Download Acute decompensation of chronic valve disease.

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
(%)
(%)
EF35%
154
25
51
27±6
9
EF30%
55
36
55
22±6
18
EF35% and
P30 mmHg
68
51
60
22±6
8
EF40%
260
47
59
-
9.6
EF30%
35
-
-
25±4
17
EF30%
155
10
13
25±5
12
EF35% and
P30 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
EF40%
(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