ESCTS 2012

1. Difficult issues in aortic valve surgery:
Management of Asymptomatic severe AS.
Magued Zikri , M.D.
Department Of Cardiothoracic surgery
Cairo University.
2012

2. Asymptomatic AS
Significance of “ASYMPTOMATIC”.
 Subjective entity.
 Subconsciously down sizing activity with AS progress
 SOB in elderly sedentary population frequently
interpreted as normal for age.
 Appearance of symptoms reporting is linked to
frequency of medical consultations.
 Delays from onset to reporting symptoms to
decision making might further delay intervention.

3. Asymptomatic AS
Criteria of severity of aortic stenosis:
1- Clinical .
2- Echocardiograhic :
A- aortic valve area < 1 cm 2
B- aortic flow velocity > 4 m/sec
C-Gradient across Aortic valve mean > 40 mmhg
D- Valve area index <0.6 cm 2 /m2
3- Stress testing :
To Unmask exercise related symptoms in severe AS.
(+) test forecast a higher probability to develop C/O within ONE year.
Abnormal hypotensive response for tell bad prognosis.
4- Angiographic :
Exclude CAD and sort out occasional confounding echo data.

4. Asymptomatic AS

5. Asymptomatic AS
Clinical decision making.
 Exclude association of other valves malfunction, either
sharing same rheumatic etiology or secondary to AS.
 Sort out CAD related ischemia from angina due to
impaired subendocardial flow.
 Evaluate left ventricular systolic and diastolic function.
 Estimate risk of development of AF over time , whether
secondary to an enlarged Lt atrium or due to I.H.D.
 Projection of AS progress over time:
 Length of follow up of a known severe AS.
 Rate of change in aortic flow velocity (0.3 m/sec/ year)
 Calcific degenerative valves deteriorate> rheumatic path.

6. Asymptomatic AS
Outcome of 622 Adults With
Asymptomatic, Hemodynamically
Significant Aortic Stenosis During
Prolonged Follow-Up
Patricia A. Pellikka, MD; Maurice E. Sarano, MD; Rick A.
Nishimura, MD; Joseph F. Malouf, MD; Kent R. Bailey, PhD;
Christopher G. Scott, MS; Marion E. Barnes, MSc;
A. Jamil Tajik, MD
Mayo Clinic and Mayo Foundation, Rochester, Minn.
(Circulation. 2005;111:3290-3295.)

7. Asymptomatic AS
Methods and Results.
Isolated, asymptomatic AS, peak systolic velocity 4 m/s
No surgery at initial evaluation
N= 622 patients
follow-up 5.4 +/-4.0 years
Mean age (SD) 72+/- 11 years
Males 384 (62%).
Probability of remaining free of cardiac C/O
while unoperated was :
1, 2, 5 years,
82%, 67%, 33%.
AVA and LV hypertrophy predicted C/O development.

8. Asymptomatic AS
Methods and Results.
 352 (57%) pts referred for aortic valve surgery.
 265 (43%)pts died, including cardiac death(19%).
 Probabilities of remaining free of surgery or
cardiac death were:
At 1, 2, 5-years
80%, 63%, 25%.

9. Asymptomatic AS
Methods and Results.
Multivariate predictors of all-cause mortality:
age (hazard ratio [HR], 1.05; P0.0001),
chronic renal failure (HR, 2.41; P0.004),
inactivity (HR,2.00; P0.001),
aortic valve velocity (HR, 1.46; P0.03).

10. Asymptomatic AS
Methods and Results.
Sudden death without preceding symptoms
occurred in 11(4.1%) of 270 unoperated pts (1%/y)
Pts with peak velocity 4.5 m/s had higher
likelihood of:
•Developing symptoms (relative risk RR, 1.34)
•Having surgery or cardiac death (RR, 1.48).

11. Asymptomatic AS
Conclusions.
•Most pts with asymptomatic, hemodynamically
significant AS will develop C/O within 5 years.
•Sudden death occurs in 1%/y.
•Age, CRF, inactivity, aortic valve velocity are
independently predictive of all-cause mortality.

12. Asymptomatic AS
Clinical Profile and Natural History of 453
Nonsurgically Managed Patients With
Severe Aortic Stenosis
Padmini Varadarajan, MD, Nikhil Kapoor, MD, Ramesh
C. Bansal, MD, and Ramdas G. Pai, MD.
Division of Cardiology, Loma Linda University Med Center, Loma Linda, California
(Ann Thorac Surg 2006;82:2111–5)

13. Asymptomatic AS
Methods.
Observational retrospective study
Search of echocardiographic database
1993 - 2003.
740 patients with severe AS
of whom 453 patients had no AVR.
These non operated cases had their clinical,
pharmacologic, and surgical data
reviewed and their survival data extracted from
National Death Index.

14. Asymptomatic AS
Results.
Age 75 +/- 13 y
Male 48%
(LV) Ejection fraction 52 +/- 21%
Coronary artery disease 34%
Hypertension 35%
Serum creatinine > 2 mg/dL 11%
DM 14%
Survival at 1 year, 5 years, 10 years
62%, 32%, 18%.

15. Asymptomatic AS
Results.
Univariate predictors of reduced survival were :
• Advanced age,
• Low LV ejection fraction, Heart failure,
• Elevated serum creatinine level,
• Severe mitral regurgitation, pulmonary hypertension.
Independent predictors of reduced survival were :
• Advanced age,
• Low LV ejection fraction, heart failure,
• Elevated serum creatinine level,
• Systemic hypertension.
Concomitant pharmacotherapy didn`t affect survival.

16. Asymptomatic AS
Conclusions.
Conservatively treated patients with severe AS
have a grave prognosis.
Survival is worse with advanced age, LV
dysfunction, heart failure, renal failure.

17. Malignant Natural History of Asymptomatic
Severe Aortic Stenosis: Benefit of Aortic
Valve Replacement
Ramdas G. Pai, Nikhil Kapoor, Ramesh C.
Bansal and Padmini Varadarajan.
Division of Cardiology, Loma Linda University Med Center, Loma
Linda, California.
Ann Thorac Surg 2006;82:2116-2122

18. Asymptomatic AS
Methods.
Retrospective observational study
Search of echocardiographic database
1993 - 2003
N = 740 patients
with severe AS(aortic valve area = <0.8 cm2)
Of these, N = 338 patients
were asymptomatic at initial encounter.

19. Asymptomatic AS
Results.
 age 71 +/ -15 y
 males 51%
 aortic valve area 0.72 +/-0.17cm2
 LV ejection fraction 0.59 +/-0.17
AVR was performed in 99 (29%) pts
during a mean follow-up of 3.5 years.

20. Asymptomatic AS
Results.
Survival at 1, 2, 5 years :
 nonoperated pts : 67%, 56%, 38%
 AVR pts : 94%, 93%, 90%
(p< 0.0001)
In nonoperated group, independent
predictors of mortality were:
 renal insufficiency (RR 3.1, 95% CI 1.5 to 6.6)
 age (per year RR 1.03, 95% CI 1.02 to 1.05)
 LV EF (per % RR 0.99, 95% CI 0.98 to 1.00)
 b blocker use (RR 0.52, 95%CI0.31to 0.88)
 statin use (RR 0.52, 95% CI 0.27 to 0.99)

21. Asymptomatic AS
Conclusions.
• Asymptomatic AS natural history
is not benign.
• Pts survival is dramatically improved by AVR.
• Survival of asymptomatic non operated pts
may be improved by beta blockers & statins.

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25. Asymptomatic AS

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27. Asymptomatic AS
Surgical Outcome:
 Referral for AVR is in context of published mortality
rates in LARGE data base e.g. for the STS is 3-4% for
isolated AVR and 5.5-6.8% for combined CABG & AVR.
 Lower volume centers have 33% higher incidence.
 Earlier referral for AVR before excessive myocardial
fibrosis settles in reflects on better long term outcome.
 Timing of referral should take in consideration longer
than CABG waiting time as “Valve” cases are “less
urgent”.

28. Asymptomatic AS
Surgical challenges:
 SEVERE calcifications present a challenge to debride
and sometime refashion a new aortic annulus.
 Elderly small sized women aortic annulus might
require an annular enlargement procedure.
 Severe , often poorly documented , LVOT hypertrophy
might require myomectomy .
 Intraoperative myocardial protection dictates
adequate cardioplegia and proper venting of the LV .

29. Asymptomatic AS
Take Home Message.
 Assure that AS is an isolated disease , truly
asymptomatic with a normal LV function.
 If such, CUSTOM tailored decision considering:
 Age ,
 Renal Function,
 Risk of developing AF,
 Rate of increase of aortic flow velocity,
 Presence and degree of valve calcification,
 Expected logistic delays of surgery.