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Case Example • 75 year old man with systolic murmur • Asymptomatic but inactive • Echocardiography shows a thickened poorly mobile valve with an AV velocity of 4.0 m/s and mean gradien

Asymptomatic Aortic Valve Disease

What Should We Do?

Michael Rinaldi, MD

The Sanger Heart and Vascular Institute

Carolinas HealthCare System

Charlotte NC USA michael.rinaldi@carolinashealthcare.org

Disclosures

Nothing relevant to the presentation

2014 AHA/ACC Guideline for the Management of Patients With

Valvular Heart Disease

2014 AHA/ACC Guideline for the Management of Patients With

Valvular Heart Disease (Journal of the American College of

Cardiology) Published on March 3, 2014, available at:

http://content.onlinejacc.org/cgi/content/full/j.jacc.2014.02.536 and

http://circ.ahajournals.org/content/early/2014/02/27/CIR.0000000000 000029.citation

The full-text guidelines are also available on the following Web sites: ACC ( www.cardiosource.org ) and AHA ( my.americanheart.org )

Aortic Stenosis Severity Assessment

Indicator Mild Moderate Severe

CW Jet Velocity (m/sec) < 3.0 3.0-4.0 > 4.0

Mean Gradient (mm Hg) < 25 25 - 40 > 40

Valve Area (cm 2 ) > 1.5 1.0 – 1.5

< 1.0 (Index <0.6 cm2/m2)

Echo f/u 3-5 yrs

*(or Δ in sx’s) 1-2 yrs* Yearly

Circulation October 2008;118:e523-e661

Case Example

• 75 year old man with systolic murmur

• Asymptomatic but inactive

• Echocardiography shows a thickened poorly mobile valve with an AV velocity of 4.0 m/s and mean gradient of 42 mmHg

• Should this patient have AVR?

Diagnostic Testing – Diagnosis and Follow-Up

Cardiac catheterization for hemodynamic

assessment is recommended in symptomatic

patients when noninvasive tests are inconclusive

or when there is a discrepancy between the

findings on noninvasive testing and physical

examination regarding severity of the valve lesion

Exercise testing is reasonable in selected

patients with asymptomatic severe VHD to 1)

confirm the absence of symptoms, or 2)

assess the hemodynamic response to

exercise, or 3) determine prognosis

Case Example

• ETT is performed

– Poor exercise tolerance

– Hypotensive response exercise

– Ventricular ectopy

• This patient is a high risk for mortality and is

functionally symptomatic and therefore

should have AVR

Another Method of Assessment

Emerging Roll of CT Derived AV Calcium Score in AS Assessment

• AV calcium score >1274 in Women and >2065 in Men

associated with far worse prognosis

• AVR indicated

Clavel, M JACC 2014;64.1202-13

Example of CTA of AV with High

Calcium Score

A Twist on our Case Example

• 75 year old man with systolic murmur

• Asymptomatic but inactive

• Severe class 4 kidney disease, DM, moderate COPD, appears frail

• Echocardiography shows a thickened poorly

mobile valve with an AV velocity of 4.0 m/s and mean gradient of 42 mmHg

• Should this patient have AVR?

Low Risk (must

meet ALL criteria

in this column )

Intermediate Risk (any 1 criteria in this column)

High Risk (any 1 criteria in this column)

Prohibitive Risk (any 1 criteria in this column)

Predicted risk with surgery

of death or major morbidity (all-cause) >50% at 1 y

procedure-Severe procedure-specific impediment

Risk Assessment for Surgical AVR

Combining STS Risk Estimate, Frailty, Major Organ System

Dysfunction, and Procedure-Specific Impediments

A Variation on our Case Example

• STS predicted mortality risk 8%

• Goal here is quality of life and symptoms relief

• We should not operate

• Consider TAVR when patient becomes

significantly symptomatic (> Class 2)

Case Example

• 65 year old man

• Asymptomatic and active

• Echocardiography shows a thickened poorly

mobile valve with an AV velocity of 5.0 m/s and mean gradient of 55 mmHg

• Normal LVEF

• No high risk markers on ETT

• Low risk for AVR

• Should this patient have AVR?

Aortic Stenosis: Timing of Intervention (cont.)

AVR is reasonable for asymptomatic patients

with very severe AS (stage C1, aortic velocity

≥5 m/s) and low surgical risk

AVR is reasonable in asymptomatic patients (stage

C1) with severe AS and decreased exercise

tolerance or an exercise fall in BP

AVR is reasonable in symptomatic patients with

low-flow/low-gradient severe AS with reduced

LVEF (stage D2) with a low-dose dobutamine

stress study that shows an aortic velocity 4 m/s

valve area 1.0 cm2 at any dobutamine dose

Case Example

• 75 year old man with systolic murmur

• Dyspnea on exertion

• Echocardiography shows a thickened poorly

mobile valve with an AV velocity of 3.0 m/s and mean gradient of 30 mmHg

Aortic Stenosis: Timing of Intervention (cont.)

AVR is reasonable for asymptomatic patients with

very severe AS (stage C1, aortic velocity ≥5 m/s)

and low surgical risk

AVR is reasonable in asymptomatic patients (stage

C1) with severe AS and decreased exercise

tolerance or an exercise fall in BP

AVR is reasonable in symptomatic patients with

low-flow/low-gradient severe AS with reduced

LVEF (stage D2) with a low-dose dobutamine

stress study that shows an aortic velocity 4

m/s (or mean pressure gradient 40 mm Hg)

with a valve area 1.0 cm 2 at any dobutamine

dose

Case Example

• DSE at 5, 10, and 20 mcg/kg/min shows LVEF increases and AV velocity of 4.0 m/s and mean gradient of 42 mmHg

• Consistent with “low flow low gradient”

severe AS

• This patient should have AVR (consider TAVR)

Case Example

• 75 year old man with systolic murmur

• Unstable angina with LM and 3 vessel CAD

• Scheduled to undergo CABG

• Echocardiography shows a thickened poorly mobile valve with an AV velocity of 3.0 m/s and mean gradient of 32 mmHg

• Should this patient have AVR?

Aortic Stenosis: Timing of Intervention (cont.)

AVR is reasonable in symptomatic patients who

have low-flow/low-gradient severe AS (stage D3)

who are normotensive and have an LVEF ≥50% if

clinical, hemodynamic, and anatomic data support

valve obstruction as the most likely cause of

symptoms

AVR is reasonable for patients with moderate AS

(stage B) (aortic velocity 3.0–3.9 m/s) who are

undergoing other cardiac surgery

AVR may be considered for asymptomatic patients

with severe AS (stage C1) and rapid disease

progression and low surgical risk

Indications for Aortic Valve Replacement in Patients With Aortic Stenosis

Thank you