evaluation and management of asymptomatic aortic stenosis.€¦ · evaluation and management of...

Evaluation and Management of

Asymptomatic Aortic Stenosis.

Augusto Pichard, M.D.

Director Innovation and Structural Heart Disease,

Vice Chair, Medstar Heart Institute,

Medstar Washington Hospital Center.

Professor of Medicine (Cardiology),

Georgetown University Medical School.

Washington, DC

Symptoms of Aortic Stenosis

• Main symptoms: – dyspnea,

– angina,

– syncope,

• Other important symptoms: – dizziness,

– weakness,

– fatigue,

– exercise intolerance.

• Patients may not be aware of symptoms.

Case Presentation

History: 87 female, very active until recently. Now uses wheel chair for mobilization, pushed by

someone else. Sleeps on recliner. Obese 220 lbs.

Anamnesis: do you have • SOB? NO • Orthopnea or PND? NO • Leg swelling? Mild in both legs, present for

years. • Chest pain? NO • Dizziness or passing out? NO

AVA: 0.6 cm2 (Index 0.3).

Mean Gradient: 48 mm Hg.

Average Max V2: 4.4 m/s. EF 35%.

Mild MR, Trace AI.

LVOT 1.9cm, Annulus 23cm.

PA systolic pressure 55 mm Hg.

Echocardiogram

Mild Coronary Disease

Case Summary

1. She “thinks” she is asymptomatic, but she

is not: cannot lye flat, barely moves,

always fatigued (FC III?).

2. No need for exercise test or Dobutamine

Echo: she has critical AS.

3. Depending on family support and

personal drive, could be good candidate

for TAVI or high risk AVR.

Second Case Presentation

64 year old male

• 180 lbs.

• Exercises on treadmill 30 min daily,

without symptoms.

• Plays golf weekly.

• Works full time as University Professor.

Cinical Data

Past history:

• Pancreatitis 2002 followed by:

- major weight loss (from 300 to 200 lbs).

- cessation of alcohol intake.

• Prior smoker

• Normal coronaries by cath in 2000

Echo:

• AVA 0.9 cm2 (index 0.55)

• Mean gradient 30 mm Hg

• V max 3 m/sec

Rest Exercise

• BP 120/76 • HR 96, AF • EF 50%. • Mean Ao gradient 30 mm Hg.

• Stage 3 Bruce • BP 190/84 • No symptoms. • HR 203, AF • EF 75% (Excellent reserve). • Exercise gradient: 32 mm Hg

(residual valve compliance).

Mortality of Asymptomatic

Severe Aortic Stenosis

1993-2003 Loma Linda Echo Lab Database.

747 Patients with AVA <0.8 cm2: 338 asymptomatic.

Pai et al. Ann Thor Surg 2006;82:2116-22

Asymptomatic Patients

Valve Replacement

No surgery

Incidence of Sudden Death in

Asymptomatic Aortic Stenosis

Rahimtoola EHJ 2008; 29:1783-91.

Lancelotti AJC 2010 126 4.8

Patients

n=

26

128

66

69

125

622

Rahimtoola, EHJ 08

Outcome of Asymptomatic Aortic Stenosis Pellikka et al. Circulation 2005;111:3290-5

During 5 year follow up:

• 57% had AVR

• 43% died (19% cardiac

death).

• Sudden death without preceding

symptoms occurred in 4.1% of 270

unoperated patients

622 patients with peak veloc >4m/sec, AVA 0.9±0.2cm2

2 y

5 y

First Concept

Patients with severe Aortic Stenosis

and no symptoms

can have

significant morbidity/mortality.

Echo Predictors of events

Predictors of Events in Asymptomatic Aortic Stenosis

Otto et al. Circulation 1997, 95:2262

Echo Predictors (all p<.001) :

• jet velocity,

• mean gradient,

• valve area,

• rate of increase in jet velocity.

• LA size and LV mass.

Aortic Jet Velocity and EFS

Otto et al. Circulation 1997, 95:2262

20% events at 5 years

40% events at 4 years

80% events at 3 years

100% events at 5 years

123 AS patients without symptoms

Jet Velocity, AVA and Outcome Otto et al. Circulation 1997, 95:2262

AVA

cm2

Ao Jet

Veloc.

m/sec

Jet Velocity Progression and Outcome

in Severe Asymptomatic Aortic Stenosis Rosenhek et al. NEJM 2000; 343:611-7

Mean Rate of Progression of Aortic-Jet

Velocity among 41 Patients with and 29

patients without Cardiac Events

34 Patients with Moderate or Severe

Calcification of the Aortic Valve and a Rapid

Increase in Aortic-Jet Velocity (at Least 0.3

m/sec within 1 Year).

>0.3 m/sec/year

Valve Calcification is a Predictor of Outcome in Severe Asymptomatic AS

Rosenhek et al. NEJM 2000; 343:611-7

Calcification by CT predicts outcome in asymptomatic AS. J Heart Valve Dis 2007;15:494

Exercise Test

in Asymptomatic Aortic Stenosis

Exercise testing in Asymptomatic AS Amato et al. Heart 2001; 86:381-6

Although asymptomatic in daily life, 6% of the patients (4/66)

experienced sudden death: all with positive exercise test and aortic

valve area 0.6 cm2.

Incremental Prognostic Value of Exercise Test Lancelotti et al. Circul 2005;112:I 377-82

Predictive

value

Why Operate Early ?

Severe AS, even asymptomatic, has

• Up to 6% incidence of SD.

• Very low surgical mortality/morbidity.

• Higher surgical mortality when more

symptomatic.

Mortality for AVR. STS Executive Summary 2008

www.sts.org

<10% of patients had STS >10

AVR in the Elderly.

Cerillo et al. Interact CardioVasc Thorac Surg 2007;6:308-13

Surgery for Asymptomatic Severe AS. Kand, Park et al. Circulation 2010;121:1502-9

197 asymptomatic patients with severe AS:

AVA <.75cm2, Mean grad >50 mm Hg, Jet velocity > 4.5m/sec,.

During a median follow-up of 1501 days, the operated group had no operative

mortalities, no cardiac deaths, and 3 noncardiac deaths; the conventional

treatment group had 18 cardiac and 10 noncardiac deaths.

If no Operation Indicated, What is

the Rate of Progression of AS ?

Progression of Aortic Stenosis Palta et al. Circ 2000, 101:2497-2502

174 patients with 2 TTE 23±11 months

apart.

Rate of progression:

- 0.1±0.27 cm2 per year

- Double if cholesterol > 200 mg

- Increased with high creatinine,

high serum calcium, smoking

and severe initial AVA.

Statins and Progression of AS

Am J Cardiol 2008;102:738 –742

1046 patients, 309 with Statins

At 5 years, Statin slowed progression in those with mild or moderate AS.

N Engl J Med 2008;359:1343-56, JACC 2009;53:A415.

1873 pts randomized. Statins did not decrease MACE at 52 months, but decreased CVA’s, and ischemic events.

Circulation. 2004;110:1291-1295.

206 patients. Statins, but not ACE inhibitors slowed progression of AS

J Am Coll Cardiol 2007;49:554–61

120 pts randomized. Rosuvastatin slowed progression of AS.

Briand. JACC 2006;47:2229-36

Metabolic syndrome doubles the rate of progression of AS.

Chan. Circulation 2010 121:306-14 Astronomer Trial.

269 pts randomized. Rosuvastatin 40 mg in mild to moder AS did not reduce progression.

Metabolic Syndrome and Progression of AS. Copoulade, Pibarot et al. JACC 2012;60:169-180

CAD in Patients with Severe AS. WHC: Ben-Dor et al. Circulation 2010;122:S37-42

Patients with CAD had higher risk scores, more females,

more PVD and lower EF.

Conclusions

• Asymptomatic Severe AS is a serious condition associated with mortality.

• Some patients “report” no symptoms in spite of significant limitations.

• Stress test indicated in truly asymptomatic AS.

• AVR improves prognosis in asymptomatic AS if the patient has high risk echo features or abnormal Exercise Test.

The end