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M.W.A. van Geldorp 1 , H.J. Heuvelman 1 , B. Arabkhani 1 , M. van Gameren 1 , A.P. Kappetein 1 ,
description
Transcript of M.W.A. van Geldorp 1 , H.J. Heuvelman 1 , B. Arabkhani 1 , M. van Gameren 1 , A.P. Kappetein 1 ,
Therapeutic decisions for patients with symptomatic severe aortic stenosis:
room for improvement?
Results of the Aortic VAlve RIJNmond study
M.W.A. van Geldorp1, H.J. Heuvelman1, B. Arabkhani1, M. van Gameren1, A.P. Kappetein1, J.J.V. Busschbach2, T.W. Galema3, J.J.M. Takkenberg1, A.J.J.C. Bogers1
1Dept. of Cardiothoracic Surgery, 2dept. of Psychology and Psychotherapy,
3Dept. of Cardiology Erasmus University Medical Center, Rotterdam
Aortic Valve Surgery: Present and FutureAMC, 12-05-2011
Background Prevalence of aortic stenosis:
2.5% @ 70 yrs, 8% @ 80 yrs
Progression: PAG +6 mmHg/yr; AVA -0.1 cm2/yr
Aortic stenosis is rising health problem (elderly)
Hospitalization for Heart Valve disease The Netherlands 1995 - 2004
80-85 years
85-90 years
> 90 years
Aortic stenosis as cause of death (NL)
4
0
50
100
150
200
250
300
350
1996 1998 2000 2002 2004 2006 2008 2010
65-70 yrs
70-75 yrs
75-80 yrs
80-85 yrs
85-90 yrs
90-95 yrs
www.cbs.nl
Aortic Stenosis as cause of death The Netherlands (1996 – 2006)
Literature
59 68 70
40
41 32 30
60
0%
25%
50%
75%
100%
Bouma 1999 Iung 2004 Pellikka 2005 Charlson 2006
AVR
Unoperated
Symptomatic patients with severe aortic stenosis
Background Prevalence of aortic stenosis:
2.5% @ 70 yrs, 8 % @ 80 yrs
Progression: PAG +6 mmHg/yr; AVA -0.1 cm2/yr
Aortic stenosis is rising health problem (elderly)
Controversy between ACC/AHA guidelines and recent literature
Diagnosis-treatment gap
New techniques to treat the stenotic aortic valve: TAVI
Why are so many (elderly) symptomatic patients denied surgery?
‘Natural history’?
Expected life gain after surgery? Quality of life?
Objectives
Symptomatic
AVR No AVR
n=179
n=2?
n=76 (42%) n=101 (56%)
Follow-up: 17 months
Age (yrs) Male Mean Log EuroSCORE Log EuroSCORE >15%
AVR67.9 (22-89)49%7.8% (1.5-56)4%
No AVR73.3 (35-92)51%11.3% (1.5-45) 18%
Pilot study
Patient preference ‘High risk’ ‘Mild symptoms’ / ‘asymptomatic’ Aortic stenosis ‘non-severe’ Decision pending Reason not clearly documented
10% 33% 19% 14% 5% 20%
Why?
Age (yrs) Mean log EuroSCORE Log EuroSCORE >15%
No AVR73
11.3%18%
Pilot
Symptomatic patients: medical treatment in 56%, AVR in 42% (!)
59 68 70
40 42
41 32 30
60 56
0%
25%
50%
75%
100%
Bouma 1999 Iung 2004 Pellikka 2005 Charlson 2006 v Geldorp 2009
AVR
Unoperated
Symptomatic patients with severe AS
AVARIJN study (Aortic VAlve RIJNmond)
Methods
Inclusion of patients with severe AS in the outpatient clinics in the wider Rotterdam area
Inclusion period: July 2006-April 2009
Baseline: -Patient data, functional status, quality of life (SF-36, EuroQol) -Echocardiography; tissue doppler imaging -Nt-proBNP -Exercise testing (asymptomatic patients only)
Follow-up: 6 months, 1- and 2-year
Participantsn=191
Symptomaticn=132
Asymptomaticn=59
AVRn=70
Conservativen=62
Severe ASn=459
Refusedn=268
Conservativen=38
AVRn=21
(12 asympt)
mean f-up 1.7 yrs mean f-up 1.4 yrs
Flow chart AVARIJN
Patient characteristics at baseline
All N=191
Asymptomatic N=59
Symptomatic N=132
P-value
Age (yrs) 70.6 ± 11.4 68.7 ± 10.5 71.5 ± 11.7 0.034 Male gender (%) 62 76 56 0.008 Previous valve surgery (%) 1 0 2 0.343 Previous CABG (%) 6 3 8 0.272 History of: Only dyspnea (%) 31.9 46.2 Only angina (%) 3.1 4.5 Only syncope (%) 2.6 3.8 Combination (%) 62.4 45.5 History of smoking (%) 61 71 56 0.049 Current smoking (%) 18 19 17 0.839 Hypertension (%) 52 49 54 0.554 Diabetes (%) 20 22 19 0.622 Dislipidemia (%) 49 47 49 0.820 COPD (%) 17 10 20 0.083 PAD (%) 13 7 15 0.108 History of MI (%) 13 8 15 0.207 Previous CABG (%) CVA (%) 19 20 18 0.725 NYHA class I+II (%) 69 100 55 <0.001 III+IV (%) 31 0 45 <0.001 Body mass index 27.5 ± 4.4 27.1 ± 3.8 27.7 ± 4.7 0.711 Body surface area (m2) 1.90 ± 0.20 1.94 ± 0.20 1.88 ± 0.20 0.107 BP systolic (mmHg) 142 ± 27 146 ± 23 141 ± 28 0.181 BP diastolic (mmHg) 79 ± 12 81 ± 9 77 ± 13 0.050 ECG Sinus rhythm (%) 90 91 90 0.794 LVH (%) 27 24 28 0.531 Old infarction (%) 21 21 21 0.935 Ischemia (%) 15 12 17 0.418 Cycle ergometry Number of patients 50 47 3 Positive outcome (patients) 16 15 1 0.960 NT-proBNP (pmol/L) 160 ± 336 122 ± 356 177 ± 327 <0.001 Medication (%) No medication 14 22 10 0.024 Statins 42 41 43 0.747 Antiplatelets 39 29 44 0.049 Betablocker 31 24 29 0.127 Diuretics 26 20 29 0.221 Follow-up (years) 1.56 ± 0.71 1.79 ± 0.65 1.46 ± 0.72 0.004
AllN=191
AsymptomaticN=59
SymptomaticN=132
P-value
Vmax (m/s) 4.2 (3.7-4.7) 4.2 (3.7-4.7) 4.3 (3.7-4.8) 0.672PAG (mmHg) 72 (54-89) 69 (54-84) 73 (56-91) 0.504MAG (mmHg) 42 (33-51) 40 (33-48) 43 (33-52) 0.419AVA (cm2) 0.74 (0.59-0.91) 0.80 (0.63-0.96) 0.72 (0.54-0.85) 0.026
AoR ≥ grade 2 (%) 17 14 18 0.494MR ≥ grade 2 (%) 11 4 15 0.027TR ≥ grade 2 (%) 8 4 11 0.359
Echocardiography parameters at baseline
93%
76%
58%
41%
Freedom from AVR
Results SF 36v2
Results SF 36v2
Results SF 36v2 Quality of life according to symptomatic status
Results SF 36v2 Quality of life according to symptomatic status
Results SF 36v2 Quality of life according to symptomatic status
Results SF 36v2 Quality of life according to symptomatic status
Results General dutch population 41-60yrs vs symptomatic patients 41-60yrs
Results General dutch population 61-70yrs vs symptomatic patients 61-70yrs
Results General dutch population >70yrs vs symptomatic patients >70yrs
Results Symptomatic patients treated medically: baseline vs 2yr f-up
Results Symptomatic patients treated surgically: before AVR vs 1yr after AVR
Conclusions
Daily practice very different from guidelines: undertreatment?• Possible overestimation of operative risk• Symptoms unrecognized or unaccounted for• Misclassification of haemodynamic severity• Patient preference
Even mild symptoms have major impact on physical and emotional/social QoL, regardless of age. Disease burden compared to general population is large!
QoL improves after AVR (in selected patients)
room for improvement!!• Accurate patient assessment (“listen to the patient, look at the
valve”, C.M. Otto)
• Heart team
• QOL survey standard armamentarium