Ανδρέας Συνετός, MD, PhD, FESC, MEAPCI Α Καρδιολογική Κλινική Πανεπιστημίου Αθηνών Ιπποκράτειο Γ.Ν.Α.

Ανδρέας Συνετός, MD, PhD, FESC, MEAPCI Α Καρδιολογική Κλινική Πανεπιστημίου Αθηνών Ιπποκράτειο Γ.Ν.Α.

No relationships to disclose

All valvular heart disease imparts a hemodynamic burden on the left and/or right ventricle. This burden can only be removed effectively by correcting the responsible valvular lesion.

SAVR TAVI Partner 5 yrs J Thorac Cardiovasc Surg 2009;137:82-90 J Am Coll Cardiol 2013;61:413 9

P. Faggiano et al. / International Journal of Cardiology 159 (2012) 94 99 Gilard et al., NEJM, 2012

Απαραίτητο να γίνει ώστε να επιτευχθεί μια κοινή μονάδα σύγκρισης : - προσαρμόζονται τα τελικά σημεία των μελετών σχετικά με τη σοβαρότητα της νόσου - μελετάται μια νέα θεραπεία συγκρινόμενη με την υπάρχουσα Οι αλγόριθμοι αυτοί βασίζονται σε ασθενείς που υποβλήθησαν σε χειρουργική αντικατάσταση αορτικής βαλβίδας και δεν μπορούν να εφαρμοστούν άμεσα σε ασθενείς που υποβάλλονται σε TAVR

Stahli E, et al. Cardiology. 2013;126(1):15-23. Toutouzas K, Stefanadis C. editorial Cardiology. 2013;126(1):12-4

STS score and log EuroSCORE have low c-indexes between 0.49-0.70. Although the 3 scores were not predictive for 30 day mortality the updated EuroSCORE II had better accuracy with area under curve of 0.70. The STS score had the worse predictive value in short term mortality and there was no difference in STS score between survivals and non-survivals 410±22 days. Toutouzas K, Stefanadis C., Cardiology, 2013

Ασθενικότητα (Frailty): Αδυναμία, εξάντληση, βραδύτητα κινήσεων, καχεξία, εύκολη κόπωση, αδυναμία επιτέλεσης απλών εργασιών, αδυναμία αυτοεξυπηρέτησης Κριτήρια: 5 m βάδιση (gait speed) (<7sec) Δύναμη στο χέρι (Grip strength) (> 18 Kg) BMI 20 kg/m2 ή απώλεια βάρους 5 kg/year Αλβουμίνη ορού<3.5 g/dl Άνοια Ατομικό Ιστορικό Κλινική εξέταση Επιτέλεση απλών εργασιών-μετρήσεων Katz Index (πλύσιμο, ντύσιμο, τροφή, εγκράτεια, τουαλέτα, μετακίνηση) (<4/6)

7% PCI In 230 TAVI pts (Edward-Sapien or Medtronic CoreValve) 1 year mortality did not correlate to the presence of CAD Gautier M et al. EuroIntervention 2011;7:549-555

GR <30 mmhg (or 40 mm Hg), aortic valve area <1 cm², EF<35% (or 40%) Survival following surgery for aortic stenosis patients with low gradient and low ejection fraction. Operative mortality was 21%, and less than half of the patients survived four years Circulation 2000;101 1940 6.

Survival for aortic stenosis patients with low gradient and low ejection fraction. Group I patients demonstrated inotropic reserve and had a better outcome with AVR than did similar patients treated medically, and better than group II patients who lacked inotropic reserve. Circulation 2003;108:319 24.

Paradoxical low flow low gradient AS

Svi (ml/m 2 ) No Yes EF (%) 70 60 50 40 30 20 10 0 No Cumulative mortality p=0.03 Yes 70 60 50 40 30 20 10 0 No No Cumulative mortality p=0.31 Yes SVi was the only independent predictor of 2-year mortality (OR: 0.95, 95% CI: 0.917-0.998, p= 0.039) M. Drakopoulou, K. Toutouzas, A. Synetos, G. Latsios, G. Trantalis, A. Mastrokostopoulos, K. Stathogiannis, D. Tousoulis, C. Stefanadis. ESC 2014

AR both Volume and Pressure overload. In both groups, (LOW EF or PRESERVED EF afterload decreased and ejection fraction increased following AVR Circulation 1990;82:798 807.

When LV end-systolic diameter (LVESD) is >50 mm, the probability of death, symptoms or LV dysfunction is reported to be 19% per year Circulation 1991;84:1625-1635

Circulation. 2002;106:2687-2693

Pure Volume overload Decrease forward SV Eccentric Hypertrophy Increase length of myocytes increase LV volume and SV Sympathetic NS Activation Supports inotropic state but leads to further Myocardial damage

Ann Thorac Surg 2004;78:820 5

European Heart Journal (2015) 36, 2733 2741

International Journal of Cardiology 149 (2011) 211 215

Saibal, EuroPCR, 2014

Nishimura et al, 2014, ACC/AHA Guidelines

TCT 2011 K Toutouzas, A Karanasos, K Spargias, K Stathogiannis, G Latsios, A Synetos, M Chrissoheris, A Chalapas, A Adoniades, G Pavlides, C Stefanadis

Postoperative outcome is shown for mitral stenosis patients with pulmonary hypertension. Long-term outcome was good but followed a high (12%) operative mortality. Circulation 1995;92 Suppl 9:II137 42.

Stratos, Toutouzas, Synetos et al HJC 2015

Surgical strategies are directed mainly to the annulus with fluctuating results because functional tricuspid regurgitation is not due only to the annulus but also to the RV, which is difficult to assess, due to its evolution being unpredictable and complicated by the interaction with LV.

Patients comorbidities and functional status has an important role in decision making for valve treatment Ventricular reserve and viability is a prerequisite for proceeding with the operation Personalized strategies

Special Contributors: G. Latsios A. Synetos K. Toutouzas