Early Surgery in Asymptomatic Severe Aortic Stenosis Pros and Cons
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1 Early Surgery in Asymptomatic Severe Aortic Stenosis Pros and Cons Duk-Hyun Kang, M.D. Division of Cardiology Asan Medical Center Seoul, Korea
2 Background Dilemma of balancing the risks versus benefits of AV replacement in asymptomatic severe AS Risks Operative mortality Prosthesis-related mortality and morbidity Benefits Preventing sudden death Lowering cardiac mortality related with refusal and delay of surgery
3 Background Surgery for asymptomatic severe AS ESC guidelines ACC/AHA guidelines LVEF < 50% Abnormal exercise test AV calcification with rapid progression Class I indication LVEF < 50% Class IIb indication Abnormal exercise test Rapid progression Extremely severe AS with operative mortality 1%
4 Case: 72 yr-old female with asymptomatic severe AS AV Vmax = 5.4 m/s PG = 106/72 mmhg
5 Continuity Equation for AV Area LA LVOT flow = AV flow LV AV level LVOT level A LVOT x TVI LVOT = A AV x TVI AV A AV = A LVOT x TVI LVOT TVI AV
6 LVOT diameter = 2.01 cm AVA = X (LVOT)2 X LVOT TVI AV TVI = X (2.01)2 X = 0.64 cm 2 LVOT TVI = 28cm
7 Early Surgery Vs. Watchful Waiting
8 Comparison of Early Surgery versus Conventional Treatment in Asymptomatic Very Severe Aortic Stenosis Duk-Hyun Kang, Sung-Ji Park*, Ji Hye Rim, Dae-Hee Kim, Jong-Min Song, Kee-Joon Choi, Seung Woo Park*, Jae-Kwan Song, Jae-Won Lee, Pyo-Won Park* Division of Cardiology, Cardiac Surgery Asan Medical Center, Samsung Medical Center* Seoul, South Korea Kang DH, et al. Circulation 2010;121:1502
9 Background The more severe AS, the worse the clinical outcomes Asymptomatic patients with very severe AS are often referred for AV surgery Recent improvements in surgical techniques and AV prosthesis
10 Methods From 1996 to consecutive patients with asymptomatic very severe AS Conventional Tx CONV (N=95) Early surgery OP (N=102) Follow-up of 59±33 months
11 Echocardiographic Evaluation Etiology of AS and grading of AV calcification on 2D echo Maximal aortic jet velocity, mean pressure gradients and aortic valve area on Doppler Very severe aortic stenosis AV area 0.75 cm 2 fulfilling one of criteria; peak aortic velocity 4.5 m/sec or mean pressure gradient 50 mmhg
12 Echocardiographic Evaluation Rheumatic AS Mild Calcification Bicuspid AV Moderate Calcification Degenerative AS Severe Calcification
13 AV area and Peak velocity m/sec AVA by cath (cm 2 ) cm Peak velocity (m/s) Oh JK, et al. J Am Coll Cardiol 1988
14 Methods From 1996 to consecutive patients with asymptomatic very severe AS Conventional Tx CONV (N=95) Early surgery OP (N=102) Follow-up of 59±33 months
15 Baseline Characteristics (I) Variables CONV (n=95) OP (n=102) P-value Age, years 63 ± ± 11 NS Gender, male 44 (46%) 55 (54%) NS EuroSCORE, 3.6 ± ± 1.7 NS LV mass index, g/m ± ± 43 NS Ejection fraction, % 63 ± 7 62 ± 7 NS AV calcification moderate 85 (90%) 95 (93%) NS
16 Baseline Characteristics (II) Variables CONV (n=95) OP (n=102) p-value Etiology of AS 0.08 Degenerative 45 (47%) 33 (32%) Bicuspid 39 (41%) 57 (56%) Rheumatic 11 (12%) 12 (12%) Aortic valve area, cm ± ± Aortic jet velocity, m/s 4.9 ± ± 0.5 <0.001 Mean gradient, mmhg 59 ± ±
17 Results Variables CONV (n=95) OP (n=102) p-value All-cause death 28 (29 %) 3 (3 %) < yr survival rate 68 ± 6 % 98 ± 1 % <0.001 Cardiac death 18 (19 %) 0 (0 %) < yr cardiac death rate 24 ± 5 % 0 % <0.001 Kang DH, et al. Circulation 2010;121:1502
18 Survival Rate OP versus CONV group 100 OP Survival (%) P<0.001 OP 6-year survival rate 98±1% CONV 6-year survival rate 68±6% CONV years No at Risk OP CONV
19 Cardiac mortality free survival (%) Survival Free of Cardiac Death in the Propensity-matched Pairs No at Risk P<0.001 OP 6-year survival rate 100% CONV 6-year survival rate 74±7% OP CONV OP CONV years
20 Survival Rate Free of Cardiac Death or Surgery in the CONV group Survival Rate (%) year survival rate 71±5% 4-year survival rate 47±5% 6-year survival rate 28±6% No at Risk CONV
21 Event-free Survival in Very Severe AS With Aortic Jet Velocity > 5 m/s Event-free Survival (%) Years Pts at risk Rosenhek et al. Circulation 2010;121:151
22 Conclusions Early surgery is associated with improved long-term survival by decreasing cardiac mortality and sudden cardiac death in very severe AS Early surgery is a therapeutic option to further improve clinical outcomes in asymptomatic patients with very severe AS and low operative risk Kang DH, et al. Circulation 2010;121:1502
23 CASE; Degenerative AS
24 CASE; Degenerative AS
25 CASE; Degenerative AS AV Vmax = 4.2m/sec Mean PG = 38mmHg
26 Continuity Equation; Measurement of AVA LVOT diameter 2.0cm LVOT TVI 28cm AVA = D 2 X X = (2.0) 2 X X = 0.97 TVI LVOT TVI AoV AoV TVI 91cm AVA = 0.97cm 2
27 Early Surgery Vs. Watchful Waiting
28 Event-Free Survival Rate 100 P<0.001 Event-free Survival (%) m/s m/s 5.5 m/s Years Pts. at risk AV-Vel m/s AV-Vel m/s AV-Vel 5.5m/s Rosenhek et al. Circulation 2010;121:151
29 Comparison of Early Surgery Versus Conventional Treatment in Asymptomatic Severe Aortic Stenosis Duk-Hyun Kang, Ji Hye Rim, Jong-Min Song, Ki-Hoon Han, Hyun Song*, Kee-Joon Choi, Jae-Kwan Song, Jae-Won Lee* Division of Cardiology, Cardiac Surgery* Asan Medical Center, University of Ulsan Seoul, South Korea
30 Event-free Survival Severe vs Very Severe AS
31 Methods From 1997 to consecutive patients with asymptomatic severe AS Conventional Treatment CONV (N=157) Early surgery OP (N=67) Median Follow-up of 62 months
32 Cardiac Event and Mortality Rates in Severe AS CONV 6-yr Event rate 15±5% OP 6-yr Event rate 9±9% 25 CONV 6-yr Cardiac mortality 9±3% OP 6-yr Cardiac mortality 9±9% Event rate (%) p=0.931 OP CONV Cardiac mortality (%) p=0.800 OP CONV Years Years
33 CASE; Degenerative AS AV Vmax = 4.2m/sec Mean PG = 38mmHg
34 Progression of Calcification Baseline 3 Year
35 Progression of Calcification Baseline 3 Year
36 Baseline 1yr 2yr AV Vmax = 4.2m/sec Mean PG = 38mmHg 3yr AV Vmax = 4.7m/sec Mean PG = 53mmHg AV Vmax = 4.7m/sec Mean PG = 58mmHg AV Vmax = 5.3m/sec Mean PG = 69mmHg
37 Predictors of Outcome in Severe AS Rosenhek et al. NEJM 2000; 343: 611
38 Marked Individual Variability in the Rate of Progression Otto CM, et al. Circulation 1997;95:2262
39 Event-free Survival According to Calcification
40 Outcome of Patients With Low-Gradient Severe Aortic Stenosis and Preserved Ejection Fraction Outcome of low-gradient severe AS (AVA < 1.0 cm 2 and mean gradient 40 mmhg compared with moderate AS (AVA: cm 2 ) AV events included cardiovascular death, AV replacement and CHF In 619 asymptomatic patients (SEAS study), AV events occurred in 48.5% versus 44.6%, respectively, during 46 months of follow-up (P= 0.37) In conclusion, outcome of low-gradient severe AS and normal ejection fraction similar to that of moderate AS Jander N, et al. Circulation 2011;123:887
41 Outcome in Low-Gradient Severe AS
42 Outcome in Low-Gradient Severe AS
43 AV Area vs. Mean Pressure Gradient Minners J, et al. Eur Heart J 2008
44 AV Area vs. Peak Flow Velocity Minners J, et al. Eur Heart J 2008
45 Conclusions The clinical outcomes were different according to severity and etiology of AS, and degree of calcification Early surgery can be a therapeutic option to further improve clinical outcomes for asymptomatic patients with very severe AS and low operative risks
46 Randomized Comparison of Early Surgery versus COnventional Treatment in Asymptomatic VERY Severe Aortic Stenosis (RECOVERY) Duk-Hyun Kang, Sung-Ji Park*, Yong-Jin Kim +, Dae-Hee Kim, Jong-Min Song, Seung Woo Park*, Jae-Kwan Song, Jae-Won Lee, Pyo-Won Park* Division of Cardiology, Cardiac Surgery AMC, SMC*, SNUH + Seoul, South Korea
47 RECOVERY (
48 Randomized Comparison of Early Surgery versus COnventional Treatment in Asymptomatic VERY Severe Aortic Stenosis (RECOVERY) Duk-Hyun Kang, Sung-Ji Park*, Yong-Jin Kim +, Dae-Hee Kim, Jong-Min Song, Seung Woo Park*, Jae-Kwan Song, Jae-Won Lee, Pyo-Won Park* Division of Cardiology, Cardiac Surgery AMC, SMC*, SNUH + Seoul, South Korea
49 Event-free Survival Rate in the CONV group
50 Event-Free Survival Rate Event-free survival (%) Severe AS: 21±18% at 2 yr Months Vmax < 3.0 m/s Vmax m/s Vmax > 4.0 m/s Otto CM, et al. Circulation 1997;95:2262
51 Outcome of 622 Patients with Severe Asymptomatic AS Severe asymptomatic AS (Vmax > 4.0m/s) 5 yr Event-free survival 25% 5 yr Sx-free survival 33% Pellikka et al. Circulation 2005;111:3290
52 Outcome in Low-Gradient Severe AS
Indicator Mild Moderate Severe
Indicator Mild Moderate Severe Jet velocity (m/s) 2.0-2.9 3.0-3.9 4.0 Mean gradient (mmhg) < 20 20-39 40 Valve area (cm 2 ) 1.0 Valve area index (cm 2 /m 2 ) 0.6 1 Abnormal AV with Reduced Systolic Opening
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