Advances in Management of Valvular Heart Disease … A. Jamil Tajik, MD 33 rd Annual...
Transcript of Advances in Management of Valvular Heart Disease … A. Jamil Tajik, MD 33 rd Annual...
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A. Jamil Tajik, MD33rd Annual Echocardiography Symposium
Miami, Florida 33rd Annual Echocardiography Symposium
Miami, Florida
Advances in Management of Valvular Heart Disease
Advances in Management of Valvular Heart Disease DISCLOSUREDISCLOSURE
Relevant Financial Relationship(s)I have no relevant financial
relationships to disclose at this time
Off Label Usage
I have no relevant financial relationships to disclose at this time
Nkomo, V.T. et al: The Lancet 368:1005, 2006
Prevalence of Valvular Heart Disease
≥75
Valve disease
AllMitral
Aortic
Age (years)
Pre
vale
nce (
%)
14
12
10
8
6
4
2
0
<45 45-54 55-64 65-74
N=11911Mod-Sev
VHD=5.2%
MILESTONES VHD
•1960 – AVR (SE)
•1961 – MVR (SE)
2000 – TRANSCATHETER PVR
(Philipp Bonehoeffer)
2002 – TAVR (Alain Cribier)
VHD 2014VHD 2014• Accurate Structure/Function
• Quantitation of Severity
• Modern Era Natural history
• Timing of Intervention (no sx)
• Selection for TCT (Heart Team)
• Medical therapy? Prevention?
• Accurate Structure/Function
• Quantitation of Severity
• Modern Era Natural history
• Timing of Intervention (no sx)
• Selection for TCT (Heart Team)
• Medical therapy? Prevention?
TCT in VHD 2014TCT in VHD 2014• TAVR
• VIV TAVR
• Mitral Edge – Edge Repair
• TMVR; Annuloplasty
Heart Team
• TAVR
• VIV TAVR
• Mitral Edge – Edge Repair
• TMVR; Annuloplasty
Heart Team
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Aortic StenosisAortic Stenosis Original Article
Transcatheter Aortic-Valve Implantation for Aortic Stenosis in Patients Who Cannot Undergo Surgery
Martin B. Leon, M.D., Craig R. Smith, M.D., Michael Mack, M.D., D. Craig Miller, M.D., Jeffrey W. Moses, M.D., Lars G. Svensson, M.D., Ph.D., E. Murat
Tuzcu, M.D., John G. Webb, M.D., Gregory P. Fontana, M.D., Raj R. Makkar, M.D., David L. Brown, M.D., Peter C. Block, M.D., Robert A.
Guyton, M.D., Augusto D. Pichard, M.D., Joseph E. Bavaria, M.D., Howard C. Herrmann, M.D., Pamela S. Douglas, M.D., John L. Petersen, M.D., Jodi J.
Akin, M.S., William N. Anderson, Ph.D., Duolao Wang, Ph.D., Stuart Pocock, Ph.D., for the PARTNER Trial Investigators
N Engl J MedVolume 363(17):1597-1607
October 21, 2010
ConclusionsIn patients with severe aortic stenosiswho were not suitable candidates for surgery, TAVI, as compared with standard therapy, significantly reduced the rates of death from any cause, the composite end point of death from any cause or repeat hospitalization, and cardiac symptoms, despite the higher incidence of major strokes and major vascular events.
In patients with severe aortic stenosiswho were not suitable candidates for surgery, TAVI, as compared with standard therapy, significantly reduced the rates of death from any cause, the composite end point of death from any cause or repeat hospitalization, and cardiac symptoms, despite the higher incidence of major strokes and major vascular events.
European Heart Journal (2014) 34, 490-494
84 year old Female84 year old Female
•Severe calcific aortic valve stenosis
Mean gradient: 64 mmHg
AVA: 0.70 cm2
•NYHA class II
TAVR
•Severe calcific aortic valve stenosis
Mean gradient: 64 mmHg
AVA: 0.70 cm2
•NYHA class II
TAVR
4
PRE
POST
PRE TAVRMean Grad = 64 mmHg
POST TAVRMean Grad = 7 mmHg
91 year old Female
•S/p bioprosthetic AVR (age 80 yrs)
•Severe CHF; Multiple comorbidities
•Severe Stenosis of Bioprosthesis
Mean gradient – 56 mmHg
AVA – 0.70 cm2
VIV TAVR
Peak Vel = 4.8 m/secMean Gradient = 56 mmHg
AVA = 0.70 cm2
AV CW Doppler
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PRE
POST
1 Year Follow Up
PRE
POST
POST:Peak Vel = 2.2 m/secMean Gradient = 10 mmHg
PRE:Peak Vel = 4.8 m/secMean Gradient = 56 mmHg
90 year old female90 year old femaleBileaflet mitral valve prolapse
Flail leaflet (posterior); Gr 4/6 murmer
Severe MR (RV 79 ml, ERO 0.6 cm2)
Severe PHTN (PASP 70 mmHg)
CABG (2006), Pacemaker
Decreased LV EF (32%)
NYHA Class III-IV
Edge to Edge Repair
Bileaflet mitral valve prolapse
Flail leaflet (posterior); Gr 4/6 murmer
Severe MR (RV 79 ml, ERO 0.6 cm2)
Severe PHTN (PASP 70 mmHg)
CABG (2006), Pacemaker
Decreased LV EF (32%)
NYHA Class III-IV
Edge to Edge Repair
7
1 Year Follow Up1 Year Follow Up
Clinically markedly improved
Grade I/6 systolic murmur of MR
PASP 40 mmHg
NYHA Class I-2
Clinically markedly improved
Grade I/6 systolic murmur of MR
PASP 40 mmHg
NYHA Class I-2
Post Clip Implant TTE
8
76 year old76 year old
•3 episodes of plum edema
•Rheumatoid Arthritis
•Renal Failure
•High STS and Euro score
•3 episodes of plum edema
•Rheumatoid Arthritis
•Renal Failure
•High STS and Euro score
Post Clip Implant
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JACC 2014; 64: 1814-9 Oct. 28
CONCLUSION: Transapical transcatheter mitral valve implantation is
technically feasible and can be performed safely. Early hemodynamic
performance of the prosthesis was excellent. Transcatheter mitral valve
implantation may become an important treatment option for patients with
severe MR who are at high operative risk.(J. Am Coll Cardiol 2014;64:1814-9) 2014 by the American College of Cardiology Foundation.
JACC: Cardiovascular Interventions VOL 7 NO 11, 2014
First-in-Man Trans-Septal Implantation of a “Surgical-Like” Mitral
Valve Annuloplasty Device for Functional Mitral Regurgitation
Cardiovascular Health StudyCardiovascular Health Study
•N= 5621: 5 year risk of death and CV death
•70% normal AV
•28% aortic sclerosis
•2% aortic stenosis
•N= 5621: 5 year risk of death and CV death
•70% normal AV
•28% aortic sclerosis
•2% aortic stenosis
Otto et al NEJM 1999; 341: 142-7
Event RatesEvent Rates
0
5
10
15
20
25
30
35
40
45
Deathall
cause
CHFDeathCV
MI† Angina† Stroke†
Normal aortic valvesAortic sclerosisAortic stenosis
%
**
*
**
*
‡
*
‡
*
*
*
*
Otto et al NEJM 1999 341: 142-7
10
Aortic Sclerosis
Aortic Stenosis
28
44
2
9Pe
rce
nt
(%)
Then
Cardiovascular Health Study8 Years Later
Cardiovascular Health Study8 Years Later
Now
JACC 2007:50:1992
Journey of the Aortic Valve
Circulation Research.2013;113:198-208
Molecular and Cellular Aspects of Calcific Aortic Valve Disease
Circulating MyeloidCalcifying Cell, COP, ePCCirculating MyeloidCalcifying Cell, COP, ePCCirculating MyeloidCalcifying Cell, COP, ePC
EC Undergoing Endothelial-Mesenchymal TransitionEC Undergoing Endothelial-Mesenchymal TransitionEC Undergoing Endothelial-Mesenchymal Transition
Valve Annulus ChondrocyteValve Annulus ChondrocyteValve Annulus Chondrocyte
Valve Interstitial Cell (VIC)Valve Interstitial Cell (VIC)Valve Interstitial Cell (VIC)Valve Osteoblast-Like CellValve Osteoblast-Like CellValve Osteoblast-Like Cell
Randomized Trial of Intensive Lipid Lowering Therapy in
Calcific AS
Randomized Trial of Intensive Lipid Lowering Therapy in
Calcific AS
•N=155 with moderate-severe AS randomized to 80 mg atorvastatin vs placebo
•No significant slowing of progression of calcific AS
•WAS THE WINDOW OF OPPORTUNITY TOO LATE?
•N=155 with moderate-severe AS randomized to 80 mg atorvastatin vs placebo
•No significant slowing of progression of calcific AS
•WAS THE WINDOW OF OPPORTUNITY TOO LATE?
NEJM 2005; 352:2389
Rosuvastatin Affecting Aortic Valve
Endothelium to Slow the Progression of
Aortic Stenosis
Conclusions: Prospective treatment
of AS with rosuvastatin by targeting serum LDL slowed the hemodynamic progression of AS.
Methods: 121 patients with asymptomatic
moderate to severe AS (aortic valve area
εεεε 1.0 cm2 . . .
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SEAS TrialSEAS Trial•1800 patients
•Exclusion criteria
•1800 patients
•Exclusion criteriaCoronary artery disease
Peripheral arterial disease
Cerebrovascular disease
Diabetes
Hyperlipidemia
Other significant valvular HD
NEJM 2008; 359:1
Rate of Disease ProgressionRate of Disease Progression
No statin
No statin
StatinStatin-0.10
0.00
0.10
0.20
0.30
No statin
No statin
StatinStatin
Aortic SclerosisP=0.01
Mild Aortic StensisP=0.001
Increase
in Vmax (m/s/y)
Increase
in Vmax (m/s/y) .04±.0
9
.04±.0
9
.07±.1
0
.07±.1
0
.09±.1
5
.09±.1
5
.15±.1
5
.15±.1
5
AJC 2008;102:738
Aortic Valve SclerosisAortic Valve Sclerosis
•Etiology of aortic stenosis is inflammatory (82%)
•Aortic sclerosis is highly associated with a worse CV prognosis
•Aortic sclerosis is progressive
•Recommend active intervention for prevention strategy
•Etiology of aortic stenosis is inflammatory (82%)
•Aortic sclerosis is highly associated with a worse CV prognosis
•Aortic sclerosis is progressive
•Recommend active intervention for prevention strategy
Thank YouThank You