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Asymptomatic Aortic Valve Disease What Should We Do? Michael Rinaldi, MD The Sanger Heart and Vascular Institute Carolinas HealthCare System Charlotte NC USA michael.rinaldi@carolinashealthcare.org Disclosures Nothing relevant to the presentation 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease (Journal of the American College of Cardiology) Published on March 3, 2014, available at: http://content.onlinejacc.org/cgi/content/full/j.jacc.2014.02.536 and http://circ.ahajournals.org/content/early/2014/02/27/CIR.0000000000 000029.citation The full-text guidelines are also available on the following Web sites: ACC (www.cardiosource.org) and AHA (my.americanheart.org) Aortic Stenosis Severity Assessment Indicator Mild Moderate Severe CW Jet Velocity (m/sec) < 3.0 3.0-4.0 > 4.0 Mean Gradient (mm Hg) < 25 25 - 40 > 40 < 1.0 Valve Area (cm2) Echo f/u > 1.5 3-5 yrs *(or Δ in sx’s) 1.0 – 1.5 (Index 1274 in Women and >2065 in Men associated with far worse prognosis • AVR indicated Clavel, M JACC 2014;64.1202-13 Example of CTA of AV with High Calcium Score A Twist on our Case Example • 75 year old man with systolic murmur • Asymptomatic but inactive • Severe class kidney disease, DM, moderate COPD, appears frail • Echocardiography shows a thickened poorly mobile valve with an AV velocity of 4.0 m/s and mean gradient of 42 mmHg • Should this patient have AVR? Risk Assessment for Surgical AVR Combining STS Risk Estimate, Frailty, Major Organ System Dysfunction, and Procedure-Specific Impediments STS PROM Frailty Major organ system compromise not to be improved postoperatively Procedurespecific impediment Low Risk (must meet ALL criteria in this column ) 8% OR or more indices (moderate-tosevere) OR No more than organ systems OR Prohibitive Risk (any criteria in this column) Predicted risk with surgery of death or major morbidity (all-cause) >50% at y OR None AND organ system OR None Possible procedure- Possible procedure- Severe procedure-specific specific impediment specific impediment impediment or more organ systems OR A Variation on our Case Example • STS predicted mortality risk 8% • Goal here is quality of life and symptoms relief • We should not operate • Consider TAVR when patient becomes significantly symptomatic (> Class 2) Case Example • 65 year old man • Asymptomatic and active • Echocardiography shows a thickened poorly mobile valve with an AV velocity of 5.0 m/s and mean gradient of 55 mmHg • Normal LVEF • No high risk markers on ETT • Low risk for AVR • Should this patient have AVR? Aortic Stenosis: Timing of Intervention (cont.) Recommendations COR LOE AVR is reasonable for asymptomatic patients with very severe AS (stage C1, aortic velocity IIa B ≥5 m/s) and low surgical risk AVR is reasonable in asymptomatic patients (stage C1) with severe AS and decreased exercise IIa B tolerance or an exercise fall in BP AVR is reasonable in symptomatic patients with low-flow/low-gradient severe AS with reduced LVEF (stage D2) with a low-dose dobutamine IIa B stress study that shows an aortic velocity 4 m/s (or mean pressure gradient 40 mm Hg) with a valve area 1.0 cm2 at any dobutamine dose Case Example • 75 year old man with systolic murmur • Dyspnea on exertion • Echocardiography shows a thickened poorly mobile valve with an AV velocity of 3.0 m/s and mean gradient of 30 mmHg • LVEF 30% • Does this patient have symptomatic AS or just systolic CHF? • Should this patient have AVR? Aortic Stenosis: Timing of Intervention (cont.) Recommendations COR LOE AVR is reasonable for asymptomatic patients with very severe AS (stage C1, aortic velocity ≥5 m/s) IIa B and low surgical risk AVR is reasonable in asymptomatic patients (stage C1) with severe AS and decreased exercise IIa B tolerance or an exercise fall in BP AVR is reasonable in symptomatic patients with low-flow/low-gradient severe AS with reduced LVEF (stage D2) with a low-dose dobutamine stress study that shows an aortic velocity 4 IIa B m/s (or mean pressure gradient 40 mm Hg) with a valve area 1.0 cm2 at any dobutamine dose Case Example • DSE at 5, 10, and 20 mcg/kg/min shows LVEF increases and AV velocity of 4.0 m/s and mean gradient of 42 mmHg • Consistent with “low flow low gradient” severe AS • This patient should have AVR (consider TAVR) Case Example • • • • 75 year old man with systolic murmur Unstable angina with LM and vessel CAD Scheduled to undergo CABG Echocardiography shows a thickened poorly mobile valve with an AV velocity of 3.0 m/s and mean gradient of 32 mmHg • Should this patient have AVR? Aortic Stenosis: Timing of Intervention (cont.) Recommendations COR LOE AVR is reasonable in symptomatic patients who have low-flow/low-gradient severe AS (stage D3) who are normotensive and have an LVEF ≥50% if IIa C clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms AVR is reasonable for patients with moderate AS (stage B) (aortic velocity 3.0–3.9 m/s) who are IIa C undergoing other cardiac surgery AVR may be considered for asymptomatic patients with severe AS (stage C1) and rapid disease IIb C progression and low surgical risk Indications for Aortic Valve Replacement in Patients With Aortic Stenosis Thank you