Stage of Valvular AS. Outline 10/14/16. Low-flow and Other Challenges to the Assessment of Aortic Stenosis. Severe AS
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1 Low-flow and Other Challenges to the Assessment of Aortic Stenosis Nithima Ratanasit, MD, FACC, FASE Siriraj Hospital, Mahidol University Bangkok, Thailand Outline Types of low-flow aortic stenosis Assessment of low-flow aortic stenosis Pitfall in the assessment of Valvular AS of Valvular AS 2014 AHA/ACC Guideline for VHD Peak aortic jet velocity 4 m/s Mean transvalvular PG 40 mmhg < 1 cm 2 A B C D At risk of AS Bicuspid AV, AV sclerosis Progressive AS Mild and moderate AS Rheumatic change Asymptomatic severe AS C1 : Normal LVEF C2 : LVEF < 50% Symptomatic severe AS D1 : High gradient AS D2 : Low-flow AS with reduced LVEF D3 : Paradoxical low-flow AS 1
2 of Valvular AS Valvular AS Low-flow AS A B C D D2 and D3 C1 C2 D1 D2 D3 of Valvular AS D Case 86- year- old female Poor controlled HT Recurrent HF JACC 2012:60: D1 D3 D2 LVEF 30% Mean PG = 13.4 mmhg = 0.5 cm 2 2
3 Classical Low-flow Aortic Stenosis with Reduced LVEF Classical Low-flow Aortic Stenosis < 1.0 cm 2 Mean PG < 40 mmhg LVEF < 50% 2012 ESC/EACTS and 2014 AHA/ACC guidelines for VHD Severity of Aortic Stenosis Doppler velocity (m/sec) Mean gradient (mmhg) (cm 2) Mild < 3.0 < 25 > 1.5 LV systolic dysfunction Moderate Severe > 4.0 > 40 < 1.0 Severe low-flow/low-gradient AS with reduced LVEF (cm 2 ) V max (m/s) Mean PG (mmhg) Rest 1.0 < 4 < 40 Dobutamine stress Aortic Stenosis Low output, low gradient AS LV systolic dysfunction Gradient < 40 mmhg < 1.0 cm 2 Low output, Low gradient Aortic Stenosis Gradient Gradient Critical AS Non-severe AS LV dysfunction Not severe AS 3
4 Dobutamine Echocardiography Protocol Used for Hemodynamic Evaluation of AS ECHO LV contractile reserve is defined by an SV of 20% compared with baseline ECHO Resting ECHO 5 µg/kg/min (5 min) ECHO 10 µg/kg/min (5 min) ECHO 15 µg/kg/min (5 min) 20 µg/kg/min (5 min) Peak and mean gradient SV at LVOT by continuity equation LVEF Assessment of LV Contractile/Flow Reserve JACC 2012:60: Projected EOA TOPAD study in Circulation 2006;113: Dobutamine Stress Echocardiography in 86 yo woman with recurrent HF and low- gradient AS with low LVEF Rest 20 mcg/kg/min 4
5 Dobutamine Challenge! SV (ml) Mean PG (mmhg) (cm 2 ) Baseline survival (%) Group I: presence of contractile reserve Group II: absence of contractile reserve Low-gradient AS Monin et al Circulation 2003;108:319 Group II Valve replacement Group I Medical treatment Group II Medical treatment Group I Valve replacement Follow-up (mo) LFAS: Timing of Intervention AVR for D2 AS Class IIa indication Symptomatic Low-dose dobutamine stress study 1.0 cm 2 V max 4 m/s or mean PG 40 mmhg Conclusions Classical low-flow, low-gradient AS Correct diagnosis leads to optimal management and improves outcome Paradoxical Low-flow Aortic Stenosis Dobutamine stress for diagnosis and risk stratification Optimal surgical candidate 5
6 Case 75-year-old female Dyspnea Recent admission due to CHF Hypertension Physical exam: BP 110/70, RR 22, PR 76 Carotid pulse: parvus et tardus Heart: sustained apical heaving, normal S 1,S 2, SEM gr.iii at radiated to neck Case: Echocardiography Case LVEF 65%, concentric LVH No regional wall motion abnormality Calcified AV cusps with limited excursion Mean PG across AV = 30 mmhg = 0.8 cm 2 Valvular Aortic Stenosis SVi = 30 ml/m 2 RVSP = 40 mmhg Diagnosis and Severity Case: 75-year-old female with dyspnea Discordant findings: Mean PG < 1.0 cm 2 and Mean PG < 40 mmhg > 40 mmhg < 1.0 cm 2 V max > 4.0 m/s Severe AS Mean PG > 40 mmhg Moderate AS < 1.0 cm 2 V max > 4.0 m/s Severe AS 2014 AHA/ACC Guideline for VHD Good LVEF 6
7 D3 of Valvular AS Paradoxical low-flow aortic stenosis (PLFAS) Paradoxical Low-Flow AS Calculated < 1.0 cm 2 Indexed < 0.6 cm 2 /m 2 Low gradient Transaortic MPG 40 mmhg Low flow LVEF > 50% = paradoxical SV index < 35 ml/m AHA/ACC Guideline for VHD Real Valvular AS PLFAS A B C D Measurement Errors Physiologic changes C1 C2 D1 D2 D3 AS: Flow-Gradient Pattern LV flow state Normal flow Low flow Aortic Stenosis Entity JACC Img 2013;6: High gradient Pressure gradient Low gradient NF/HG LF/HG 52% 10% D1 D1 NF/LG LF/LG 31% 7% D3 Low flow = LV-SVI < 35 ml/m 2 Low gradient = PG < 40 mmhg JACC 2012;59: D1 Classic severe AS D3 Paradoxical low flow AS D2 Classical low flow AS 7
8 by Continuity Equation Real = A1 x Artefact Measurement Errors PLFAS Physiologic changes = 2 x x Measurement Errors LVOT Diameter LVOT diameter: Inaccurate measurement Shape of LVOT AV / LVOT VTI: PW sample volume Flow alignment Measurement of LVOT Diameter by Continuity Equation Underestimation of LVOT diameter A1 à à Underestimation = of by continuity equation 2 x = x x 8
9 by Continuity Equation LVOT Shape: Elliptical Geometry The continuity equation assumes A1 circular geometry of = LVOT. x 2 = x x JACC Imag 2013;6: LVOT and Aortic Annulus Measurement Errors CT study Noncircular geometry 17% underestimation of LVOT area and Less error with annulus measurement, more circular than LVOT Use of 3D-Echo, CT, MRI JACC Imag 2013;6: JASE 2012;25: JACC Imag 2011;4: Heart 2011;97: LVOT diameter: Inaccurate measurement Shape of LVOT AV / LVOT VTI: Doppler sample volume Flow alignment = A1 x Doppler Echo: Parallel to Flow 9
10 Multiple Echocardiographic Windows Highest Peak Velocity Doppler Echocardiography Nonimaging Doppler probe JASE 2015;28:780-5 PLFAS: Real or Artefact? Physiologic Changes Real Hypertension Low flow states Artefact PLFAS Artefact Small body size (Indexed ) Prolonged LV ejection time Measurement Errors Physiologic changes Discordant findings: < 1.0 cm 2 and Mean PG < 40 mmhg, LVEF > 50% Step 1: Measurement errors Normotensive Step 2: Indexed > 0.6 cm 2 Step 3: Low-flow state (SVi < 35 ml/m 2 ) PLFAS Yes = Nonsevere AS Yes = Nonsevere AS Yes = Paradoxical LF/ LG severe AS Measurement Errors Physiologic changes No Step 2 No Step 3 No NF/LG severe AS 10
11 D3 AS: Timing of Intervention PLFAS Summary Physiologic changes Measurement errors Paradoxical low-flow AS AS: Timing of Intervention Valvular AS Summary Low-flow AS is a common entity of valvular AS. Correct diagnosis is essential. A B C D Echocardiography is very useful for the assessment. Class I C1 C2 D1 D2 D3 Appropriate management improves outcome Class IIa Thank You for Your Attention 11
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