1) The document discusses a case of a 76-year-old woman with severe aortic stenosis, left ventricular dysfunction, and no contractile reserve on stress echocardiography. 2) Tests including aortic valve calcium scoring by CT and low/high-dose dobutamine stress echocardiography were used to further evaluate the severity of stenosis and operative risk. 3) Based on the results, transapical transcatheter aortic valve replacement (TAVR) was performed and led to improvements in symptoms, valve hemodynamics, and left ventricular function at one-year follow-up.

1. TAVR in a Patient with LV Dysfunction
Philippe Pibarot, DVM, PhD, FACC, FAHA, FESC, FASE
Canada Research Chair in Valvular Heart Diseases
UniversitéUniversité
LAVALLAVAL
InstitutInstitut UniversitaireUniversitaire de Cardiologiede Cardiologie
et de Pneumologie de Québec /et de Pneumologie de Québec /
Québec Heart & Lung InstituteQuébec Heart & Lung Institute

2. Disclosure
Philippe Pibarot
Financial relationship with industry:
Ø Edwards Lifesciences
Ø V-Wave
Other financial disclosure:
Ø Research Grants from Canadian Institutes of Health
Ø Research and Heart & Stroke Foundation of Quebec
Off label Use: None

3. CaseCase
Ø 76 y.o. woman
Ø Risk factors:
Ø Hyperchol, Hypertension, COPD
Ø 3-vessel CAD
Ø CABG3, 5 years ago
Ø Coronary angio shows patent grafts
Ø CHF: LVEDD: 64 mm, LVEF: 25%, BNP: 832 pg/ml
Ø Worsening of HF symptoms recently
Ø Aortic stenosis: AVA: 0.8 cm2, Peak/Mean gradients: 46/27 mmHg
Ø Current medication: ASA, ARBs, Statin, Digoxin, Brochodil.

4. What do you do next?
1- Low dose (up to 20) dobutamine stress echo
2- High dose (up to 40) dobutamine stress echo
3- Close echo/clinical follow-up
4- Refer to AVR
Question #1

5. What do you do next?
1- Low dose (up to 20) dobutamine stress echo
2- High dose (up to 40) dobutamine stress echo
3- Close echo/clinical follow-up
4- Refer to AVR
Answer #1

6. LVEF=25%LVEF=25% SV= 51 mlSV= 51 ml
AVA= 0.8 cmAVA= 0.8 cm2
∆P∆P= 46 /= 46 / 2727 mmHgmmHg
LVEF=30%LVEF=30% SV= 57 mlSV= 57 ml
AVA= 0.8 cmAVA= 0.8 cm2
∆P∆P= 52 /= 52 / 3030 mmHgmmHg
DSEDSEResting EchoResting Echo
Case

7. What is the severity of the stenosis?
1- Moderate
2- Severe
3- Very severe
4- I can not tell from the DSE
Question #2

8. What is the severity of the stenosis?
1- Moderate
2- Severe
3- Very severe
4- I can not tell from the DSE
Answer #2

9. LVEF≤40%
AVA≤1.0
ΔP<40
No Contractile (Flow) Reserve
 SV < 20 %
AS Severity:
Indeterminate
 SV ≥ 20 %
Contractile (Flow) Reserve
SAVR  CABG
TAVR  PCI
ΔP≥40
AVA<1.0
True-Severe AS Pseudo-Severe AS
ΔP<40
AVA ≥1.0
Dobutamine-Stress Echo
HF Therapy
?

10. What would you do next?
1- Refer to surgical AVR
2- Refer to transcatheter AVR
3- Aortic valve calcium scoring by CT
4- Close echo/clinical follow-up
Question #3

11. What would you do next?
1- Refer to surgical AVR
2- Refer to transcatheter AVR
3- Aortic valve calcium scoring by CT
4- Close echo/clinical follow-up
Answer #3

12. Fig. 4
AVC Score: 2682 AU
Case

13. What is the severity of the stenosis?
1- Mild
2- Moderate
3- Severe
4- I can not tell from the CT
Question #4

14. What is the severity of the stenosis?
1- Mild
2- Moderate
3- Severe
4- I can not tell from the CT
Answer #4

15. Fig. 4 Mayo-Québec-Bichat Collaboration:
Accuracy of AVC to identify severe AS
Gender Threshold AUC
Sensitivity
(%)
Specificity
(%)
PPV
(%)
NPV
(%)
Women 1274 AU 0.91 89 86 93 79
Men 2065 AU 0.90 89 80 88 82
0
20
40
60
80
100
0 20 40 60 80 100
Sensibility,
(%)
1- Specificity, (%)
Clavel et al. JACC 2013
Case:
2682 AU

16. Mayo-Québec-Bichat Collaboration:
Impact of AVC on Survival In patients with AS
Clavel et al.
JACC
2014
Whole Cohort Patients treated Medically

17. LVEF≤40%
AVA≤1.0
ΔP<40
No Contractile (Flow) Reserve
 SV < 20 %
AS Severity:
Indeterminate
Yes
True-Severe AS
Dobutamine-Stress Echo
MSCT: AoV Ca
Score >1200♀
>2000♂
?

18. Absence of LV contractile / flow reserve is a marker for:
1- High operative risk for AVR
2- Lack of recovery of LV function following AVR
3- Increased risk of long-term mortality
following AVR
4- All of the above
Question #5

19. Absence of LV contractile / flow reserve is a marker for:
1- High operative risk for AVR
2- Lack of recovery of LV function following AR
3- Increased risk of long-term mortality
following AVR
4- All of the above
Answer #5

20. Preoperative Contractile Reserve
vs. Postoperative Ejection Fraction
Quere et al, Circulation 2006;113:1738-1734
Group I
(CR+)
6%
97±7%
Group II
(CR-)
33%
90±5%
Operative
Mortality
2-year
Survival
66 Patients who underwent AVR

21. Total Population Matched Patients
Tribouilloy et al. JACC, 53;1865-1873, 2009

22. What do you recommend now?
1- Surgical AVR
2- Transcatheter AVR
3- Staged approach with BAV and TAVR
4- Medical management
Question #6

23. What do you recommend now?
1- Surgical AVR
2- Transcatheter AVR
3- Staged approach with BAV and TAVR
4- Medical management
Answer #6

24. Case: TransapicalCase: Transapical ValveValve
ImplantationImplantation
Early Postop.
Peak ∆P: 14 mmHg
Mean ∆P: 7 mmHg
Trace AR
Evidence of Severe AS on MDCT
No LV Flow Reserve
Logistic Euroscore: 60%

25. Impact ofImpact of ApproachApproach (TF vs. TA) on(TF vs. TA) on
MyocardialMyocardial InjuryInjury FollowingFollowing TAVRTAVR
Rodés-Cabau et al. JRodés-Cabau et al. J. Am. Coll. Cardiol. 2011;57;1988-1999. Am. Coll. Cardiol. 2011;57;1988-1999

26. Pre-Procedure 1-Year Post-Procedure1-Year Post-Procedure

27. LVEF (%) BNP (pg/ml)
Pre 7-dy 1-mo 1-yr Pre 7-dy 1-mo 1-yr
6MWT (m)
Pre 7-dy 1-mo 1-yr
Case:Case:

28. Treatment Comparison in
Low-EF, Low-Flow, Low-Gradient (both cohorts)
2-YearDeath(%)
0
10
20
30
40
50
60
70
80
90
Time in Days
0 60 120 180 240 300 360 420 480 540 600 660 720
56 50 45 39 38 37 35 32 32
49 38 36 35 35 32 29 29 27
17 15 14 12 11 9 9 9 9
25 19 13 10 10 8 5 5 5
Number At Risk
A-TAVR
A-Surgery
B-TAVR
B-Std Rx
Log Rank P= 0.001
42.9%
37.1%
47.1%
80.0%
LF, LEF and LG - A-TAVR
LF, LEF and LG - A-Surgery
LF, LEF and LG - B-TAVR
LF, LEF and LG - B-Std Rx
Herrmann et al Circulation 2013Herrmann et al Circulation 2013

29. Recovery of LVEF in Patients with Low-LVEF,
Low-Flow, Low-Gradient AS: TAVR versus SAVR
Clavel Circulation,
122:1928-36., 2010
LVEjectionFraction,(%)
Baseline Discharge 1 year
Visits
t: different from baseline
*: different from SAVR
‡: different from discharge
30
35
40
45
50
SAVR
TAVI20
25
*t‡
t
t
t
68
24
68
24
68
24
7 ±13%
15 ±14%
Low-Flow, Low-Gradient AS

30. DeathfromAnyCause(%)
0
10
20
30
40
50
60
70
Time in Days
0 60 120 180 240 300 360 420 480 540 600 660 720
22 18 18 15 14 13 12 9 9
68 68 63 60 58 57 56 54 45
22 20 19 18 18 17 17 17 13
44 42 42 40 39 36 35 33 28
Number At Risk
TAVR - No Improvement
TAVR - Improvement
SAVR - No Improvement
SAVR - Improvement
Log Rank P= <.001
59.1%
20.6%
24.0%
21.1%
TAVR - No Improvement
TAVR - Improvement
SAVR - No Improvement
SAVR - Improvement
PARTNER-IA: All Cause Mortality
LVEF Improvement at 30-days (LVEF<50%)
Elmariah et al.Elmariah et al. Circ Cardiovasc Interv.Circ Cardiovasc Interv. 2013;6:604-142013;6:604-14..

31. 2012 ESC/EACTS Guidelines on Management
of VHD: Indications for AVR in AS
Vahanian et al.
EHJ 2012
Severe AS on DSE: Final AVA <1 cm2; mean gradient >40 mmHg)
Flow reserve: ∆SV ≥ 20%

32. Low-LVEF, Low-Flow,Low-LVEF, Low-Flow,
Low-Gradient AS:Low-Gradient AS:
DSEDSE
Contractile/FlowContractile/Flow
Reserve +Reserve +
SAVRSAVR (Class IIb)(Class IIb)
TAVRTAVR (TF or TAo)(TF or TAo)??
BAV+TAVR?BAV+TAVR?
Medical?Medical?
MedicalMedical
True-True-
Severe ASSevere AS
Pseudo-Pseudo-
Severe ASSevere AS
Contractile/FlowContractile/Flow
Reserve -Reserve -
True-True-
Severe ASSevere AS
SAVRSAVR (Class IIa)(Class IIa)
TAVRTAVR
CTCT

33. Take home messages
ØAortic valve calcium scoring may be useful to
corroborate stenosis severity in patients with low
LVEF, low-flow, low-gradient and no flow reserve
ØAbsence of flow reserve is a marker for increase
operative risk but does not predict long-term
survival or LVEF recovery
ØAbsence of flow reserve should not preclude
consideration of AVR
ØTAVR may provide a valuable alternative in these
patients