Aortic Stenosis

Август 1, 2022

Содержание

2. Aortic Stenosis Etiology Physical Examination Assessing Severity Natural History Prognosis Timing of Surgery
3. Aortic Stenosis: Etiology Congenital bicuspid valve is the most common abnormality Rheumatic heart disease and degeneration
4. Bicuspid Aortic Valve
5. Aortic Stenosis - Etiology Young or middle-aged patient (4 & 5th decades) think congenital or rheumatic
6. Aortic Stenosis: Symptoms Cardinal Symptoms Chest pain (angina) Reduced coronary flow reserve Increased demand-high afterload Syncope/Dizziness
7. Aortic Stenosis: Physical Findings Intensity DOES NOT predict severity Presence of thrill DOES NOT predict severity
8. Aortic Stenosis: Physical Findings S1 S2 S1 S2 Mild-Moderate Severe
9. Severity of Stenosis Normal aortic valve area 2.5-3.5 cm2 Mild stenosis 1.5-2.5 cm2 Moderate stenosis 1.0-1.5
10. Diagnosis: Echocardiogram Etiology Valve gradient and area LVH Systolic LV function Diastolic LV function LA size
11. Echocardiogram
12. Doppler estimation of AVA
13. Cardiac catheteriztion Gorlin Method Simplified: Hakke’s formula AVA=CO/√(p-p gradient)
14. Low gradient AS Calculated AVA is AV gradient is Stenotic or not Stenotic?
15. Low gradient AS
16. Aortic Stenosis: Prognosis Therapy: Valve replacement for severe aortic stenosis Operative mortality (elderly) ~ 4%/Morbidity ~
17. Natural History of Aortic Stenosis Heart failure reduces life expectancy to less than 2 years Angina
19. Operative mortality of AVR in the elderly ~ 4-24%/year Risk factors for operative mortality Functional class
20. AVR is recommended in symptomatic patients with severe AS (stage D1) with : Decreased systolic opening
21. PARTNER Study Design N = 358 Inoperable Standard Therapy n = 179 ASSESSMENT: Transfemoral Access TF
22. All-Cause Mortality Landmark Analysis
24. Prosthetic Heart Valves
25. Caged-Ball Valve
26. Disc Valve
27. Bio-prosthetic Valve
28. Prosthetic Valves MECHANICAL Durable Large orifice High thromboembolic potential Best in Left Side Chronic warfarin therapy
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Слайд 2

Aortic Stenosis
Etiology
Physical Examination
Assessing Severity
Natural History
Prognosis
Timing of Surgery

Слайд 3

Aortic Stenosis: Etiology
Congenital bicuspid valve is the most common abnormality
Rheumatic heart

disease and degeneration with calcification are found as well

Normal Bicuspid Ao V “Normal” geriatric Rheumatic calcific valve

Слайд 4

Bicuspid Aortic Valve

Слайд 5

Aortic Stenosis - Etiology
Young or middle-aged patient (4 & 5th decades)

think congenital or rheumatic
Bicuspid
2% population
3:1 male:female distribution
Co-existing coarctation 6% of patients

Rarely
Unicuspid valve
Sub-aortic stenosis
Discrete
Diffuse (Tunnel)
Old patient think degenerative (6,7,8th decades)

Слайд 6

Aortic Stenosis: Symptoms
Cardinal Symptoms
Chest pain (angina)
Reduced coronary flow reserve
Increased demand-high afterload
Syncope/Dizziness

(exertional pre-syncope)
Fixed cardiac output
Vasodepressor response
Dyspnea on exertion & rest
Impaired exercise tolerance
Other signs of LV failure
Diastolic & systolic dysfunction

Слайд 7

Aortic Stenosis: Physical Findings
Intensity DOES NOT predict severity
Presence of thrill DOES

NOT predict severity
“Diamond” shaped, harsh, systolic crescendo-decrescendo
Decreased, delay & prolongation of pulse amplitude
Decreasing intensity of S2
S4 (with left ventricular hypertrophy)
S3 (with left ventricular failure)

Слайд 8

Aortic Stenosis: Physical Findings
S1 S2 S1 S2
Mild-Moderate Severe

Слайд 9

Severity of Stenosis
Normal aortic valve area 2.5-3.5 cm2
Mild stenosis 1.5-2.5 cm2
Moderate

stenosis 1.0-1.5 cm2
Severe stenosis < 1.0 cm2
Critical stenosis < 0.7 cm2
Onset of symptoms
0.9 cm2 with CAD
0.7 cm2 without CAD

Слайд 10

Diagnosis: Echocardiogram
Etiology
Valve gradient and area
LVH
Systolic LV function
Diastolic LV function
LA size
Concomitant regional

wall motion abnormalities
Coarctation associated with bicuspid AV

Слайд 11

Echocardiogram

Слайд 12

Doppler estimation of AVA

Слайд 13

Cardiac catheteriztion
Gorlin Method
Simplified: Hakke’s formula AVA=CO/√(p-p gradient)

Слайд 14

Low gradient AS
Calculated AVA is < 1.0 cm2 , But…
AV gradient

is <30mmHg.
Stenotic or not Stenotic?

Слайд 15

Low gradient AS

Слайд 16

Aortic Stenosis: Prognosis
Therapy: Valve replacement for severe aortic stenosis
Operative mortality (elderly)

~ 4%/Morbidity ~ 3-11%
Event rate in asymptomatic severe AS ~ 1%/year

Слайд 17

Natural History of Aortic Stenosis
Heart failure reduces life expectancy to less

than 2 years
Angina and syncope reduce life expectancy between 2 and 5 years
Rate of progression ↓ @ 0.1 cm2/year

Слайд 18

Слайд 19

Operative mortality of AVR in the elderly
~ 4-24%/year
Risk factors for operative

mortality
Functional class
Lack of sinus rhythm
HTN
Pre-existing LV dysfunction

Aortic regurgitation
Concomitant surgical procedures:CABG/MV surgery
Previous bypass
Emergency surgery
CAD
Female gender

Слайд 20

AVR is recommended in symptomatic patients with severe AS (stage D1)

with :

Decreased systolic opening of a calcified or congenitally
stenotic aortic valve; and
An aortic velocity 4.0 m per second or greater or mean
pressure gradient 40 mm Hg or higher; and
Symptoms of HF, syncope, exertional dyspnea,
angina, or (pre)syncope by history or on exercise testing.

Слайд 21

PARTNER Study Design
N = 358
Inoperable
Standard
Therapy
n = 179
ASSESSMENT: Transfemoral Access
TF TAVR
n =

179

Primary Endpoint: All-Cause Mortality Over Length of Trial (Superiority)

1:1 Randomization

Symptomatic Severe Aortic Stenosis

Primary endpoint evaluated when all patients reached one year follow-up.
After primary endpoint analysis reached, patients were allowed to cross-over to TAVR.

Severe Symptomatic AS with AVA< 0.8 cm2 (EOA index < 0.5 cm2/m2), and mean gradient > 40 mmHg or jet velocity > 4.0 m/s

Inoperable defined as risk of death or serious irreversible morbidity of AVR as assessed by cardiologist and two surgeons exceeding 50%.

Слайд 22

All-Cause Mortality Landmark Analysis

Слайд 23

Слайд 24

Prosthetic Heart Valves

Слайд 25

Caged-Ball Valve

Слайд 26

Disc Valve

Слайд 27

Bio-prosthetic Valve

Слайд 28

Prosthetic Valves
MECHANICAL
Durable
Large orifice
High thromboembolic potential
Best in Left Side
Chronic warfarin therapy
BIO-PROSTHETIC
Not durable
Smaller

orifice/functional stenosis
Low thromboembolic potential
Consider in elderly
Best in tricuspid position

Aortic Stenosis

Содержание

Aortic StenosisEtiologyPhysical ExaminationAssessing SeverityNatural History PrognosisTiming of Surgery

Aortic Stenosis: EtiologyCongenital bicuspid valve is the most common abnormalityRheumatic heart

Bicuspid Aortic Valve

Aortic Stenosis - EtiologyYoung or middle-aged patient (4 & 5th decades)

Aortic Stenosis: SymptomsCardinal SymptomsChest pain (angina)Reduced coronary flow reserveIncreased demand-high afterloadSyncope/Dizziness

Aortic Stenosis: Physical FindingsIntensity DOES NOT predict severityPresence of thrill DOES

Aortic Stenosis: Physical FindingsS1 S2 S1 S2 Mild-Moderate Severe

Severity of StenosisNormal aortic valve area 2.5-3.5 cm2Mild stenosis 1.5-2.5 cm2Moderate

Diagnosis: EchocardiogramEtiologyValve gradient and areaLVHSystolic LV functionDiastolic LV functionLA sizeConcomitant regional