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Potential Conflicts of Interest ESC Stockholm 2010 Bernard Iung, MD Speaker’s fee / Consultancy: • St. Jude Medical • Edwards Lifesciences • Sanofi-Aventis • Servier • Boehringer Ingelheim Acute Decompensation of Chronic Valve Disease Bernard Iung Groupe Hospitalier Bichat - Claude Bernard Paris, France Background • Valvular disease may cause acute heart failure 7% of patients with acute heart failure had aortic stenosis (Euro Heart Survey on Heart Failure Eur Heart J 2003;24:442-63) • Heterogeneity of mechanisms − AS / chronic organic regurgitations / functional MR − Contribution of valvular disease and LV dysfunction − Triggering factors • Difficulties in diagnosis • Particularities of medical therapy • Indications for surgery Diagnosis of Valvular Disease • Clinical examination − Valvular disease revealed by acute heart failure − Low-intensity cardiac murmur • Echocardiographic analysis − Pitfalls in quantitation due to low-output (gradients, severity indices of regurgitation) − Fluctuations in the severity of regurgitations (medical therapy, functional MR…) − Interaction with triggering factors (tachyarrhythmia…) Euro Heart Survey LV Function and Heart Failure • 5001 pts included • 3547 patients with native valve disease (Iung et al. Eur Heart J 2003;24:1244-53) LVEF 60 (%) 40 p<0.001 20 0 I II III IV NYHA Class European Society of Cardiology – Euro Heart Survey Aortic Stenosis Medical Therapy in Decompensated AS • Nitroprusside 25 patients with AS ≤ 1 cm², LVEF ≤ 35%, cardiac index ≤ 2.2 l/min/m² and heart failure (Khot et al. N Engl J Med 2003;348:1756-63) • Dobutamine (mean 27 µg/Kg/min in 27 pts) (Lin et al. Am Heart J 1998; 136:1010-6) Natural History of AS • Median survival 2 years if congestive heart failure (Ross and Braunwald Circulation 1968;38(Suppl.V):61-7) • Median survival < 1 year if heart failure and LVEF < 50% (Aronow et al. Am J Cardiol 1993;72:846-8) AVR for AS with LV Dysfunction Connolly et al. Selection n= Prev. CABG MI (%) (%) LVEF Op.Death (%) (%) EF35% 154 25 51 27±6 9 EF30% 55 36 55 22±6 18 EF35% and P30 mmHg 68 51 60 22±6 8 EF40% 260 47 59 - 9.6 EF30% 35 - - 25±4 17 EF30% 155 10 13 25±5 12 EF35% and P30 mmHg 217 23 34 28±6 16 (Circulation 1997) Powell et al. (Arch Intern Med 2000) Pereira et al. (J Am Coll Cardiol 2002) Sharony et al. (Ann Thorac Surg 2003) Rothenburger at al. (Eur J Cardiothorac Surg 2003) Vaquette et al. (Heart 2005) Levy et al. (J Am Coll Cardiol 2008) Spontaneous Prognosis Natural History of Aortic Stenosis • 205 patients aged 70 yrs, 94 pts (46%) operated on • Stratification of spontaneous prognosis - LV dysfunction - mitral regurgitation - class III or IV (RR=4.8) (RR=2.0) (RR=1.6) 3 risks groups (Bouma et al. Heart 1999;82:143-8) AS with LV Dysfunction Surgery vs. Natural History • 159 pts with AS, LV EF 35% and mean gradient 30 mmHg • Subgroup of 95 propensity-matched patients : – 39 underwent AVR – 56 were medically treated (Pereira et al. J Am Coll Cardiol 2002;39:1356-63) Aortic Valve Disease and LV Dysfunction Clinical Features EF40% (n=986) EF<40% (N=416) p 67±0.5 69±0.6 0.06 Previous cardiac surgery (%) 17 27 <0.001 Previous MI (%) 26 42 <0.001 Diabetes (%) 10 16 0.002 Renal disease (%) 4.5 12 <0.001 Peripheral vascular disease (%) 10 21 0.01 CHF (%) 26 57 <0.001 Urgent / Emergent surgery (%) 44 66 <0.001 Age (years) (Sharony et al. Ann Thorac Surg 2003;75:1808-14) Indications for Surgery in Symptomatic Aortic Stenosis Class Patients with severe AS and any symptoms IB Patients with severe AS undergoing coronary artery bypass surgery, surgery of the ascending aorta, or on another valve IC Patients with moderate AS* undergoing CABG, surgery of the ascending aorta or another valve IIaC AS with low gradient (< 40 mmHg) and LV dysfunction with contractile reserve IIaC AS with low gradient (< 40 mmHg) and LV dysfunction without contractile reserve IIbC * Moderate AS is defined as valve area 1.0 to 1.5 cm² (0.6 cm²/m² to 0.9 cm²/m² BSA) or mean aortic gradient 30 to 50 mmHg in the presence of normal flow conditions. VHD Guidelines Slide-set © 2007 European Society of Cardiology Balloon Aortic Valvuloplasty in Cardiogenic Shock n Mortality Secondary (%) AVR (%) FU (mo) Survival (%) Moreno 21 43 33 6 38 Cribier 10 20 75 27 100 Smedira 5 0 100 - 100 Losordo 5 - 33 11 66 Desnoyers 2 - - 6 100 Friedman 0 - 3 100 1 Balloon valvulopalsty can be considered as a bridge to surgery in haemodynamically unstable patients who are at high risk for surgery (IIbC). (ESC Guidelines 2007) TAVI in High-Risk Patients with AS • 345 procedures in 339 patients (6 centres) • 30-day mortality 10.4% Transfemoral Transapical • Predictors of late mortality procedural sepsis, hemodynamic support, pulmonary hypertension, chronic kidney disease, COPD (Rodés-Cabau et al. J Am Coll Cardiol 2010;55:1080-90) Aortic Regurgitation AR with LV Dysfunction • 166 patients with AR with LVEF ≤ 35% (53 patients operated on) • After adjustment on propensity analysis RR of intervention 0.59 [0.42-0.98] (p=0.04) (Kamath et al. Circulation 2009;120[suppl.I]:S134-8) Indications for Surgery in Aortic Regurgitation Severe AR Class Symptomatic patients (dyspnoea NYHA class II, III, IV or angina) IB Asymptomatic patients with resting LV EF 50% IB Patients undergoing CABG or surgery of ascending aorta, or on another valve IC Asymptomatic patients with resting LV EF > 50% with severe LV dilatation: End diastolic dimension > 70 mm IIaC or End systolic dimension > 50 mm (or > 25 mm/m² BSA)* * Changes in sequential measurements should be taken into account. VHD Guidelines Slide-set © 2007 European Society of Cardiology IIaC Organic Mitral Regurgitation Impact of LV Function on Operative Mortality • Predictors of operative mortality in 409 patients operated on for organic MR – Age (p=0.0003) – Date of intervention (p=0.003) – Functional class (p=0.016) (Enriquez-Sarano et al. Circulation 1994;90:830-7) • Low operative mortality reported in patients with MR and severe LV dysfunction • 2.1% in 46 pts with organic MR and LVEF <45% (Shah et al. Ann Thorac Surg 2005;80:1309-14) • 5.4% in 727 pts with LVEF 30% vs. 3.1% in 13855 pts with LVEF >30% (univariate p=0.01, multivariate p=0.09) (Haan et al. Ann Thorac Surg 2004;78:820-5) Impact of LV Function on Late Survival After Surgery • 488 patients undergoing valve repair for organic MR • 61 ± 6% survival at 15 years Multivariate predictors RR [95% CI] p Age (per 5 yrs). 1.2 [1.1-1.4] 0.002 NYHA class III/IV COPD LVEF <40% Prior stroke Redo surgery 3.0 [1.3-6.8] 3.1 [1.4-7.0] 2.7 [1.4-5.3] 3.2 [1.6-6.1] 4.6 [1.4-15] 0.008 0.005 0.004 0.001 0.01 (David et al. J Thorac Cardiovasc Surg 2003;125:1143-52) Indications for Surgery in Severe Chronic Organic Mitral Regurgitation Class Symptomatic patients with LV EF > 30% and ESD < 55 mm* IB Asymptomatic patients with LV dysfunction (ESD > 45 mm* and /or LV EF 60%) IC Asymptomatic patients with preserved LV function and AF or pulmonary hypertension (sPAP >50 mmHg at rest) IIaC Patients with severe LV dysfunction (LV EF < 30% and/or ESD > 55 mm*) refractory to medical therapy with high likelihood of durable repair and low comorbidity IIaC Asymptomatic patients with preserved LV function, high likelihood of durable repair, and low risk for surgery IIbB Patients with severe LV dysfunction (LV EF < 30% and/or ESD > 55 mm*) refractory to medical therapy with low likelihood of repair and low comorbidity IIbC * Lower values can be considered for patients of small stature. VHD Guidelines Slide-set © 2007 European Society of Cardiology Ischaemic / Functional Mitral Regurgitation Acute Decompensation of Ischaemic MR Mechanisms • Underlying LV systolic dysfunction • Transient increase in functional MR – May cause acute pulmonary oedema – Exercise-induced changes in the severity of MR, LVEF, and PAP (Pierard et al. N Engl J Med 2004;351:1627-34) (ESC Textbook) Acute Decompensation of Ischaemic MR Therapeutic Issues • Optimal treatment of LV systolic dysfunction (medical therapy ± CRT) – Efficacy on heart failure – Decrease of regurgitant volume • Surgical correction of MR ± CABG – Decrease of MR, but risk of late recurrence after repair (Gelsomino et al. Eur Heart J 2008;29:231-40) – Left ventricular reverse remodelling in 60% of patients (Braun et al. Eur J Cardiothorac Surg 2005;27:847-53) – No proven benefit on late survival (Wu et al. J Am Coll Cardiol 2005;45:381-7) Impact of Surgery of Ischaemic MR CABG With or Without Valve Repair • 2 groups of 54 patients with ischaemic MR 3/4 matched according to a propensity score – 54 had isolated CABG – 54 had CABG + valve repair • No significant difference in survival and NYHA class III-IV during follow-up (Mihajlevic et al. J Am Coll Cardiol 2007;49:2191-201) Surgery for Functional MR vs. Medical Therapy 682 patients with functional MR and severe LV dysfunction 126 had valve repair, 556 were treated medically Predictors of cardiac event Hazard Ratio [95% CI] p Sodium (1mMol/l increase) 0.93 [0.90-0.96] <0.0001 Coronary artery disease 1.80 [1.30-2.49] 0.0004 Mean arterial pressure (1 mm increase) 0.98 [0.97-0.99] 0.0006 Blood urea nitrogen (1 mg/dl increase) 1.01 [1.005-1.02] 0.0009 Cancer 2.77 [1.45-5.30] 0.002 Beta-blockers use 0.59 [0.42-0.83] 0.003 Digoxin use 1.66 [1.15-2.39] 0.007 ACE-inhibitor use 0.65 [0.44-0.95] 0.03 Mitral annuloplasty was not a predictor of late cardiac events (death, ventricular assistance, or transplantation) (Wu et al. J Am Coll Cardiol 2005;45:381-7) Indications for Surgery in Ischaemic / Functional MR Chronic Ischaemic MR Class Patients with severe MR, LV EF > 30% undergoing CABG IC Patients with moderate MR undergoing CABG if repair is feasible IIaC Symptomatic patients with severe MR, LV EF < 30% and option for revascularization IIaC Patients with severe MR, LVEF > 30%, no option for revascularization, refractory to medical therapy, and low comorbidity IIbC Functional MR: surgery can be considered only in selected patients with severe symptoms despite optimal medical therapy VHD Guidelines Slide-set © 2007 European Society of Cardiology Percutaneous Mitral Valve Repair Edge-to-Edge Technique Coronary Sinus Annuloplasty Mitral Stenosis Mitral Stenosis • Left ventricular function is preserved in > 90% of patients • Decompensation is often favoured by tachycardia – – – – Supraventricular tachycardia Fever Anemia Pregnancy (high risk of pulmonary edema) • Medical therapy: rhythm control (beta-blockers++), diuretics • Consider percutaneous mitral commissuromy according to patient characteristics (pregnancy) Treatment of Associated Conditions • Atrial fibrillation Improvement of haemodynamics vs. risk of recurrence • Hypertension In particular for regurgitations • Renal failure Impact on loading conditions • Sepsis Need to reevaluate promptly the severity and consequences of valvular disease Conclusions (I) • The possibility of underlying valvular disease should be considered in acute heart failure • All medical resources should be used in patients with aortic stenosis and acute heart failure • Short-term prognosis of medically treated patients is poor • Surgery carries a high operative mortality but late results favour intervention in most cases as compared with natural history Conclusions (II) • Patients should not be denied surgery on the basis of acute heart failure or LV dysfunction • When indicated, intervention should be not be delayed until the need for urgent surgery • The results of transcatheter procedures should be assessed in high-risk patients with AS or MR • Importance of early evaluation of valvular diseases