Скачать презентацию Aortic Stenosis Randall Harada Echo conference 12 Sep Скачать презентацию Aortic Stenosis Randall Harada Echo conference 12 Sep

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Aortic Stenosis Randall Harada Echo conference: 12 Sep 2007 Aortic Stenosis Randall Harada Echo conference: 12 Sep 2007

Etiology Age < 70 Echo conference: 12 Sep 2007 Age ≥ 70 Etiology Age < 70 Echo conference: 12 Sep 2007 Age ≥ 70

Pathophysiology • Congential AS: turbulent flow → fibrosis, calcification • Rheumatic AS: vascularization of Pathophysiology • Congential AS: turbulent flow → fibrosis, calcification • Rheumatic AS: vascularization of leaflets → retraction, stiffening, adhesions, fusion • Calcific / degenerative AS: • Similarities to atherosclerosis: lipid accumulation, inflammatory cell infiltration, calcification • Clinical factors mirror CAD risk factors (Dissimilarities: little SM cell proliferation, lack of neovascularization, and more prominent micro-calcification) Echo conference: 12 Sep 2007 Otto CM. Circulation 90; 1994

Pathophysiology Stepwise multiple logistic regression Stewart BF, JACC 29(3) 1997 Echo conference: 12 Sep Pathophysiology Stepwise multiple logistic regression Stewart BF, JACC 29(3) 1997 Echo conference: 12 Sep 2007

Pathophysiology Aortic stenosis Increased afterload Atrial contraction LVH Increased preload Preserved wall stress Normal Pathophysiology Aortic stenosis Increased afterload Atrial contraction LVH Increased preload Preserved wall stress Normal systolic function Echo conference: 12 Sep 2007

Pathophysiology Aortic stenosis Increased afterload LVH ↑ O 2 demand ↓ coronary perfusion Compression Pathophysiology Aortic stenosis Increased afterload LVH ↑ O 2 demand ↓ coronary perfusion Compression of pressure intramyocardial arteries LVH inadequate (afterload mismatch) ↓ CBF per unit of mass Myocardial ischemia Echo conference: 12 Sep 2007 Reduced myocardial contractility

Natural history • Long latent period: 10 years 25 years Mild 88% 63% 38% Natural history • Long latent period: 10 years 25 years Mild 88% 63% 38% Moderate 4% 15% 25% Severe 8% 22% 38% Horstkotte D, Eur Heart J 9(supp. E) 1988 • Mortality is low during the latent period; similar to age-matched • Progression to symptomatic or severe aortic stenosis has marked individual variability – Average rate of progression 0. 10 – 0. 12 cm 2 per year Echo conference: 12 Sep 2007

Natural history • Severe stenosis with symptoms: Avg life expectancy (y) Angina 5 Syncope Natural history • Severe stenosis with symptoms: Avg life expectancy (y) Angina 5 Syncope 3 Heart failure <2 Ross J, Circ 36(supp IV) 1968 Echo conference: 12 Sep 2007

Clinical care of AS • Assessment of symptoms; patient education • Careful exercise testing Clinical care of AS • Assessment of symptoms; patient education • Careful exercise testing for asymptomatic patients with unclear medical histories: • Serum BNP – non-specific marker • Echocardiography: eval AS severity, LV function ACC/AHA, Circ 114, 2006 Echo conference: 12 Sep 2007

Medical therapy • Antibiotic prophylaxis no longer recommended • No medical therapies proven to Medical therapy • Antibiotic prophylaxis no longer recommended • No medical therapies proven to prevent or delay AS • In severe AS, atrial fibrillation is often poorly tolerated Echo conference: 12 Sep 2007

Medical therapy Rajamannan NM, Circ 110, 2004 Echo conference: 12 Sep 2007 Medical therapy Rajamannan NM, Circ 110, 2004 Echo conference: 12 Sep 2007

SALTIRE trial (atorvastatin 80 vs placebo) Cowell SJ, NEJM 352, 2005 Echo conference: 12 SALTIRE trial (atorvastatin 80 vs placebo) Cowell SJ, NEJM 352, 2005 Echo conference: 12 Sep 2007

RAAVE study • 121 patients • Not randomized – Active arm: patients who need RAAVE study • 121 patients • Not randomized – Active arm: patients who need statin due to hyperlipidemia • Mean LDL 160 mg/d. L → at end of study: 93 mg/d. L • Higher prevalence of HTN and diabetes – Control arm: patients who do not meet guidelines for a statin • Mean LDL 119 mg/d. L → at end of study: 118 mg/d. L Moura LM, JACC 49, 2007 Echo conference: 12 Sep 2007

RAAVE study Moura LM, JACC 49, 2007 Echo conference: 12 Sep 2007 RAAVE study Moura LM, JACC 49, 2007 Echo conference: 12 Sep 2007

Ongoing Statin RCTs • Stop Aortic Stenosis (STOP-AS) - U. S. • Simvastatin and Ongoing Statin RCTs • Stop Aortic Stenosis (STOP-AS) - U. S. • Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) Europe • Aortic Stenosis Progression Observation Measuring Effects of Rosuvastatin (? ? ? ) - Canada ASTRONOMER Echo conference: 12 Sep 2007

Evaluation of AS severity • Maximum aortic velocity • Mean transvalvular gradient • Aortic Evaluation of AS severity • Maximum aortic velocity • Mean transvalvular gradient • Aortic valve area by continuity equation Echo conference: 12 Sep 2007

Evaluation of AS severity • Maximum aortic velocity ↔ max instantaneous gradient ← 71 Evaluation of AS severity • Maximum aortic velocity ↔ max instantaneous gradient ← 71 mm. Hg 4. 2 m/s Echo conference: 12 Sep 2007 http: //www. grc. nasa. gov/WWW/K-12/airplane/bern. html

Evaluation of AS severity • Maximum aortic velocity ↔ max instantaneous gradient • Modified Evaluation of AS severity • Maximum aortic velocity ↔ max instantaneous gradient • Modified Bernoulli equation: ∆P = 4 [(V 2)2 – (V 1)2] • Simplified equation (assuming V 2 >>> V 1) : ∆P = 4 V 2 Echo conference: 12 Sep 2007

Evaluation of AS severity • Maximum aortic velocity • Most reproducible • Strongest predictor Evaluation of AS severity • Maximum aortic velocity • Most reproducible • Strongest predictor of clinical outcomes • Mild: • Moderate: • Severe: Echo conference: 12 Sep 2007 2. 6 – 3. 0 m/s 3 – 4 m/s >4 m/s

Evaluation of AS severity • Maximum aortic velocity • Mean transvalvular gradient • Aortic Evaluation of AS severity • Maximum aortic velocity • Mean transvalvular gradient • Aortic valve area by continuity equation Echo conference: 12 Sep 2007

Evaluation of AS severity • Mean transvalvular gradient Echo conference: 12 Sep 2007 Evaluation of AS severity • Mean transvalvular gradient Echo conference: 12 Sep 2007

Evaluation of AS severity • Mean transvalvular gradient • Mild: • Moderate: • Severe: Evaluation of AS severity • Mean transvalvular gradient • Mild: • Moderate: • Severe: Echo conference: 12 Sep 2007 < 25 mm Hg 25 – 40 mm Hg > 40 mm Hg

Evaluation of AS severity • Maximum aortic velocity • Mean transvalvular gradient • Aortic Evaluation of AS severity • Maximum aortic velocity • Mean transvalvular gradient • Aortic valve area by continuity equation Echo conference: 12 Sep 2007

Evaluation of AS severity • Aortic valve area by continuity equation • Volume flow Evaluation of AS severity • Aortic valve area by continuity equation • Volume flow proximal to valve = volume flow thru orifice • CSALVOT x VTILVOT = AVA x VTIAV • CSALVOT x VLVOT = AVA x VAV • AVA = (CSALVOT x VLVOT) / VAV • Velocity ratio = VLVOT / VAV Echo conference: 12 Sep 2007

Evaluation of AS severity • Aortic valve area by continuity equation • Severity by Evaluation of AS severity • Aortic valve area by continuity equation • Severity by AHA criteria: – Mild: – Moderate: – Severe: > 1. 5 cm 2 1. 0 – 1. 5 cm 2 < 1. 0 cm 2 • Severity by BIDMC criteria: – Mild: – Moderate: – Severe: > 1. 2 cm 2 0. 8 – 1. 2 cm 2 < 0. 8 cm 2 • Dimensionless ratio < 0. 25 corresponds to severe AS Echo conference: 12 Sep 2007

Evaluation of AS severity • Aortic valve area by continuity equation • Assumes: – Evaluation of AS severity • Aortic valve area by continuity equation • Assumes: – Geometry of the LVOT is round – Acquired imaging plane (PLAX) is parallel to the LVOT • 3 D-echo may improve measurements Echo conference: 12 Sep 2007 Doddamani S. Echocardiography 24; 2007

Evaluation of AS severity • • 55 consecutive patients w/ nl AV Estimations of Evaluation of AS severity • • 55 consecutive patients w/ nl AV Estimations of LVOT area: a. 2 D-echo PLAX: (π r 2) b. 3 D-echo idealized PLAX: (π r 2) c. 3 D-echo planimetry in the “transverse plane” d. 3 D-echo “ellipse”: (π x LVOTlong x LVOTshort) Echo conference: 12 Sep 2007 Doddamani S. Echocardiography 24; 2007

Evaluation of AS severity • Eccentricity index = 1 – (LVOTshort / LVOTlong) median Evaluation of AS severity • Eccentricity index = 1 – (LVOTshort / LVOTlong) median ←Round Echo conference: 12 Sep 2007 Oblate → Doddamani S. Echocardiography 24; 2007

Evaluation of AS severity • Comparison of LVOT area estimations Echo conference: 12 Sep Evaluation of AS severity • Comparison of LVOT area estimations Echo conference: 12 Sep 2007 Doddamani S. Echocardiography 24; 2007

Evaluation of AS severity • Comparison of LVOT area estimations Echo conference: 12 Sep Evaluation of AS severity • Comparison of LVOT area estimations Echo conference: 12 Sep 2007 Doddamani S. Echocardiography 24; 2007

Timing of valve replacement Echo conference: 12 Sep 2007 Otto CM, JACC 47, 2006 Timing of valve replacement Echo conference: 12 Sep 2007 Otto CM, JACC 47, 2006

Timing of valve replacement Echo conference: 12 Sep 2007 Otto CM, JACC 47, 2006 Timing of valve replacement Echo conference: 12 Sep 2007 Otto CM, JACC 47, 2006

Asymptomatic patients • Risk of sudden death with AS < 1% • What is Asymptomatic patients • Risk of sudden death with AS < 1% • What is the risk of surgery? Echo conference: 12 Sep 2007

In-hospital, post-op mortality Echo conference: 12 Sep 2007 Ambler G, Circ 112, 2005 In-hospital, post-op mortality Echo conference: 12 Sep 2007 Ambler G, Circ 112, 2005

In-hospital, post-op mortality Echo conference: 12 Sep 2007 Ambler G, Circ 112, 2005 In-hospital, post-op mortality Echo conference: 12 Sep 2007 Ambler G, Circ 112, 2005

Exceptions to the asymptomatic rule Undergoing other cardiac sx Echo conference: 12 Sep 2007 Exceptions to the asymptomatic rule Undergoing other cardiac sx Echo conference: 12 Sep 2007 Otto CM, JACC 47, 2006

Problematic situations • Hypertension – May mask the severity of AS • For a Problematic situations • Hypertension – May mask the severity of AS • For a given AVA, transaortic ∆P (velocity) decreases when systemic arterial compliance decreases. Echo conference: 12 Sep 2007 Otto CM, JACC 47, 2006

Problematic situations • LV dysfunction – Primary cardiomyopathy vs. secondary due to true AS Problematic situations • LV dysfunction – Primary cardiomyopathy vs. secondary due to true AS – Low stroke volume may reduce leaflet motion in a nonstenotic valve – Dobutamine stress echo to differentiate • Flexible leaflets: increase in EF, leaflet excursion, and AVA • Severe AS: increase in EF, no change in AVA • “Lack of contractile reserve”: no increase in EF Echo conference: 12 Sep 2007

Congenital AS • Subvalvar • Supravalvar • Valvar Echo conference: 12 Sep 2007 Congenital AS • Subvalvar • Supravalvar • Valvar Echo conference: 12 Sep 2007

Subvalvar / Subaortic stenosis • Dynamic stenosis: – HOCM • Fixed stenosis: – Thin Subvalvar / Subaortic stenosis • Dynamic stenosis: – HOCM • Fixed stenosis: – Thin membrane – Thick fibromuscular ridge Echo conference: 12 Sep 2007

Subvalvar / Subaortic stenosis Echo conference: 12 Sep 2007 Subvalvar / Subaortic stenosis Echo conference: 12 Sep 2007

Subvalvar / Subaortic stenosis Echo conference: 12 Sep 2007 Subvalvar / Subaortic stenosis Echo conference: 12 Sep 2007

Subaortic stenosis • Pathophysiology – Underlying abnormality of LVOT structure – Turbulent flow → Subaortic stenosis • Pathophysiology – Underlying abnormality of LVOT structure – Turbulent flow → progressive LVOT fibrosis → AV leaflet thickening → AR 55% – Infectious endocarditis 12% • Timing of surgery – Children: gradient ≥ 30 mm Hg – Adults: gradient ≥ 50 mm Hg – AR • Recurrence rate: 15 - 27% reoperation Echo conference: 12 Sep 2007

Supravalvar stenosis • Hourglass deformity (discrete constriction) 60 -75% • Diffuse narrowing of variable Supravalvar stenosis • Hourglass deformity (discrete constriction) 60 -75% • Diffuse narrowing of variable length in ascending aorta 2540% Echo conference: 12 Sep 2007

Supravalvar stenosis • Etiologies – – Homozygous familial hypercholesterolemia Familial autosomal dominant form – Supravalvar stenosis • Etiologies – – Homozygous familial hypercholesterolemia Familial autosomal dominant form – mutation of elastin gene Sporadic mutation form As a feature of Williams syndrome • Gene deletions (including elastin) • Short stature, facial abnormalities, visuospatial cognition defects, renovascular HTN, mental retardation • Endocarditis prophylaxis • Indications for surgery uncertain Echo conference: 12 Sep 2007

Valvar AS • Unicuspid or unicommissural valve • Bicuspid or bicommissural valve • Aortic Valvar AS • Unicuspid or unicommissural valve • Bicuspid or bicommissural valve • Aortic annular hypoplasia Echo conference: 12 Sep 2007

Bicuspid AV • Prevalence estimate: 0. 5 -2% • 3: 1 male: female • Bicuspid AV • Prevalence estimate: 0. 5 -2% • 3: 1 male: female • Peak age of symptom onset: 40 – 60 years-old • Familial – Present in ~9% 1 st degree relatives Echo conference: 12 Sep 2007 Huntington K, JACC 30, 1997

Bicuspid AV Echo conference: 12 Sep 2007 Bicuspid AV Echo conference: 12 Sep 2007

Bicuspid AV Echo conference: 12 Sep 2007 Bicuspid AV Echo conference: 12 Sep 2007

Bicuspid AV • Aortic abnormalities – – – Coarctation: 6% Dilatation of aortic root Bicuspid AV • Aortic abnormalities – – – Coarctation: 6% Dilatation of aortic root and/or ascending aorta: ~50% Predictor of ascending aorta aneurysm or dissection Presence is independent of the functional state of the AV Defects in aortic media Echo conference: 12 Sep 2007

Bicuspid AV – aortic media Tricuspid valve Echo conference: 12 Sep 2007 Bicuspid valve Bicuspid AV – aortic media Tricuspid valve Echo conference: 12 Sep 2007 Bicuspid valve de Sa M, J Thorac Cardiovasc Surg 118, 1999

Bicuspid AV – aortic media Echo conference: 12 Sep 2007 Cotrufo M, J Thorac Bicuspid AV – aortic media Echo conference: 12 Sep 2007 Cotrufo M, J Thorac Cardiovasc Surg 130, 2005

Percutaneous AVR (Core. Valve) • 86 consecutive patients – 8/05 -9/06: 2 nd generation Percutaneous AVR (Core. Valve) • 86 consecutive patients – 8/05 -9/06: 2 nd generation 21 -F device (n=50) – 9/06 -2/07: 3 rd generation 18 -F device (n=36) • Required less access site surgical cut-down, lower procedural time, and less frequent hemodynamic support (i. e. ECMO, bypass, cardiac assist) Age Women CAD Prior CABG Prior stroke NYHA III/IV LVEF Euro. SCORE Peak grad AVA 82 ± 6 years 65% 56% 19% 11% 83% 54 ± 16% 22 ± 13% 71 ± 13 mm. Hg 0. 60 ± 0. 16 cm 2 Echo conference: 12 Sep 2007 Grube E, JACC 50; 2007

Percutaneous AVR (Core. Valve) Echo conference: 12 Sep 2007 Grube E, JACC 50; 2007 Percutaneous AVR (Core. Valve) Echo conference: 12 Sep 2007 Grube E, JACC 50; 2007

Percutaneous AVR (Core. Valve) Acute device success 88% Conversion to surgery 6% Only valvuloplasty Percutaneous AVR (Core. Valve) Acute device success 88% Conversion to surgery 6% Only valvuloplasty 2% Valve in valve placement 2% 48 -hour AE Death 6% Stroke 10% MI 0% Cardiac tamponade 9% Coronary flow impairment 0% 30 -day AE Death Stroke 10% MI Echo conference: 12 Sep 2007 12% 1% Grube E, JACC 50; 2007

Percutaneous AVR (Cribier Edwards) • 50 consecutive patients Age Women CAD Prior stroke NYHA Percutaneous AVR (Cribier Edwards) • 50 consecutive patients Age Women CAD Prior stroke NYHA III/IV Euro. SCORE Mean grad AVA 82 ± 7 years 40% 72% 12% 90% 28% 46 ± 17 mm. Hg 0. 6 ± 0. 2 cm 2 Echo conference: 12 Sep 2007 Webb JG, Circulation 116; 2007

Percutaneous AVR (Cribier Edwards) Echo conference: 12 Sep 2007 Webb JG, Circulation 116; 2007 Percutaneous AVR (Cribier Edwards) Echo conference: 12 Sep 2007 Webb JG, Circulation 116; 2007

Percutaneous AVR (Cribier Edwards) Procedural success Inability to pass iliac artery Inability to cross Percutaneous AVR (Cribier Edwards) Procedural success Inability to pass iliac artery Inability to cross AV Defect in prototype delivery catheter Malpositioning of the prosthesis 43 (86%) 1 3 1 2 Procedural death (aortic injury) Emergent cardiac surgery 30 -day death Stroke MI 1 (2%) 0 6 (12%) 2 (4%) 1 (2%) Echo conference: 12 Sep 2007 Webb JG, Circulation 116; 2007