Unraveling low-flow , low-gradient aotic stenosis fabian nestispach Head TAVI

1. Unravelling low-flow low-gradient aortic stenosis
Fabian Nietlispach, MD PhD
Head TAVI

2. Disclosures
• Consultant for
• Edwards Lifesciences
• Direct Flow Medical
• Medtronic
• St. Jude Medical

3. Case vignette
• 81 y/o htn, dyslip, female in AFib
• Presents in NYHA III-IV
• Previous CABG x2 and AVR (CE); LVEF 40%

4. LVEF 40%, aortic P-mean 21mmHg
RHC: CI 2.1; PA 69/29/45; PCW 40

5. Aortic stenosis:
the ‘easy’ valve pathology?
• Simple anatomy…
Piazza N et al. Circ Cardiovasc Interv. 2008

6. • …not so simple pathophysiology
• Gorlin Formula:
• Continuity equation
Aortic stenosis:
the ‘easy’ valve pathology?
Baumgartner at al., JASE 2009

7. • …not so simple pathophysiology
• Gorlin Formula (with CO 6, HR 80, SEP 0.33):
– AVA 1cm2  Pmean = 26mmHg
– AVA 0.8 cm2  Pmean = 41mmHg
– AVA 0.7 cm2  Pmean = 53mmHg
Aortic stenosis:
the ‘easy’ valve pathology?
Courtesy C. Seiler

8. • …not so simple pathophysiology
• Continuity equation
Aortic stenosis:
the ‘easy’ valve pathology?
Baumgartner at al., JASE 2009 Piazza N et al. Circ cv Interv. 2008 Zamorano et al. EHJ 2014

9. • …not so simple clinical management
Aortic stenosis:
the ‘easy’ valve pathology?
Calcification
Rapid increase in
jet velocity
Rosenhek et al, NEJM 1996

10. • …not so simple clinical management
Aortic stenosis:
the ‘easy’ valve pathology?
Circulation 2012

11. Low-flow low-gradient AS
• Classification
Pibarot, JACC 2012
5-10%
Poor prognosis
High operative risk
10-20%
small cavities
advanced diast. Dysf.
Normal LVEF
Normal-Flow
LOW-GRADIENT
Small body size  indexed
AVA 1cm2  Pmean 26mmHg
Pseudo-AS

12. AVA = 0.8  CO 2l/min  gradient: 19mmHg
Low-flow low-gradient AS
modest changes in flow  relevant reduction in gradient

13. • Definition
• Low EF LFLG severe AS:
– LVEF <40%, Gradient <40mmHg, Low Flow: SVI <35 (or CI <3)
• Normal EF LFLG AS
– LVEF >50%, Gradient <40mmHg, Low Flow: SVI <35 (or CI <3)
• Pseudo-AS
– LVEF <40%, Gradient <40mmHg, Low Flow: SVI <35 (or CI <3)
• Normal EF NFLG AS
– LVEF >50%, Gradient <40mmHg, Flow: SVI >35

14. Diagnostic challenges
• Stroke volume index
Reduced even in HIGH-gradient AS
O’Sullivan, EHJ 2013

15. Gradient ‘per se’ not suited for AS quantification
Gradient: marker for myocardial function / risk assessment
AVA-calculations come with many confounders

16. Diagnostic challenges
• Low EF LFLG without contractile reserve
With contractile reserve (SV increase >20%)
- Dobutamine SE
- AVA <1  severe AS
- AVA >1  Pseudo AS
Without contractile reserve (SV increase <20%)
- Severe AS? Pseudo AS?
Highest surgical risk

17. Is the distinction important?
• …maybe not so much…!
Group I: contractile reserve
Group II: no contractile reserve
Monin et al, Circulation 2003

18. Should patients with pseudo-AS
undergo AVR??
Pseudo with (T)AVR?
Adapted from Fougeres et al, EHJ 2012
(T)AVR facilitating myocardial recovery?
(T)AVR slowing down myocardial deterioration?

19. Therapeutic options
• Medical therapy
Normal EF LFLG AS benefits from AVR
Prognosis of Low EF LFLG AS with MedTx is dismal
Hachicha et al, Circulation 2007

20. Therapeutic options
• Surgical valve replacement
Excess of 30-day mortality for LGLF (6.3%)
(Odds Ratio for PLF: 3)
Excess 10year mortality for Low EF LGLF
Clavel et al, JACC 2015

21. Therapeutic options
• Transcatheter Aortic Vave Implantation
– Theoretical advantages
• Less invasive  faster recovery, suited for high-risk pts
• No extracorporal circulation
– suited for hypertrophic LV’s with diastolic dysfunction
– Suited for failing LV’s with systolic dysfunction
• Better hemodynamics
– Less risk of PPM

22. Smith C et al, PARTNER A, NEJM
Faster recovery

23. Day 1 post
TAVI

24. Pibarot et al, JACC 2014
Less PPM
d/t larger valve areas

25. TAVI in LFLG
30d MACCE
O’Sullivan, EHJ 2013

26. cvDeath @ 30d and 1year
O’Sullivan, EHJ 2013

27. Symptomatic benefit
O’Sullivan, EHJ 2013

28. Randomized data
(with 1st generation TAVI device)
• Low EF LFLG
Herrmann et al, Circ 2013

29. Randomized data
(with 1st generation TAVI device)
• Normal EF LFLG
Herrmann et al, Circ 2013

30. • Main advantage: faster recovery
Herrmann et al, Circ 2013

31. Case vignette
• Decision:
• TAVI Valve in valve
• MitraClip
• Left Atrial Appendage Closure

38. Follow-up after 3 and 6mts
• Patient doing well
• NYHA I
• P-mean 10mmHg
• Mild mitral regurgitation

39. Complex patients
• Diagnostic challenge
• Do we have the right cut-off values?
• Clinical challenge
• When to treat?
– Earlier d/t concomitant myocardial disease ( additional
benefit)
• How to treat?
– SAVR versus TAVI

40. Thank you