liver disease, DM Two Points Hemiplegia, Moderate or severe renal disease, DM with endorgan damage, Tumor without metastasis, Leukemia, Lymphoma Three Points Moderate or severe liver disease Six Points Metastatic solid tumor AIDS (not just HIV positive)
7 Comorbidity & severe AS in octogenarians PEGASO Registry M. Martínez-Sellés et al. / International Journal of Cardiology 189 (2015) 61 66
8 Comorbidity & severe AS in Nonagenarians Step 2 E. Bernal et al. HLC
9
10 Frailty Aging-associated Decline in reserve and function across multiple physiologic systems
11 Frailty Score Independence in feeding, bathing, dressing, transferring, toileting, urinary continence Measurements of gait speed, grip strength, and muscle mass
12 Frailty Score No frailty Able to perform all activities of daily living and perform a 5-meter walk in <6 seconds Mild degree of frailty Unable to perform 1 activity of daily living Moderate-to-severe degree of frailty Unable to perform 2 activities of daily living.
13 JACC Cardiovasc Interv Sep; 5(9):
14 JACC Cardiovasc Interv Sep; 5(9):
15 Risk scale for non-frail and frail patients
16 Procedure at risk Chest deformity LIMA adherent to chest
17 Severe AS Octogenarians with comorbidities Risk Stratification Step 1 Intervention (AVR & TAVR) is futile in: 1) a life expectancy of <1 year, even with a successful procedure Comorbidities Frailty 2) chance of survival with benefit. In symptoms Frailty In quality of life
18 Survival with benefit: Improvement by at least 1 New York Heart Association (NYHA) class in heart failure (HF) Improvement in angina symptoms Improvement in quality of life Improvement in life expectancy.
19 STS PROM Frailty Low Risk (All Criteria) < 4 % AND None AND Risk Stratification Step 2 Intermediate Risk (Any 1 Cr.) 4-8 % OR 1 Index(mild) OR High Risk (Any 1 Cr.) > 8 % OR 2 Indicies Prohibitive Risk (Any 1 Criterion) Predicted risk with surgery of death > 50 % at 1 year Major organ compromise None AND 1 Organ OR 2 Organs OR Procedurespecific impediment Type of Prcedure None Possible Possible Severe Procedure-specific impediment Surgery Surgery or TAVI Surgery or TAVI TAVI
20 Preoperative Assessment of Comorbidities
21 Non Cardiac Comorbidities
22
23 Prognosis in AS patiends with Moderate to Severe CKD Bruch et al. Clin Res Cardiol 96:23-29
24 Management & Outcomes in severe AS patients with Cancer Am Heart J 2011;161:
25 Prognosis of anemic pts undergoing TAVI Eurointervention 2011; 7: 184
26 Cardiac Comorbidities
27 Revascularisation & TAVI Wenaweser P et al. Eurointervention 2011;7:541
28 Revascularization & TAVI Not all patients with significant CAD require revascularization before TAVR Revascularization for patients with a large area of myocardium at risk Proximal stenoses in large epicardial arteries Fractional flow reserve-guided PCI or multivessel CAD
29 Pulmonary hypertension & Severe AS J Thorac Cardiovasc Surg 2011;141:
30 Effect of AVR for AS on Severity of MR Eynden et Al. Ann Thor Surgery 2007; 83:
31 Functional MR Organic MR TAVI Double Valve Intervention (Sutureless AV)
32 Combined AS & MR : TAVI & MitralClip
33 Causes of Death among Octagenarians with severe AS Comorbidity and intervention in octogenarians with severe symptomatic AS M. Martínez- Sellés et al. International Journal of Cardiology 189 (2015) AS.
34
35
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38 92 years old patient Symptoms: Shortness of breath Medical history: Known benign AS AF, RBBB
39
40 True Severe or Pseudo-Severe AS?
41
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43 SV: 40 ml 60 ml ( 16 % αύξηση)? Stress Echocardiography
44 New Dob Stress (Referral Center for TAVI) Study for flow reserve: dobutamine dose up to 20 μg/kgr/min Results Without flow reserve: Increase of SV < 20 %
45 DECISION FOR BALLOON AORTIC VALVULOPLASTY
46
47 After Valvuloplasty Remarquable improvement of symptoms ( NYHA I) Decrease of diuretic dose
48
49 AVA projected = 0.8 cm2
50 Take Home Messages Comorbidities in the eldrely with severe AS are basic components in risk stratification Clinical evaluation and sophisticated echo techniques allow to find the role of these comorbidities in decision making
51 Geriatrician
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