1. Hemodynamics: essentials for future TAVR and mitral valve disease Morton J. Kern, MD Professor of Medicine Chief of Cardiology Associate Chief Cardiology University California Irvine Orange, California

2. Calcific Aortic Stenosis: A Disease of the Valve and the Myocardium. J Am Coll Cardiol. 2012 Normal aortic valve cusps have a 4-layered structure 1.Endothelium 2.Fibrosa 3.Spongiosa 4.ventricularis

3. Etiology of Aortic Stenosis From the Euro Heart Survey Goldbarg, S. H. et al. J Am Coll Cardiol 2007;50:1205-1213

4. J Am Coll Cardiol. 2012;60(3):169-180. Pathophysiology of AS

5. Tri/MV valves open Pa/Ao valves are closed Pa/Ao valves open Tri/MV valves close Pa/Ao valves close Tri/MV valves open systole =Valve action

6. Mechanism of AS: LV-Ao Gradient Consequences of LV-Ao Gradient: 1.late peaking Systolic murmur 2.Single A2 3.Slow pulse upstroke

7. BAMC Case #3117: Patient: 61 yo male Dx: 3V CAD filter: 50 Hz/ sample 250 Hz Pre Contrast Normal LV and Aortic Pressure Fluid-filled system micromanometer transducers Fluid filled, FA sheath

8. P-P grad Mean Grad Peak instantaneous vs P-P Unshifted=larger Grad LV Fusberg and Feldman T, Cath and CV Int 53:553;2001 Hemodynamic Technique

9. Techniques for Aortic Valve Gradient Measurement Single Catheter LV-Ao pullback LV and Femoral Sheath LV and Long aortic sheath Bilateral femoral access Double-lumen pigtail catheter Transeptal LV access with ascending Ao Pressure Guidewire with ascending Ao Multi-transducer micromanometer catheters Fusberg and Feldman T, Cath and CV Int 53:553;2001

10. Calculating Aortic Valve Area AVA: Gorlin equation AVA: Hakke formula (“poor man’s Gorlin”) –Assumes HR*SEP*44.3 = 1000 in most patients –Valid for HR ~65-100 AVA = cardiac output (L/min)/√Peak-Peak Pressures

11. Grading Severity of Aortic Stenosis AVAAVA Index Aortic Stenosis(cm 2 ) (cm 2 /m 2 ) Mild>1.5>0.9 Moderate1.1-1.5>0.6-0.9 Severe<0.8-1.0<0.4-0.6

14. Hemodynamic Differentiation of LVOT Obstruction ASHOCM 3 Differentiating features a.Aortic upstroke b.Pulse pressure c.Contour –spike/dome

15. Low Gradient, Low EF AS? LVEF 25% P-P gradient 30mmHg CO = 3.2l/m Fick AVA = 0.7cm 2

16. Base 10 Dob+Pace 8020 Dob + Pace 95 Dobutamine challenge for LG AS P-P = 50mmHg CO = 4.2l/m AVA = 0.6cm 2

17. Grayburn, P. A. Circulation 2006;113:604-606 What should you do with Symptomatic AS patient, low gradient, low flow? The Dobutamine Challenge AVA = 0.7cm 2 AVA = 1.0cm 2 AVA = 1.5cm 2 Fixed area

18. Chiam, P. T.L. et al. J Am Coll Cardiol Intv 2008;1:341-350 Edwards-Sapien PHV CoreValve PHV

21. Pre- Post 26mm Sapien Edwards Anachrotic shoulder, dichrotic notch Diastolic dysfunction? Delayed upslope

22. AS+AI

24. Normal LA and LV diastolic pressures LA-LV Diastolic Gradient

25. PCW does not always equal LA

26. Hemodynamics and Doppler Echo findings before MVBP

28. Hemodynamic and Doppler Echo findings after MVBP

30. Hemodynamics for Structrual Heart Disease Low Gradient AS Complications of AVP – AI AS vs. HOCM Mitral Regurgitation after MVP for MS Diastolic CHF – constrictive v Restrictive Tamponade For your own review consider Intracardiac Shunts