Valvular Heart Disease management

Transcription

1 Valvular Heart Disease management Dr Karl Poon MBBS FRACP Interventional cardiologist Structural intervention and TAVI specialist Queensland Cardiovascular Group

2 Outline VHD General principles on diagnosis and management of VHD When to refer? When to intervene? How to intervene? How often to monitor? Aortic valve disease Mitral valve disease

3 VHD practice guidelines

4 The key principle in VHD management SYMPTOMS AND SEVERE LESION

5 General principle when to intervene? When the valvular lesion is causing symptoms Symptoms of VHD Heart failure symptoms Exertional dypsnoea, orthopnoea, PND, ankle swellings Exertional chest pain or angina Presyncope/syncope Palpitations Caveat Confounding factor e.g. COAD or coexisting coronary artery disease Disconnect between symptoms and severity of VHD

6 General principle when to intervene? When a valve lesion becomes severe Severe valve lesions generally require treatment, as severe valve lesions generally cause symptoms Aortic stenosis pressure overload in LV Aortic regurgitation volume overload in LV Mitral regurgitation volume overload in LV/LA Mitral stenosis pressure overload in LA Severe valve lesions, if truly not symptomatic, must be monitored closely 6 monthly

7 General principle asymptomatic patient? Few patients with severe valve lesions (aortic stenosis) are truly asymptomatic Exceptions for treatment in truly asymptomatic patients Critical, rapidly progressive, heavily calcified aortic stenosis Impact on ventricle or atrium Left ventricular systolic dysfunction Left ventricular dilatation (regurgitant lesions) Pulmonary hypertension or atrial arrhythmia (MR) Concomitant cardiac surgery

8 Aortic Stenosis

9 Aortic stenosis pathophysiology Increased left ventricular pressure, diastolic dysfunction, LV hypertrophy, decreased cardiac output Associated mitral regurgitation, LA dilatation Endpoint LV systolic dysfunction Otto CM et al, NEJM, 2014; 371:

10 Aortic stenosis natural history 100 Latent Period Survival (percent) Increasing obstruction, myocardial overload Symptoms Average Age Death Age (years) Ross and Braunwald, Circulation 1968;38:V-61

11 Aortic stenosis severity Parameter Mild Moderate Severe Jet velocity (m/s) Ø4.0 Mean gradient (mmhg) < Ø40 Aortic Valve Area (cm 2 ) > < 1.0 (< 0.8) Aortic Valve Index (cm 2 /m 2 ) < 0.6 (<0.5) 50% mortality in 2 years in untreated severe AS 50% of truly severe AS patients have NO symptoms Otto C et al. Circulation 1997;95:

12 Mortality with Medical Rx Perspectives 5 Year Survival: Metastatic Cancer Percent % 30% 28% % 12% 3% * 0 Breast Lung Colorectal Prostate Ovarian * Constant Hazard Model Severe Inoperable AS

13 Aortic stenosis management Surgical aortic valve replacement (SAVR) remains the gold standard. Paradigm shift in transcatheter aortic valve implant (TAVI), rapidly becoming an established therapy. Superior to SAVR in high risk candidates What to expect from TAVI in 2016? 60 min procedural time; 50-80mL contrast Day 2-3 discharge 30D mortality: 0% Stroke: 2% Vascular injury: 5% Acute kidney injury: <3% Pacemaker: <5% Severe paravalvular regurgitation: <2%

14 Management of asymptomatic severe AS Genereux P et al, JACC, 67(19)

15 Asymptomatic Severe AS Pellika et al. Circulation 2005;111: Pai et al. Ann Thorac Surg 2006;82: Survival worse than age- and sex-matched controls Sudden death in absence of sx occurs at rate of 1% per year 50% of severe AS patients are asymptomatic 13.5% mortality over 5 years for conservative treatment Genereux P et al, JACC, 67(19)

16 Exercise Testing in Asymptomatic AS 66 patients with severe AS (AVA <1.0 cm 2, mean 0.6 cm 2 ) Exercise stress abnormal in 44 (67%) Clinical Implications of Abnormal Stress Test

17 Management of severe asymptomatic AS Close monitoring of severe Asx AS mandatory 6 monthly clinical/echo review Current guideline remains conservative management Current subject of multicentre RCT: TAVI vs. conservative (AVATAR) Genereux P et al, JACC, 67(19)

18 VHD prioritisation of referrals Prioritisation of referrals Urgent any symptomatic patients with severe valvular lesions Semi urgent asymptomatic severe lesions Non-urgent asymptomatic moderate lesions, incidental findings Avoid deferring referral of appropriate patients Severe LV dysfunction, severe functional deconditioning Avoid patients who won t benefit from treatment

19 Summary Severe symptomatic aortic stenosis portends poor outcome if untreated. Severe asymptomatic aortic stenosis requires close follow up. If there is a disconnect between symptom severity and valve lesion severity, question your cardiologist or TTE report. Avoid referring late in symptomatology. Request regular cardiology follow up for mild to moderate valvular lesions. TAVI has been a paradigm shift and will extend into younger and lower risk patients and even asymptomatic severe AS patients (trial patients).