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HIGH TECH 2012

HIGH TECH 2012. 25-26 et 27 janvier 2012 – Marseille - Palais des Congrès RAC et dysfonction VG Docteur Bertrand CORMIER. Cas clinique n°1 Mr DEL. André, 73 ans. HTA ancienne – Tabac modéré RA connu de longue date, jugé modéré Poussée récente d’insuffisance cardiaque Auscultation pauvre

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HIGH TECH 2012

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  1. HIGH TECH 2012 25-26 et 27 janvier 2012 – Marseille - Palais des Congrès RAC et dysfonction VG Docteur Bertrand CORMIER

  2. Cas clinique n°1Mr DEL. André, 73 ans • HTA ancienne – Tabac modéré • RA connu de longue date, jugé modéré • Poussée récente d’insuffisance cardiaque • Auscultation pauvre • ECG : RS, QRS fins – Coro normale • Echo VG 58/47 SIV/PP = 10/10 FE 20 % VTi sous Ao = 8 cm – gradient moyen 15 – Sa0 =0.7 • Dobutamine = O réserve contractile • Dilatation aortique : O résultat fonctionnel

  3. Cas clinique n°1 • Scanner cardique:valve tricuspide calcifiée,anneau:23 • TAVI prothese Edwards 26

  4. cas clinique n°1 Suites simples; O SF Retour à domicile sous traitement medical Pronostic?(def à discuter)

  5. Cas Clinique n°2Mr ALV. Serge, 70 ans • Tabac sevré – DNID – 112 kg, 1m78 • CMD connue depuis 2006  coro : sténose D1 • Sclérose mitro-aortique - FEVG = 35 % • 2011 : 2 poussées d’IC globale • Echo FEVG = 35 % - gradient moyen 25 – Sao = 0.8 cm²

  6. Cas Clinique n°2Mr ALV. Serge, 70 ans – 2 • Echo Dobu RC +  gradient moyen = 45 • Scanner = valve tricuspide calcifiée – Sao = 0.9 cm² • RVA BP 23 – Suites simples, sortie à J+8

  7. EuroHeart Survey on VHDB.Iung Eur Heart J, 2003 • Prospective study in 92 centers from 25 countries = 5001 VHD • AS = 1197 pts  512 interventions : • EF ≥ 60 = 56.5 % 50-60 = 24.2 % 30-50 = 16.4 % < 30 = 2.9 %

  8. To operate or not pts with severe ASBT.Bouma, Heart 1999 • 205 pts prospectively evaluated; AVA < 1 cm², mean age= 78 yrs, 48% CAD • 94 pts : AVR 111: medical • 41 symptomatic pts no surgery : • LV dysfunction 14% • Advanced age 13% • Comorbidity 13% • Symptoms attributed to CAD 11% • Functional improvement 9% • Main risk factors:impaired LVF, NYHA Cl, age

  9. Why are so many pts with AS denied surgery ?B.Iung, Eur Heart J 2005 • EHS : 216 pts with severe symptomatic AS (angina or NYHA Cl III/IV) • AVR = 67 % medical= 33 % • Multivariate analysis • LVEF [OR = 2.27 for EF 30-50 % = 5.15 for EF ≤ 30 % • Age [OR = 1.84 for 80-85 yrs = 3.38 for ≥ 85 yrs vs 75-80 Associated with no surgery

  10. AS and LV systolic dysfunction • In the majority of pts with mild-moderate systolic dysfunction, decrease in SV and EF is related to reversible mismatch, likely to reverse when obstruction is relieved  pts with severe AS and EF < 50 % : Cl IC for AVR (ESC guidelines, 2008)

  11. AS and LV systolic dysfunction • Severe decrease in EF may be caused by decreased contractility associated with fibrosis due to hypertrophy or surimposed MI. Secondary improvement in LV function is uncertain. • The subgroup of pts with severely depressed EF and low flow raises diagnostic and therapeutic difficulties

  12. Flow dependence of AV resistance and LV stroke work loss • Valve resistance = 1.333 x P/Q dynes/s/cm-5 • LV SWL = 100 x P/ LVP (%) (Burwash, 1994)

  13. Calcific AS : time to look more closely at the valveCM OTTO, NEJM 2008

  14. Scanner MSCTThresholds

  15. Dobutamine Echocardiography in AS with LV dysfunction (EF< 0.35) and low gradient (P< 30 mm) • De Filippi (1995) • Severe AS :  VTI,  P, no change (<0.3 cm²) in AVA • Mild AS :  VTI,  AVA (> 0.3 cm²), no change in P • No reserve ? • Nishimura (2002) • Severe AS : P > 30 and AVA < 1.2 cm²

  16. Surgery of AS with LV dysfunction

  17. Low gradient AS : risk stratification by DSEJL Monin Circulation 2003 • Prospective multicenter study : 136 symptomatic pts, AVA = 0.7 cm² (0.6-0.8), MPG 29 mmHg (23-34), LVEF : 0.30 (0.24-0.35) – CI : 2.11 l/mn/m² (1.75-2.55) • Significant CAD = 46 % (MVD = 33 %) • Gr I : 92 pts with CR ( SV ≥ 20%) vs Gr 2 = 44 pts without CR • AVR in 70% of each Gr ;medical tt in pts with older age, comorbidities of pseudo severe AS (9/92 pts) • OM = 14 % (5% Gr I, vs 32 % Gr II, p < .002) • Predictors of OM : lack of CR (OR : 10.9, p< .001) and MPG ≤ 20 mmHg (OR : 4.7, p<.04) • Predictors of LT survival : AVR (p=.001) and CR (p.001)

  18. Indications for AVR in AS with LV dysfunction • ACC/AHA  no recommendation • ESC : AS with low MPG (< 40 mmHg), LV dysfunction and contractile reserve : Cl II a C and no contractile reserve: Cl II b C • Decision making according to clinical condition, valve calcification, extent of CAD

  19. Outcome after AVR for LF/LG AS without CRC. Tribouilloy, JACC 2009 • 81 pts prospectively included – AVA < 1 cm², EF ≤ 40 %, MPG ≤ 40 mmHg; no contractile reserve • 55 pts : AVR – 26 :medical; Mean Fu : 37 ± 41 m • Operative mortality : 22%, 5 yrs survival (excluding OM) : 69 ± 8%

  20. Therapeutic decision in patients without CR • BAV as a diagnostic test • AVR considered in pts with calcified valve, low comorbidity, with MPG > 20 mmHg and without large scar of infarction

  21. Comparison of hemodynamic performance of percutaneous and surgical BP in ASMA Clavel, JACC 2009 50 PAVI (femoral : 38 ; apical 12)matched with 50 CE Magna (ST gr) or freestyle (SL gr) for sex, aortic annulus diameter, LVEF, BSA and BMI

  22. Long-term outcomes after TAVI in high-risk ptsThe UK registry – NE MOAT JACC 2011 ; 58 : 2130-8 • All TAVI prospectively collected (2007-2009) within the UK (25 centers), mortality status in 100% by December 2010 • 870 pts = TF route : 599 (69 %) other 271 (31 %) Medtronic Corevalve = 452 (52 %) Edwards Sapien = 410 (48 %) • 213 pts alive at 2 years FU

  23. NE Moat JACC 2011

  24. NE Moat JACC 2011

  25. AS and poor LV functionConclusion - 1 • LV dysfunction is an uncommon consequence of AS (< 10 %) • MPG > 30 mmHg despite low EF in favor of mismatch and represents an indication for AVR

  26. Conclusion - 2 • The subgroup of pts with severe LV dysfunction, LF, LMPG poses diagnostic and therapeutic difficulties : due to the flow dependence of the main hemodynamic criteria, the diagnosis of severe AS is based on anatomy and the response to Dobutamine infusion • Patients with CR should undergo valve intervention as well as patients without CR but with low comorbidity, MPG > 20 mmHg and no extensive scar of MI

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