How to improve patient selection in aortic stenosis? Fausto J. Pinto, FESC
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Aortic stenosis aetiology: morphology of calcific AS, bicuspid valve, and rheumatic AS (Adapted from C. Otto, Principles of Echocardiography, 2007)
Type of AoV Disease Passik CS Mayo Clin Proc 1987;62:119
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Quantification of Valvular Gradients
Planimetry of Aortic Valve
Reccomendations for assessment of AS Severity EAE/ASE Recommendations Eur J Echocardiogr 2009;10:1-25
Early Elective Surgery for Very Severe AS? 116 patients with AV-Vel 5.0 m/s AV-Vel 5 to 5.5m/s P = 0.001 96 events: 90 indication for aortic valve replacement according to guidelines 6 cardiac death (previously asymptomatic): 1 sudden death in a 62-year old asymptomatic patient t 1myocardialinfarction 1 congestive heart failure 3 congestive heart failure with multiorgan failure in the setting of a febrile state AV-Vel 5.5m/s 55m/s Years Rosenhek - AT - FP 5164 Highlight Session 2009
Risk Stratification in Moderate and Severe AS Baseline AVA 1.5 cm² and/ or peak velocity 3.0 m/s, Sinus rhythm, preserved LVF > 50% Risk Score: [Peak vel (m/s) x 2] + [nat Log BNP x 1.5] + 1.5 (if female) Event-free sur rvival (%) Development cohort: n=104 Quartile 1 (<12.9) 100 75 50 Quartile 2 (<14.6) 25 Quartile 3 (<16.2) 0 Quartile 4 (<19.7) 0 5 10 15 20 25 Analysis time (months) Event-free sur rvival (%) Validation cohort: n= 107 100 Quartile 1 75 50 Quartile 2 25 Quartile 3 0 Quartile 4 0 5 10 15 20 25 Analysis time (months) Monin - FR - FP 254 Highlight Session 2009
Evaluation of pts with AS and Calculate standard measures of Stenosis Severity and LV EF Severity of Ao valve calcification Assess risk:benefit of AVR Dobutamine Stress Echo in selected cases: Hemodynamic response Contractile reserve LV dysfunction
Plot of the relationship between mean gradient (y-axis) and transvalvular flow (x-axis, bottom) according to the Gorlin formula for 3 different values of AVA (0.7, 1.0, and 1.5 cm2) Grayburn, P. A. Circulation 2006;113:604-606
DSE in low gradient AS Low dose dobutamine: Startwith25to5mcg/kg/min 2.5 to 5 Incremental doses up to maximum 20 mcg/kg/min Measure gradient, EF and stroke volume.
Dobutamine stress echocardiography in aortic stenosis
Dobutamine stress echocardiography in aortic stenosis
Low dose DSE Fixed AS AVA does not increase with increase in EF Pseudo AS AVA increases with increase in EF
DSE in low gradient AS LV contractile reserve: Increase in peak velocity >0.6 m/s Increase in stroke volume >20% Increase in mean transvalvular pressure gradient >10 mm hg
Kaplan-Meier survival estimates by group and treatment Monin, J.-L. et al. Circulation 2003;108:319-324
Low dose DSE Fixed AS AVA does not increase with increase in EF (SURGERY) Pseudo AS AVA increases with increase in EF (MEDICAL Rx) Lack of cardiac reserve No improvement in cardiac output or ejection fraction (look at baseline gradient, CAD, other comorbidities)
Distribution of Stenosis Severity and Paradoxical Low-Flow Pattern Versus Zva Z VA (Ventriculo- Arterial Impedance) Hachicha, Z. et al. J Am Coll Cardiol 2009;54:1003-1011
Overall Survival Versus Zva Hachicha, Z. et al. J Am Coll Cardiol 2009;54:1003-1011
Overall Survival Versus Zva and Type of Treatment Hachicha, Z. et al. J Am Coll Cardiol 2009;54:1003-1011
Increased Afterload and Impaired Intrinsic Ventricular Function in Paradoxical Low Flow Aortic Stenosis Aortic stenosis (iava 0,6cm²/m²) with preserved LV function (EF 50%) Paradoxical low flow AS SVI 35 ml/m² Normal Flow AS SVI >35 ml/ml n 35 85 Age 77 (+/-10) 73 (+/-8) NS mgrad (mmhg) 44.1 (+/-19.3) 55.1 (+/-13.7) P=0.0103 LVEDV (ml/m²) 59.7 (+/-20.9) 73.2 (+/-21.7) P= 0.0077 LVEF (%) 62.3 (+/-7.9) 66.9 (+/-8.8) P= 0.0155 Cardiac index (l/min/m²) 2.19 (+/-0.39) 3.20 (+/-0.64) P<0.0001 Zva (mmhg/ml/m²) 5.89 (+/-0.98) 4.03 (+/-0.71) P< 0.0001 Global strain (%) -13.8 (+/-4.2) -15 (+/-4.1) p= 0.007 Radial strain (%) 24 (+/-13.5) 36 (+/-17.2) P= 0.001 Circumferential strain (%) -17.5 (+/-4.5) -20.4 (+/-5) P= 0.0142 Mielot - FR - FP 4107 Highlight Session 2009
Risk Stratification in Severe AS 163 asymptomatic pts with severe AS (iava 0.6 cm²/m², Sinus rhythm, preserved LVEF 55%) Risk stratification by consideration of ventricular, vascular and valvular components of the disease Risk factors: Peak aortic jet velocity, Valvulo-arterial impedance, longitudinal strain, indexed LA area Multivariate Analysis Lancellotti, - FR - FP 4093 Highlight Session 2009
Purpose Assess the impact of increased valvulo-arterial l l impedance on LV torsional dynamics in pts with severe aortic stenosis and preserved LV ejection fraction Methods 71 pts with severe AS and preserved LVEF Zva 4,5 mmhg ml -1 m 2 Group 1-33 pts (Zva 4,5 mmhg ml -1 m 2 ) Group 2-38 pts (Zva < 4,5 mmhg ml -1 m 2 ) - Group comparison for clinical and echocardiographic parameters Group comparison for clinical and echocardiographic parameters were obtained for categorical variables with χ 2 test and for continuous variables with Student s t test (SPSS 13). A. Călin et al. EuroEcho 2010
LV untwisting parameters Group 1 Group 2 n=33 n=38 p Time to peak apical backrotation rate 0.54±0.070.07 0.48±0.050.05 0.002 Time to peak basal backrotation rate 0.50±0.070.07 0.46±0.040.04 0.004 Time to peak LV untwisting rate 0.51±0.070.07 0.47±0.060.06 0.016 EuroEcho 2010
Conclusions In severe AS, LV untwisting is significantly delayed in pts with significantly increased global LV afterload, when compared to those with lower global afterload, despite similar LV dimensions, ejection fraction and torsion These results suggest that increased global LV afterload might impair LV untwisting and thus contributes to increased LV filling pressures in this setting EuroEcho 2010
Myocardial Fibrosis in Low Gradient Aortic Valve Stenosis Group 1: mgrad 40mmHg, EF 50% Group 2: mgrad < 40mmHg, EF 50% Group 3: mgrad < 40mmHg, EF < 50% p<0.01 Severe Fibrosis Mild Fibrosis No Fibrosis In severe aortic stenosis a low mean gradient is associated with: Lower longitudinal myocardial function Higher degree of interstitial / subendocardial Fibrosis Poor long term outcome Herrmann- FR - FP 2861 Highlight Session 2009
Patient Evaluation Clinical Assessment Symptoms, comorbidities Physical Examination Echocardiography Key examination to confirm diagnosis and assess severity and prognosis Check consistency between echo findings (severity, mechanism, anatomy of valvular disease) and clinical assessment
Echocg Assessment of Aortic Stenosis Use clinical judgement Take your time and your best pictures Use TEE if bad window If still in doubt: Use other methods (cath??)