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©2017 MFMER | 3645199-1
Rick A. Nishimura, M.D. MACC MACP2nd Annual New York Valve Conference
Valvular Heart DiseaseState of the Art 2020
©2017 MFMER | 3645199-2
Rick A. Nishimura, M.D. MACC MACP2nd Annual New York Valve Conference
Valvular Heart DiseaseState of the Art 2020
©2017 MFMER | 3645199-3
Rick A. Nishimura, M.D.
No disclosures
©2017 MFMER | 3645199-4
Valvular Heart Disease – State of the Art 2020
What we did
What we are doing
What we need to do
From the perspective of a plain old
clinical cardiologist
©2017 MFMER | 3645199-5
©2012
MFMER |
3200979-
2003-5
AorticStenosis
©2017 MFMER | 3645199-6
©2012
MFMER |
3200979-
2003-6
Intervention
Benefit >> Risk
©2017 MFMER | 3645199-7
Valvular Heart Disease – State of the Art 2020
What we did
What we are doing
What we need to do
©2017 MFMER | 3645199-8
S1 S2
S4
3/6
LV
Ao
Severe aortic stenosis
✓ Gradient > 50 mmHg
✓ Gradient > 40 mmHg
✓ AVA < 1.0 cm2
✓ AVA < .7 cm2
✓ AVA < .5 cm2/m2
©2017 MFMER | 3645199-9
0
20
40
60
80
100
0 10 20 30 40 50 60 70 80
Natural History of Aortic Stenosis
0 2 4 6
Avg survival (yr)
Angina
Syncope
Failure
Age (yr)
Latent period(increasing obstruction,myocardial overload)
Onset severe symptoms
Average death
age ( )
Ross J Jr. and Braunwald E: Circ 38(Suppl 5):61, 1968
©2017 MFMER | 3645199-10
High operative risk
8-10%
Adverse outcome of AVR
50% emboli or bleed – 10 years
50% tissue degeneration
Only indication for AVR
Symptoms
Severe stenosis
©2017 MFMER | 3645199-11
Valvular Heart Disease – State of the Art 2020
What we did
What we are doing
What we need to do
©2017 MFMER | 3645199-12
Long Term Followup of
Asymptomatic Severe Aortic
StenosisPellikka et al
Circulation 2005:3290
622 patients
Followup 5.3-10.6 years
Asymptomatic
Peak Vel > 4 m/s
©2017 MFMER | 3645199-13
Years
Su
rviv
al
free o
f sym
pto
ms (
%)
0 1 2 3 4 5 6 7 8 9 10
100
60
20
0
80
40
Circulation 2005
Pellikka et al
Asymptomatic Severe Aortic Stenosis
At 5 yrs
72% CHF or died
©2017 MFMER | 3645199-14
Low operative risk
< 1%
Better AVR
Emboli, bleed < 1% yr
Longevity tissue valves
With lower risk AVR and better outcomes
Further risk stratification
©2017 MFMER | 3645199-15
ACC/AHA Valve Disease Guidelines
Stage A - D
At risk for disease
Progressive disease
Severe disease
(asymptomatic)
Severe disease
(symptomatic)
Stage A
Stage B
Stage C
Stage D
Define “severe”
based on
outcome studies
Grad > 40 mmHg
AVA < 1.0 cm2
©2017 MFMER | 3645199-16
ACC/AHA Valve Disease Guidelines
Stage A - D
At risk for disease
Progressive disease
Severe disease
(asymptomatic)
Severe disease
(symptomatic)
C1: Compensated LV
C2: Decompensated LV
©2017 MFMER | 3645199-17
ACC/AHA Valve Disease Guidelines
Stage A - D
Definition of “decompensated LV”
➢ Long standing pressure overload on the LV
➢ Ventricular state when
➢ Outcome is reduced
➢ LV function postop is reduced
©2017 MFMER | 3645199-18
ACC/AHA Valve Disease Guidelines
Aortic Stenosis
Stage C: Severe
disease
(asymptomatic)
Stage D: Severe
disease
(symptomatic)
C1:EF > 50%
C2:EF < 50%
D1: high gradient
D2: low gradient (low EF)
D3: low gradient (normal EF)
AV Velocity > 4m/s
©2017 MFMER | 3645199-19
ACC/AHA Valve Disease Guidelines
Stage A - D
At risk for disease
Progressive disease
Severe disease
(asymptomatic)
Severe disease
(symptomatic)
Observe
Intervene
C1
C2Intervene
?
©2017 MFMER | 3645199-20
©2012
MFMER |
3200979-
2003-20
Results of Exercise TestingEvent-Free Survival
Amato et al: Heart 86:381, 2001
Months
P=0.0001
Positive (44 patients)
Negative (22 patients)
0.0
0.2
0.4
0.6
0.8
1.0
0 12 24 36 48 60
Negative
Positive
Further risk stratification by exercise testing
©2017 MFMER | 3645199-21
Rosenhek et al: Circ 121:151, 2010
Event-
free s
urv
ival (%
)
0
20
40
60
80
100
0 1 2 3YearsPatients at risk
82 69 59 3872 53 29 1844 20 11 5
AV-Vel
4.0-5.0 m/sec
AV-Vel
5.0-5.5 m/sec
AV-Vel
≥5.5 m/sec
P<0.0001
Further risk stratification by stenosis severity
Stenosis Severity – Doppler VelocityEvent-Free Survival
©2017 MFMER | 3645199-22
Aortic Stenosis : ACC AHA Guidelines
• Indications for SAVR – all patients
• Symptoms (any)
• Drop in EF
• Indications for SAVR – asymptomatic low risk patients
• Positive TMET
• Very severe AS
©2017 MFMER | 3645199-23
Then came transformation
©2017 MFMER | 3645199-24
©2012
MFMER |
3200979-
2003-24
A dramatic relief of obstruction within seconds
©2017 MFMER | 3645199-25
©2012
MFMER |
3200979-
2003-25
TAVR(Transcatheter Aortic Valve Replacment)
• TAVR - inoperable pts
• Lower mortality vs medical Rx
• TAVR - high risk patients
• Comparable to SAVR
• TAVR – intermediate risk patients
• Comparable to SAVR
• TAVR – low risk patients
• Comparable (maybe even better)
©2017 MFMER | 3645199-26
Evaluation of patients with aortic stenosisChanging paradigm
Low Intermediate High InoperableRisk
SAVR TAVR
SAVR
vs
TAVR
Nothing
(futile)Rx
2014 Guidelines
©2017 MFMER | 3645199-27
Evaluation of patients with aortic stenosisChanging paradigm
Low Intermediate High InoperableRisk
SAVR TAVRSAVR vs TAVRNothing
(futile)Rx
2017 Guidelines
©2017 MFMER | 3645199-28
Evaluation of patients with aortic stenosisChanging paradigm
Low Intermediate High InoperableRisk
TAVRSAVR vs TAVRNothing
(futile)Rx
©2017 MFMER | 3645199-29
Evaluation of patients with aortic stenosisChanging paradigm
Low Intermediate High InoperableRisk
TAVRSAVR vs TAVRNothing
(futile)Rx
Dependent upon anatomy
Longevity (patient and valve)
©2017 MFMER | 3645199-30
Valvular Heart Disease – State of the Art 2020
What we did
What we are doing
What we need to do
©2017 MFMER | 3645199-31
Valvular Heart Disease – State of the Art 2020
We now have better and better interventions
But if we only intervene according to guidelines
CV death still occurs following AVR
Persistent heart failure symptoms occur
©2017 MFMER | 3645199-32
Pressure overload
Compensatory hypertrophy
(normalize wall stress)
MVO2
Mismatch
Myocardial
Ischemia
Fibrosis
Scarring
©2017 MFMER | 3645199-33
Bing et al JACC
Imaging 2019:12:283
Papanastasiou et al
JACC Imaging 2019
2x increase mortality
with GDE defects
By the time we operate now, the LV
is already damaged
©2017 MFMER | 3645199-34
What we are finding out – “conventional” criteria too late
• Even “moderate” AS portends poorer outlook
• Outdated “cut-off” – peak velocity > 4.0 m/s
©2017 MFMER | 3645199-35
“Moderate” aortic stenosis
Outcome similar to
“Severe” aortic stenosis
©2017 MFMER | 3645199-36
What we are finding out – “conventional” criteria too late
• Even “moderate” AS portends poorer outlook
• EF < 60% may be “decompensated”
©2017 MFMER | 3645199-37
EF < 60%, not 50%
Poorer prognosis
Ito et al JACC 2019;71;11
©2017 MFMER | 3645199-38
What we are finding out – “conventional” criteria too late
• Even “moderate” AS portends poorer outlook
• EF < 60% may be “decompensated”
• Other measures of LV performance – prognostic value over EF
• Stroke volume index, diastolic parameters
• Myocardial strain and DTI
• Other clinical parameters important
• Body mass, nutrition, gait speed
©2017 MFMER | 3645199-40
EF
Symptoms
Gradient
Valve area
Current criteria
Timing of AVR
©2017 MFMER | 3645199-41
EF
Symptoms
Gradient
Valve area
Diastolic SVI
Strain Biomarkers
Torsion
GDE
©2017 MFMER | 3645199-42
Machine learning processes to
provide precise phenotypic risk
assessment for an individual
patient
EF
Symptoms
Gradient
Valve area
Diastolic SVI
Strain Biomarkers
Torsion
GDE
??????
©2017 MFMER | 3645199-43JACC CVI:2019:12:236-48
©2017 MFMER | 3645199-44
A general perspective on aortic stenosis
Better and better interventions
Need lower and lower thresholds
Identify higher risk patients
Prevent adverse consequences of pressure overload
Machine learning - precise individualized risk assessment
©2017 MFMER | 3645199-45
A general perspective on primary MR
We are operating too late
After the onset of irreversible LV dysfunction
Need lower risk interventions
Need effective durable interventions
Intervene earlier and earlier
©2017 MFMER | 3645199-46
A general perspective on secondary MR
We always thought this was a disease of the LV
We are just finding out that correcting the MR
percutaneously itself may be beneficial
We need to determine who will benefit
©2017 MFMER | 3645199-47
RV
RA
A general perspective on tricuspid regurgitation
A growing problem
Device leads
Atrial fibrillation
We have been reluctant to intervene
We need alternative approaches
©2017 MFMER | 3645199-48
What we did
What we are doing
What we need to do
From the perspective of a plain old
clinical cardiologist
©2017 MFMER | 3645199-49
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