Asymptomatic Valvular Disease:

Transcription

1 Asymptomatic Valvular Disease: Can Echocardiography Help You Decide When to Intervene? Neil J. Weissman, MD MedStar Health Research Inst at MedStar Washington Hospital Center & Professor of Medicine Georgetown University Washington, D.C. Disclosures Academic Echo Core Lab with multiple pharmaceutical and device commercial sponsors No direct COI with this lecture 1

2 Valvular Heart Disease General Agreement Operate for symptomatic severe valve stenosis or regurgitation General Disagreement Operate for asymptomatic severe valve stenosis or regurgitation Chronic Severe MR - When to Operate What You Need to Know Etiology Pathphysiology Echocardiographic findings Natural history Surgical morbidity, mortality Expertise of surgeon 2

3 What You Need To Know Aortic vs Mitral Regurgitation Pathophysiology Preload MR Pure volume overload AR Volume & pressure overload Afterload Normal to 3

4 Aortic vs Mitral Regurgitation Pathophysiology Preload MR Pure volume overload AR Volume & pressure overload Afterload Normal to Aortic vs Mitral Regurgitation Pathophysiology Preload MR Pure volume overload AR Volume & pressure overload Afterload Normal to EF after surgery = 4

5 Mitral Regurgitation Major Challenge 1. Identify contractile LV dysfunction 2. Correct MR before irreversible LV dysfunction develops Aortic vs Mitral Regurgitation AR MR EF reflects (closer to) true LV performance EF is overestimation of true LV performance 5

6 Survival (%) Survival (%) Late Survival of Operative Survivors Pre-op Echo EF vs Postop Survival p = EF 60% EF 50-60% EF <50% Enriquez-Sarano Circulation 90:830(1994) Years 72% 53% 32% MR Due to Flail Leaflet Long-Term Survival with Medical Therapy annual mortality = 6.3%/yr Expected 65% Observed 57% p = Years after Diagnosis Ling (Mayo Clinic) NEJM 335:1417(1996) 6

7 Survival (%) 100 The more severe the regurgitation the poorer the prognosis ERO < 20 mm2 ERO mm2 ERO > 40 mm2 50 Enriquez-Sarano, M. et al. N Engl J Med 2005;352: Years 3 5 7

8 Recommendations for MV Operation in Chronic Severe MR 3. Indication MV surgery is beneficial for asymptomatic patients with chronic, severe MR and mild to moderate LV dysfunction, EF 30-60% and/or end-systolic dimension > 40mm (Level of evidence: B) Class I I IIa IIb III B Bonow ACC/AHA Practice Guidelines JACC 48:e1(2006) 8

9 Recommendations for MV Operation in Chronic Severe MR Indication Class MV repair is reasonable in experienced surgical centers for IIa asymptomatic pts with chronic severe MR with preserved LV function (ejection fraction greater than 0.60 and end-systolic dimension less than 40 mm) in whom the liklihood of successful repair without residual MR is greater than 90% 95% and mortality <1% with Heart Valve Center I IIa IIb III (Level of evidence: B) MV surgery is reasonable for asymptomatic pts with chronic severe MR with preserved LV function, and new onset atrial fibrillation. (Level of evidence: C) Bonow ACC/AHA Practice Guidelines JACC 48:e1(2006) B IIa I IIa IIb III C 2017 Updated Guidelines 9

10 2017 Updated Guidelines 10

11 Asymptomatic AR 11

12 AR patients with decreased EF or LVIDs > 40mm progress to develop symptoms and need AVR within 3 years (25%/yr develop symptoms) 12

13 13

14 AS 14

15 Survival (%) Asymptomatic Severe AS: Is It Time to Operate? Pro: Con: All patients should be operated Truly asymptomatic patients do not need surgery now AVR Should be Performed in Symptomatic AS Valve Replacement No surgery 20 No. at Risk Valve replacement No surgery p<0.05 p< Year Carabello N Engl J Med 2002;346(9) Chi-square = 23.5 p<

16 16

17 The only class I indication for valve replacement in severe AS is development of symptoms or in conjunction with other CV surgery or EF < 50% 17

18 Event-Free Survival (%) Very Severe Aortic Stenosis p < AV-Vel 4.0 to 5.0 m/s AV-Vel 5.0 to 5.5 m/s AV-Vel 5.5 m/s Years Rosenhek Circulation 2010;121: Updated Guidelines - TAVR not studied in asymptomatic patients so not considered as an option for Asx AS 18

19 19