Presentation is loading. Please wait.

Presentation is loading. Please wait.

Greater New York Geriatric Cardiology Consortium: Valve Disease in Older Adults Allan Schwartz, MD Columbia University Medical Center New York Presbyterian.

Published byMaximilian Gregory Modified over 8 years ago

Similar presentations

Presentation on theme: "Greater New York Geriatric Cardiology Consortium: Valve Disease in Older Adults Allan Schwartz, MD Columbia University Medical Center New York Presbyterian."— Presentation transcript:

1 Greater New York Geriatric Cardiology Consortium: Valve Disease in Older Adults Allan Schwartz, MD Columbia University Medical Center New York Presbyterian Hospital March 2012

2 Disclosures None

3 Valvular Disease in Older Adults Prevalence is increasing dramatically as the population ages Predominantly AS and MR Predictably associated with heart failure, arrhythmia and death. Medical treatment has limited effectiveness. Mechanical therapies (surgical and percutaneous) are becoming more “routine” in the elderly.

4 Valvular Disease in Older Adults Presence of co-morbidities including frailty make patient selection difficult and prediction of overall response to therapy less predictable than in younger patients. Goals of therapy are different in this age group with an emphasis placed on QOL, functionality/independence and palliation of severe symptoms.

5 Increases in the Very Old U.S. Population Aged 85+ (in millions) Sources of data: U.S. Census Bureau, “65+ in the United States: 2005,” December 2005; U.S. Census Bureau, U.S. Interim Projections by Age, Sex, Race, and Hispanic Origin, 2004.

6 Nkomo VT et al. Lancet 2006. 368:1005-1011 Valvular Heart Disease Has Increasing Prevalence With Age Olmstead County Population Studies

7 33.9% 24.8% Lung B et al. Eur Heart J 2003. 24:1231-1243 Type of Valvular Heart Disease 20.2% n=5,001

8 Valvular Heart Disease Impact Nkomo VT et al. Lancet 2006. 368:1005-1011

9 Adapted from Ross and Braunwald, Circulation 1968

10 Pellikka, P. A. et al. Circulation 2005;111:3290-3295 Survival of asymptomatic patients with AS N=622

11 Schwartz F et al. Circulation 1982 66:1105-10 Medical Rx Group: 19 surgical candidates who refused surgery Mean age: 56 Mean EF: 57% Peak cath gradient: 87mmHg (+/-17mmHg) 20% survival at 2 years ¼ sudden death ¾ CHF/low output Survival of symptomatic patients with AS

12 Therapeutic Goals Prevent progression to severe AS Improve survival Prevent sudden death Symptom relief Prevent or reverse LV dysfunction/CHF Improve the outcomes of other surgery Minimize treatment related morbidity and mortality

13 Prevent progression to severe AS Rossebo et al. NEJM,2008,359;13:1343-56 n = 1873

14 Current ACC/AHA Guidelines Class I (“should do it”) –Level of Evidence: A None –Level of Evidence: B Symptomatic patients with severe AS –Level of Evidence: C Patients with severe AS undergoing Ao or other heart valve surgery Patients with severe AS and LV systolic dysfunction - EF<50% ACC/AHA VHD 2006 Guidelines: 2008 Update

15 Current ACC/AHA Guidelines Class I (“should do it”) –Level of Evidence: A None –Level of Evidence: B Symptomatic patients with severe AS –Level of Evidence: C Patients with severe AS undergoing Ao or other heart valve surgery Patients with severe AS and LV systolic dysfunction - EF<50% ACC/AHA VHD 2006 Guidelines: 2008 Update

16 Aortic Valve Replacement Hospital Mortality n = 108,791 isolated AVR Brown et al. JCTVS 2009;137:82-90

17 Mortality and Stroke after AVR Brown, et al. JTCVS, January 2009 In current era 37% > 75 yrs

18 Average hospital mortality: 8.8% Low volume centers: 13.0% Low volume centers: 13.0% High volume centers: 6.0% High volume centers: 6.0% Goodney et al, Ann Thorac Surg 2003;76:1131-1337 Aortic Valve Replacement Hospital Mortality Data from national Medicare database 1994-1999 684 hospitals 142,488 AVRs Medicare data

19 Aortic Valve Replacement in the Elderly, Contemporary Results n = 1,193 Age >80 Mortality 6.9% CVA 1.7% Langanay, Ann Thorac Surg, 2012, 93, 70-8

20 Bakaeen et al., Ann Thorac Surg, 2010, 90, 769-74 Short-Term Outcomes of AVR Stratified by Age

21 The Oldest Old: Survival of Octogenarians with Severe AS with and without AVR Varadarajan et al. Eur J Cardiothorac Surg. 2006; (5):722-727.

22 Asimakopoulos et al, Circulation 1997;96:3403-8 AVR/year in Patients >80y Johns Hopkins Octegenarians 1100 pts 1986-1995 6.6% 30-d mortality Trends in AVR in the Elderly

23 Functional status following aortic valve replacement in the elderly Florath I et al. Heart 2005; 91:1023-1029.

24 But Would They Do It Again? Maillet et al. Arch Gerontology + Geriatrics 2009; 48:391-396. In one study, 84 patients age ≥ 80 years of age who underwent AVR +/- CABG for symptomatic AS were queried at least 1 year after surgery whether they would accept being operated on again. 39.3% reported they would not and this was significantly related to loss of autonomy, suspected depression, and cardiac symptoms.

25 Transcatheter Aortic Valve Replacement (TAVR) Leon, NEJM, 363:17, October 2010

26 Symptomatic Severe Aortic Stenosis ASSESSMENT: High Risk AVR Candidate 3105 Total Patients Screened ASSESSMENT: High Risk AVR Candidate 3105 Total Patients Screened PARTNER Study Design High Risk TA ASSESSMENT: Transfemoral Access TAVITrans femoralTAVITrans Surgical AVR High Risk TF Primary Endpoint: All Cause Mortality (1 yr) (Non-inferiority) TAVITransapicalTAVITransapical Surgical AVR 1:1 Randomization VS Standard Therapy (usually BAV) Standard Therapy (usually BAV) ASSESSMENT: Transfemoral Access Not In Study TAVITransfemoralTAVITransfemoral Primary Endpoint: All Cause Mortality over length of trial (Superiority) 1:1 Randomization VS Total = 1058 patients 2 Parallel Trials: Individually Powered High Risk n= 700 InoperableInoperable n=358

27 Patient Characteristics - 1CharacteristicTAVIn=179 Standard Rx n=179 P value Age - yr 83.1 ± 8.683.2 ± 8.30.95 Male sex (%)45.846.90.92 STS Score 11.2 ± 5.812.1 ± 6.10.14 Logistic EuroSCORE26.4 ± 17.230.4 ± 19.10.04 NYHA I or II (%) III or IV (%) 7.8 92.2 6.1 93.9 0.68 CAD (%)67.674.30.20 Prior MI (%)18.626.40.10 Prior CABG (%)37.445.60.17 Prior PCI (%)30.524.80.31 Prior BAV (%)16.224.40.09 CVD (%)27.427.51.00

28 Patient Characteristics - 2Characteristic TAVI TAVI n= 179 Standard Rx Standard Rx n=179 P value PVD (%) 30.325.10.29 COPD Any (%) Any (%) O2 dependent (%) O2 dependent (%) 41.3 21.2 52.5 25.7 0.04 0.38 Creatinine >2mg/dL (%) 5.69.60.23 Atrial fibrillation (%) 32.948.80.04 Perm pacemaker (%) 22.919.50.49 Pulmonary HTN (%) 42.443.80.90 Frailty (%) 18.128.00.09 Porcelain aorta (%) 19.011.20.05 Chest wall radiation (%) 8.98.41.00 Chest wall deformity (%) 8.45.00.29 Liver disease (%) 3.4 1.00

29 Characteristic TAVR (N = 348) AVR (N = 351) p-value Age (yr)83.6 ± 6.884.5 ± 6.40.07 Male sex - %57.856.70.82 STS Score11.8 ± 3.311.7 ± 3.50.61 Logistic EuroSCORE29.3 ± 16.529.2 ± 15.60.93 NYHA II - % III or IV - %94.394.00.79 CAD - %74.976.90.59 Previous MI - %26.830.00.40 Prior CV Intervention - %72.171.60.93 Prior CABG - %42.644.20.70 Prior PCI - %34.032.50.68 Prior BAV - %13.410.20.24 29.327.40.60 Patient Characteristics (1) Cerebrovascular disease - % 5.7 6.0

30 Characteristic TAVR (N = 348) AVR (N = 351) p-value Peripheral vascular disease - %43.041.60.76 COPD Any 43.4 Oxygen dependent9.27.10.34 Creatinine > 2mg/dL - %11.17.00.06 Atrial fibrillation - %40.842.70.75 Permanent pacemaker - %20.021.90.58 Pulmonary hypertension - %42.436.40.15 Frailty - %15.617.60.58 Porcelain aorta - %0.61.10.69 Chest wall radiation - %0.9 1.00 Liver disease - %2.02.60.80 Patient Characteristics (2) 43.0 0.94

31 TAVR Results Smith, NEJM, 364:23, June 2011Leon, NEJM, 363:17, October 2010 High Risk PatientsInoperable Patients

32 Symptom Improvement After TAVR and Surgery Smith, NEJM, 364:23, June 2011

33 Quality of Life after Transcatheter Valve Cohen, et al. Slide Presentation, ACC 2011 KCCQ

34 Primary Endpoint KCCQ Overall Summary 34 MCID = 5 points  = 5.5 P = 0.01  = -2.6 P = NS  = -0.5 P = NS Growth curve analysis; adjusted for baseline MCID = minimum clinically important difference 26 - 30 points Cohen et al, TCT 2011

35 PARTNER Cohort A P = 0.06 P = 0.18 P = 0.03 P = 0.04 TAVI (n=179) Standard Rx (n=179) percent Neurologic Events in PARTNER at 30 days PARTNER Cohort B

36 At Least 30% of Patients with Severe Symptomatic AS Do Not Undergo AVR Severe Symptomatic Aortic Stenosis Percent of Cardiology Patients Treated 1.Bouma B J et al. To operate or not on elderly patients with aortic stenosis: the decision and its consequences. Heart 1999;82:143-148 2.Iung B et al. A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease. European Heart Journal 2003;24:1231-1243 (*includes both Aortic Stenosis and Mitral Regurgitation patients) Pellikka, Sarano et al. Outcome of 622 Adults with Asymptomatic, Hemodynamically Significant Aortic Stenosis During Prolonged Follow-Up. Circulation 2005 Charlson E et al. Decision-making and outcomes in severe symptomatic aortic stenosis. J Heart Valve Dis2006;15:312-321 No AVR AVR

37 31.8% did not undergo intervention, despite NYHA class III/IV symptoms Do patients with valvular heart disease receive Do patients with valvular heart disease receive treatment according to established guidelines? 92 hospitals from 25 countries 92 hospitals from 25 countries 5,001 patients from April-July, 2001 5,001 patients from April-July, 2001

38 Decision to operate according to age range Iung, Eur Heart J (December 2005) 26 (24): 2714

39 Decision to operate according to comorbidities Iung, Eur Heart J (December 2005) 26 (24): 2714

40 N = 16 STS 11.8 LES 33 N =16 STS 6.3 LES 19 N=52 STS 11.3 LES 31 N=21 STS 10.9 LES 33 Dewey et al, Ann Thorac Surg 2008;86:1450-7 High Risk Patients Referred for TAVI

Download ppt "Greater New York Geriatric Cardiology Consortium: Valve Disease in Older Adults Allan Schwartz, MD Columbia University Medical Center New York Presbyterian."

Similar presentations

Jeffrey W. Moses, MD Columbia University Medical Center Cardiovascular Research Foundation New York City The State of TAVR -PARTNER: From Concept to Mortality.

Jeffrey W. Moses, MD Columbia University Medical Center Cardiovascular Research Foundation New York City The State of TAVR -PARTNER: From Concept to Mortality.
STS 2015 John V. Conte, MD Professor of Surgery Johns Hopkins University School of Medicine On Behalf of the CoreValve US Investigators Transcatheter Aortic.

STS 2015 John V. Conte, MD Professor of Surgery Johns Hopkins University School of Medicine On Behalf of the CoreValve US Investigators Transcatheter Aortic.
Health-Related Quality of Life After Transcatheter vs. Surgical Aortic Valve Replacement in High-Risk Patients With Severe Aortic Stenosis Results From.

Health-Related Quality of Life After Transcatheter vs. Surgical Aortic Valve Replacement in High-Risk Patients With Severe Aortic Stenosis Results From.
ACC 2015 Michael J Reardon, MD, FACC On Behalf of the CoreValve US Investigators A Randomized Comparison of Self-expanding Transcatheter and Surgical Aortic.

ACC 2015 Michael J Reardon, MD, FACC On Behalf of the CoreValve US Investigators A Randomized Comparison of Self-expanding Transcatheter and Surgical Aortic.
Lessons from TAVR Randomized Trials and Registries E Murat Tuzcu, MD Professor of Medicine Cleveland Clinic Financial disclosures: None PARTNER Executive.

Lessons from TAVR Randomized Trials and Registries E Murat Tuzcu, MD Professor of Medicine Cleveland Clinic Financial disclosures: None PARTNER Executive.
Asymptomatic Aortic Stenosis and Exercise Test

Asymptomatic Aortic Stenosis and Exercise Test
Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From.

Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From.
Use of Psoas Muscle Size as a Frailty Assessment Tool for Open and Transcatheter Aortic Valve Replacement Raghavendra Paknikar BS Jeffrey Friedman BS David.

Use of Psoas Muscle Size as a Frailty Assessment Tool for Open and Transcatheter Aortic Valve Replacement Raghavendra Paknikar BS Jeffrey Friedman BS David.
Predicting Patients at Risk for Poor Global Outcomes after DT- MCS Therapy Suzanne V. Arnold, MD, MHA Saint Luke’s Mid America Heart Institute/UMKC May.

Predicting Patients at Risk for Poor Global Outcomes after DT- MCS Therapy Suzanne V. Arnold, MD, MHA Saint Luke’s Mid America Heart Institute/UMKC May.
Impact of Concomitant Tricuspid Annuloplasty on Tricuspid Regurgitation Right Ventricular Function and Pulmonary Artery Hypertension After Degenerative.

Impact of Concomitant Tricuspid Annuloplasty on Tricuspid Regurgitation Right Ventricular Function and Pulmonary Artery Hypertension After Degenerative.
A shifting paradigm of care: Advances in transcatheter heart valve procedures Sandra Lauck MSN, RN, CCN(C) Clinical Nurse Specialist, Arrhythmia Management.

A shifting paradigm of care: Advances in transcatheter heart valve procedures Sandra Lauck MSN, RN, CCN(C) Clinical Nurse Specialist, Arrhythmia Management.
PARTNER Objective To compare surgical aortic valve replacement (AVR) with transcatheter aortic valve replacement (TAVR) in high-risk patients with severe.

PARTNER Objective To compare surgical aortic valve replacement (AVR) with transcatheter aortic valve replacement (TAVR) in high-risk patients with severe.
Surgical outcome of native valve infective endocarditis in srinagarind hospital 2004-2005.

Surgical outcome of native valve infective endocarditis in srinagarind hospital
Transcatheter Aortic-Valve Replacement with a Self-Expanding Prosthesis David H. Adams et al (U.S. CoreValve Clinical Investigators) Journal Club November.

Transcatheter Aortic-Valve Replacement with a Self-Expanding Prosthesis David H. Adams et al (U.S. CoreValve Clinical Investigators) Journal Club November.
Postoperative Delirium is Associated with Increased Operative and One Year Mortality in Patients Treated with Surgical and Transcatheter Aortic Valve Replacement.

Postoperative Delirium is Associated with Increased Operative and One Year Mortality in Patients Treated with Surgical and Transcatheter Aortic Valve Replacement.
A Contemporary Analysis of Pulmonary Hypertension in Patients Undergoing Mitral Valve Surgery: Is this a Risk Factor? Thank you to the society and panel.

A Contemporary Analysis of Pulmonary Hypertension in Patients Undergoing Mitral Valve Surgery: Is this a Risk Factor? Thank you to the society and panel.
Bleeding in Patients Undergoing Percutaneous Coronary Interventions: A Risk Model From 302,152 Patients in the NCDR. Sameer K. Mehta MD, Andrew D. Frutkin.

Bleeding in Patients Undergoing Percutaneous Coronary Interventions: A Risk Model From 302,152 Patients in the NCDR. Sameer K. Mehta MD, Andrew D. Frutkin.
TCT 2015 | San Francisco | October 15, 2015 Transcatheter Aortic Valve Replacement for Failed Surgical Bioprostheses Danny Dvir, MD John G. Webb, MD and.

TCT 2015 | San Francisco | October 15, 2015 Transcatheter Aortic Valve Replacement for Failed Surgical Bioprostheses Danny Dvir, MD John G. Webb, MD and.
TCT 2015 | San Francisco | October 15, 2015 Transcatheter Aortic Valve Replacement for Failed Surgical Bioprostheses Danny Dvir, MD John G. Webb, MD and.

TCT 2015 | San Francisco | October 15, 2015 Transcatheter Aortic Valve Replacement for Failed Surgical Bioprostheses Danny Dvir, MD John G. Webb, MD and.
The Impact of Prior Stroke on the Outcome of Patients with Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement Romain Didier, MD;

The Impact of Prior Stroke on the Outcome of Patients with Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement Romain Didier, MD;

Similar presentations

Ads by Google