Ελληνική Καρδιολογική Εταιρεία 36o Πανελλήνιο Καρδιολογικό Συνέδριο 29-31/10/2015 Θεσσαλονίκη O Δείκτης Όγκου Παλμού Έχει Προγνωστική Αξία για την Θνησιμότητα των Ασθενών με Σοβαρή Στένωση της Αορτικής Βαλβίδας που Υποβάλλονται σε Διαδερμική Εμφύτευση Αορτικής Βαλβίδας και Παρουσιάζουν Ανεπάρκεια της Μιτροειδούς Νικόλαος Ανουσάκης-Βλαχοχρήστου, Μ. Δρακοπούλου, Κ. Τούτουζας, Α. Συνετός, Γ. Λάτσιος, Κ. Αγγέλη, Σ. Μπρίλη, Κ. Σταθογιάννης, Α. Μαστροκωστόπουλος, Ο Καϊτόζης, Γ. Τρανταλής, Ε. Τσιάμης, Δ. Τούσουλης Α Πανεπιστημιακή Καρδιολογική Κλινική, Ιπποκράτειο Νοσοκομείο Αθηνών The Predictive Value for All-Cause Mortality of Stroke Volume Index in Patients with Severe Aortic Stenosis and Concomitant Mitral Regurgitation Undergoing Transcatheter Aortic Valve Implantation
H μ έ τ ρ ι α / σ ο β α ρ ή α ν ε π ά ρ κ ε ι α μ ι τ ρ ο ε ι δ ο ύ ς σ τ ο υ ς α σ θ ε ν ε ί ς π ο υ υ π ο β ά λ λ ο ν τ α ι σ ε T A V I In SAVR usually repaired during procedure In TAVI left untreated: clinical impact? Evolution of degree of regurgitation?
H μ έ τ ρ ι α / σ ο β α ρ ή α ν ε π ά ρ κ ε ι α μ ι τ ρ ο ε ι δ ο ύ ς σ τ ο υ ς α σ θ ε ν ε ί ς π ο υ υ π ο β ά λ λ ο ν τ α ι σ ε T A V I Etiology of Mitral Regurgitation in Patients Undergoing Transcatheter Aortic Valve Replacement Percentage of patients with organic and functional mitral regurgitation across transcatheter aortic valve replacement studies. L. Nombela-Franc, JACC, 2014
Σ υ χ ν ό τ η τ α Μ έ τ ρ ι α ς / Σ ο β α ρ ή ς Α ν ε π ά ρ κ ε ι α ς Μ ι τ ρ ο ε ι δ ο ύ ς σ τ η ν Α ο ρ τ ι κ ή Σ τ έ ν ω σ η Average among 8927 pts Prevalence of concomitant moderate/severe mitral regurgitation in patients undergoing transcatheter aortic valve implantation for symptomatic severe aortic stenosis J. Bax et al, EHJ, 2014, T. Chakravarty et al, AJC, 2015
Π α θ ο φ υ σ ι ο λ ο γ ί α τ η ς α ν ε π ά ρ κ ε ι α ς μ ι τ ρ ο ε ι δ ο ύ ς σ τ η ν σ τ έ ν ω σ η α ο ρ τ ή ς Pathophysiology of concomitant mitral regurgitation in aortic stenosis P Unger et al, Heart 2010
Π ε ρ ι γ ρ α φ ή τ η ς μ ε λ έ τ η ς P u r p o s e : E v a l u a t i o n o f t h e i m p a c t o f M R o n m i d - t e r m A l l - C a u s e m o r t a l i t y o f A S p a t i e n t s u n d e r g o i n g T A V I a n d c o r r e l a t i o n s w i t h e c h o c a r d i o g r a p h i c a s s e s s m e n t M e t h o d s : 119 prospective patients All-Cause Mortality Echocardiographic Predictors Pre-implantation echo assessment None/Mild MR (n=76) Moderate/Severe MR (n=43) 6-months Echo and 2-year Clinical follow-up Transcatheter aortic valve implantation with CoreValve system
Β α σ ι κ ά χ α ρ α κ τ η ρ ι σ τ ι κ ά τ ω ν α σ θ ε ν ώ ν Total (n=119) None/Mild MR (n=76) Moderate/Severe MR (n=43) p Value Male gender (%) 52 (43.7%) 39 (51.3%) 13 (30.2%) 0.026 Age (y) 79.8 ± 7.3 79.1 ± 8.2 81.2 ± 4.9 0.131 BMI (km/m 2 ) 25.9 ± 3.3 25.7 ± 3.5 26.1 ± 2.9 0.608 BSA (m 2 ) 1.4 ±0.2 1.4 ±0.2 1.3 ± 0.2 0.396 Euroscore 25.1 ± 11.1 24.2 ± 11.4 26.8 ± 10.3 0.210 Creatinine (mg/dl) 1.2 ± 0.7 1.2 ± 0.7 1.1 ± 0.4 0.658 egfr (ml/min/m 2 ) 60.8 ± 21.1 61.3 ± 20.1 59.9 ± 22.9 0.746 CAD 57 (47.9 %) 29 (38.2 %) 28 (65.1 %) 0.005 DM 26 (21.8 %) 14 (18.4 %) 12 (27.9 %) 0.229 COPD 24 (20.2 %) 11 (14.5 %) 13 (30.2 %) 0.040 PAD 41 (34.5 %) 27 (35.5 %) 14 (32.6 %) 0.842 Baseline Characteristics of the Study Population Unpublished data
Υ π ε ρ η χ ο κ α ρ δ ι ο γ ρ α φ ι κ ά χ α ρ α κ τ η ρ ι σ τ ι κ ά π ρ ο T A V I Total (n=119) None/Mild MR (n=76) Moderate /Severe MR (n=43) p Value EF (%) 50.4 ±0.1 51.4 ±0.1 48.7 ±0.1 0.128 V max (cm/sec) 4.5 ± 0.6 4.5 ±0.5 4.4 ±0.8 0.513 Peak Gradient (mmhg) 81.4 ± 22.9 81.8 ±18.6 80.6 ±29.4 0.786 Mean Gradient (mmhg) 49.6 ± 15.1 50.3 ±11.8 48.5 ±19.5 0.524 Low Mean Gradient (%) 28 (23.5 %) 14 (18.4 %) 14 (32.6 %) 0.081 PASP (mmhg) 43.1 ± 11.4 41.1 ±10.3 46.7 ±12.3 0.048 AVA (cm 2 ) 0.6 ±0.1 0.6 ±0.1 0.5 ±0.2 0.124 AVA indexed (cm 2 /m 2 ) 0.4 ± 0.1 0.43 ±0.1 0.41 ± 0.1 0.235 Stroke Volume (ml) 58.2 ± 14.6 59.9 ± 14.2 55.2 ±14.9 0.091 Stroke Volume indexed (ml/cm 2 ) 43.3 ± 12.1 44.3 ±12.3 41.3 ± 11.6 0.194 Low Stroke Volume Index (%) 33 (27.7 %) 19 (25%) 14 (32.6 %) 0.376 Intra-Ventricular Septum (mm) 12.4 ± 1.3 12.5 ± 1.3 12.2 ±1.2 0.247 Severe Calcification of Aorta 25 (21.0 %) 12 (15.8 %) 13 (30.2 %) 0.063 Bicuspid Aortic Valve 12 (10.1 %) 7 (9.2 %) 5 (11.6%) 0.755* * Fisher s exact test, Kolmogorov-Smirnov s test Baseline Echocardiographic Characteristics of the Study Population Unpublished data
Υ π ε ρ η χ ο κ α ρ δ ι ο γ ρ α φ ι κ ά χ α ρ α κ τ η ρ ι σ τ ι κ ά 6 μ ή ν ε ς μ ε τ ά τ η ν T A V I Total (n=119) None/Mild MR (n=76) Moderate/Severe MR (n=43) p Value EF (%) 51.6 ± 0.1 52.4 ± 0.1 50.1 ± 0.1 0.125 V max (cm/sec) 2.9 ± 0.6 2.9 ± 0.5 2.9 ± 0.8 0.803 Peak Gradient (mmhg) 18.4 ± 7.9 18.2 ± 5.5 18.6 ± 11.3 0.821 Mean Gradient (mmhg) 9.8 ± 4.7 9.5 ± 2.9 10.3 ± 6.9 0.434 PASP (mmhg) 40.7 ± 8.6 38. 5 ± 7.1 44.7 ± 9.1 0.001 * AVA (cm 2 ) 1.5 ± 0.5 1.5 ± 0.4 1.5 ± 0.6 0.506 AVA indexed (cm 2 /m 2 ) 1.1 ± 0.4 1.1 ± 0.4 1.1 ± 0.4 0.550 Stroke Volume (ml) 55.8 ± 14.1 56.2 ± 15.4 55.1 ± 18.5 0.715 Stroke Volume indexed (ml/cm 2 ) 41.7 ± 14.7 42.1 ± 14.9 41.1 ± 13.3 0.710 Mitral regurgitation improvement (%) 31 (26.1 %) 2 (2.6 %) 29 (67.4 %) 0.001 Paravalvular Leakage 0.721 None 32 (26.9%) 22 (28.9%) 10 (23.2%) Mild 80 (67.2%) 49 (64.4%) 31 (72.9%) Moderate 7 (5.9%) 5 (6.5%) 2 (4.7%) * Kolmogorov-Smirnov s test, Fisher s exact test Echocardiographic Follow-Up 6 months after TAVI Unpublished data
Ο λ ι κ ή Θ ν η σ ι μ ό τ η τ α σ τ α 2 έ τ η None/Mild MR Moderate/Severe MR p Value At 30-Days 1.3 % 2.3 % 0.999 At 12 months 7.9 % 18.6 % 0.201 At 24 months 9.2 % 30.2 % 0.006 During FU period 14.5 % 34.9 % 0.006 * Percentage (Fisher s exact test), Cumulative probability (log-rank test) Follow Up Cumulative probability for survival from all-cause mortality at 2 years (median time of follow-up) Unpublished data
Α ν ε ξ ά ρ τ η τ ο ι π ρ ο γ ν ω σ τ ι κ ο ί δ ε ί κ τ ε ς θ ν η σ ι μ ό τ η τ α ς HR 95% CI p Value Low Stroke Volume Index 5.13 [2.21, 11.92] 0.001 Moderate/Severe MR pre-tavi 3.44 [1.06, 11.12] 0.039 MR improvement after-tavi 0.73 [0.24, 2.22] 0.582 PASP pre-tavi 1.00 [0.96, 1.04] 0.984 CAD 0.62 [0.25, 1.51] 0.290 COPD 1.29 [0.51, 3.31] 0.584 GENDER 1.38 [0.55, 3.47] 0.493 Independent predictors of all-cause mortality from final multivariate model (Cox regression analysis model adjusted for baseline group differences) Evaluated echo variables in univariate analysis that did not contribute to final model: AVA, AVAi, SV, mean gradient, low mean gradient, peak gradient, Vmax, EF, PASP Unpublished data
Β ε λ τ ί ω σ η α ν ε π ά ρ κ ε ι α ς μ ι τ ρ ο ε ι δ ο ύ ς μ ε τ ά τ η ν T A V I At 6 months, mitral regurgitation degree improved in 31 patients (26.1%) : 67.4% vs 2.6% of moderate/severe MR and none/mild MR group respectively, p<0.001) whereas 88 patients (73.9%) had the same degree of MR after TAVI Unpublished data
Δ ι ε θ ν ή ς Β ι β λ ι ο γ ρ α φ ί α Β ε λ τ ί ω σ η τ η ς α ν ε π ά ρ κ ε ι α ς μ ι τ ρ ο ε ι δ ο ύ ς μ ε τ ά τ η ν T A V I TAVI is associated with a significant improvement in MR, especially in severe types. MR improvement was not influenced by the etiology of MR, the type of valve implanted, and the operative risk. NYHA classification at baseline and 1-year follow-up among patients undergoing TAVI stratified according to the severity of baseline MR J. Crochan et al, Circ Cardiovasc Interv. 2015, Almasood et al, J Saudi Heart Assoc 2015, G. Hekimian, JASE, 2011
Δ ι ε θ ν ή ς Β ι β λ ι ο γ ρ α φ ί α Β ε λ τ ί ω σ η τ η ς α ν ε π ά ρ κ ε ι α ς μ ι τ ρ ο ε ι δ ο ύ ς μ ε τ ά τ η ν T A V I Mitral regurgitation improvement early and late after transcatheter aortic valve implantation. J. Bax et al, EHJ, 2014
Δ ι ε θ ν ή ς Β ι β λ ι ο γ ρ α φ ί α Ε π ί δ ρ α σ η τ η ς α ν ε π ά ρ κ ε ι α ς μ ι τ ρ ο ε ι δ ο ύ ς σ τ η ν θ ν η σ ι μ ό τ η τ α α σ θ ε ν ώ ν μ ε σ τ έ ν ω σ η α ο ρ τ ι κ ή ς β α λ β ί δ α ς Forest plot evaluating the impact of baseline MR on outcomes RR for all-cause mortality comparing moderate-severe MR versus none-mild MR at baseline. T. Chakravarty et al, AJC, 2015
Δ ι ε θ ν ή ς Β ι β λ ι ο γ ρ α φ ί α I m p a c t o f l o w E F, l o w f l o w, l o w g r a d i e n t o n m o r t a l i t y All-cause mortality in patients with low EF AS after TAVI All-cause mortality in patients with low SVI AS after TAVI All-cause mortality in patients with LG AS after TAVI M. Eleid et al, AJC, 2015
Δ ι ε θ ν ή ς Β ι β λ ι ο γ ρ α φ ί α A D J U S T E D?? All-cause mortality in patients with low EF AS after TAVI All-cause mortality in patients with low SVI AS after TAVI All-cause mortality in patients with LG AS after TAVI M. Eleid et al, AJC, 2015
Σ υ μ π ε ρ ά σ μ α τ α In patients with symptomatic severe aortic stenosis undergoing TAVI with CoreValve, the presence of concomitant moderate or severe mitral regurgitation, increases risk for all-cause mortality in a two-year period. Low stroke volume index is the strongest echocardiographic predictor of mortality after TAVI - independently of mitral regurgitation improvement. Further study is needed in order to accurately determine the prognostic role of SVi in conjunction with other echo variables Future studies will determine the best therapeutic strategy for such patients.
Ελληνική Καρδιολογική Εταιρεία 36o Πανελλήνιο Καρδιολογικό Συνέδριο 29-31/10/2015 Θεσσαλονίκη Α Πανεπιστημιακή Καρδιολογική Κλινική, Ιπποκράτειο Νοσοκομείο Αθηνών Ε υ χ α ρ ι σ τ ώ! T h a n k y o u! The Predictive Value for All-Cause Mortality of Stroke Volume Index in Patients with Severe Aortic Stenosis and Concomitant Mitral Regurgitation Undergoing Transcatheter Aortic Valve Implantation