unraveling low-flow , low-gradient aotic stenosis fabian nestispach head tavi
TRANSCRIPT
Unravelling low-flow low-gradient aortic stenosisFabian Nietlispach, MD PhDHead TAVI
Disclosures
• Consultant for• Edwards Lifesciences• Direct Flow Medical• Medtronic• St. Jude Medical
Case vignette
• 81 y/o htn, dyslip, female in AFib• Presents in NYHA III-IV• Previous CABG x2 and AVR (CE); LVEF 40%
LVEF 40%, aortic P-mean 21mmHgRHC: CI 2.1; PA 69/29/45; PCW 40
Aortic stenosis:the ‘easy’ valve pathology?
• Simple anatomy…
Piazza N et al. Circ Cardiovasc Interv. 2008
• …not so simple pathophysiology• Gorlin Formula:
• Continuity equation
Aortic stenosis:the ‘easy’ valve pathology?
Baumgartner at al., JASE 2009
• …not so simple pathophysiology• Gorlin Formula (with CO 6, HR 80, SEP 0.33):
– AVA 1cm2 Pmean = 26mmHg– AVA 0.8 cm2 Pmean = 41mmHg– AVA 0.7 cm2 Pmean = 53mmHg
Aortic stenosis:the ‘easy’ valve pathology?
Courtesy C. Seiler
• …not so simple pathophysiology• Continuity equation
Aortic stenosis:the ‘easy’ valve pathology?
Baumgartner at al., JASE 2009 Piazza N et al. Circ cv Interv. 2008 Zamorano et al. EHJ 2014
• …not so simple clinical management
Aortic stenosis:the ‘easy’ valve pathology?
Calcification
Rapid increase in jet velocity
Rosenhek et al, NEJM 1996
• …not so simple clinical management
Aortic stenosis:the ‘easy’ valve pathology?
Circulation 2012
Low-flow low-gradient AS
• Classification
Pibarot, JACC 2012
5-10%
Poor prognosis
High operative risk10-20%
small cavities
advanced diast. Dysf.
Normal LVEFNormal-FlowLOW-GRADIENT
Small body size indexedAVA 1cm2 Pmean 26mmHg
Pseudo-AS
AVA = 0.8 CO 2l/min gradient: 19mmHg
Low-flow low-gradient AS
modest changes in flow relevant reduction in gradient
• Definition• Low EF LFLG severe AS:
– LVEF <40%, Gradient <40mmHg, Low Flow: SVI <35 (or CI <3)
• Normal EF LFLG AS– LVEF >50%, Gradient <40mmHg, Low Flow: SVI <35 (or CI <3)
• Pseudo-AS– LVEF <40%, Gradient <40mmHg, Low Flow: SVI <35 (or CI <3)
• Normal EF NFLG AS– LVEF >50%, Gradient <40mmHg, Flow: SVI >35
Diagnostic challenges
• Stroke volume indexReduced even in HIGH-gradient AS
O’Sullivan, EHJ 2013
Gradient ‘per se’ not suited for AS quantification
Gradient: marker for myocardial function / risk assessment
AVA-calculations come with many confounders
Diagnostic challenges
• Low EF LFLG without contractile reserve
With contractile reserve (SV increase >20%)- Dobutamine SE
- AVA <1 severe AS- AVA >1 Pseudo AS
Without contractile reserve (SV increase <20%)- Severe AS? Pseudo AS?
Highest surgical risk
Is the distinction important?
• …maybe not so much…!
Group I: contractile reserveGroup II: no contractile reserve
Monin et al, Circulation 2003
Should patients with pseudo-AS undergo AVR??
Pseudo with (T)AVR?
Adapted from Fougeres et al, EHJ 2012
(T)AVR facilitating myocardial recovery?
(T)AVR slowing down myocardial deterioration?
Therapeutic options
• Medical therapy
Normal EF LFLG AS benefits from AVR
Prognosis of Low EF LFLG AS with MedTx is dismal
Hachicha et al, Circulation 2007
Therapeutic options
• Surgical valve replacement
Excess of 30-day mortality for LGLF (6.3%)
(Odds Ratio for PLF: 3)
Excess 10year mortality for Low EF LGLF
Clavel et al, JACC 2015
Therapeutic options
• Transcatheter Aortic Vave Implantation– Theoretical advantages
• Less invasive faster recovery, suited for high-risk pts• No extracorporal circulation
– suited for hypertrophic LV’s with diastolic dysfunction– Suited for failing LV’s with systolic dysfunction
• Better hemodynamics– Less risk of PPM
Smith C et al, PARTNER A, NEJM
Faster recovery
Day 1 post TAVI
Pibarot et al, JACC 2014
Less PPM
d/t larger valve areas
TAVI in LFLG
30d MACCE
O’Sullivan, EHJ 2013
cvDeath @ 30d and 1year
O’Sullivan, EHJ 2013
Symptomatic benefit
O’Sullivan, EHJ 2013
Randomized data(with 1st generation TAVI device)
• Low EF LFLG
Herrmann et al, Circ 2013
Randomized data(with 1st generation TAVI device)
• Normal EF LFLG
Herrmann et al, Circ 2013
• Main advantage: faster recovery
Herrmann et al, Circ 2013
Case vignette
• Decision:• TAVI Valve in valve• MitraClip• Left Atrial Appendage Closure
Follow-up after 3 and 6mts
• Patient doing well• NYHA I• P-mean 10mmHg• Mild mitral regurgitation
Complex patients
• Diagnostic challenge• Do we have the right cut-off values?
• Clinical challenge• When to treat?
– Earlier d/t concomitant myocardial disease ( additional benefit)
• How to treat?– SAVR versus TAVI
Thank you