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 Severe AS V max 4 m/sec P mean 40 mmhg V max 3.0-3.9 m/sec P mean 20-39 mmhg Symptomatic (stage D1) Asymptomatic (stage C) Symptomatic Asymptomatic LVEF < 50% (stage C2) Other cardiac surgery Vmax 5 m/sec P mean 60mmHg Low surgical risk LVEF<50% Yes DSE with AVA 1 cm 2 and V max 4m/sec (stage D2) No AVA 1 cm 2 and LVEF 50% (stage D3*) Other cardiac surgery Abnormal ETT V max 0.3 m/s/y Low surgical risk AS likely cause of symptoms AVR (Class I) AVR (Class IIa) AVR (Class IIb) AVR (Class IIa) 2
Case. Asymptomatic Severe AS Case. Asymptomatic Severe AS AV Vmax = 4.6 m/sec AV Vmax = 5.5 m/sec 3
Case. Asymptomatic Severe AS LVOT diameter 2.1 cm LVOT TVI 21 cm Vmax = 5.5 m/sec AV TVI 154 cm 0.785 2 0.785 2.1 2 21 154. 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 4
Survival Free of Cardiac Death OP versus CONV group Cardiac mortality free survival (%) 100 80 60 40 0 P<0.001 OP 6-year survival rate 100% CONV 6-year survival rate 76±5% 0 2 4 6 OP CONV years No at Risk OP 102 96 48 29 CONV 95 82 54 32 Abnormal AV with Reduced Systolic Opening Severe AS V max 4 m/sec P mean 40 mmhg V max 3.0-3.9 m/sec P mean 20-39 mmhg Symptomatic (stage D1) Asymptomatic (stage C) Symptomatic Asymptomatic LVEF < 50% (stage C2) Other cardiac surgery Vmax 5 m/sec P mean 60mmHg Low surgical risk LVEF<50% Yes DSE with AVA 1 cm 2 and V max 4m/sec (stage D2) No AVA 1 cm 2 and LVEF 50% (stage D3*) Other cardiac surgery Abnormal ETT V max 0.3 m/s/y Low surgical risk AS likely cause of symptoms AVR (Class I) AVR (Class IIa) AVR (Class IIb) AVR (Class IIa) 5
Indicator Mild Moderate Severe Jet velocity (m/s) < 3.0 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 6
Minners J, et al. Eur Heart J 2008;29:1043 48 AVA 1.0cm2 & Mean PG < 40mmHg LVEF < 50% 50% SV index (ml/m 2 ) 35 >35 Classical LF LG AS Paradoxical LF LG AS Normal-flow LG AS Clavel MA et al., Eur Heart J, 2016 7
67 year old female with exertional dyspnea Case: low gradient AS with depressed LVEF LVOT diameter 2.0 cm LVOT TVI 12.5cm AV Vmax 3.7m/s Mean PG 35mmHg 0.785 2 0.785 2.0 2 12.5 73.7. 8
Pibarot P and Dumesnil JG. J Am Coll Cardiol 2012;60:1845 53 Baseline LVOT TVI 13.2cm Vmax 3.6m/sec PG 51/32mmHg AVA 0.52cm 2 Dobutamine 5 μg LVOT TVI 13.8cm Vmax 4.1m/sec PG 66/41mmHg Dobutamine 10 μg LVOT TVI 14.4cm Vmax 4.8m/sec PG 93/54mmHg AVA 0.50cm 2 9
Low-gradient severe AS with depressed LVEF - Low LVEF (<40%) causing low stroke volume - True severe AS versus pseudosevere AS Paradoxical Low-flow, Low-gradient severe AS with preserved LVEF - Severe concentric LVH and smaller LV cavity size - High valvuloarterial impedance and low stroke volume Pibarot P and Dumesnil JG. J Am Coll Cardiol 2012;60:1845 53 10
Impaired Diastolic Filling Pronounced Concentric Remodeling Atrial Fibrillation Impaired Longitudinal Systolic function Reduced Forward Stroke Volume Reduced Transvalvular flow rate Mitral Regurgitation Mitral Stenosis Tricuspid Regurgitation Low-Flow, Low gradient AS with Preserved LVEF Pibarot P, Dumesnil JG. Circulation 2013:1729 100 80 NF group 100 80 PLF surgical NF surgical Survival (%) 60 40 P=0.006 PLF group Survival (%) 60 40 P<0.001 PLF medical NF medical 20 20 0 0 1 2 3 4 5 Follow-up (year) 0 0 1 2 3 4 5 Follow-up (year) Hachicha Z, et al. Circulation 2007;115:2856 64 11
1.0 Unadjusted 1.0 Adjusted 0.8 AVR 0.8 Survival (%) 0.6 0.4 Standard Survival (%) 0.6 0.4 AVR Standard 0.2 0.0 Log rank P<0.001 0.2 0.0 HR: 2.03, P=0.013 0 12 24 36 48 60 Follow up, (month) 0 12 24 36 48 60 Follow up, (month) Ozkan et al. Circulation 2013;128:622 631 PARTNER-I B (inoperable): Medical vs. TAVR 2-Year Death (%) 80 70 60 50 40 30 20 10 LF-Cohort B-TAVR LF-Cohort B-MM Log Rank P<0.001 76.2% 45.9% 0 0 60 120 180 240 300 360 420 480 540 600 660 720 No. at Risk Time in Days B-TAVR 85 74 65 58 55 50 47 46 46 B-MM 95 78 60 47 39 35 26 25 18 2-Year Death (%) 90 80 70 60 50 40 30 20 10 LF,NEF and-lg-cohort B-TAVR LF,NEF and LG-Cohort B-MM Log Rank P=0.047 76.9% 56.5% 0 0 60 120 180 240 300 360 420 480 540 600 660 720 No. at Risk Time in Days B-TAVR 23 21 19 17 15 13 11 10 10 B-MM 29 22 15 10 9 9 6 5 4 Herrman HC et al, Circulation, 2013 12
AVA < 1.0 cm 2 Low gradient (severe?) AS LVEF < 50% Low LVEF 50% Preserved LVEF Classical Low-Flow, Low-gradient AS D2 Stage < 35 ml/m 2 Low Flow Paradox, Low Flow, Low-gradient AS D3 Stage Flow SVi 35 ml/m 2 Normal Flow Normal Flow, Low-gradient AS? Stage Confirm AS severity: 2D echo, DSE, MDCT Assess surgical risk Confirm AS severity: 2D echo, MDCT Assess surgical risk Confirm AS severity: 2D echo, MDCT AVR-Class IIa TAVR > SAVR? AVR-Class IIa TAVR > SAVR? AVR? SAVR or TAVR Pibarot P et al. J Am Coll Cardiol 2016:2359 2363 AVA 1.0cm2 & Mean PG < 40mmHg LVEF < 50% 50% SV index (ml/m 2 ) 35 >35 Classical LF LG AS Paradoxical LF LG AS Normal-flow LG AS Clavel MA et al., Eur Heart J, 2016 13
Case: 70 year old male with low gradient AS and dyspnea Case: low gradient AS with preserved LV ejection fraction LVOT 2.08 cm LVOT TVI 25 cm AV Vmax 3.7 m/s meanpg 35 mmhg AV TVI 90 cm AVA LVOT 0.785 2.08 0.785 25 90 0.94 cm BSA = 1.77 m 2 AVAI = 0.53 cm 2 /m 2 Stroke Volume = 80.0 ml SVI = 45.2 ml/m 2 14
Paradoxical Low-flow, Low-gradient severe AS - Severe concentric LVH and smaller LV cavity size - High valvuloarterial impedance and low stroke volume Normal-flow, Low-gradient severe AS - Measurement error - Small body surface area - Inconsistency between cutoff values of AVA and gradient Aortic valve area (cm 2 ) Mean gradient (mmhg) 3.0 2.9 2.0 6.6 1.0 26 0.9 32 0.8 41 0.7 53 0.6 73 Carabello BA. N Engl J Med 2002;346:677 15
AVA < 1.0 cm 2 Low gradient (severe?) AS LVEF < 50% Low LVEF 50% Preserved LVEF Classical Low-Flow, Low-gradient AS D2 Stage < 35 ml/m 2 Low Flow Paradox, Low Flow, Low-gradient AS D3 Stage Flow SVi 35 ml/m 2 Normal Flow Normal Flow, Low-gradient AS? Stage Confirm AS severity: 2D echo, DSE, MDCT Assess surgical risk Confirm AS severity: 2D echo, MDCT Assess surgical risk Confirm AS severity: 2D echo, MDCT AVR-Class IIa TAVR > SAVR? AVR-Class IIa TAVR > SAVR? AVR? Pibarot P et al. J Am Coll Cardiol 2016:2359 2363 Watchful Observation Versus Early Aortic Valve Replacement for Patients with Normal flow, Low Gradient Severe Aortic Stenosis Duk-Hyun Kang, Jeong Yoon Jang, Sung-Ji Park, Dae Hee Kim, Jong-Min Song, Seung Woo Park, Jae-Kwan Song, Jae Won Lee, Seung-Jung Park Asan and Samsung Medical Center Seoul, Korea Kang DH, et al. Heart 2015;1375 81 16
Study Flow Normal flow LG AS (n = 284) Early AVR Group (n = 98, 35%) Early elective AVR within 6 months after initial echocardiography Watchful Observation Group (n = 186, 65%) Referred for late AVR Symptoms worsened Aortic jet velocity > 4 m/s Mean gradient > 40 mmhg Clinical and Echocardiographic follow-up until June 2014 Kang DH, et al. Heart 2015;1375 81 100 Overall mortality rate, % 80 60 40 20 p = 0.840 8 year overall mortality rate Early AVR Watchful Observation 17 ± 5 % 27 ± 5% No. at Risk Early AVR Watchful Observation 0 0 2 4 6 8 98 186 90 178 Time after baseline, years 64 123 38 74 22 39 17
100 CV mortality rate, % 80 60 40 20 p = 0.806 8 year CV mortality rate Early AVR Watchful Observation 11 ± 4 % 18 ± 4 % No. at Risk Early AVR Watchful Observation 0 0 2 4 6 8 98 186 90 178 Time after baseline, years 64 123 38 74 22 39 100 Overall mortality rate, % 80 60 40 20 p = 0.741 8 year overall mortality rate Early AVR Watchful Observation 20 ± 5% 22 ± 7 % No. at Risk Early AVR Watchful Observation 0 0 2 4 6 8 83 83 75 80 Time after baseline, years 54 54 34 30 21 16 18
75 year old female with exertional dyspnea AV Vmax 3.8 m/s AV TVI 89 cm LVOT 1.96 cm AVA... LVOT TVI 20.4 cm BSA = 1.57 m 2 AVAI = 0.43 cm 2 /m 2 SVI = 39.2 ml/m 2 Case. What is your diagnosis? 1) Moderate AS 2) High-gradient Severe AS 3) Normal-flow, Low-gradient Severe AS 4) Low-flow, Low-gradient Severe AS 19
75 year old female with high gradient, severe AS AV Vmax 3.8 m/s AV Vmax 4.2 m/s Case. What is your diagnosis? 1) Moderate AS 2) High-gradient Severe AS 3) Normal-flow, Low-gradient Severe AS 4) Low-flow, Low-gradient Severe AS 20
Flow gradient pattern, AVA, ejection fraction, symptoms and operative risk should be considered in a decision for AVR in severe AS Clinical trials are required to evaluate benefit of surgical AVR or TAVR for symptomatic patients with LG severe AS and asymptomatic patients with very severe AS 21