ESC CONGRESS HIGHLIGHTS VALVULAR HEART DISEASE AND PULMONARY CIRCULATION N. Ajmone Marsan (Leiden, NL) MD, PhD, FESC Conflicts of Interest None
CONTENTS Pulmonary arterial hypertension Rheumatic heart disease Mitral regurgitation and aortic stenosis TAVI Mitral valve intervention Tricuspid regurgitation
Morbidity and Mortality (%) Griphon study: pulmonary arterial hypertension in congenital heart disease Pulmonary arterial hypertension with repaired shunt lesion (ASD, VSD or PDA) Selexipag (oral selective IP prostacyclin-receptor agonist) 1 8 6 Selexipag Placebo 4 No. at Risk 2 Risk reduction 42% 6 12 18 24 3 Months Placebo 5 42 36 24 18 12 Selexipag 6 53 43 29 2 12 M. Beghetti (Geneva, CH), FP 692
Event Free Survival Joint-intention study: initial oral combination therapy in pulmonary arterial hypertension Mortality, Hospitalization and treatment escalation-free survival Initial Bosentan and Sildenafil p=.12 Initial Bosentan or Sildenafil At risk: Combo: 23 17 13 8 Mono: 46 17 12 5 M. Palazzini, (Bologne, IT), P2782
Survival Rate Survival Rate Balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension 1 Balloon Pulmonary Angioplasty (n=5) 1 Balloon Pulmonary Angioplasty (n=17),9 Pulmonary Endarterectomy (n=12),9,8,8 Medical Therapy (n=12),7,7,6 12 24 36 48 6 Time (Months),6 2 4 6 8 Years S. Darocha, (Otwock, PL), P335 T. Inami, (Tokyo, JP) P 579
Mortality (%) Survival REMEDY: 2-year follow-up of the global rheumatic heart disease registry 3 1 2 Presentation with Heart Failure,9 1 Without Heart Failure,8 Upper-middle-income countries Low-middle-income countries Low-income countries,5 1 Years 1,5 2 2,5,7 1 Years 2 14 countries, N=3343, median age 28 [18-4] High rates of death, CHF and stroke despite low age for symptomatic patients. Higher mortality for low-income countries and less educated patients Better access to quality tertiary care and optimised use of interventions are likely to improve outcomes. L. Zühlke (Cape Town, SA), FP 5733
% of pregnancies ROPAC registry: Pregnancy in women with rheumatic mitral valve disease N=39 6 p=.3 p<.1 p=ns p=ns p=.2 Mild MR (n=43) Maternal mortality: MS: 1 during pregnancy; 2 after pregnancy MR: during pregnancy; 1 after pregnancy 4 Moderate-severe MR (n=65) Mild MS (n=57) Moderate MS (n=17) 2 Moderate-severe MS (n=54) Heart failure Fetal loss Small-forgestational age High risk of heart failure and fetal growth restriction Counselling and close follow-up during and after pregnancy I. Van Hagen, (Rotterdam, NL), FP 686
Very severe MR predicts postoperative LV dysfunction after mitral valve repair for primary MV disease N=83 pts with primary MR undergoing MV repair Severe Mitral Regurgitation (Reg Volume 8 ml ) Very Severe Mitral Regurgitation (Reg Volume > 8 ml) p value PREOPERATIVE End-systolic Diameter 3.52 ±.57 3.87 ±.54.5 Ejection Fraction.67 ±.1.67 ±.8.91 EROA (cm 2 ).43 ±.16.83 ±.27 <.1 Regurgitant Volume (ml) 58 ±16 113 ±29 <.1 POSTOPERATIVE End-systolic Diameter 3.64 ±.6 3.97 ±.54.1 (acute postoperative) Ejection Fraction < 5% 43% 64%.3 LM Laufer-Perl (Tel Aviv,IL), P5541
Overall Survival Overall Survival Current aortic stenosis registry All asymptomatic patients AV Vmax 4.5m/s 1 Aortic Valve Replacement 1 Aortic Valve Replacement,8 Initial Conservative,8,6,6 Initial Conservative,4,4,2 p=.33 A 285 265 239 179 111 72 C 377 265 177 17 67 32 1 2 3 4 5 Years after AVR,2 p=.3 A 18 164 155 112 76 52 C 8 6 49 33 21 13 1 2 3 4 5 Years after AVR M. Miyake (Kyoto, JP), P5935
Mortality Temporal trends of TAVI outcomes 28-214,4 P=.31 28-1,3,2 211 212,1 214 213 6 12 18 24 3 36 Months Evolution from novel technology to mainstream therapy Learning curve, structured program and utilization in lower risk patients, procedural simplification U. Landes (Tel Aviv,IL), P6464
ITER registry: Single vs. dual antiplatelet therapy after TAVI N=1364 (Aspirin 65, DAPT 759) 3-day outcome 15 1 (%) 11.5 1.7 9.1 8. 7.5 7.3 8. Aspirine alone Dual antiplatelet therapy 3 2 (%) Long term outcome 26 27 Aspirine alone Dual antiplatelet therapy 5 4.1 4.1 5.3 4.6 1 1.5 1.5 1.9 1.5 1.3 1.2.5 2.8 3. 1.2 3.6.7 4.1 Aspirin alone was associated with reduced risk of major vascular complications and bleedings. No increased risk of prosthetic valve dysfunction, lower risk of peri-procedural complications and all cause mortality. M. Bianco (San Francesco AL CAN, IT), FP 669
Event Free Survival EVEREST II REALISM. Edge-to-edge repair: survival by symptoms and discharge MR N = 525 1% Significant functional MR 9% 8% 7% FMR NYHA I/II & Disch MR 2+ FMR NYHA I/II & Disch MR 3+ FMR NYHA III/IV & Disch MR 2+ 6% 5% FMR NYHA III/IV & Disch MR 3+ 4% 3% 2% 1% % 4 8 12 16 2 24 28 32 36 4 Days S. Kar, (Los Angeles, USA), FP 2114
% Patients % of population Percutaneous mitral annulopasty (Cardioband) >> >> >> 7 centers N = 5 31 ischemic 19 non ischemic MR Severity 1% 8% 6% 4% 2% % 2+ 3-4+ Baseline N=5-1+ -1+ 2+ 2+ 2+ 3-4+ 3-4+ Discharge N=48 3 days N=45-1+ -1+ -1+ 2+ 2+ 3-4+ 3-4+ 3-4+ 6 Months N=34 12 Months N=25 24 Months N=1 1 8 6 4 2 II III NYHA Class P<.5 I II III Baseline 24 months K.H. Kuck, (Hamburg GE), FP 1278
Outcome of mitral valve surgery for primary MR with and without tricuspid annuloplasty 287 patients, primary mitral regurgitation Associated TA N=165 (57%) No associated TA N=122 (43%) p value Male gender 6 (36%) 65 (53%).2* Age (years) 61 ± 16 62 ± 17.68 Coronary artery disease 7 (4%) 14 (12%).2* TTE Findings Tricuspid annulus (mm) 41±6 37±6.1* Moderate to severe TR 79 (48%) 18 (15%).1* Systolic PAP (mmhg) 53±15 46±15.2* Reduced LVEF (< 5%) 25 (15%) 1 (7%).4* Outcome Death 8 (5%) 16 (13%).1* Major Bleeding 11 (7%) 17 (14%).4* A. Darmon, (Paris, FR), P2768
Risk of Death (%) Death and Heart Failure (%) Diuretics in severe secondary tricuspid regurgitation? 5 Patients with moderate-to-severe TR before diuretic therapy 1 1 Improved TR severity (N=15) Improved TR severity (N=15),8 No Improved TR severity (N=35),8 No Improved TR severity (N=35),6,6,4,4,2,2 P=.51 25 5 75 1 125 15 175 2 Days P=.69 2 4 6 8 1 12 14 16 18 Days TR decreased in 3% of patients with diuretics without association to a better prognosis Cardiac surgery (when indicated) should not be delayed by diuretic therapy H. L. Doan (Paris, Fr), P2775
TAKE HOME MESSAGE VALVULAR HEART DISEASE AND PULMONARY CIRCULATION Pulmonary Arterial Hypertension Potential benefit of initial oral combination therapy Promising role for balloon pulmonary angioplasty in CTEPH GRIPHON: Role for Selexipag in patients with corrected congenital heart disease Valvular Heart Disease Burden of rheumatic disease in general and in pregnancy Prognostic relevance of very severe valve disease Encouraging results for percutaneous treatment of secondary MR (edge-to-edge repair and direct annuloplasty) Improved outcomes with TAVI over time Potential role for single antithrombotic therapy after TAVI Don t forget to treat tricuspid regurgitation