Download Post Operative Clinical Improvement in the Absence of Reverse

POST OPERATIVE CLINICAL
IMPROVEMENT IN THE ABSENCE OF
REVERSE REMODELING.
CLINICAL MANAGEMENT AND QUALITY
OF LIFE WITH THE COMPROMISED
VENTRICLE
Ernesto E Salcedo, MD
Professor of Medicine University of Colorado School of Medicine
Director of Echocardiography University of Colorado Hospital
Key Concepts
• Ventricular adaptation to Pressure and Volume Overload
• Determinants of Remodeling and Reverse Remodeling
• Determinants of Post Operative Clinical Improvement
• Clinical Management and Quality of Life in patients with
Compromised Ventricle
The cardiac myocyte
• The most physically energetic cell in the body
• Contracting constantly, (without tiring), 3 billion times
or more in an average human lifespan
• Coordinating its beating activity with that of its 3
billion neighbors in the main pump of the human
heart
• Over 7,000 litres of blood are pumped per day, along
100,000 miles of blood vessels
Nicholas J. SeversBioEssays 22:188–199, 2000
Walker A J Thorac Cardiovasc Surg 1999;118:375-82
Ventricular adaptation to Pressure and
Volume Overload
• Aortic Stenosis: pure pressure overload
• Mitral Regurgitation: pure volume overload
• Aortic regurgitation: combined pressure and volume
overload
• Mitral stenosis: volume underload
• Hypertrophy means an increase in mass whereas
• Remodeling indicates a change in geometry and/or
volume
AORTIC STENOSIS
Pressure Overload
LV Remodeling Patterns Based on LVH
and LV M-C Ratio
Rodriguez C J Am Coll Cardiol 2010;55:234–42
CMR definitions of the six patterns of left ventricular hypertrophy
and remodeling in aortic stenosis
Normal ventricular structure:
characterized by a normal LV mass index,
indexed LVEDV, and a normal M/V.
Concentric remodeling: characterised by
an increased M/V and normal LV mass
index. Asymmetric remodeling: similar to
concentric remodeling except that in
addition there is evidence of asymmetric
wall thickening. Concentric Hypertrophy:
characterised by an increased M/V and LV
mass index.
Asymmetric hypertrophy: similar to
concentric hypertrophy except that in
addition there is evidence of asymmetric
wall thickening.
Left Ventricular Decompensation:
characterised by a dilated left ventricle and
normal M/V. The LV mass index may be
increased primarily due to LV dilatation.
Dweck et al. Journal of Cardiovascular Magnetic Resonance 2012, 14:50
Patterns
of LVH
Khouri M Circ
Cardiovasc
Imaging
2010;3;164-171
Types of hypertrophy and remodeling that occur
in valvular heart disease
A, Normal.
B, Concentric left ventricular
hypertrophy (LVH).
C, Concentric remodeling.
D, Eccentric LVH.
E, Eccentric remodeling.
Mass
Index
(g/m2)
r/h
m/v
NL
86
3.05
(88)
1.25
(225)
MR
158
4.03
(64)
0.87
(117)
AR
230
3.52
(31)
1.00
(141)
AS
178
2.35
(93)
1.55
(296)
Carabelo B
J Heart Valve Dis 1995 (Suppl 2):S132-S138
LV volume, mass, and geometry, stress, and
systolic shortening in various cardiac disorders
Aurigemma GP, Gaasch WH, Villegas B, Meyer TE: Curr Probl Cardiol 20:385, 1995
Lack of correlation between aortic valve area and
left ventricular mass index
A. Total population.
B. Population after
excluding patients
with hypertension.
C. Males.
D. Females.
Left Ventricular Reverse Remodeling After Surgical
Therapy for Aortic Stenosis
Left ventricular mass index (LVMI, in g/m2), maximum aortic pressure gradient (Pmax, in
mm Hg), and myocardial fiber index (in m/m2) at baseline (A), after development of left
ventricular hypertrophy (B), and after corrective surgical therapy (C).
Walther T Circulation. 2002;106[suppl I]:I-23-I-26.)
Correlation to Renin-Angiotensin System Gene Expression
The association between left ventricular mass index (LVMI) and gene expression for
angiotensin-converting enzyme (ACE) as well as angiotensin receptor subtype 1 and 2
(AT1-R, AT2-R) is shown according to the different time intervals using the symbols as
indicated in the figure. On the left side, baseline (A) vs. left ventricular hypertrophy (B) is
shown and on the right side, (B) vs. regression of LVH (C).
Prevalence and characteristics of patients with
clinical improvement but not significant left
ventricular reverse remodeling after cardiac
resynchronization therapy
Auger D Am Heart J. 2010 Oct;160(4):737-43
Normalization of diastolic dysfunction in
aortic stenosis late after valve replacement
Villari B, Circulation. 1995;91:2353-8.
Yarbrough WJ Thorac Cardiovasc Surg. 2012 March; 143(3): 656–664
Transcatheter aortic-valve replacement for
inoperable severe aortic stenosis
Two-year mortality stratified according to the Society of Thoracic Surgeons (STS)
risk score. In patients with an STS score of ≥ 15%, transcatheter aortic valve
replacement (TAVR) is no longer superior over standard therapy
R.R. Makkar N Engl J Med, 366 (2012), pp. 1696–1704
Health-Related Quality of Life After TAVR
PARTNER trial
Kansas City Cardiomyopathy Questionnaire (23 Questions)
5 health domains pertaining to heart failure:
symptoms,
physical limitation,
social limitation,
self-efficacy,
and quality of life.
NYHA
KCCQ
Class I
Increased in KCCQ
75-100
Clinical
Improvement
Class II
60-74
Small
5
Class III
45-59
Moderate
10
Class IV
0-44
Large
20
Reynolds, M Circulation. 2011;124:1964-1972
Health-Related Quality of Life After TAVR
PARTNER trial
Medical Outcomes Study Short-Form 12 (SF-12) Health Survey
• Generic health status was evaluated with the Medical
Outcomes Study Short-Form 12 (SF-12) Health Survey
• The SF-12 was derived from the original SF-36 health
survey by selecting those items having the greatest
explanatory power.
• Higher scores are better
• Multiple groups have agreed that the minimal clinically
important changes in the mental and physical summary
scores are roughly 2 to 2.5 points
Reynolds, M Circulation. 2011;124:1964-1972
Health-Related Quality of Life After TAVR
PARTNER trial
Reynolds, M Circulation. 2011;124:1964-1972
Health-Related Quality of Life Twelve
Months After TAVR -PARTNER trial
Medical Therapy in Aortic Stenosis with
Heart Failure
• Statin therapy should therefore not be used in AS patients
•
•
•
•
where their only purpose is to slow progression.
Patients who are unsuitable candidates for surgery or
TAVI—or who are currently awaiting a surgical or TAVI
procedure—may be treated with digoxin, diuretics, ACE
inhibitors, or ARBs if they experience HF symptoms.
Co-existing hypertension should be treated.
Treatment should be carefully titrated to avoid
hypotension and patients should be re-evaluated
frequently.
Maintenance of sinus rhythm is important.
MITRAL REGURGITATION
Volume Overload
Percutaneous
Mitral Valve Repair
Feldman T Curr Probl Cardiol 2012;37:42-68.
LV Response to Mitral Regurgitation
Carabello BA Curr Probl Cardiol 28:553, 2003
LV Structure and Function in the 3 Stages of Chronic MR
Stage 1
Stage 2
Stage 3
Chronic compensated
MR with LV
enlargement, eccentric
hypertrophy, and
normal systolic function
Transitional phase with
mild LV dysfunction that
is reversible after
surgical correction of
the regurgitant lesion
Decompensated MR
with progressive and
irreversible structural
and functional changes
in the ventricle
Gash W Circulation 2008 vol. 118 no. 22 2298-2303
Chronic MR
Mitral valve surgery in heart failure: Insights
from the Acorn Clinical Trial
Acker, M J Thorac Cardiovasc Surg 2006;132:568-77
Mitral valve surgery in heart failure:
Insights from the Acorn Clinical Trial
Mitral valve surgery in heart failure:
Insights from the Acorn Clinical Trial
Minnesota Living with Heart Failure Questionnaire.
Medical Therapy in Patients with Severe
Mitral Regurgitation and Heart Failure
• In acute MR, reduction of filling pressures can be
obtained with nitrates and diuretics. Sodium nitroprusside
reduces afterload and regurgitant fraction, as does an
intra-aortic balloon pump. Inotropic agents and intra-aortic
balloon pump should be added in case of hypotension.
• There is no evidence to support the use of vasodilators,
including ACE inhibitors, in chronic MR without HF.
• However, when HF has developed, ACE inhibitors are
beneficial and should be considered in patients with
advanced MR and severe symptoms, who are not suitable
for surgery or when there are still residual symptoms
following surgery
AORTIC REGURGITATION
Mixed Pressure and Volume Overload
Exercise echocardiography predicts development of left ventricular dysfunction
in medically and surgically treated patients with asymptomatic severe aortic
regurgitation
Change in left ventricular end systolic volume (ESV) with exercise (Ex) and on follow
up (F/U) compared with baseline at rest (R), in patients with maintained left ventricular
function (A) and latent dysfunction (B).
Wahi S Heart. 2000 December; 84(6): 606–614
Different Stages of Aortic Regurgitation
Medical Management in Aortic
Regurgitation with Heart Failure
• Vasodilators [angiotensin-converting enzyme (ACE)
inhibitors or angiotensin receptor blockers (ARBs)] are
useful in the presence of hypertension when surgery is
contraindicated, or LV dysfunction persists
postoperatively.
• A positive effect of these agents, or dihydropyridine
calcium channel blockers, in asymptomatic patients
without hypertension in order to delay surgery is unproven
Vahanian A European Heart Journal (2012) 33, 2451–2496
Conclusions
• Ventricular remodeling results from pressure or volume
•
•
•
•
overload of the left ventricle
Reverse remodeling may occur when the overload is
corrected
Symptomatic improvement usually follows reverse
remodeling…but not always
Quality of life improvement is an important marker of
therapeutic success
Severe valvular heart disease usually requires a
mechanical solution since medical therapies are limited.