AS with reduced LV ejection fraction: Contractile reserve should be systematically assessed: PRO
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1 AS with reduced LV ejection fraction: Contractile reserve should be systematically assessed: PRO Jean-Luc MONIN, MD, PhD Henri Mondor University Hospital Créteil, FRANCE
2 Potential conflicts of interest (JLM) Grants and/ or consulting fees : GE Healthcare, Medtronic CoreValve, Philips Saint-Jude Medical, Siemens, Toshiba
3 Male patient, 57 years old NYHA Class III, systolic ejection murmur, single S2 3
4 Low LVEF/ High filing pressures 4 LVEF = 25% (Biplane Simpson) E/A > 2
5 Cardiac index = 1.8 L/min/m 2 5
6 MPG = 21 mm Hg / AVA = 0.8 cm 2 6
7 Low-EF / Low-gradient AS DEFINITION : Valve area < 1.0 cm² (< 0.6 cm²/m²) WITH LV systolic dysfunction (LVEF< 40%) AND Transaortic MPG< 40 (30*) mm Hg 7 ESC Task Force on VHD. Eur Heart J. 2007;88: * ACC/ AHA Guidelines. J. Am. Coll. Cardiol. 2006;48: e1-148
8 Low-flow / Low-gradient AS : Dismal prognosis under conservative TT 95 patients, AVA <0.75 cm², LVEF <35%, MPG <30 mm Hg 4-year Survival = 78% 4-year Survival = 15% 8 Pereira et al. J Am Coll Cardiol. 2002;39:
9 LV dysfunction + Low pressure gradient = Highest operative risk Author Patients Mean PG Deaths (D 30) (year) (n) (mm Hg) Brogan (1993) % Connolly (2000) % Nishimura (2002) % Monin (2007) % Levy (2008) % 9 Standard operative risk for AVR: 3-6% according to STS/ EuroHeart Survey
10 Low-flow / Low-gradient aortic stenosis : The clinical challenge When facing a patient with LF / LGAS, the cardiologist has to choose between: - Dismal prognosis under medical therapy - High operative risk Operative risk stratification is mandatory 10
11 Low-Flow/ Low Gradient AS With low LV ejection fraction 11
12 Dobutamine Stress Echocardiography 12 Baseline Dobutamine
13 Low-dose Dobutamine Echo in AS : Study Protocol Continuous monitoring from the apical window: comfortable supine position ++ Progressive increase in Dobutamine infusion: steps of 2.5 μg/kg per min every 5 min Maximal dose of 20 μg/kg per min. Endpoint: heart rate acceleration >10 BPM (compared to baseline) No serious adverse event reported in more than 300 procedures (European registry on LF/ LGAS) Monin et al. J Am Coll Cardiol. 2001; 37: Tribouilloy et al. J Am Coll cardiol. 2009;53:
14 Dobutamine (μg/kg/min) Direct monitoring of LV stroke volume Baseline 5 7,5 7, LVOT Time Velocity Integral (cm)
15 Dobutamine (μg/kg/min) Changes in MPG / Valve area Baseline 5 7,5 7, Mean Pressure Gradient (mm Hg)
16 Low-dose Dobutamine Echocardiography Low-flow / Low-gradient AS (n=136) LV Contractile Reserve = Stroke Volume > 20% Contractile Reserve n= 92 (68%) No Reserve n=44 (32%) AVR : 64 patients (70%) Deaths (D30) n= 3 (5%) Associated CABG (n= 19): Deaths (D 30) n= 2 (11%) * p< vs Group I AVR : 31 patients (70%) Deaths (D 30) n= 10 (32%)* Associated CABG (n= 8): Deaths (D 30) n= 5 (68%)* Monin et al. Circulation. 2003;108: 319
17 Patient Survival (%) Henri Mondor Contractile reserve present: Most patients benefit from surgery at 5% risk * p= vs medical Group I, Valve Replacement * Group II, Valve Replacement Group I, Medical Treatment Group II, Medical Treatment Months Monin et al. Circulation. 2003;108: 319
18 LV contractile reserve is the main determinant of risk stratification 152 consecutive patients with Low-flow/ Low-gradient AS undergoing AVR after Dobutamine Echo (100%) 18 Monin et al. Eur Heart J. 2007; 28:
19 Low-flow / low-gradient AS : Predictors of postoperative outcome 217 consecutive patients (77% men) with severe AS, LVEF <35% and MPG <30 mm Hg, who underwent AVR between 1990 and 2005 Predictors of perioperative mortality 19 Levy et al. J Am Coll cardiol. 2008;51: 1472
20 Predictors of outcome in Low-flow / lowgradient AS: TOPAS study 101 consecutive patients (77% men) with LF/ LGAS (AVA <1.2 cm 2, LVEF <40%, MPG <40 mm Hg), who underwent DSE between 2002 and Clavel et al. Circulation. 2008;118: S234-42
21 Low-Flow/ Low Gradient AS With low LV ejection fraction 21
22 Substantial benefit of AVR in Patients without contractile reserve Multicenter Registry: 81 consecutive patients with Low-gradient AS But no contractile reserve, Operative mortality = 22% Whole cohort, n= 81 Matched patients, n= Tribouilloy et al. J Am Coll cardiol. 2009;53:
23 Alternative Strategies for High-risk Patients: TAVI? Edwards SAPIEN XT Medtronic CoreValve 23
24 Alternative Strategies for High-risk Patients: TAVI? SOURCE Registry: 1038 patients / TAVI at 32 centers in Europe Transapical (n = 575): average EuroSCORE = 29.1% Transfemoral (n = 463): EuroSCORE = 25.7% 24 Thomas et al. Circulation. 2010;122:62
25 Therapeutic options in AS : The role of LV contractile reserve Severe / Symptomatic AS: Contra-indication or High risk for No Yes Limited life expectancy Yes No Surgery Medical Rx TAVI 25 Adapted from Vahanian & Otto. Eur Heart J. 2010; 31: 416
26 Low-flow/ Low-gradient AS: Why should we assess LV contractile reserve? Risk stratification is mainly based on LV contractile reserve, along with CAD, baseline MPG, extra-cardiac comorbidity (EuroSCORE) Assessment of LV contractile reserve still has strong therapeutic implications in the TAVI era 26
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