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M.W.A. van Geldorp 1 , H.J. Heuvelman 1 , B. Arabkhani 1 , M. van Gameren 1 , A.P. Kappetein 1 ,

Therapeutic decisions for patients with symptomatic severe aortic stenosis: room for improvement? Results of the A ortic VA lve RIJN mond study. M.W.A. van Geldorp 1 , H.J. Heuvelman 1 , B. Arabkhani 1 , M. van Gameren 1 , A.P. Kappetein 1 ,

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M.W.A. van Geldorp 1 , H.J. Heuvelman 1 , B. Arabkhani 1 , M. van Gameren 1 , A.P. Kappetein 1 ,

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  1. Therapeutic decisions for patients with symptomatic severe aortic stenosis:room for improvement?Results of the AorticVAlveRIJNmond study M.W.A. van Geldorp1, H.J. Heuvelman1, B. Arabkhani1, M. van Gameren1, A.P. Kappetein1, J.J.V. Busschbach2, T.W. Galema3, J.J.M. Takkenberg1, A.J.J.C. Bogers1 1Dept. of Cardiothoracic Surgery, 2dept. of Psychology and Psychotherapy, 3Dept. of Cardiology Erasmus University Medical Center, Rotterdam AorticValveSurgery: Present and Future AMC, 12-05-2011

  2. Background • Prevalence of aortic stenosis: 2.5% @ 70 yrs, 8% @ 80 yrs • Progression: PAG +6 mmHg/yr; AVA -0.1 cm2/yr • Aortic stenosis is risinghealthproblem (elderly)

  3. Hospitalization for Heart Valve disease The Netherlands 1995 - 2004 > 90 years 85-90 years 80-85 years

  4. Aortic Stenosis as cause of death The Netherlands (1996 – 2006) 350 Aortic stenosis as cause of death (NL) 300 250 65 - 70 yrs 70 - 75 yrs 200 75 - 80 yrs 80 - 85 yrs 150 85 - 90 yrs 90 - 95 yrs 100 50 0 1996 1998 2000 2002 2004 2006 2008 2010 www.cbs.nl

  5. Unoperated AVR Literature Symptomatic patients with severe aortic stenosis

  6. Background • Prevalence of aortic stenosis: 2.5% @ 70 yrs, 8 % @ 80 yrs • Progression: PAG +6 mmHg/yr; AVA -0.1 cm2/yr • Aortic stenosis is risinghealthproblem (elderly) • Controversybetween ACC/AHA guidelines and recent literature • Diagnosis-treatment gap • New techniques to treat the stenotic aorticvalve: TAVI

  7. Objectives • Why are so many (elderly) symptomatic patients denied surgery? • ‘Natural history’? • Expected life gain after surgery? Quality of life?

  8. Pilotstudy Symptomatic n=179 Follow-up: 17 months ? n=2 AVR n=76 (42%) No AVR n=101 (56%) Age (yrs) Male Mean Log EuroSCORE Log EuroSCORE >15% No AVR 73.3 (35-92) 51% 11.3% (1.5-45) 18% AVR 67.9 (22-89) 49% 7.8% (1.5-56) 4%

  9. Patient preference ‘High risk’ ‘Mild symptoms’ / ‘asymptomatic’ Aortic stenosis ‘non-severe’ Decision pending Reason not clearly documented 10% 33% 19% 14% 5% 20% Pilot Symptomaticpatients: medicaltreatment in 56%, AVR in 42% (!) Why? Age (yrs) Mean log EuroSCORE Log EuroSCORE >15% No AVR 73 11.3% 18%

  10. Unoperated AVR Symptomaticpatientswithsevere AS

  11. AVARIJN study (Aortic VAlve RIJNmond)

  12. Methods • Inclusion of patients with severe AS in the outpatient clinics in the wider Rotterdam area • Inclusion period: July 2006-April 2009 • Baseline: • -Patient data, functional status, quality of life (SF-36, EuroQol) • -Echocardiography; tissue doppler imaging • -Nt-proBNP • -Exercise testing (asymptomatic patients only) • Follow-up: 6 months, 1- and 2-year

  13. Flowchart AVARIJN

  14. Patientcharacteristics at baseline

  15. Echocardiography parameters at baseline

  16. 93% 76%

  17. Freedomfrom AVR 58% 41%

  18. Results SF 36v2

  19. Results SF 36v2

  20. Results SF 36v2 Quality of lifeaccording to symptomatic status

  21. Results SF 36v2 Quality of lifeaccording to symptomatic status

  22. Results SF 36v2 Quality of lifeaccording to symptomatic status

  23. Results SF 36v2 Quality of lifeaccording to symptomatic status

  24. Results General dutch population 41-60yrs vs symptomatic patients 41-60yrs

  25. Results General dutch population 61-70yrs vs symptomatic patients 61-70yrs

  26. Results General dutch population >70yrs vs symptomatic patients >70yrs

  27. ResultsSymptomatic patients treated medically: baseline vs 2yr f-up

  28. Results Symptomatic patients treated surgically: before AVR vs 1yr after AVR

  29. Conclusions • Daily practice very different from guidelines: undertreatment? • Possibleoverestimation of operative risk • Symptomsunrecognizedorunaccountedfor • Misclassification of haemodynamicseverity • Patientpreference • Even mild symptoms have major impact on physical and emotional/social QoL, regardless of age. Disease burden compared to general population is large! • QoL improves after AVR (in selected patients)

  30. room for improvement!! • Accurate patientassessment (“listen to the patient, look at the valve”, C.M. Otto) • Heart team • QOL surveystandardarmamentarium

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