TAVR in a patient with LV dysfunction
- 1. TAVR in a Patient with LV Dysfunction Philippe Pibarot, DVM, PhD, FACC, FAHA, FESC, FASE Canada Research Chair in Valvular Heart Diseases UniversitéUniversité LAVALLAVAL InstitutInstitut UniversitaireUniversitaire de Cardiologiede Cardiologie et de Pneumologie de Québec /et de Pneumologie de Québec / Québec Heart & Lung InstituteQuébec Heart & Lung Institute
- 2. Disclosure Philippe Pibarot Financial relationship with industry: Ø Edwards Lifesciences Ø V-Wave Other financial disclosure: Ø Research Grants from Canadian Institutes of Health Ø Research and Heart & Stroke Foundation of Quebec Off label Use: None
- 3. CaseCase Ø 76 y.o. woman Ø Risk factors: Ø Hyperchol, Hypertension, COPD Ø 3-vessel CAD Ø CABG3, 5 years ago Ø Coronary angio shows patent grafts Ø CHF: LVEDD: 64 mm, LVEF: 25%, BNP: 832 pg/ml Ø Worsening of HF symptoms recently Ø Aortic stenosis: AVA: 0.8 cm2, Peak/Mean gradients: 46/27 mmHg Ø Current medication: ASA, ARBs, Statin, Digoxin, Brochodil.
- 4. What do you do next? 1- Low dose (up to 20) dobutamine stress echo 2- High dose (up to 40) dobutamine stress echo 3- Close echo/clinical follow-up 4- Refer to AVR Question #1
- 5. What do you do next? 1- Low dose (up to 20) dobutamine stress echo 2- High dose (up to 40) dobutamine stress echo 3- Close echo/clinical follow-up 4- Refer to AVR Answer #1
- 6. LVEF=25%LVEF=25% SV= 51 mlSV= 51 ml AVA= 0.8 cmAVA= 0.8 cm2 ∆P∆P= 46 /= 46 / 2727 mmHgmmHg LVEF=30%LVEF=30% SV= 57 mlSV= 57 ml AVA= 0.8 cmAVA= 0.8 cm2 ∆P∆P= 52 /= 52 / 3030 mmHgmmHg DSEDSEResting EchoResting Echo Case
- 7. What is the severity of the stenosis? 1- Moderate 2- Severe 3- Very severe 4- I can not tell from the DSE Question #2
- 8. What is the severity of the stenosis? 1- Moderate 2- Severe 3- Very severe 4- I can not tell from the DSE Answer #2
- 9. LVEF≤40% AVA≤1.0 ΔP<40 No Contractile (Flow) Reserve SV < 20 % AS Severity: Indeterminate SV ≥ 20 % Contractile (Flow) Reserve SAVR CABG TAVR PCI ΔP≥40 AVA<1.0 True-Severe AS Pseudo-Severe AS ΔP<40 AVA ≥1.0 Dobutamine-Stress Echo HF Therapy ?
- 10. What would you do next? 1- Refer to surgical AVR 2- Refer to transcatheter AVR 3- Aortic valve calcium scoring by CT 4- Close echo/clinical follow-up Question #3
- 11. What would you do next? 1- Refer to surgical AVR 2- Refer to transcatheter AVR 3- Aortic valve calcium scoring by CT 4- Close echo/clinical follow-up Answer #3
- 12. Fig. 4 AVC Score: 2682 AU Case
- 13. What is the severity of the stenosis? 1- Mild 2- Moderate 3- Severe 4- I can not tell from the CT Question #4
- 14. What is the severity of the stenosis? 1- Mild 2- Moderate 3- Severe 4- I can not tell from the CT Answer #4
- 15. Fig. 4 Mayo-Québec-Bichat Collaboration: Accuracy of AVC to identify severe AS Gender Threshold AUC Sensitivity (%) Specificity (%) PPV (%) NPV (%) Women 1274 AU 0.91 89 86 93 79 Men 2065 AU 0.90 89 80 88 82 0 20 40 60 80 100 0 20 40 60 80 100 Sensibility, (%) 1- Specificity, (%) Clavel et al. JACC 2013 Case: 2682 AU
- 16. Mayo-Québec-Bichat Collaboration: Impact of AVC on Survival In patients with AS Clavel et al. JACC 2014 Whole Cohort Patients treated Medically
- 17. LVEF≤40% AVA≤1.0 ΔP<40 No Contractile (Flow) Reserve SV < 20 % AS Severity: Indeterminate Yes True-Severe AS Dobutamine-Stress Echo MSCT: AoV Ca Score >1200♀ >2000♂ ?
- 18. Absence of LV contractile / flow reserve is a marker for: 1- High operative risk for AVR 2- Lack of recovery of LV function following AVR 3- Increased risk of long-term mortality following AVR 4- All of the above Question #5
- 19. Absence of LV contractile / flow reserve is a marker for: 1- High operative risk for AVR 2- Lack of recovery of LV function following AR 3- Increased risk of long-term mortality following AVR 4- All of the above Answer #5
- 20. Preoperative Contractile Reserve vs. Postoperative Ejection Fraction Quere et al, Circulation 2006;113:1738-1734 Group I (CR+) 6% 97±7% Group II (CR-) 33% 90±5% Operative Mortality 2-year Survival 66 Patients who underwent AVR
- 21. Total Population Matched Patients Tribouilloy et al. JACC, 53;1865-1873, 2009
- 22. What do you recommend now? 1- Surgical AVR 2- Transcatheter AVR 3- Staged approach with BAV and TAVR 4- Medical management Question #6
- 23. What do you recommend now? 1- Surgical AVR 2- Transcatheter AVR 3- Staged approach with BAV and TAVR 4- Medical management Answer #6
- 24. Case: TransapicalCase: Transapical ValveValve ImplantationImplantation Early Postop. Peak ∆P: 14 mmHg Mean ∆P: 7 mmHg Trace AR Evidence of Severe AS on MDCT No LV Flow Reserve Logistic Euroscore: 60%
- 25. Impact ofImpact of ApproachApproach (TF vs. TA) on(TF vs. TA) on MyocardialMyocardial InjuryInjury FollowingFollowing TAVRTAVR Rodés-Cabau et al. JRodés-Cabau et al. J. Am. Coll. Cardiol. 2011;57;1988-1999. Am. Coll. Cardiol. 2011;57;1988-1999
- 26. Pre-Procedure 1-Year Post-Procedure1-Year Post-Procedure
- 27. LVEF (%) BNP (pg/ml) Pre 7-dy 1-mo 1-yr Pre 7-dy 1-mo 1-yr 6MWT (m) Pre 7-dy 1-mo 1-yr Case:Case:
- 28. Treatment Comparison in Low-EF, Low-Flow, Low-Gradient (both cohorts) 2-YearDeath(%) 0 10 20 30 40 50 60 70 80 90 Time in Days 0 60 120 180 240 300 360 420 480 540 600 660 720 56 50 45 39 38 37 35 32 32 49 38 36 35 35 32 29 29 27 17 15 14 12 11 9 9 9 9 25 19 13 10 10 8 5 5 5 Number At Risk A-TAVR A-Surgery B-TAVR B-Std Rx Log Rank P= 0.001 42.9% 37.1% 47.1% 80.0% LF, LEF and LG - A-TAVR LF, LEF and LG - A-Surgery LF, LEF and LG - B-TAVR LF, LEF and LG - B-Std Rx Herrmann et al Circulation 2013Herrmann et al Circulation 2013
- 29. Recovery of LVEF in Patients with Low-LVEF, Low-Flow, Low-Gradient AS: TAVR versus SAVR Clavel Circulation, 122:1928-36., 2010 LVEjectionFraction,(%) Baseline Discharge 1 year Visits t: different from baseline *: different from SAVR ‡: different from discharge 30 35 40 45 50 SAVR TAVI20 25 *t‡ t t t 68 24 68 24 68 24 7 ±13% 15 ±14% Low-Flow, Low-Gradient AS
- 30. DeathfromAnyCause(%) 0 10 20 30 40 50 60 70 Time in Days 0 60 120 180 240 300 360 420 480 540 600 660 720 22 18 18 15 14 13 12 9 9 68 68 63 60 58 57 56 54 45 22 20 19 18 18 17 17 17 13 44 42 42 40 39 36 35 33 28 Number At Risk TAVR - No Improvement TAVR - Improvement SAVR - No Improvement SAVR - Improvement Log Rank P= <.001 59.1% 20.6% 24.0% 21.1% TAVR - No Improvement TAVR - Improvement SAVR - No Improvement SAVR - Improvement PARTNER-IA: All Cause Mortality LVEF Improvement at 30-days (LVEF<50%) Elmariah et al.Elmariah et al. Circ Cardiovasc Interv.Circ Cardiovasc Interv. 2013;6:604-142013;6:604-14..
- 31. 2012 ESC/EACTS Guidelines on Management of VHD: Indications for AVR in AS Vahanian et al. EHJ 2012 Severe AS on DSE: Final AVA <1 cm2; mean gradient >40 mmHg) Flow reserve: ∆SV ≥ 20%
- 32. Low-LVEF, Low-Flow,Low-LVEF, Low-Flow, Low-Gradient AS:Low-Gradient AS: DSEDSE Contractile/FlowContractile/Flow Reserve +Reserve + SAVRSAVR (Class IIb)(Class IIb) TAVRTAVR (TF or TAo)(TF or TAo)?? BAV+TAVR?BAV+TAVR? Medical?Medical? MedicalMedical True-True- Severe ASSevere AS Pseudo-Pseudo- Severe ASSevere AS Contractile/FlowContractile/Flow Reserve -Reserve - True-True- Severe ASSevere AS SAVRSAVR (Class IIa)(Class IIa) TAVRTAVR CTCT
- 33. Take home messages ØAortic valve calcium scoring may be useful to corroborate stenosis severity in patients with low LVEF, low-flow, low-gradient and no flow reserve ØAbsence of flow reserve is a marker for increase operative risk but does not predict long-term survival or LVEF recovery ØAbsence of flow reserve should not preclude consideration of AVR ØTAVR may provide a valuable alternative in these patients