Aortic Valve Stenosis: Flow and Gradient stratification and association with TAVR outcomes
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1 Aortic Valve Stenosis: Flow and Gradient stratification and association with TAVR outcomes Kostis Raisakis General Hospital of Athens «G. Gennimatas»
2 Severe Aortic Stenosis Peak Velocity 4 m/s Up to 40% of the AS patients Mean PG harbor discordant Doppler echocardiographic findings 40 mmhg AVA <1.0 cm 2
3 High Gradient Normal Flow Normal EF High Gradient Low Flow Normal EF Low Gradient Normal Flow Low Gradient Low Flow Low EF High Gradient Low Flow Normal EF High Gradient Low Flow Low EF Low Gradient Low Flow Normal EF Low Gradient Low Flow Low EF with Flow Reserve Low Gradient Low Flow Low EF with No Flow Reserve Baumgartner et al, J Am Soc Echocardiog, 2017
4 AVA 1.0 cm 2 MG <40 mmhg SVI 35ml/m 2 EF<50% 5% to 10% of the AS population More prevalent in men Often associated with CAD Enlarged LV cavity with depressed LV systolic function Functional MR Clinical similarities with reduced-lvef HF Clavel et al, EHJ, 2016
5 AVA 1.0 cm 2 MG <40 mmhg SVI 35ml/m 2 EF 50% 5% to 20% of the AS population More prevalent in women and elderly small LV cavity with pronounced LV concentric remodeling Impaired LV diastolic filling, and reduced LV systolic longitudinal function, Clinical similarities with preserved-lvef HF 25% amyloidosis Clavel et al, EHJ, 2016
6 What is the impact of each parameter on outcome? What is the prognostic significance of each type of AS? Which is the best therapy for each type of AS?
7 Outcome after SAVR Impact of LVEF Halkos et al, Ann Thorac Surg, 2009
8 Outcome after SAVR Impact of LVEF and Flow Clavel et al, JACC, 2015
9 Outcome after SAVR Impact of LV Contractile Reserve Monin JL et al, Circulation, 2003
10 Low-Gradient Aortic Stenosis SAVR Without Contractile Reserve Probability of Survival in LF/LGAS Patients Without CR on DSE Late Survival in Operated LF/LGAS Patients Without CR on DSE High operative mortality (22%) 5-year mortality of 31% in patients operated vs 87% on on conservative management Tribouilloy C et al, JACC, 2009
11 Outcome in PARTNER Trial Impact of Flow All-cause mortality to 2 years for patients with low flow vs normal flow Herrmann HC et al, Circulation, 2013
12 PARTNER Trial-LF AS Outcome after TAVI TAVR vs medical management (MM) in inoperable cohort TAVR vs SAVR in high-risk cohort Herrmann HC et al, Circulation, 2013
13 Outcome in German TAVR Registry Impact of EF and Gradient Lauten A et al, Eurointervention, 2014
14 Outcome in UK TAVR Registry Impact of LVEF and Gradient Malkin C et al, Eurointervention, 2016
15 Outcome after TAVR Impact of Gradient and EF Baron et al, JACC, 2016
16 Meta-analysis of TAVR Registries Impact of Gradient on Outcome Cornotto F et al, Catheter Cardiovasc. Interv. 2017
17 Outcome after TAVR Impact of Flow, Gradient and LVEF Carreras E et al, Catheter Cardiovasc. Interv. 2017
18 Outcome after TAVR Impact of Flow, Gradient and LVEF Carreras E et al, Catheter Dardiovasc. Interv. 2017
19 Outcome after TAVR Impact of Flow, Gradient and LVEF Carreras E et al, Catheter Cardiovasc Interv 2017
20 TAVR in LFLG-AS Predictors of Mortality and Outcome Manger N et al, JAHA, 2018
21 TAVR in LFLG-AS Predictors of Mortality and Outcome Manger N et al, JAHA, 2018
22 TOPAS-TAVI Registry in LF-LG AS Global and 30d Mortality after TAVR Multicenter registry including 287 patients with LFLG-AS Mortality rate at 30d was 3.8%, lower compared to the STS risk calculator-predicted mortality rate of 7.7% and impressively lower compared mortality rate at 30d after SAVR performed in similar cohorts ( 30% ) Ribeiro et al, JACC, 2018
23 TOPAS-TAVI Registry in LF-LG AS Prognostic Role of DSE Ribeiro et al, JACC, 2018
24 TOPAS-TAVI Registry in LF-LG AS Changes in LVEF Ribeiro et al, JACC, 2018
25 Classic LF-LG AS Proposed Decision-Tree Algorithm Généreux, JACC, 2018
26 2017 ESC Guidelines Indications for Intervention Baumgartner H et al, EHJ, 2017
27 2017 ESC Guidelines Choice of Intervention Baumgartner H et al, EHJ, 2017
28 Take home messages Different subtypes of severe aortic stenosis are recognized after the implementation of a stepwise grading algorithm. Not all AS subtypes are the same in terms of prognosis. Low transaortic flow appears to be a stronger independent predictor for outcomes than low AVG and reduced EF. Nevertheless, even patients with low flow severe AS benefit from AVR. TAVR is possible the preferred therapeutic option in LFLG-AS patients independently of contractile reserve in DSE.
29 Thank you for your attention
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