Aortic Valve Replacement Improves Outcome in Patients with Preserved Ejection Fraction: PRO!
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1 ESC 2011, Paris Controversies in Low-Flow, Low-Gradient Aortic Stenosis Aortic Valve Replacement Improves Outcome in Patients with Preserved Ejection Fraction: PRO! Philippe Pibarot, DVM, PhD, FACC, FAHA, FESC Canada Research Chair in Valvular Heart Diseases Université LAVAL
2 Disclosure: None Except that 1- Gilbert Habib is a good friend 2- I like Champagne!!!
3 Indication for AVR in AS SEVERE STENOSIS Mean gradient: 40 mmhg Aortic valve area (AVA): 1.0 cm 2 Indexed AVA: 0.6 cm 2 /m 2 Discordance! 30 mmhg 0.8 cm cm 2 /m 2 AHA/ACC/ESC Guidelines + SYMPTOMS and/or LVEF<50% = AVR (Class I)
4 Patients with reduced LVEF may have a low gradient despite the presence of severe AS Gradient = Q 2 K AVA 2 Low Flow Normal Flow AVA P
5 Case Study: Low LVEF Resting Echo SV= 53 ml LVEF=40% Peak P= 49 mmhg Mean P= 29 mmhg AVA= 0.77 cm 2 Dobutamine Stress Echo SV= 73 ml LVEF=50% Peak P= 92 mmhg Mean P= 52 mmhg AVA= 0.75 cm 2
6 In patients with Preserved LVEF: Is it possible to have a low-flow, low-gradient despite the presence of severe AS??? IF YES.Champagne!!!
7 Does aortic valve replacement improves outcome in patients with Low-Flow, Low-Gradient AS and Preserved LVEF?
8 In patients with Preserved LVEF: Is it possible to have a low-flow, low-gradient despite the presence of severe AS??? IF NO
9 Case Study: Discrepancy between AVA and gradient in patient with preserved LVEF 78 y.o. female with history of calcific AS NYHA class III Mild hypertension No evidence of obstructive CAD LVEF: 60% AS severity on echo: AVA: 0.7 cm 2 BSA: 1.7 m 2, indexed AVA: 0.41 cm 2 /m 2 Peak/mean gradient: 51/29 mmhg
10 Case Study: Discrepancy between AVA and gradient in patient with preserved LVEF LVEF: 60% Small LV cavity: LVEDD: 39 mm LVEDV: 66 ml
11 LVOT-D: 2.0 cm LVOT-A: 3.1 cm 2 LVOT-VTI: 15 cm Peak ΔP: 51 mmhg Mean ΔP: 29 mmhg Ao-VTI: 65 cm LVOT- SV: 46 ml (SVi=27 ml/m 2 ) Other method to corroborate SV measurement: LVEDV (66 ml) LVEF (60%) = 40 ml / AVA: 0.7 cm 2
12 Dobutamine Stress Echo Multislice CT 15 µg/kg/min Peak ΔP: 94 mmhg Mean ΔP: 57 mmhg Valve Calcium score: 1900 AU
13 Performance of MSCT Calcium score > 1651 AU to correctly differentiate severe from non-severe AS Normal Flow Low Flow-Low Gradient Sensitivity Specificity PPV NPV Cueff et al. Heart 97:721-6, 2011
14 Surgical Findings Valve Weight: 2.4 g
15 Hachicha Z et al., Circulation. 115: , 2007
16 Normal Flow AS LVEDV: 115 ml LVEF: 60% SV: 70 ml AVA: 0.7 cm 2 P: 45 mmhg «Paradoxical» Low-Flow AS Age Women Hypertension MetS - Diabetes LVEDV: 85 ml LVEF: 60% SV: 50 ml AVA: 0.7 cm 2 P: 25 mmhg Pibarot & Dumesnil ijacc; 2:400-3, 2009
17 Gradient vs. valve weight 250 patients with AVA<1.0 cm 2 undergoing AVR ESC 2010 Valve Weight: 2.4 g
18 Patients with paradoxical low-flow, low-gradient AS have abnormal myocardial structure and systolic function Low-Flow, Low-Gradient, Preserved LVEF Hermann et al. JACC 2011;58;
19 LVEF underestimates myocardial systolic dysfunction in AS Preserved LVEF Normal -Flow High Gradient Low-Flow Low-Gradient Lee et al. J Am Soc Echocardiogr, 2011 Lancellotti et al. Eur J Echo 2010
20 Relationship between gradient and LV Longitudinal Shortening Hermann et al. JACC 2011;58;
21 Features of Paradoxical Low-Flow, Low-Gradient AS The Aortic Valve: AVA< 1.0 cm 2 AVAi < 0.6 cm 2 /m 2 DVI<0.25 Severely thickened/calcified valve Mean gradient <40 mmhg Valvulo-arterial impedance > 4.5 mmhg.ml -1.m -2 The Left Ventricle EDD<47 mm EDV< 55 ml/m 2 RWT ratio > 0.50 Myocardial fibrosis Impaired LV filling LVEF > 50% GLS < 16% SVi < 35 ml/m 2 Pibarot & Dumesnil, JACC 58; , 2011
22 Prevalence of Paradoxical Low-Flow, Prevalence (%) Hachicha 2006 Echo (512 pts) Barasch 2006 Echo (215 pts) Low-Gradient AS Cramariuc 2009 Echo (1591 pts) Lancellotti 2010 Echo (173 pts) Minners 2010 Echo (333 pts) Minners 2010 Cath (333 pts) Hermann 2011 Echo & Cath (86 pts) Paradoxical Low-Flow (AVA<1.0 cm 2 LVEF>50% SVi<35 ml/m 2 ) Colonne3 Colonne2 Paradoxical Low-Flow Low-Gradient (AVA<1.0 cm 2 LVEF>50% SVi<35 ml/m 2 MG<40 mmhg)
23 In patients with Preserved LVEF: Is it possible to have a low-flow, low-gradient despite the presence of severe AS??? YES!!!...Champagne!!!
24 YES!!! BUT!!! Does aortic valve replacement improves outcome in patients with Low-Flow, Low- Gradient AS and Preserved LVEF?
25 Outcome of Patients with Paradoxical Low-Flow, Low-Gradient AS Patients with indexed AVA<0.6 cm 2, LVEF 50% Percentage of Patients Treated Surgically NF 65 % 47 % PLF ΔP: 40±15 32±17 Hachicha Z et al., Circulation. 115: , P < Overall Survival (%) Surgical Surgical Medical Medical Follow-up (years) NF: Normal Flow: SVI>35 (65%) PLF: Paradoxical Low Flow: SVI 35 (35%)
26 Benefit of AVR in Paradoxical Low-Flow AS 825 patients, AVA<1.0 cm 2 ; indexed AVA<0.6 cm 2, LVEF>50% P values are adjusted for propensity score Clavel et al. ESC 2010
27 Impact of AVR on Survival According to Gradient in Patients with Preserved LVEF ΔP > 40 mmhg 248 patients AVA < 1.0 cm 2 LVEF 50% ΔP mmhg ΔP< 30 mmhg Belkin et al., Echocardiography 2011
28 Impact of AVR on Survival According to LVEF in Patients with Low Gradient LVEF< 35% 168 patients AVA 0.8 cm 2 ΔP 30 mmhg LVEF < 35-54% LVEF 55% Pai et al., Ann Thorac Surg 86: , 2008
29 Impact of AVR on Survival in Patients with Low-Gradient Severe AS and Preserved LVEF 102 patients, AVA<1.0 cm 2 ΔP Mean < 40 mmhg LVEF 50% Whole Cohorts Propensity Score-Matched Cohorts Tarantini et al. Ann Thorac Surg, 91: , 2011
30 Key Messages A preserved LVEF ( 50%) does not exclude the presence of myocardial systolic dysfunction and low transvalvular flow in AS patients A low transvalvular gradient (<40 mmhg) or velocity (<4 m/s) does not exclude the presence of a severe stenosis in patients with small AVA and preserved LVEF Paradoxical low-flow, low-gradient is found in 10-20% of AS patients and is often associated with more advanced stage of the disease and worse prognosis
31 THE END... AVR improves outcome in patients with low-flow, low-gradient severe AS and preserved LVEF It is important to recognize this entity so we do not deny surgery to a symptomatic patient with small AVA and low gradient
32 Santé Gilbert!
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