Evaluation of Patients with Aortic Stenosis before Replacement (Surgical or Transdermal)

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2 Evaluation of Patients with Aortic Stenosis before Replacement (Surgical or Transdermal) Leonidas E. Poulimenos MD, FESC Cardiologist Department of Cardiology Asklepeion General Hospital, Voula, GR Head: Prof. A. J. Manolis

3 Conflict of Interest (Honoraria and/or Advisory Boards) Astra Zeneca Bayer Menarini MSD Sanofi Win Medica

4 Συχνότητα επανεκτίµησης Patients with mixed valve disease may require serial evaluations at intervals earlier than recommended for single valve lesions Nishimura RA, Otto CM, Bonow RO, et al. J Am Coll Cardiol

5 Είναι σηµαντική η νόσος ; a In patients with normal cardiac output/transvalvular flow. Vahanian A, et al. Eur Heart J 2012;33(19):

6 Accounting for pressure recovery Accounting for body size Accounting for inconsistencies in the guidelines criteria Interaction between hypertension and aortic stenosis severity criteria. Accounting for low flow states Pibarot P, Dumesnil JG. J Am Coll Cardiol 2012;60(3):

7 Tardif, J. C., et al.the American Journal of Cardiology 1995 ; 76(3),

8 Impact of variations in SV on AVA in patients with AoS and AF Sudhakar et al. JACC 2014; 63:A1023; Donegan et al. JACC 2014; 63:A 1024

9 Continuity equation: Average of multiple beats Long cycle length Aortic Valve Area Correlation coefficient=0.963, p<0.001 (Pearson) Similar results when indexed to BSA Sudhakar et al. JACC 2014; 63:A1023; Donegan et al. JACC 2014; 63:A 1024

10 Is the patient asymptomatic? Amato, MC. Heart 2001;86:

11 Comorbidities in Symptomatic vs Non Symptomatic Severe AoS N= 164 Ramamurthi A, et al. Echocardiography 2013;30(1):1

12 Vahanian A, et al. Eur Heart J 2012;33(19):

13 Risk Scores How to improve discrimination between low- and high-surgical risk (including SAVR), How to identify patients who should be referred for TAVI, and How to predict procedural risk and outcome in TAVI candidates.

14 Εκτίµηση κινδύνου για χειρουργική αντικατάσταση αορτικής βαλβίδας. STS- Society of Thoracic Surgeons LES -EuroSCORE (logistic) EuroSCORE (additive) Ambler (UK) NNE-Northern New England New York State Providence Health System VA Risk Score

15 Εκτίµηση κινδύνου για χειρουργική αντικατάσταση αορτικής βαλβίδας. «Νεότερα» Risk Scores. ACEF Score Australian-AVR-Score STS Upgrade v EuroSCORE II

16 European System for Cardiac Operative Risk Evaluation (EuroSCORE) II

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18 Discrimination vs Calibration

19 Euroscore II vs STS Durand J et al. Am J Cardiol 2013;111:

20 Euroscore II vs STS

21 Porcelain thoracic aorta (hazard ratio [HR] 2.56) Anemia (HR 2.03) Left ventricular dysfunction (HR 1.98) Recent myocardial infarction (HR 3.78) Male sex (HR 1.81) Critical aortic valve stenosis (HR 2.46) Old age (HR 1.68) Renal dysfunction (HR 1.76) Debonnaire P, et al. Am J Cardiol 2015;115:234-2

22 Debonnaire P, et al. Am J Cardiol 2015;115:234-2

23 Εκτίµηση κινδύνου Use of the STS PROM to predict risk in a given institution with reasonable reliability is appropriate only if institutional outcomes are within 1 standard deviation of STS average observed/expected ratio for the procedure in question Nishimura RA, Otto CM, Bonow RO, et al. J Am Coll Cardiol

24 Frailty Katz Activities of Daily Living Independence in Feeding Bathing Dressing Transferring Toileting Urinary continence Independence in ambulation (no walking aid or assist required or 5-meter walk in <6 s) Nishimura RA, Otto CM, Bonow RO, et al. J Am Coll Cardiol

25 Major Organ System compromise Cardiac Severe LV systolic or diastolic dysfunction or RV dysfunction, Fixed pulmonary hypertension; CKD stage 3 or worse; Pulmonary dysfunction FEV1 <50% or DLCO 2 <50% of predicted; CNS dysfunction Dementia, Alzheimer s disease, Parkinson s disease, CVA with persistent physical limitation GI dysfunction Crohn s disease, Ulcerative colitis, Nutritional impairment, or serum albumin <3.0; Cancer active malignancy Liver Any history of cirrhosis, variceal bleeding, or elevated INR in the absence of VKA therapy.

26 Procedure Specific Impediment Tracheostomy present Heavily calcified ascending aorta Chest malformation Arterial coronary graft adherent to posterior chest wall Radiation damage Nishimura RA, Otto CM, Bonow RO, et al. J Am Coll Cardiol

27 Limitations of risk scores 1. Different risk factors selected 2. Different weighting of these risk factors 3. Variable patient characteristics in the initial derivation cohort 4. Differences in outcome data used for risk score development (partly related to caseload at enrolling centers) 5. Changing patient characteristics (age, comorbidity, and redo surgery) over time, resulting in a disproportionate number of high-risk patients 6. Changing operative techniques and reduced mortality with time, resulting in discrepancies between estimated and observed outcome Rosenhek R, et al. Eur Heart J 2012;33(7):822

28 Score variables should be defined by the following characteristics 1. Frequent representation in the derivation and validation cohorts to avoid inaccurate estimation of predictive power 2. Easy and reproducible assessment; 3. Clinically relevant impact on operative mortality (but not surrogate endpoints). Rosenhek R, et al. Eur Heart J 2012;33(7):822

29 Conditions that are relative or absolute contraindications to conventional surgery (and are therefore very rare in surgical series) Severe calcification of the ascending aorta (porcelain aorta, preferably defined using standardized imaging criteria) Previous chest wall radiation Hepatic failure Chest wall malformation Rosenhek R, et al. Eur Heart J 2012;33(7):822

30 Vahanian A, et al. Eur Heart J 2012;33(19):

31 Αγγειακός Έλεγχος. Η αξιολόγηση των περιφερειακών αγγείων απαιτεί την εκτίµηση 3 σηµαντικών χαρακτηριστικών: Το µέγεθος (η ελάχιστη διάµετρος του αυλού), Η ελίκωση των αγγείων και Η ασβέστωση των λαγονοµηριαίων αρτηριών. Η αγγειακή εκτίµηση πραγµατοποιείται µε τη χρήση αγγειογραφίας αντίθεσης ή µε την Multidetector Computed Tomography (MDCT).

32 MDCT/TEE

33 MDCT/TEE

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36 Porcelain aorta and SAVR Transaortic TAVR

37 Kurra V, et al. J Am Coll Cardiol Intv. 2010;3(1):105-1

38 Επιλογή του κατάλληλου µεγέθους

39 Επιλογή του κατάλληλου µεγέθους

40 TAVI size selection

41 Windecker S, Kolh P, Alfonso F, et al Eur Heart J 2014;35(37):

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