Download Aortic stenosis with hypertension: the double loaded ventricle.

Aortic Valve Stenosis with Hypertension.
The double loaded ventricle
Javier Bermejo
DEPARTMENT OF CARDIOLOGY
I have no financial relationships to disclose
The Problem
AS
CAD
- AS is present in 1-3 % of pts. with HT
- HT is present in 30-60 % of pts. with AS
- HT is a “risk factor” for degenerative AS
- Common findings are disruption of elastic fibers
Hypertension
The double loaded ventricle
Aortic Valve
Arterial Bed
AS & Hypertension




Diagnostic implications
Physiological consequences
Impact on outcome
Therapeutic issues
In the Echo-Lab:


Measure BP in all pts. with AS
Reassess severity if extreme values
+
JACC 2005
Briand et al JACC 2005
Hachicha Circulation 2007
Rosebbo N Engl J Med 2008
Carmaruic JACC Img 2009
Jander et al Circulation 2011
Rieck et al Hypertension 2012
Rieck et al Hypertension 2012
Rieck et al Hypertension 2012
Treat Hypertension!
brain/ kidney
other vascular beds
brain/ kidney
other vascular beds
Courtesy of MF O’Rourke
Target for drug therapy
•
•
•
•
•
•
•
N= 20 pts. with severe AS & HT
73 years old (87 – 29)
13 male / 7 female
AVA= 0.7 ± 0.3 cm2
Normal EF
Stress Echocardiography
Randomized with/without - test/retest
Jiménez Candil et al. Heart 2005
Jiménez Candil et al. Heart 2005
Nadir et al. JACC 2011
Nadir et al. JACC 2011
Treat Aortic Valve Stenosis…
(if symptomatic)
Circulation Research 1992
Valvular and Ventricular
Aortic Valve Area (cm2)
Mean Transvalvular Pressure Gradient (mm Hg)
Stroke Volume (ml)
Ejection Fraction (%)
LV End-systolic Elastance (mm Hg/ml)
LV pressure (mmHg)
Vascular
Mean Blood Pressure (mmHg)
Pulse Pressure (mmHg)
Systemic Vascular Resistance (dynes/s/cm-5)
Aortic Input Impedance Z1 (mmHg/ml)
Characteristic Impedance (dynes/s/cm-5)
Aortic Compliance (·10-3 cm5/dynes)
Ea (mmHg/ml)
Ea/Ees
Non-Invasive Valvuloarterial Impedance (mmHg/ml)
Wave Intensity Analysis
Wave Speed (m/s)
Peak dIw FCW (· 106 W·m-2·s-2)
Reflexion Distance (m)
*Wilcoxon test
Pre-TAVI
Post-TAVI
p*
0.7 ± 0.1
39 ± 18
75 ± 13
47 ± 21
0.76 ± 0.2
128 ± 18
1.8 ± 0.6
11 ± 4
64 ± 17
55 ± 17
1.3 ± 0.7
115 ± 25
0.007
0.005
0.14
0.038
0.09
0.12
62 ± 14
39 ± 13
820 ± 259
337 ± 142
147 ± 78
1.47 ± 0.78
1.05 ± 0.30
1.38 ± 0.37
2.1 ± 0.5
74 ± 17
52 ± 14
1137 ± 597
510 ± 188
207 ± 109
0.80 ± 0.27
1.61 ± 0.63
1.38 ± 0.23
1.9 ± 0.9
0.05
0.005
0.08
0.028
0.14
0.08
0.023
0.92
0.5
2.48 ± 1.18
4.06 ± 1.76
0.01
0.91 ± 0.49
0.06 ± 0.03
1.52 ± 0.78
0.08 ± 0.12
0.012
0.81
Yotti et al AHA 2012
Valve and the Arterial Bed:
More than simple lumped-model
LV load interaction after valve intervention
Effects of Load in AS
competititive
complementary
Dahl et al Am J Cardiol 2010
Treat them both!
Dahl et al Am J Cardiol 2010
Conclusions (1/2)



AS & HT are two highly prevalent diseases, with
important interactions regarding pathophysiology,
diagnosis, LV function, and outcome.
In case of severe HT, reassess severity after
controlling BP.
Increased load reduces cardiac output and
modifies LV remodelling response.
Conclusions (2/2)





HT in pts. with AS doubles the risk of hard CV
events.
HT should be aggressively treated
ACEI and ARB are the drugs of choice.
HT after AVR blunts the acute and chronic benefits
of valvular interventions.
Treatment is advocated for the long-term after
AVR.