Triggers for Aortic Stenosis and Regurgitation Vinod H. Thourani, MD Professor of Surgery Chair, Department of Cardiac Surgery MedStar Heart and Vascular Institute Georgetown University Washington, DC, USA AATS Valve Symposium (Brazil) December 8, 2017
Disclosures Abbott Medical/St. Jude Medical Structural Heart Advisory board Executive Committee: Portico trial Boston Scientific Advisory Board, Executive Committee (Lotus Valve Trial) National Co-PI, REPRISE IV trial Claret Medical Advisory Board Cryolife Advisor Executive Committee, PROACT II trial Edwards Lifesciences National Co-PI: PARTNER 2 (SAPIEN 3 Trial) National Co-PI: ACTIVE Trial Executive Committee: PARTNER 3 trial Advisory Board Gore Vascular Advisor Jenavalve National Co-PI TAVR trial
Aortic Stenosis Complex relationship between EF, gradient, and flow in severe AS effects on geometry, symptoms, outcomes Does AVR improve symptoms? Does AVR improve EF? What if the EF fails to improve? Should we intervene sooner in CHF?
All Aortic Stenoses Are Not Created Equal Anjan and Herrmann, JACC 2015;65:654-6
Step 1: Assess EF and SVI Algorithm AVA < 0.8-1.0 cm 2 and MG < 30-40 mmhg Consider hydration status Low EF and Low SVI Normal EF and Low SVI Normal SVI Step 2: Classification Classical LF Severe AS Paradoxical LF Severe AS Probably Moderate AS Step 3: Additional Testing Additional Testing: DSE Dimensionless Index Valve calcium (CTA) Additional Testing: DSE or Nipride Dimensionless Index Valve Calcium (CTA) Co-morbidity Assessment Additional Clinical Assessment for Cause of Symptoms: COPD Comorbid Valve Disease Pulm/Systemic HTN HFpEF / HFrEF Hydration Status If findings are equivocal, there is equipoise to err on the side of TAVR (assuming low procedural risk), but important to set appropriate patient expectations regarding symptom improvement Saybolt, et al: CCI. 2017
Does AVR improve EF? What are the implications of failure of EF to improve?
657 patients with LV dysfunction (EF <50%) treated with either TAVR or SAVR LV EF improved (mostly by 30 d) after both TAVR and SAVR Failure to improve at 30 d was associated with higher MACE, but only after TAVR Elmariah et al, CCI 2013;6:604-14
Baron et al, JACC 2016;67:2349-58 11,292 patients undergoing TAVR in the STS/TVT Registry Baseline lower EF and lower gradient were both associated with higher 1-year mortality and hospitalization for recurrent heart failure.
Chen et al, CCI 2016;87:1164-72 60 patients with low EF: mean = 37% Failure to improve EF >10% after TAVR in ½ of patients associated with higher 1-year mortality Predictors of improved EF (multivariate ROC AUC = 0.832): Lower baseline LV EF Lower SVI Conclusions: Higher E, E/E (more severe diastolic dysfunction) Higher PASP Greater benefit to TAVR when LEF and LSVI are due to afterload mismatch Possible greater benefit with TAVR due to superior valve hemodynamics
Should we intervene sooner?
Currently, AVR is driven by Symptoms and Fall in EF Reduced EF occurs late in progression of AS Is there a subset of patients that would benefit from AVR before fall in EF? 1. Chin Expert Rev. Cariovasc. Ther. Early online, 1 12 (2014) 2. Dweck et al. JACC 2011 (LGE = Late gadolinium enhancement) 3. Lindman B. et al. JACC Cardiovascular Interventions June 2014 High Risk Cohort A Partner Trial
Role of CMR Late gadolinium enhancement (LGE) on Cardiovascular Magnetic Resonance (CMR) is a measure of mid-wall replacement fibrosis Both LGE and extracellular volume correlate with AS severity and survival Adds prognostically to EF Associated with hs Tn-I, ECG strain which can be used to identification Dweck et al, JACC 2011;58:1271-9
Speckle Tracking Echocardiography (STE) Global longitudinal strain (GLS) by STE The endocardial borders manually contoured and 2D and 3D volumetric strain can be measured Impaired GLS assessed by either 2D or 3D speckle tracking was associated with increased adverse CV events Chin Calvin et al, Circ CV Imaging 2015
Biomarkers Among biomarkers, lipoprotein (a), 18 F-sodium floride, BNP, and highsensitivity cardiac troponin are probably the most promising and ready for clinical use Shen Mylene et al, Curr Opin Cardiol 2017
Biomarkers Now there is compelling evidence demonstrating that AV stenosis is not simply a dz of the AV, but also a dz of the LV Development of novel approach that includes the combination of multiple circulating biomarkers linked to both the pathobiological process involved with the aortic valve and LV may have incremental value to traditional clinical tools.
Courtesy of Dr. Dweck, University of Edinbugh
Aortic Regurgitation Indication for SAVR
Bonow JACC 2013 Early Surgery is Better
Pizarro JACC 2011 High BNP is Problematic
Conclusions There are AS variants based on complex interactions between flow, gradient, and ejection fraction with potential implications on geometric remodeling Current indications for AVR in patients with severe AS are based on symptoms and LV dysfunction AVR improves symptoms, LV function, and flow, but the failure of EF or SVI to improve is associated with worse outcome CMR, echo, and biomarkers can identify early LV remodeling and fibrosis before EF falls and symptoms develop
Thank You Vinod H. Thourani, MD vinod.h.thourani@medstar.net