1 / 32

Aortic Stenosis

Aortic Stenosis. Outline. Pathogenesis/Natural History Medical management -Asymptomatic -Symptomatic Surgical management - TAVI. Pathogenesis. Calcific AS is the most common valve disorder in the western world 2% of people >65, 3% >75 and 4% >85 have AS (in those with trileaflet valve)

wallis
Download Presentation

Aortic Stenosis

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Aortic Stenosis

  2. Outline • Pathogenesis/Natural History • Medical management-Asymptomatic -Symptomatic • Surgical management - TAVI

  3. Pathogenesis • Calcific AS is the most common valve disorder in the western world • 2% of people >65, 3% >75 and 4% >85 have AS (in those with trileaflet valve) • Initially thought to be a passive process of calcium buildup • Evidence now shows that it is an active process-Accumulation of LDL-Inflammation-Calcification Rajamannan NM, et. al. Calcific aortic stenosis: an update. Nat Clin Pract Cardiovasc Med 2007;4:254–262. Stewart BF, et. al. Clinical factors associated with calcific aortic valve disease. Cardiovascular Health Study. J Am Coll Cardiol. 1997; 29: 630-634.

  4. Natural History of AS • Prolonged asymptomatic period until AVA becomes <1/2 normal (3-4cm²) • Average gradient increase is 4-7 mmHg per year • Valve area decreases at an average rate of 0.1cm² per year • Patient’s with jet velocity <3m/sec are unlikely to develop symptoms in next 5 years Otto, CM et. al. Circulation 1997;95(9):2262

  5. Medical ManagementAsymptomatic Patients • Serial echo’s in combination with H&P and assessment of functional status • How often?-Mild AS: Every 3-5 years-Moderate AS: Every 1-2 years-Severe AS: Annually

  6. Medical ManagementAsymptomatic Patients • Hypercholesterolemia/Statin Therapy-A few studies show an association between AS progression and elevated cholesterol-In patients with LDL >130mg/dL, AS progression is more rapid • Does lowering cholesterol slow or prevent progression?

  7. Medical ManagementLipid Trials • SEAS Study1-1873 patients with mean age of 68-Mild to moderate AS-Randomized to simvastatin/ezetimibe vs. placebo-52 month f/u => No difference in rate of hemodynamic progression of AS • SALTIRE Trial²-155 patients with at least moderate calcific AS-Randomized to atorvastatin 80mg vs. placebo-No difference in rate of increase in AoV velocities over 25 month f/u 1. N Engl J Med 2008;359:1343-56. 2. N Engl J Med 2005;352:2389-97.

  8. Medical ManagementHyperlipidemia • Statin therapy for isolated AS does not reduce rates of disease progression • Studies to evaluate potential benefit earlier in disease process have not been performed • Most AS patients have other indications for statin therapy

  9. Medical ManagementHypertension • AS and hypertension often coexist • Afterload is elevated due to increased SBP and valve stenosis (“double-load”) • Axiom of “start low and go slow” especially important in patients with more severe AS

  10. Medical ManagementAntihypertensives • ACE-Inhibitors-Known to have beneficial effects on LV function/remodeling-Little clinical evidence that they benefit patients with AS-Usually tolerated well...watch for hypotension • Diuretics/Nitrates-Use cautiously; preload reduction => Hypotension

  11. Medical ManagementAntihypertensives • Beta-blockers-Bicuspid AS associated with root dilatation which can lead to aneurysm/dissection-AHA/ACC guidelines recommend β-blocker in patients with root >40mm -Patients with low BSA’s should be considered for β-blocker therapy based on aortic size index

  12. Medical ManagementExercise • CO increases with exercise and can therefore exacerbate valve gradient and LVSP • Magnitude of this effect increases with AS severity and exercise intensity • Specific guidelines exist for professional athletes-Even patients with severe AS can bowl and play golf

  13. Medical ManagementSymptomatic Patients • Limited options for medical management once patient becomes symptomatic • Classic triad of symptoms:-Angina-Heart Failure-Syncope Circulation Journal Vol. 75, Jan 2011

  14. Medical ManagementSymptomatic Patients • What about those patients who refuse or are not candidates for surgical correction?-Up to 1/3 of patients are not surgical candidates! • Goals of medical therapy:-treat concurrent conditions-maintain optimal hemodynamics -manage symptoms • Long-term medical therapy for palliation only

  15. Medical ManagementBalloon Valvuloplasty • Performed in those patients who display hemodynamic instability due to AS • Can be used as a bridge to AVR or strictly for palliation of symptoms • Associated with high morbidity and short-lived efficacy-10%-20% rate of stroke, MI and AI-Restenosis and clinical worsening occur within 6-12 months - similar to untreated AS1 J Am Coll Cardiol 1995; 26: 1522

  16. Surgical ManagementThe Beginning • First performed in 1952 by Dr. Charles Hufnagel • Definitive treatment of symptomatic severe AS Hufnagel Artificial Heart Valve in the collection of the National Museum of Health and Medicine

  17. Surgical ManagementModern Day • Multiple options for replacement:-Mechanical-Bioprosthetic-Stented/Stentless-Homografts-Ross (fallen out of favor) • Which is best...

  18. Choice of AVR2006 ACC/AHA/ESC Recommendations • Mechanical Valves-Already have another mechanical valve-<65 without contraindication for anticoagulation (weaker recommendation) • Bioprosthetic Valves-Contraindication or unwilling to take warfarin (any age)-≥65 without risk factors for thromboembolism-<65 in those who make an informed decision

  19. Choice of AVRBioprosthetic • Concerns about bioprosthetic AVR durability and long-term mortality in patients <65 -Veterans Affairs Trial 1 • Subsequent study showed that long-term mortality was not higher in <60 year olds with initial bioprosthetic AVR² • Patient preference and likelihood of repeat surgery 1.J Am Coll Cardiol 2000; 36:1152 2.Circulation 2007; 116: I-294-I-300

  20. AS TreatmentPresent and Future • TAVI first performed in France in 2002 • Increased use throughout the world in patients who are not candidates for surgical AVR • Recently approved for use in the US

  21. TAVICoreValve ReValving System • Manufactured by Medtronic • Self-expandable, trilevel frame of nitinol with porcine pericardium valve • Anchored within the annulus but function is supra-annular

  22. CoreValve SystemClinical Data • Randomized trial comparing CoreValve to surgical replacement is ongoing • Most common complication is need for PPM (10%-15%) Spaccarotella, C et.al. Circulation Journal Vol.75;Jan 2001

  23. TAVIEdwards SAPIEN • Edwards Lifesciences LLC • Balloon-expandable stainless steel frame with equine pericardium valve • Anchoring and function are both intra-annular

  24. Edwards SAPIENClinical Data • SOURCE Registry-463 transfemoral and 575 transapical patients-Overall all-cause mortality was 8.3% at 30 days Transfemoral: 6.3% Transapical: 10.3%-Overall stroke rate of 2.5%; similar in both groups Schymik, G et. al. Circ 2010; 122: 62-69

  25. AS TreatmentPARTNER • Placement of Aortic Transcatheter Valves-Multicenter, randomized trial comparing TAVI with standard therapy in patients with severe AS-Divided into two cohorts: 1) STS of ≥10% but still considered surgical candidates 2) Not surgical candidates due to probability of death or serious irreversible condition of 50% 30 days post-OP • PARTNER reported results of those not deemed surgical candidates

  26. AS TreatmentPARTNER • 3105 patients screened, 358 enrolled from 21 sites (17 in the US) • Followed for at least 1 year (median 1.6; max 2.8) • Primary endpoint was all cause mortality over the trial duration

  27. PARTNEROutcomes • TAVI Group-Median time to TAVI - 6 days-2 deaths, 3 major strokes, 1 valve embolization during procedure or in 1st 24 hours-11/173 died within 30 days • Standard Therapy Group-150/185 underwent balloon valvuloplasty-12 underwent surgical AVR

  28. PARTNERPrimary Endpoint • All cause mortality at 30 days - 5% in TAVI - 2.8% in SMT 20% Reduction in mortality

  29. PARTNERSecondary Endpoints • Increased major bleeding and major vascular complications with TAVI • Greater improvement in symptoms with TAVI-Improvement in 6 minute walk test with TAVI-No change in standard therapy group • Echo evaluation-Mod or severe paravalvular regurg in ~11% of TAVI patients at one year-Mod or severe transvalvular regurg in 1.3 %

  30. “PARTing” Shots • Standard medical therapy did not alter the natural history of severe AS-84% received balloon valvuloplasty • TAVI superior to standard therapy with regard to all cause mortality (1° Endpoint) • More neurologic events in TAVI group • No evidence of valve deterioration one year post-implantation

  31. Let’s Review... • AS is the most common heart valve disease in the industrialized world • No effective long-term medical therapies • AVR is the only therapy that offers prolonged morbidity and mortality benefits • TAVI is a safe alternative in those who are not surgical candidates

  32. http://www.nejm.org/doi/full/10.1056/NEJMoa1008232#

More Related