25-26 et 27 janvier 2012 – Marseille - Palais des Congrès RAC et dysfonction VG Docteur Bertrand CORMIER

25-26 et 27 janvier 2012 – Marseille - Palais des Congrès Conflit d’Intérêt : aucun Docteur Bertrand CORMIER

Cas clinique n°1 Mr DEL. André, 73 ans HTA ancienne – Tabac modéré RA connu de longue date, jugé modéré Poussée récente d’insuffisance cardiaque Auscultation pauvre ECG : RS, QRS fins – Coro normale Echo VG 58/47 SIV/PP = 10/10 FE 20 % VTi sous Ao = 8 cm – gradient moyen 15 – Sa0 =0.7 Dobutamine = O réserve contractile  Dilatation aortique : O résultat fonctionnel

Cas clinique n°1 Scanner cardique:valve tricuspide calcifiée,anneau:23 TAVI prothese Edwards 26

cas clinique n°1 Suites simples; O SF Retour à domicile sous traitement medical Pronostic?(def à discuter)

Cas Clinique n°2 Mr ALV. Serge, 70 ans Tabac sevré – DNID – 112 kg, 1m78 CMD connue depuis 2006  coro : sténose D1 Sclérose mitro-aortique - FEVG = 35 % 2011 : 2 poussées d’IC globale Echo FEVG = 35 % - gradient moyen 25 – Sao = 0.8 cm²

Cas Clinique n°2 Mr ALV. Serge, 70 ans – 2  Echo Dobu RC +  gradient moyen = 45  Scanner = valve tricuspide calcifiée – Sao = 0.9 cm²  RVA BP 23 – Suites simples, sortie à J+8

EuroHeart Survey on VHD B.Iung Eur Heart J, 2003 Prospective study in 92 centers from 25 countries = 5001 VHD AS = 1197 pts  512 interventions : EF ≥ 60= 56.5 % = 24.2 % 30-50= 16.4 % < 30= 2.9 %

To operate or not pts with severe AS BT.Bouma, Heart pts prospectively evaluated; AVA < 1 cm², mean age= 78 yrs, 48% CAD 94 pts : AVR 111: medical 41 symptomatic pts no surgery : LV dysfunction 14% Advanced age 13% Comorbidity 13% Symptoms attributed to CAD 11% Functional improvement 9% Main risk factors:impaired LVF, NYHA Cl, age

Why are so many pts with AS denied surgery ? B.Iung, Eur Heart J 2005 EHS : 216 pts with severe symptomatic AS (angina or NYHA Cl III/IV)  AVR = 67 % medical= 33 %  Multivariate analysis LVEF [OR= 2.27 for EF % = 5.15 for EF ≤ 30 % Age [OR= 1.84 for yrs = 3.38 for ≥ 85 yrs vs Associated with no surgery

AS and LV systolic dysfunction In the majority of pts with mild-moderate systolic dysfunction, decrease in SV and EF is related to reversible mismatch, likely to reverse when obstruction is relieved  pts with severe AS and EF < 50 % : Cl IC for AVR (ESC guidelines, 2008)

AS and LV systolic dysfunction Severe decrease in EF may be caused by decreased contractility associated with fibrosis due to hypertrophy or surimposed MI. Secondary improvement in LV function is uncertain. The subgroup of pts with severely depressed EF and low flow raises diagnostic and therapeutic difficulties

Guidelines for severe AS

Inconsistencies of echo criteria for grading AS J Minners, EHJ 2008 ; 29 : pts with AS

Flow dependence of AVA : T he Gorlin equation S = F / K   P cm² ml/sec mmHg Cannon, 1985

The continuity equation AVA = VTI lvot / VTI AS x CSA lvot

Flow dependence of AV resistance and LV stroke work loss Valve resistance = x  P/Q dynes/s/cm -5 LV SWL = 100 x  P/ LVP (%) (Burwash, 1994)

Planimetry of the Aortic Valve Direct measurement of the aortic orifice Using TEE Using TTE (harmonic) Possibly less flow-dependent Max Min AVA Gorlin TEE planimetry cm 2 NS p< pts with dobutamine echo (Tardif et al. J Am Coll Cardiol 1997;29: )

Flow dependence of AVA Relation to valve morphology Shively, pts with AS. TEE planimetry and Dobutamine infusion

Calcific AS : time to look more closely at the valve CM OTTO, NEJM 2008

Aortic valve area, cm 2 EBCT Score R=-0.79, p< R=0.86, p< Peak aortic valve velocity, m/sec EBCT Score AVC and Hemodynamic Severity Messika-Zeitoun Circulation 2004

Thresholds Scanner MSCT Thresholds Score calcique Sensibilité, %Spécificité, %VPP, %VPN, %

Dobutamine Echocardiography in AS with LV dysfunction (EF< 0.35) and low gradient (  P< 30 mm) De Filippi (1995) Severe AS :  VTI,   P, no change (<0.3 cm²) in AVA Mild AS :  VTI,  AVA (> 0.3 cm²), no change in  P No reserve ? Nishimura (2002) Severe AS :  P > 30 and AVA < 1.2 cm²

Operative mortality surgery for valvular heart disease Guidelines, ESC 2008

Surgery of AS with LV dysfunction Study (n pts) AVA (cm²) EF (%) CAD/ Previous MI (%) MPG (mmHg) OM (%) 5 yrs survival (%) Predictive factors VAQUETTE (2005) 155 pts (4.1 % of 3819) < 1< 3030/ NYHA Cl, SPAP TOPAS (2008) 101 pts < 1.2<40 /60≤ 4018 PAI (2008) 194 Pts < 0.8< 3551/≤ LEVY (2008) 217 pts < 1< 3528/23≤ MPG < 20 multivessel CAD lack of CR

Low gradient AS : risk stratification by DSE JL Monin Circulation 2003 Prospective multicenter study : 136 symptomatic pts, AVA = 0.7 cm² ( ), MPG 29 mmHg (23-34), LVEF : 0.30 ( ) – CI : 2.11 l/mn/m² ( ) Significant CAD = 46 % (MVD = 33 %) Gr I : 92 pts with CR (  SV ≥ 20%) vs Gr 2 = 44 pts without CR AVR in 70% of each Gr ;medical tt in pts with older age, comorbidities of pseudo severe AS (9/92 pts) OM = 14 % (5% Gr I, vs 32 % Gr II, p <.002) Predictors of OM : lack of CR (OR : 10.9, p<.001) and MPG ≤ 20 mmHg (OR : 4.7, p<.04) Predictors of LT survival : AVR (p=.001) and CR (p.001)

Many Patients Considered too High Risk

Indications for AVR in AS with LV dysfunction ACC/AHA  no recommendation ESC : AS with low MPG (< 40 mmHg), LV dysfunction and contractile reserve :Cl II a C and no contractile reserve: Cl II b C  Decision making according to clinical condition, valve calcification, extent of CAD

Outcome after AVR for LF/LG AS without CR C. Tribouilloy, JACC pts prospectively included – AVA < 1 cm², EF ≤ 40 %, MPG ≤ 40 mmHg; no contractile reserve 55 pts : AVR – 26 :medical; Mean Fu : 37 ± 41 m Operative mortality : 22%, 5 yrs survival (excluding OM) : 69 ± 8%

Therapeutic decision in patients without CR BAV as a diagnostic test AVR considered in pts with calcified valve, low comorbidity, with MPG > 20 mmHg and without large scar of infarction

Survival benefit of AVR in pts with severe AS and low EF RG. Pai Ann Thorac Surg 2008 Echo Database : 194 pts with AVA ≤ 0.8 and EF ≤ 0.35

Symptomatic severe AS : Room for improvement ? MWA Van Geldorps – Eur J Cardiovasc Surg 2009 Echo database – 179 severe symptomatic AS FU : 17 m  76 intervention : AVR 63,TAVI or apical = 10  100 (56 %) medical treatment Operative risk deemed too high = 34 % (mean Euroscore : 11.6) Mildly symptomatic pts = 19 % AS considered non-severe = 14 % Patient preference = 9 % Missing reason = 20 %

PARTNER T.Lefevre, Eur Heart J 2011

Hemodynamics results and changes in myocardial function after TAVI M. Gotzmann, Am Heart J TAVI (Medtronic CoreValve) before, 30 d and 6 m Before30 days6 monthsp NYHA III/IV %921518<.001 BNP (pg/ml)744±708367±273279±186- Aortic MPg47.4± ±410±3.2- AVA0.83± ± ±0.3- AR III/IV (%)23108 LV Mi (g/m²)158±46147±40138±45- EF (%)44.1±654± ±9.5- E/E’20± ±517.2±5NS

Comparison of hemodynamic performance of percutaneous and surgical BP in AS MA Clavel, JACC PAVI (femoral : 38 ; apical 12)matched with 50 CE Magna (ST gr) or freestyle (SL gr) for sex, aortic annulus diameter, LVEF, BSA and BMI

Long-term outcomes after TAVI in high-risk pts The UK registry – NE MOAT JACC 2011 ; 58 : All TAVI prospectively collected ( ) within the UK (25 centers), mortality status in 100% by December pts = TF route : 599 (69 %) other 271 (31 %) Medtronic Corevalve = 452 (52 %) Edwards Sapien = 410 (48 %) 213 pts alive at 2 years FU

NE Moat JACC 2011

AS and poor LV function Conclusion - 1 LV dysfunction is an uncommon consequence of AS (< 10 %) MPG > 30 mmHg despite low EF in favor of mismatch and represents an indication for AVR

Conclusion - 2 The subgroup of pts with severe LV dysfunction, LF, LMPG poses diagnostic and therapeutic difficulties : due to the flow dependence of the main hemodynamic criteria, the diagnosis of severe AS is based on anatomy and the response to Dobutamine infusion Patients with CR should undergo valve intervention as well as patients without CR but with low comorbidity, MPG > 20 mmHg and no extensive scar of MI

Conclusion - 3 Despite the recommendations and a risk-benefit ratio in favor of surgery,a large proportion of symptomatic pts remains not operated on and referral to surgical departments should be encouraged to have more interdisciplinary discussions and to optimize therapeutic indications