valvular heart disease state of the art 2020 · valvular heart disease –state of the art 2020 we...

©2017 MFMER | 3645199-1

Rick A. Nishimura, M.D. MACC MACP2nd Annual New York Valve Conference

Valvular Heart DiseaseState of the Art 2020

©2017 MFMER | 3645199-2

Rick A. Nishimura, M.D. MACC MACP2nd Annual New York Valve Conference

Valvular Heart DiseaseState of the Art 2020

©2017 MFMER | 3645199-3

Rick A. Nishimura, M.D.

No disclosures

©2017 MFMER | 3645199-4

Valvular Heart Disease – State of the Art 2020

What we did

What we are doing

What we need to do

From the perspective of a plain old

clinical cardiologist

©2017 MFMER | 3645199-5

©2012

MFMER |

3200979-

2003-5

AorticStenosis

©2017 MFMER | 3645199-6

©2012

MFMER |

3200979-

2003-6

Intervention

Benefit >> Risk

©2017 MFMER | 3645199-7


What we did

What we are doing

What we need to do

©2017 MFMER | 3645199-8

S1 S2

S4

3/6

LV

Ao

Severe aortic stenosis

✓ Gradient > 50 mmHg

✓ Gradient > 40 mmHg

✓ AVA < 1.0 cm2

✓ AVA < .7 cm2

✓ AVA < .5 cm2/m2

©2017 MFMER | 3645199-9

0

20

40

60

80

100

0 10 20 30 40 50 60 70 80

Natural History of Aortic Stenosis

0 2 4 6

Avg survival (yr)

Angina

Syncope

Failure

Age (yr)

Latent period(increasing obstruction,myocardial overload)

Onset severe symptoms

Average death

age ( )

Ross J Jr. and Braunwald E: Circ 38(Suppl 5):61, 1968

©2017 MFMER | 3645199-10

High operative risk

8-10%

Adverse outcome of AVR

50% emboli or bleed – 10 years

50% tissue degeneration

Only indication for AVR

Symptoms

Severe stenosis

©2017 MFMER | 3645199-11


What we did

What we are doing

What we need to do

©2017 MFMER | 3645199-12

Long Term Followup of

Asymptomatic Severe Aortic

StenosisPellikka et al

Circulation 2005:3290

622 patients

Followup 5.3-10.6 years

Asymptomatic

Peak Vel > 4 m/s

©2017 MFMER | 3645199-13

Years

Su

rviv

al

free o

f sym

pto

ms (

%)

0 1 2 3 4 5 6 7 8 9 10

100

60

20

0

80

40

Circulation 2005

Pellikka et al

Asymptomatic Severe Aortic Stenosis

At 5 yrs

72% CHF or died

©2017 MFMER | 3645199-14

Low operative risk

< 1%

Better AVR

Emboli, bleed < 1% yr

Longevity tissue valves

With lower risk AVR and better outcomes

Further risk stratification

©2017 MFMER | 3645199-15

ACC/AHA Valve Disease Guidelines

Stage A - D

At risk for disease

Progressive disease

Severe disease

(asymptomatic)

Severe disease

(symptomatic)

Stage A

Stage B

Stage C

Stage D

Define “severe”

based on

outcome studies

Grad > 40 mmHg

AVA < 1.0 cm2

©2017 MFMER | 3645199-16


Stage A - D

At risk for disease

Progressive disease

Severe disease

(asymptomatic)

Severe disease

(symptomatic)

C1: Compensated LV

C2: Decompensated LV

©2017 MFMER | 3645199-17


Stage A - D

Definition of “decompensated LV”

➢ Long standing pressure overload on the LV

➢ Ventricular state when

➢ Outcome is reduced

➢ LV function postop is reduced

©2017 MFMER | 3645199-18


Aortic Stenosis

Stage C: Severe

disease

(asymptomatic)

Stage D: Severe

disease

(symptomatic)

C1:EF > 50%

C2:EF < 50%

D1: high gradient

D2: low gradient (low EF)

D3: low gradient (normal EF)

AV Velocity > 4m/s

©2017 MFMER | 3645199-19


Stage A - D

At risk for disease

Progressive disease

Severe disease

(asymptomatic)

Severe disease

(symptomatic)

Observe

Intervene

C1

C2Intervene

?

©2017 MFMER | 3645199-20

©2012

MFMER |

3200979-

2003-20

Results of Exercise TestingEvent-Free Survival

Amato et al: Heart 86:381, 2001

Months

P=0.0001

Positive (44 patients)

Negative (22 patients)

0.0

0.2

0.4

0.6

0.8

1.0

0 12 24 36 48 60

Negative

Positive

Further risk stratification by exercise testing

©2017 MFMER | 3645199-21

Rosenhek et al: Circ 121:151, 2010

Event-

free s

urv

ival (%

)

0

20

40

60

80

100

0 1 2 3YearsPatients at risk

82 69 59 3872 53 29 1844 20 11 5

AV-Vel

4.0-5.0 m/sec

AV-Vel

5.0-5.5 m/sec

AV-Vel

≥5.5 m/sec

P<0.0001

Further risk stratification by stenosis severity

Stenosis Severity – Doppler VelocityEvent-Free Survival

©2017 MFMER | 3645199-22

Aortic Stenosis : ACC AHA Guidelines

• Indications for SAVR – all patients

• Symptoms (any)

• Drop in EF

• Indications for SAVR – asymptomatic low risk patients

• Positive TMET

• Very severe AS

©2017 MFMER | 3645199-23

Then came transformation

©2017 MFMER | 3645199-24

©2012

MFMER |

3200979-

2003-24

A dramatic relief of obstruction within seconds

©2017 MFMER | 3645199-25

©2012

MFMER |

3200979-

2003-25

TAVR(Transcatheter Aortic Valve Replacment)

• TAVR - inoperable pts

• Lower mortality vs medical Rx

• TAVR - high risk patients

• Comparable to SAVR

• TAVR – intermediate risk patients

• Comparable to SAVR

• TAVR – low risk patients

• Comparable (maybe even better)

©2017 MFMER | 3645199-26

Evaluation of patients with aortic stenosisChanging paradigm

Low Intermediate High InoperableRisk

SAVR TAVR

SAVR

vs

TAVR

Nothing

(futile)Rx

2014 Guidelines

©2017 MFMER | 3645199-27



SAVR TAVRSAVR vs TAVRNothing

(futile)Rx

2017 Guidelines

©2017 MFMER | 3645199-28



TAVRSAVR vs TAVRNothing

(futile)Rx

©2017 MFMER | 3645199-29



TAVRSAVR vs TAVRNothing

(futile)Rx

Dependent upon anatomy

Longevity (patient and valve)

©2017 MFMER | 3645199-30


What we did

What we are doing

What we need to do

©2017 MFMER | 3645199-31


We now have better and better interventions

But if we only intervene according to guidelines

CV death still occurs following AVR

Persistent heart failure symptoms occur

©2017 MFMER | 3645199-32

Pressure overload

Compensatory hypertrophy

(normalize wall stress)

MVO2

Mismatch

Myocardial

Ischemia

Fibrosis

Scarring

©2017 MFMER | 3645199-33

Bing et al JACC

Imaging 2019:12:283

Papanastasiou et al

JACC Imaging 2019

2x increase mortality

with GDE defects

By the time we operate now, the LV

is already damaged

©2017 MFMER | 3645199-34

What we are finding out – “conventional” criteria too late

• Even “moderate” AS portends poorer outlook

• Outdated “cut-off” – peak velocity > 4.0 m/s

©2017 MFMER | 3645199-38



• EF < 60% may be “decompensated”

• Other measures of LV performance – prognostic value over EF

• Stroke volume index, diastolic parameters

• Myocardial strain and DTI

• Other clinical parameters important

• Body mass, nutrition, gait speed

©2017 MFMER | 3645199-42

Machine learning processes to

provide precise phenotypic risk

assessment for an individual

patient

EF

Symptoms

Gradient

Valve area

Diastolic SVI

Strain Biomarkers

Torsion

GDE

??????

©2017 MFMER | 3645199-44

A general perspective on aortic stenosis

Better and better interventions

Need lower and lower thresholds

Identify higher risk patients

Prevent adverse consequences of pressure overload

Machine learning - precise individualized risk assessment

©2017 MFMER | 3645199-45

A general perspective on primary MR

We are operating too late

After the onset of irreversible LV dysfunction

Need lower risk interventions

Need effective durable interventions

Intervene earlier and earlier

©2017 MFMER | 3645199-46

A general perspective on secondary MR

We always thought this was a disease of the LV

We are just finding out that correcting the MR

percutaneously itself may be beneficial

We need to determine who will benefit

©2017 MFMER | 3645199-47

RV

RA

A general perspective on tricuspid regurgitation

A growing problem

Device leads

Atrial fibrillation

We have been reluctant to intervene

We need alternative approaches

©2017 MFMER | 3645199-48

What we did

What we are doing

What we need to do

From the perspective of a plain old

clinical cardiologist

valvular heart disease state of the art 2020 · valvular heart disease –state of the art 2020 we...

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