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

Snowmass 2014

Symptoms of Aortic Stenosis

• Main symptoms:– dyspnea, – angina, – syncope,

• Other important symptoms: – dizziness,– weakness, – fatigue, – exercise intolerance.

• Patients may not be aware of symptoms.

Asymptomatic Aortic Stenosis

Main Message:

• Asymptomatic severe AS is not a benign condition.

• Patients with asymptomatic severe AS may need AVR before symptoms are manifest.

Mortality of Asymptomatic Severe Aortic Stenosis

Incidence of Sudden Death in Asymptomatic Aortic Stenosis

Rahimtoola EHJ 2008; 29:1783-91.

Lancelotti AJC 2010 126 4.8

Patients

n=

26128 66 69125

622

Rahimtoola, EHJ 08

Outcome of Asymptomatic Aortic StenosisPellikka 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

Predictors of events

Aortic Jet Velocity and Survival. Otto et al. Circulation 1997, 95:2262

20% events at 5 years

40% events at 4 years

80% events at 3 years100% events at 5 years

123 AS patients without symptoms

Jet Velocity, AVA and OutcomeOtto 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 Testis indicated

in Asymptomatic Aortic Stenosis

Exercise testing in Asymptomatic ASAmato 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 TestLancelotti et al. Circul 2005;112:I 377-82

Predictive value

AHA/ACC Guidelines for AVRCirculation, ahead of Print March 2014

New in 2014:

AVR indicated in patients with Asymptomatic Severe AS and exercise testing showing:

• decreased exercise tolerance

• drop in BP during treadmill testing

Other Predictors of events

ECG in Asymptomatic ASGreve, Wachtell et al. Copenhagen.

Exhausted Coronary Flow Reserve in ASPichard, Gorlin et al. Am J Cardiol 1981;47: 547-54

• As LV Mass increases, coronary flow needs to augment.

• In severe AS, resting coronary flow is high and flow reserve is exhausted. These patients have ischemia during exercise.

• LVH with “strain” on ECG may be a sign of exhausted CFR and underlying ischemia at rest.

• Rapid clinical deterioration may follow after this threshold of CBF is reached.

LA Size and Survival in Asymptomatic Severe ASCasaglang-Verzos, Pellika et al. Echocardiography 2010;27:105-9

Diastolic function, evaluated by LA size, determines Mortality independent of age, gender, AS severity, and Doppler diastolic function.

Survival of Asymptomatic AS According to Score. Monin et al. Circulation 2009;120:69-75

Independent predictors used in Score:

female sex, peak aortic-jet velocity, and BNP at baseline.

n=214 pts.

BNP and Tissue Doppler in Asymptomatic AS.Rajani et al. J Heart Valve Dis 2009;18:565-571

65 asymptomatic patients with AVA 0.8-1.2 cm2

Patients with BNP < 58 have no symptoms for the next 12 months.

88% of patients with BNP >250, and 50% of patients with BNP >58 developed symptoms within 1 year.

Valvulo-Arterial Impedance in Asymptomatic ASHachicha et al. Laval Univ. JACC 2009;54;1003-1011

544 patients with moderate or severe AS

mmHg/ml/m2

ZVA= SAP+MG

SVi

Low Flow, Low Gradient Asymptomatic ASCramariuc et al. JACC imaging 2009;2:390-9

• 1873 asymptomatic AS patients from the SEAS Study.

• 28% had severely reduced energy loss index and:

- more concentric LVH.

- smaller LV cavity (normal EF).

- increased valvulo-arterial impedance.

- decreased stress corrected midwall shortening.

- decreased survival.

Excessive LV Mass and OutcomeRahimtoola EHJ 2008;29:1783-90

•Some patients have more LVH than appropriate for the degree of AS (>12-14 mm in women and > 14-16mm in men, with high EF).

•Occurs more often in women.

•These patients have higher surgical mortality and persistent symptoms of diastolic dysfunction after surgery.

•These patients should have surgery early.

Summary of Predictors

Pts with severe AS and no symptoms are at higher risk of events if:

• Symptoms during exercise test.• AVA <1.0 cm2• Jet velocity >4 m/sec • Increase in jet velocity >.3 m/s x year• Severe valve calcification• Disproportionate LVH• Elevated BNP, elevated Zva, etc.

Why Operate Early ?

Severe AS, even asymptomatic, has

• Very low surgical mortality/morbidity.

• Higher surgical mortality when more symptomatic.

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

n=197

AVR in USA 1999-2011Barretto-Filha et al. JAMA 2013;310:2078-84

2001 2011

# Patients 26,598 31,380

30 day Mortality

7.3 4.2

Age 65-74 5.7 3.3

Age 75-84 7.8 4.4

Age > 85 10.8 5.8

1993-2003 Loma Linda Echo Lab Database.Pai et al. Ann Thor Surg 2006;82:2116-22

Asymptomatic Patients

Valve ReplacementValve Replacement

No surgeryNo surgery

338 asymptomatic patients with AVA <0.8 cm2

338 asymptomatic patients with AVA <0.8 cm2

AVR in the Elderly.Cerillo et al. Interact CardioVasc Thorac Surg 2007;6:308-13

Conclusions

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

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

• Follow these patients with yearly exercise echo-doppler.

• All patients with severe AS should be evaluated for possible AVR, independent of symptoms.

The end

0

2

4

6

8

P<0.001P<0.001

4.14.1

5.35.3

NF NF PLFPLF

Global LV Hemodynamic Load:Valvulo-Arterial Impedance (Zva)

Hachicha Z et al., Circ 2007; 115:2856-64Hachicha Z et al., Circ 2007; 115:2856-64

(mmHg/ml/m2)ZVA=

SAP+MGSVi

Briand, JACC, 46:291-296,2005

Mortality for AVR.STS Executive Summary 2008

www.sts.org

<10% of patients had STS >10