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A. Jamil Tajik, MD33rd Annual Echocardiography Symposium

Miami, Florida 33rd Annual Echocardiography Symposium

Miami, Florida

Advances in Management of Valvular Heart Disease

Advances in Management of Valvular Heart Disease DISCLOSUREDISCLOSURE

Relevant Financial Relationship(s)I have no relevant financial

relationships to disclose at this time

Off Label Usage

I have no relevant financial relationships to disclose at this time

Nkomo, V.T. et al: The Lancet 368:1005, 2006

Prevalence of Valvular Heart Disease

≥75

Valve disease

AllMitral

Aortic

Age (years)

Pre

vale

nce (

%)

14

12

10

8

6

4

2

0

<45 45-54 55-64 65-74

N=11911Mod-Sev

VHD=5.2%

MILESTONES VHD

•1960 – AVR (SE)

•1961 – MVR (SE)

2000 – TRANSCATHETER PVR

(Philipp Bonehoeffer)

2002 – TAVR (Alain Cribier)

VHD 2014VHD 2014• Accurate Structure/Function

• Quantitation of Severity

• Modern Era Natural history

• Timing of Intervention (no sx)

• Selection for TCT (Heart Team)

• Medical therapy? Prevention?

• Accurate Structure/Function

• Quantitation of Severity

• Modern Era Natural history

• Timing of Intervention (no sx)

• Selection for TCT (Heart Team)

• Medical therapy? Prevention?

TCT in VHD 2014TCT in VHD 2014• TAVR

• VIV TAVR

• Mitral Edge – Edge Repair

• TMVR; Annuloplasty

Heart Team

• TAVR

• VIV TAVR

• Mitral Edge – Edge Repair

• TMVR; Annuloplasty

Heart Team

2

Aortic StenosisAortic Stenosis Original Article

Transcatheter Aortic-Valve Implantation for Aortic Stenosis in Patients Who Cannot Undergo Surgery

Martin B. Leon, M.D., Craig R. Smith, M.D., Michael Mack, M.D., D. Craig Miller, M.D., Jeffrey W. Moses, M.D., Lars G. Svensson, M.D., Ph.D., E. Murat

Tuzcu, M.D., John G. Webb, M.D., Gregory P. Fontana, M.D., Raj R. Makkar, M.D., David L. Brown, M.D., Peter C. Block, M.D., Robert A.

Guyton, M.D., Augusto D. Pichard, M.D., Joseph E. Bavaria, M.D., Howard C. Herrmann, M.D., Pamela S. Douglas, M.D., John L. Petersen, M.D., Jodi J.

Akin, M.S., William N. Anderson, Ph.D., Duolao Wang, Ph.D., Stuart Pocock, Ph.D., for the PARTNER Trial Investigators

N Engl J MedVolume 363(17):1597-1607

October 21, 2010

ConclusionsIn patients with severe aortic stenosiswho were not suitable candidates for surgery, TAVI, as compared with standard therapy, significantly reduced the rates of death from any cause, the composite end point of death from any cause or repeat hospitalization, and cardiac symptoms, despite the higher incidence of major strokes and major vascular events.

In patients with severe aortic stenosiswho were not suitable candidates for surgery, TAVI, as compared with standard therapy, significantly reduced the rates of death from any cause, the composite end point of death from any cause or repeat hospitalization, and cardiac symptoms, despite the higher incidence of major strokes and major vascular events.

European Heart Journal (2014) 34, 490-494

84 year old Female84 year old Female

•Severe calcific aortic valve stenosis

Mean gradient: 64 mmHg

AVA: 0.70 cm2

•NYHA class II

TAVR

•Severe calcific aortic valve stenosis

Mean gradient: 64 mmHg

AVA: 0.70 cm2

•NYHA class II

TAVR

3

AV CW Doppler

Peak Vel = 4.9 m/secMean Gradient = 64 mmHg

AVA = 0.70 cm2 PRE

POST

4

PRE

POST

PRE TAVRMean Grad = 64 mmHg

POST TAVRMean Grad = 7 mmHg

91 year old Female

•S/p bioprosthetic AVR (age 80 yrs)

•Severe CHF; Multiple comorbidities

•Severe Stenosis of Bioprosthesis

Mean gradient – 56 mmHg

AVA – 0.70 cm2

VIV TAVR

Peak Vel = 4.8 m/secMean Gradient = 56 mmHg

AVA = 0.70 cm2

AV CW Doppler

5

PRE

POST

1 Year Follow Up

PRE

POST

POST:Peak Vel = 2.2 m/secMean Gradient = 10 mmHg

PRE:Peak Vel = 4.8 m/secMean Gradient = 56 mmHg

90 year old female90 year old femaleBileaflet mitral valve prolapse

Flail leaflet (posterior); Gr 4/6 murmer

Severe MR (RV 79 ml, ERO 0.6 cm2)

Severe PHTN (PASP 70 mmHg)

CABG (2006), Pacemaker

Decreased LV EF (32%)

NYHA Class III-IV

Edge to Edge Repair

Bileaflet mitral valve prolapse

Flail leaflet (posterior); Gr 4/6 murmer

Severe MR (RV 79 ml, ERO 0.6 cm2)

Severe PHTN (PASP 70 mmHg)

CABG (2006), Pacemaker

Decreased LV EF (32%)

NYHA Class III-IV

Edge to Edge Repair

6

Regurg Vol = 79 mlERO = 0.60 cm2

7

1 Year Follow Up1 Year Follow Up

Clinically markedly improved

Grade I/6 systolic murmur of MR

PASP 40 mmHg

NYHA Class I-2

Clinically markedly improved

Grade I/6 systolic murmur of MR

PASP 40 mmHg

NYHA Class I-2

Post Clip Implant TTE

8

76 year old76 year old

•3 episodes of plum edema

•Rheumatoid Arthritis

•Renal Failure

•High STS and Euro score

•3 episodes of plum edema

•Rheumatoid Arthritis

•Renal Failure

•High STS and Euro score

Post Clip Implant

9

JACC 2014; 64: 1814-9 Oct. 28

CONCLUSION: Transapical transcatheter mitral valve implantation is

technically feasible and can be performed safely. Early hemodynamic

performance of the prosthesis was excellent. Transcatheter mitral valve

implantation may become an important treatment option for patients with

severe MR who are at high operative risk.(J. Am Coll Cardiol 2014;64:1814-9) 2014 by the American College of Cardiology Foundation.

JACC: Cardiovascular Interventions VOL 7 NO 11, 2014

First-in-Man Trans-Septal Implantation of a “Surgical-Like” Mitral

Valve Annuloplasty Device for Functional Mitral Regurgitation

Cardiovascular Health StudyCardiovascular Health Study

•N= 5621: 5 year risk of death and CV death

•70% normal AV

•28% aortic sclerosis

•2% aortic stenosis

•N= 5621: 5 year risk of death and CV death

•70% normal AV

•28% aortic sclerosis

•2% aortic stenosis

Otto et al NEJM 1999; 341: 142-7

Event RatesEvent Rates

0

5

10

15

20

25

30

35

40

45

Deathall

cause

CHFDeathCV

MI† Angina† Stroke†

Normal aortic valvesAortic sclerosisAortic stenosis

%

**

*

**

*

‡

*

‡

*

*

*

*

Otto et al NEJM 1999 341: 142-7

10

Aortic Sclerosis

Aortic Stenosis

28

44

2

9Pe

rce

nt

(%)

Then

Cardiovascular Health Study8 Years Later

Cardiovascular Health Study8 Years Later

Now

JACC 2007:50:1992

Journey of the Aortic Valve

Circulation Research.2013;113:198-208

Molecular and Cellular Aspects of Calcific Aortic Valve Disease

Circulating MyeloidCalcifying Cell, COP, ePCCirculating MyeloidCalcifying Cell, COP, ePCCirculating MyeloidCalcifying Cell, COP, ePC

EC Undergoing Endothelial-Mesenchymal TransitionEC Undergoing Endothelial-Mesenchymal TransitionEC Undergoing Endothelial-Mesenchymal Transition

Valve Annulus ChondrocyteValve Annulus ChondrocyteValve Annulus Chondrocyte

Valve Interstitial Cell (VIC)Valve Interstitial Cell (VIC)Valve Interstitial Cell (VIC)Valve Osteoblast-Like CellValve Osteoblast-Like CellValve Osteoblast-Like Cell

Randomized Trial of Intensive Lipid Lowering Therapy in

Calcific AS

Randomized Trial of Intensive Lipid Lowering Therapy in

Calcific AS

•N=155 with moderate-severe AS randomized to 80 mg atorvastatin vs placebo

•No significant slowing of progression of calcific AS

•WAS THE WINDOW OF OPPORTUNITY TOO LATE?

•N=155 with moderate-severe AS randomized to 80 mg atorvastatin vs placebo

•No significant slowing of progression of calcific AS

•WAS THE WINDOW OF OPPORTUNITY TOO LATE?

NEJM 2005; 352:2389

Rosuvastatin Affecting Aortic Valve

Endothelium to Slow the Progression of

Aortic Stenosis

Conclusions: Prospective treatment

of AS with rosuvastatin by targeting serum LDL slowed the hemodynamic progression of AS.

Methods: 121 patients with asymptomatic

moderate to severe AS (aortic valve area

εεεε 1.0 cm2 . . .

11

SEAS TrialSEAS Trial•1800 patients

•Exclusion criteria

•1800 patients

•Exclusion criteriaCoronary artery disease

Peripheral arterial disease

Cerebrovascular disease

Diabetes

Hyperlipidemia

Other significant valvular HD

NEJM 2008; 359:1

Rate of Disease ProgressionRate of Disease Progression

No statin

No statin

StatinStatin-0.10

0.00

0.10

0.20

0.30

No statin

No statin

StatinStatin

Aortic SclerosisP=0.01

Mild Aortic StensisP=0.001

Increase

in Vmax (m/s/y)

Increase

in Vmax (m/s/y) .04±.0

9

.04±.0

9

.07±.1

0

.07±.1

0

.09±.1

5

.09±.1

5

.15±.1

5

.15±.1

5

AJC 2008;102:738

Aortic Valve SclerosisAortic Valve Sclerosis

•Etiology of aortic stenosis is inflammatory (82%)

•Aortic sclerosis is highly associated with a worse CV prognosis

•Aortic sclerosis is progressive

•Recommend active intervention for prevention strategy

•Etiology of aortic stenosis is inflammatory (82%)

•Aortic sclerosis is highly associated with a worse CV prognosis

•Aortic sclerosis is progressive

•Recommend active intervention for prevention strategy

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