Current Challenges in Management of Aortic Stenosis?

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1 Current Challenges in Management of Aortic Stenosis? Robert O. Bonow, MD, MS Northwestern University Feinberg School of Medicine Bluhm Cardiovascular Institute Northwestern Memorial Hospital No Relationships to Disclose

2 Survival (percent) Natural History of Aortic Stenosis 100 Latent Period Increasing obstruction, myocardial overload Symptoms Average Age Death Age (years) from Ross and Braunwald, Circulation 1968;38:V-61

3 Survival (percent) Aortic Stenosis Survival of Symptomatic Patients Circ Cardiovasc 100 Qual Outcomes 2009;2: % Time (months) Bach et al, Circ Cardiovasc Qual Outcomes 2009;2:

4 Aortic Stenosis Indications for AVR Symptomatic patients with severe AS class I if it is likely that the symptoms are cardiac in origin

5 Aortic Stenosis Management challenges: The asymptomatic patient with severe AS Low-flow, low gradient severe AS Indications for TAVR

6 Vmax: Mean Δ: AVA: Severe AS: >4.0 m/s >40 mmhg <1.0 sq cm

7 Event-Free Survival (%) Natural History of Severe Asymptomatic AS Medicare 80 data Average hospital mortality: 8.8% 60 Vmax > 4.0 m/s Low volume centers: 13.0% Stewart High volume centers: 6.0% Otto Rosenhek Pellikka Nistri Time (years) Otto et al. Circulation 1997;95: Rosenhek et al. N Engl J Med 2000;343: Pellikka et al. Circulation 2005;111: Stewart et al. Eur Heart J 2010;31: Nistri et al. Am J Cardiol 2012;109;

8 Event-Free Survival (%) Natural History of Severe Asymptomatic AS Medicare 80 data Average hospital mortality: 8.8% 60 Vmax > 4.0 m/s No or mild calcification Low volume centers: 13.0% Moderate or severe calcification High p<0.001 volume centers: 6.0% Time (years) Rosenhek et al. N Engl J Med 2000;343:

9 Event-Free Survival (%) Natural History of Severe Asymptomatic AS Medicare 80 data Average hospital mortality: 8.8% Vmax m/s Low volume centers: 13.0% Vmax m/s High p<0.001 volume centers: 6.0% Vmax >5.5 m/s Time (years) Rosenhek et al. Circulation 2010;121:

10 Vmax Mean Δ AVA Aug Jan Dec Nov Sept

11 Asymptomatic Aortic Stenosis Indications for valve replacement: Very severe AS: Vmax 5 m/s Rapid progression and low surgical risk class IIa class IIb Very severe AS: Vmax >5.5 m/s Severe valve calcification and rate of progression 0.3 m/s / year Markedly elevated BNP Increase in gradient with exercise >20 mmhg Excessive LVH class IIa class IIa class IIb

12 Aortic stenosis Management challenges: The asymptomatic patient with severe AS Low-flow, low gradient severe AS Indications for TAVR

13 Aortic stenosis Management challenges: The asymptomatic patient with severe AS Low-flow, low gradient severe AS Indications for TAVR The symptomatic patient with LV dysfunction and low gradient AS The symptomatic patient with normal LV function and paradoxical low flow, low gradient AS

14 Normal Flow High Gradient Normal LV Function Low Flow Low Gradient Normal LV Function Diastole Systole from Pibarot and Dumesnill, J Am Coll Cardiol 2012:60:

15

16 Aortic Valve Calcification (AU) Mean Aortic Valve Gradient <40 mmhg Men p<0.001 Women p< >0.6 cm/m cm/m 2 >0.6 cm/m cm/m 2 Aortic Valve Area Aortic Valve Area Clavel et al, J Am Coll Cardiol 2013;62:

17 Clavel et al, J Am Coll Cardiol Ozkan et al, Nat Review Cardiol Herrmann et al, J Am Coll Cardiol 2013;62: ;8: ;58:

18 Survival (percent) Survival in Low Flow AS with Normal LVEF n=260 AVR n=123 Medical n= p< Time (years) from Ozkan et al, Circulation 2013;128:

19 Low Flow, Low Gradient Aortic Stenosis Indications for valve replacement: Normal EF, if clinical, hemodynamic and anatomic data support severe AS class IIa Normal EF only after careful confirmation of severe AS class IIa

20 Aortic stenosis Management challenges: The asymptomatic patient with severe AS Low-flow, low gradient severe AS Indications for TAVR

21 Intervention for Severe AS Indications for TAVR vs surgical AVR: Evaluation by a Heart Team Surgical AVR for patients at low or intermediate risk TAVR for patients with prohibitive surgical risk and life expectancy >12 months TAVR alternative for patients at high surgical risk Percutaneous aortic balloon valvotomy as a bridge to TAVR or surgical AVR class I class I class I class IIa class IIb

22 Transcatheter Therapy for Severe AS Balancing benefits, risks and expectations TAVR represents a transformative technology with enormous potential Clinical efficacy and safety must temper consumer expectations Surgical AVR represents standard with proven safety and durability for majority of patients Broad application of TAVR presents challenges in patient selection, cost effectiveness, and need for dedicated, expert heart valve centers Desai CS, Bonow RO. JAMA 2012;210:

23 Cumulative Incidence Rate (%) n=12,182 Composite Mortality Stroke Time (months) from Holmes et al, JAMA 2015;313:

24 30 Day AVR Mortality (percent) Aortic Valve Replacement Hospital Mortality % Medicare Medicare % Year Barreto-Filho et al, JAMA 2013;210:

25 30 Day AVR Mortality (percent) Aortic Valve Replacement Hospital Mortality % 5.9% Medicare Medicare Year Age 85 Age % Age % Barreto-Filho et al, JAMA 2013;210:

26

27 Challenges in management of AS: Have the guidelines filled the gap?

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