Valvular Heart Disease for GIM trainees. Aortic Stenosis. Chris Malkin, Leeds Teaching Hospitals

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1 Valvular Heart Disease for GIM trainees Aortic Stenosis Chris Malkin, Leeds Teaching Hospitals

2 2002 1st TAVI, st UK TAVI

3 Current Status Aortic valve implants, conscious patient, beating heart Mortality <2% high volume centres (30 day) Treat the inoperable Treat the high risk with less morbidity median discharge day 2 Germany TAVI > SAVR for calcific AS

4 Need to know? Diagnose it Recognise those patients at high risk needing rapid decisions and treatment Understanding of how patients get processed and decision making

5 A recent case 78m, severe AS, severe pulmonary hypertension moderate MR normal coronaries, diabetic (metformin) Bit frail but ambulant Class 3 dyspnoea - cant get up stairs in one go High risk but operable: logistic euroscore 14%, STS 3.8%, 17% morbidity

6 Referred Surgeon Clinically deteriorated - admitted APO In-patient pathway CT bicuspid valve, egfr reduced 35mls Offer TAVI (consented for UK registry and valve registry)

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12 Progress Lines out & mobilise 12 hours Home day 3 30day follow up asymptomatic Improvements in LV function, PA pressure & MR

13 Diagnosis

14 Severe AS Aortic valve orifice area (AVOA) 0.8-1cm(2) (indexed to body size) Velocity through valve: 4m/s Gradient: peak >64mmHg, mean >40mmHg

15 who has severe AS? 85m: PPG 100mmHg, MPG 50mmHg, AVOA 0.6cm(2), EF 60% 76F: PPG 56mmHg, MPG 30mmHg, AVOA 1cm(2), ef 70% 70m: PPG 60mmHg, MPG 33mmHg, AVOA 0.9cm(2), ef 32%

16 sources of error 10-15% reduced LV function / contractility low gradient AS 10% small LV cavity and small stroke volume low gradient AS 10-20% mixed pathology AR increase stroke volume and velocity high gradient moderate AS MR and severe hypertension cause of low-gradient severe AS Valve area is calculated 2D measure assumes equal circle

17 What is the valve area? it depends on what you assume the LVOT area is Min = 16.1 x 265/97 = 0.43cm(2) Max = 16.1 x 568/97 = 0.95cm(2)

18 which patient has severe AS? 85m: PPG 100mmHg, MPG 50mmHg, AVOA 0.6cm(2), EF 60% severe AS, high gradients/cardiac output/flow 76F: PPG 56mmHg, MPG 30mmHg, AVOA 1cm(2), ef 70% Paradoxical low gradient severe AS - small stroke volume 70m: PPG 60mmHg, MPG 33mmHg, AVOA 0.9cm(2), ef 32% Low flow low gradient severe AS - low cardiac output and flow

19

20 which patient has severe AS? 85m: PPG 100mmHg, MPG 50mmHg, AVOA 0.6cm(2), EF 60% severe AS, high gradients/cardiac output/flow 76F: PPG 56mmHg, MPG 30mmHg, AVOA 1cm(2), ef 70% Paradoxical low gradient severe AS - small stroke volume 70m: PPG 60mmHg, MPG 33mmHg, AVOA 0.9cm(2), ef 32% Low flow low gradient severe AS - low cardiac output and flow

21 Paradoxical Low Gradient Severe AS (PLG-AS) Small crowded vigorous heart LVH and small LV cavity Stroke volume low trans-aortic valve velocity is low 2x common women

22 which patient has severe AS? 85m: PPG 100mmHg, MPG 50mmHg, AVOA 0.6cm(2), EF 60% severe AS, high gradients/cardiac output/flow 76F: PPG 56mmHg, MPG 30mmHg, AVOA 1cm(2), ef 70% Paradoxical low gradient severe AS - small stroke volume 70m: PPG 60mmHg, MPG 33mmHg, AVOA 0.9cm(2), ef 32% Low flow low gradient severe AS - low cardiac output and flow

23 Low gradient low EF (LF-LG) severe AS Poor LV function and contractility Low velocity / gradient through aortic valve Men / Coronary disease with previous MI

24 Things that look like severe AS that are not AR, hyperdynamic states, HOCM, eccentric MR, EOA >1cm(2) Things that look like non-severe AS that are Hypertension, Poor LV function, Small hearts with low stroke volume, Severe MR, Severe MS,

25 Decisions / Treatment

26

27

28 Presentation Walk in: c/o Dyspnoea / Chest pain / Syncope Carried in: decompensated failure (APO) Picked up: incidental finding on echo (IP or OP)

29

30 SAVR more likely Young (? <70) Co-existent:- severe valve disease, severe coronary disease aortopathy (bi-cuspid valve)

31 TAVI more likely Old (?>75) previous sternotomy, radiation, immunosuppression, CKD, frailty poor LV, chronic lung disease anaemia small patients,? female

32 Palliation more likely Severe dementia Very frail Very poor LV function with scarring Non-cardiac prognosis poor (<2 years)

33 Incidental severe AS

34 Aortic Stenosis & non-cardiac surgery Emergency Surgery Elective surgery with severe AS (risk dependent on type surgery / severity and symptoms of patient with AS)

35 Outcomes after non-cardiac surgery in patients without aortic stenosis moderate AS severe AS stratified by degree of surgical risk. Shikhar Agarwal et al. Circ Cardiovasc Qual Outcomes. 2013;6:

36 Outcomes after non-cardiac surgery. 30-day and 1-year survival severe AS (red) and controls (blue). Tashiro et al EHJ 2014;35:

37

38 operate Urgent surgery: Elective Surgery: No symptoms, Normal exercise tolerance (CPEX) low or intermediate risk surgery

39 consider not operate. Symptoms Abnormal CPEX Either very high gradient or poor LV function or both

40 Treat? How? 62F severe AS Obese, steroids, ESRF 3x week dialysis, mild/mod LVSI, previoustia, diffuse mild coronary disease, class II SOB Planned: renal transplant

41

42

43 Treat? How? 84m, severe AS, blocked LAD other coronaries OK, LV mild-moderate impairment, class IV SOB (in patient on general surgical ward): Rectal Cancer (T3.NO.M0). Planned: Hemicolectomy

44 Some doubts about reversibility generally and in cardiac status BAV (balloon aortic valvuloplasty)- leave LAD occluded and therefore avoid need for dual antiplatelets. Got much better, discharged Surgery delayed but done Readmitted in cardiac failure - TAVI.

45 Balloon Aortic Valvuloplasty Quick Safe (1-1.5% complication) Useful (i) get patients better (ii) bridge to SAVR or TAVI (iii) get patients through major surgery (iv) when not sure of outcomes

46 Treat? How? 75M, severe AS, enlarging 6cm AAA, PVD (claudicates), distal diffuse coronary disease, good LV, not frail

47 High gradient on echo: symptoms probably obscured by claudication Risk of AAA sequela 10% per year TAVI if adequate vascular access

48

49 If you have an ambulant patient with severe AS should get a cardiology opinion Symptomatic patients with severe AS - urgent Unstable patients can sometimes be rescued with emergency BAV But a frail dependent patient with no reserve will do badly and should be palliated often the most difficult decision

50 watch this space for more valve stuff!

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56 more another time thanks for your attention

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