Stress-echocardiography to guide decision making in valvular heart disease: Low-Flow, Low-Gradient Aortic Stenosis
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1 Stress-echocardiography to guide decision making in valvular heart disease: Low-Flow, Low-Gradient Aortic Stenosis Philippe Pibarot, DVM, PhD, FACC, FAHA, FESC Canada Research Chair in Valvular Heart Diseases Disclosures: None Université LAVAL
2 Low-EF, low-flow, low-gradient AS AVA 1.0 cm 2, mean gradient 40 mmhg and LVEF 40% Approximately 5-10% of AS population High risk patients: 3-year survival 50-60% If operated (AVR): operative mortality: 8-30%
3 True Severe AS vs. Pseudo Severe AS? True Severe AS Pseudo Severe AS Low Flow Normal Flow Low Flow Normal Flow AVA P
4 ΔP<40 AVA 1.0 Dobutamine-Sress Echo SV 20 % Contractile Reserve SV < 20 % No Contractile Reserve ΔP 40 & AVA<1.2 True Severe AS ΔP<40 & AVA 1.2 Pseudo Severe AS ΔP<40 AVA 1.0 Indeterminate AVR CABG (OP Mortality: 5-8%) MEDICAL AVR (OP Mortality: 12-33%) TAVI? MEDICAL?
5 Case Study #1 Resting Echo Dobutamine Stress Echo
6 Case Study #1 Resting Echo SV= 53 ml LVEF=40% Peak P= 49 mmhg Mean P= 29 mmhg AVA= 0.77 cm 2 Dobutamine Stress Echo SV= 73 ml LVEF=50% Peak P= 92 mmhg Mean P= 52 mmhg AVA= 0.75 cm 2
7 Case Study #1: Contractile reserve: Yes Stenosis severity: True-severe
8 Case Study #2 Resting Echo SV= 34 ml LVEF=15% Peak P= 18 mmhg Mean P= 12 mmhg AVA= 0.85 cm 2 Dobutamine Stress Echo SV= 46 ml LVEF=25% Peak P= 21 mmhg Mean P= 13 mmhg AVA= 1.2 cm 2
9 Case Study #2: Contractile reserve: Yes Stenosis severity: Pseudo-severe
10 Case Study #3: Low-Flow, Low-Gradient, Aortic Stenosis Stroke Volume (cc) Ejection Fraction Mean Gradient (mm Hg) AVA (cm 2 ) Rest Dobutamine
11 Case Study #3: Contractile reserve: Yes Stenosis severity:?
12 Blais et al, Circulation 2006;113:
13 Concept of the Projected AVA (250 ml/s) Aortic Valve Area (cm 2 ) Blais et al, Circulation 2006;113: Projected AVA * * Mean Transvalvular Flow Rate (ml/s) * * * Peak AVA during DSE
14 Blais et al, Circulation 2006;113: Calculation of the Projected AVA * Peak AVA with DSE AVA (cm 2 ) * Baseline AVA and Q Slope = valve compliance (VC) Simplified method: VC=0.35/ VC= AVA/ 70=0.005 Q Mean Transvalvular Flow Rate (ml/s) AVA projected = = 0.6 AVA baseline + (250 VC - ( ) - = Q1.18 baseline cm) 2
15 Case Study #3 : Low-Flow, Low-Gradient, Aortic Stenosis Stroke Volume (cc) Ejection Fraction Mean Gradient (mm Hg) AVA (cm 2 ) Rest Dobutamine Projected AVA (cm 2 ) 1.18
16 Projected AVA vs. Valve Weight Clavel et al. JASE, ;23:380-6, 2010
17 Usefulness of Projected AVA to Predict Outcome Multivariate predictors of overall mortality in 84 patients treated medically Clavel et al. JASE, ;23:380-6, 2010
18 Usefulness of Dobutamine Stress Echo. Dobutamine Sress Echo SV 20 % Contractile Reserve SV < 20 % No Contractile Reserve ΔP mean 40 & AVA<1.2 Projected AVA 1.0 ΔP mean <40 & AVA 1.2 Projected AVA>1.0 True Severe AS Pseudo-Severe AS Indeterminate AVR CABG MEDICAL AVR/TAVI? MEDICAL?
19 76 y.o. woman Risk factors: Obese, Hyperchol. Hypertension, COPD 3-vessel CAD CABG 3: Aug 95 MI: Jan 96 Case Study #4 CHF: LVEDD: 64 mm, LVEF 25%, BNP: 832 pg/ml Aortic stenosis, 2+ mitral regurgitation Current medication: ASA, ARBs, Statin, Digoxin, Brochodil.
20 Resting Echo Dobutamine Stress Echo LVEF=25% SV= 51 ml AVA= 0.8 cm 2 P= 46 / 28 mmhg LVEF=30% SV= 57 ml AVA= 0.8 cm 2 P= 52 / 31 mmhg
21 Case Study #4: Contractile reserve: No Stenosis severity: Indeterminate
22 Performance of MSCT Calcium score > 1651 AU to correctly differentiate severe from non-severe AS Normal Flow Low Flow-Low Gradient Case study #4 Score: 2000 Sensitivity Specificity PPV NPV Cueff et al. Heart 97:721-6, 2011
23 Usefulness of DSE and MSCT Dobutamine Sress Echo SV 20 % Contractile Reserve SV < 20 % No Contractile Reserve ΔP mean 40 & AVA < 1.2 AVA Proj 1.0 MSCT: Ca+++ True Severe AS AVR CABG ΔP mean < 40 & AVA 1.2 AVA Proj > 1.0 MSCT: Ca+- Pseudo Severe AS MEDICAL Ca+- MSCT Ca+++ True Severe AS AVR? (High Op. Risk) TAVI? MEDICAL?
24 Risk Stratification using Contractile Reserve Group I = contractile reserve SV 20% under DSE 126 Patients Group II = no contractile reserve Monin et al, Circulation 2003;108:
25 Tribouilloy et al. JACC, 53; , 2009 Total Population Matched Patients
26 Preoperative Contractile Reserve vs. Postoperative Ejection Fraction 66 Patients who underwent AVR Group I (CR+) Group II (CR-) Operative Mortality 2-year Survival 6% 97±7% 33% 90±5% Quere et al, Circulation 2006;113:
27 Case study #4: No Contractile Reserve Logistic Euroscore: 60% AVR?
28 Case Study #4: What would you do this patient? 1- AVR 2- Medical 3- TAVI 4- Heart transplant
29 Combined Impact of PPM and LV Dysfunction on Operative Mortality 1200 patients undergoing AVR 80 67% P< % 7% P=0.05 5% P= % P< % P<0.001 Non significant Moderate Severe Prosthesis-Patient Mismatch Blais et al, Circulation,108: , 2003
30 Surgical Options if Anticipating PPM Use of better performing prosthesis Newer generation supra-annular bioprosthesis Stentless bioprosthesis Newer generation mechanical prosthesis Homografts / Ross operation Aortic root enlargement Transcatheter aortic valve implantation Acceptance of PPM in light of other clinical factors
31 Prosthesis-Patient Mismatch vs. Prosthesis Type: A Case-Match Study VS. VS. Clavel et al., JACC, 53: , 2009
32 LV Ejection Fraction, (%) Recovery of LVEF in Patients with Severe AS and LV Systolic Dysfunction (LVEF<50%): TAVI versus AVR 50 * t 14 ±15% 45 * t t 40 7 ±11% Baseline Discharge 1 year Visits SAVR TAVI *: different from SAVR t: different from baseline : different from discharge Clavel Circulation, 122: , 2010
33 Case #4: Transapical Valve Implantation Early Postop. Peak P: 14 mmhg Mean P: 7 mmhg
34 LVEF (%) BNP (pg/ml) Pre 7-dy 1-mo 1-yr 0 Pre 7-dy 1-mo 1-yr MWT (m) Pre 7-dy 1-mo 1-yr
35 Usefulness of DSE and MSCT Dobutamine Sress Echo SV 20 % Contractile Reserve SV < 20 % No Contractile Reserve ΔP mean 40 & AVA< 1.2 AVA Proj 1.0 MSCT: Ca+++ True Severe AS AVR CABG ΔP mean <40 & AVA 1.2 AVA Proj > 1.0 MSCT: Ca+- Pseudo Severe AS MEDICAL MSCT Ca+- Ca+++ True Severe AS AVR/TAVI
36 Usefulness of Dobutamine Stress Echo in Low-Flow, Low-Gradient AS Dobutamine stress echocardiography is essential for risk stratification and clinical decision making in low-flow, lowgradient AS The projected AVA: a new index to distinguish true severe from pseudo-severe AS Assessment of stenosis severity remains a major challenge in patients with no or poor contractile reserve: usefulness of MSCT Particularly important to avoid patient-prosthesis mismatch (PPM) when operating on these patients Transcatheter valve implantation: a new promising therapeutic avenue in patients with low-flow, low-gradient AS and no contractile reserve??
37 Usefulness of Dobutamine Stress Echo in Low-Flow, Low-Gradient AS and Preserved LV Ejection Fraction???
38 Usefulness of Projected AVA in Preserved LVEF, Low-Flow, Low-Gradient AS 42 patients 22 % had pseudo-severe AS Percentage of correct classification by AVA Proj : 89% EOA proj, cm r=0.87 ;p=0.01 Valve weight, g Clavel et al. ESC 2011
39 Please, join the Working Group in Valvular Heart Disease European Society of Cardiology
40 Philippe Pibarot Ian Burwash Helmut Baumgartner Jean G. Dumesnil Gerald Mundigler Robert Beanlands Jutta Bergler-Klein Patrick Mathieu Éric Larose Mario Sénéchal Christian Couture Julia Mascherbauer Senta Graaf Rob DeKemp Éric Dumont Josep Rodes John Webb Robert Moss Benjamin Chow Aliasghar Khorsand Philipp Pichler TOPAS Study Investigators Coordinators Students / Fellows Isabelle Laforest Dominique Labrèche Linda Garrard Florian Rader Nicole Loho Kym Mcaulay Philipp Eickhoff Andrée Pépin Thomas Resch Brenda Johnston Diana Meshkat Olga Walter Heidi Zach Centers Québec Heart Institute / Laval Hospital, Québec U. Ottawa Heart Institute St. Paul Hospital, Vancouver Vienna General Hospital, Vienna Munster U. Hospital, Munster Marie-Annick Clavel Zeineb Hachicha Christina Fuchs Claudia Blais Dania Mohty Philip Bartko
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