Valve Disease in Patients With Heart Failure TAVI or Surgery? Miguel Sousa Uva Hospital Cruz Vermelha Lisbon, Portugal
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1 Valve Disease in Patients With Heart Failure TAVI or Surgery? Miguel Sousa Uva Hospital Cruz Vermelha Lisbon, Portugal
2 I have nothing to disclose.
3 Wide Spectrum Stable vs Decompensated NYHA II IV? Ejection Fraction: Reduced vs Preserved Symptoms Correlate Poorly With Ventricular Function
4 Aortic Stenosis in Patients With Heart Failure And Reduced Ventricular Function TAVI or Surgery?
5 TAVI vs Surgery Heart Failure + LV Dysfunction What Are The Goals? 1. Lowest Mortality 2. Lowest Morbidity 3. Recovery of LV Function 4. Good Valve Hemodynamics 5. Persistent Long Term Outcomes
6 Predictors of Mortality After Surgery Aortic Stenosis With Heart Failure and Reduced Ventricular Function
7 Results of Surgery in Severe Aortic Stenosis Ejection Fraction < 35% Mortality 30 d: 4-12% Survival 5 Years: 65-70% Predictors of Mortality: LVESVI, CardioThoracic Index Coronary Artery Disease Mean Gradient Ejection Fraction (Late Mortality) Connoly,, Circulation 1997 Vaquette, Heart 2005 Chukwuemeka, EJTCS, 2006 Pai Ann ThoracSurg, 2008 Ding, Eur Heart J 2009 Halkos, Ann Thorac Surg 2009 Chikwe, Am J Cariol, 2009
8 Functional Results of Surgery Aortic Stenosis With Ejection Fraction < 35% NYHA II NYHA III IV 20 0 Pre Op Post Op Connoly Circulation 1997 Vaquette Heart 2005 Pai Ann ThoracSurg 2008 Ding Eur Hear J 2009
9 NYHA III-IV + EF 30% N = Day Mortality : 12% Independent Predictor : CardioThoracic Ratio 0.6
10 Change in Ejection Fraction 80% Have Improved EF c N = 55 (44%) > 10 EF Units c < 10 EF Units
11 Survival Depends on Recovery of Ejection Fraction Predictors of EF >10% 1/ CardioThoracicRatio 2/ Mean Gradient
12 PPM: AVA <0.85cm2/m2 J Thorac Cardiovasc Surg 2006;131:
13 TAVI & Heart Failure / LV Dysfunction What Do We Know?
14 N = 147 EF<50% vs EF 50%
15 No Mortality Difference (But Higher MACCE)
16 No Survival Difference With Matched SAVR
17 Circ Cardiovasc Interv.2012; 5: LVEF N 30d Mortality 1 Year Survival 35% 50 10% 69% >35% 334 3% 87% Predictors of Late Mortality: 1. Congestive Heart failure 2. Log EuroSCORE 3. Moderate-Severe PeriValvular Leak P=0.01 p<0.001
18 3195 patients FRANCE 2 Registry Log EuroSCORE 21.9±14.3% STS score 14.4±12.0% At 1 year Stroke 4.1% Periprosthetic Aortic Regurgitation 64.5%. Independent predictors of 1-year mortality o Increased logistic EuroSCORE, o NYHA functional class III or IV otransapical approach operiprosthetic regurgitation grade 2 or more N Engl J Med 2012;366:
19 FRANCE 2 Registry N Engl J Med 2012;366:
20 What Is The Impact of Coronary Artery Disease?
21 Associated CABG pdf/ndb2010/1stharvestexecutivesummary%5b1%5d.pdf.
22 What About TAVI + Coronary Disease? RCTs Excluded Patients Requiring Revascularization Extent of CAD Impacts Safety AND Long Term Durability EF=30% + NYHA IV + 3 Vessel Disease: Is TAVI Safe?
23 PCI in Severe Aortic Stenosis
24 Low Flow Low Gradient and Reduced Ejection Fraction
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27 Prognostic Impact of Low Gradient and/or Reduced EF After TAVI Reduced EF, Low Gradient Preserved EF, High Gradient
28 Decompensated Heart Failure & Aortic Stenosis
29 Role of Balloon Valvuloplasty Recovery High Risk TAVI
30 Decompensated Heart Failure J Thorac Cardiovasc Surg 2012;143: EF 10%-25% N = 21 Log EuroScore 66% 30 D Mortality: 4.8% No Neuro Events Post Op EF 38% 1 y Survival 76%
31 TAVI vs SAVR in Severe AS and Reduced LV Function
32 TAVI EF 50% SAVR N On multivariable analysis, the predictors of absolute change in LVEF after the procedure were female gender (P 0.004), absence of atrial fibrillation (P 0.01), baseline LVEF (P 0.005), TAVI (P 0.007), AVA (P 0.01), and complete or no need for coronary revascularization (P 0.01) Mortality 30d 19% 13% EF >50% 1 Y 58% 20% A Regurgitation 37% 5%
33 Change in Ejection Fraction Predictors of absolute change in LVEF: Whole Cohort -Female gender -Absence of atrial fibrillation -Baseline LVEF -TAVI -Greater Increase AVA -Complete or no need for coronary EF < 35% revascularization Circulation. 2010;122:
34 How Do We Decide? TAVI or Surgery?
35 TAVI vs Surgery in Heart Failure Gaps in Knowledge Limitations of The Evidence No Randomized Studies Different Cut Offs for Ejection Fraction Aortic Stenosis as Continuum: High Gradient Low Ejection Fraction Low Gradient Low Ejection Fraction: Few Patients Selection Bias Publication Bias: Learning Curve Results UnderReported
36 N Engl J Med 2012;366:
37 Circulation. 2012;126: LBBB=34% Multivariate Cox Regression All-Cause Mortality Female Sex Creatinine COPD LVEF<50% TAVI Induced LBBB
38 Consequences of Pace Maker Induced Dyssynchrony? European Journal of Heart Failure (2010) 12,
39 Risk Assessment Conditions Requiring Individual Approach Low Flow Low Gradient AS Conditions Likely To Be Associated With Insufficient Validation Requiring Further Study LV Dilatation, Diastolic Dysfunction, RV Dysfunction
40 The Heart Team Risk Assessment No Decision Without MultiDisciplinary Clinical Judgement SURGEON CARDIOLOGISTS Imaging specialists (Echo, CT, MRI) Surgery Or TAVI? Anesthesiologist Gerontologist
41 What Do Guidelines Say?
42 If mean gradient is >40 mmhg, there is theoretically no lower EF limit for aortic valve replacement in symptomatic patients with severe aortic stenosis.
43 In patients not medically fit for surgery transcatheter aortic valve replacement should be considered
44
45
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47 Take Home Messages (1) 1. Advanced Heart Failure and/or Reduced Ejection Fraction Increases the Risk of Early and Late Death After AVR But Also After TAVI 2. Risk Is Higher in Patients With Low Flow Low Gradient AS, No Contractile Reserve, Coronary Disease, Large Ventricles and NYHA III/IV 3. TAVI Provides Better Hemodynamic Than SAVR But More Aortic Regurgitation and Pace Makers 4. Surgical AVR is A Safe, Effective and Durable Option Which Should Not Be Denied to Patients On The Basis of Low LVEF Alone
48 Take Home Messages (2) 5. Avoid Patient Prosthesis Mismatch Since Depressed LV Systolic Function Patients Are Most Vulnerable to Residual LV Afterload Associated With PPM 6. TAVI May Provide a Good Alternative to Surgical AVR in patients with severe AS and Depressed Left Ventricular Systolic Function At High or Prohibitive Surgical Risk, Due to Severe Comorbidities, Small Aortic Root, and/or Lack of Myocardial Contractile Reserve. 7. Heart Team Based Approach Foundational Requirement for Risk Assessment, Decision Making, and Patient Information
49 Thank You for Your Attention
50 J Am Coll Cardiol 2012;59: As TAVI becomes more routine and widely available, operators may be tempted to implant the device in younger patients with less comorbidities. Uncertainties about the long-term durability, in addition to the unresolved issues of paravalvular aortic regurgitation and conduction abnormalities, should be cautiously weighed against the immediate benefits being widely reported.
51
52 Survival % Natural history of symptomatic Aortic Stenosis is very bad without treatment TAVI vs AVR Onset of severe symptoms Latent period (increasing obstruction, myocardial overload) Age yr Angina Syncope Failure Average survival (yr) Average age death (male) Ross J, Braunwald E. Aortic stenosis. Circulation.1968; 38 [Suppl 5]:61-7
53 LV End Systolic Volume Index
54 N = 254 EF 30% 5.4% EF > 30% 1.2% 30 D Mortality p <0.01 STS 10% 10.4% STS < 10 0% <0.01 <
55 Surgical Aortic Valve Replacement Does Ejection Fraction Influence Mortality? Rahimtoola Eur Heart J 2008;;29:1783
56 Current Risk Scores Do Not Provide Reliable Estimate of Operative Mortality Specific Risk Models Should Be Developed for TAVI Future Risk Scores Should Include: Cognitive Status Functional Capacity, Nutritional Status
57 Cathet Cardiovasc Interv 2012;79:
58 TAVI in Low-Flow, Low Gradient Aortic Stenosis Low Flow Low Gradient (N=15) 33% No LF/LG (N=152) 13% Mortality (6 Months) P < Ejection Fraction Survivors N=10 Cathet Cardiovasc Interv 2012;79:
59
60 Low Flow Low Gradient Aortic Stenosis 5 Year Survival All patients N = 81 SAVR Medical p 54% 13% <0.001 Propensity Matched 65% 11% <0.02 despite a high operative mortality of 22%
61 No Contractile Reserve Influence of Mean Gradient and Coronary Disease JACC 2009;53:
62
63 Predictors of mortality after aortic valve replacement. Tjang Y S et al. Eur J Cardiothorac Surg 2007;32:
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