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Key Questions. Can AVR be performed? Should AVR be performed?. Can AVR Be Performed?. Identify Obstacles to Success Technical: Prior Cardiac Surgery (patent LIMA), Prior XRT, PVD, etc Organ Morbidity: Renal, Pulmonary, Neuro/Cognitive Patient Frailty

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key questions
Key Questions
  • Can AVR be performed?
  • Should AVR be performed?
can avr be performed
Can AVR Be Performed?
  • Identify Obstacles to Success
    • Technical: Prior Cardiac Surgery (patent LIMA),

Prior XRT, PVD, etc

    • Organ Morbidity: Renal, Pulmonary, Neuro/Cognitive
    • Patient Frailty
    • Institutional: Presence of Multidisciplinary Care Team with Excellent Outcomes
    • Estimate Risks: STS, NYS, Euroscore, etc
    • Family/Social Support
should avr be performed
Should AVR Be Performed?
  • Is the AS severe?
    • Is there a clear indication for AVR

(ie symptoms or CHF)?

  • Are there other causes for symptoms or for CHF?
  • Will success impact overall functional status and quality of life? If the Answer is Yes, Don’t Wait for Higher Risk!
case 1
Case 1
  • 95 y/o woman
  • History of hypertension and aortic stenosis
  • NYHA class IV symptoms
  • Multiple admissions for heart failure in the past year
  • Echo with critical AS and decreased LV function
  • Most recent admission, treated with diuretics and discharged home due to advanced age
  • Readmitted within one week with CHF and BNP >5000
  • Renal function: BUN/Cr 24/0.9
case 1 echocardiogram
Case 1: Echocardiogram
  • EF – 25%
  • Severe AS
    • Peak Velocity - 4.2 m/s
    • Mean Gradient - 45 mmHg
    • Valve Area - 0.6 cm2
  • Moderate Pulm HTN ~ 50 mmHg
case 1 cardiac catheterization
Case 1: Cardiac Catheterization
  • RA – 30 mmHg
  • PA – 70/34/48 mmHg
  • PCW – 35 mmHg
  • C.O. – 2.0 L/min, C.I. – 1.2 L/min/m2
  • Aortic Valve
    • Peak Gradient – 71 mmHg
    • Mean Gradient – 45 mmHg
    • Valve Area – 0.25 cm2
  • Severe CAD
case 1 high mortality risk
Case 1: High Mortality Risk!
  • STS Risk Calculator
    • CABG/AVR – Mortality Risk – 33.8%
    • AVR Alone – Mortality Risk – 27.9%
  • Logistic EuroSCORE
    • CABG/AVR – Mortality Risk – 78.8%
case 11
Case 1

What Would You Do?

  • BAV
  • TAVI
  • Surgical AVR – surgeons refused
  • Palliative Care
slide9

Patient is now 100 years old and still lives independently.

There have been no admissions for CHF in the last 5 years

case 2
Case 2
  • 80 y/o man with history of CABG 18 years ago presents with progressive dyspnea on exertion
  • Asymptomatic with negative stress tests until 3 years ago when his walking became limited by spinal stenosis
  • 1 year ago, his wife noted that he was SOB walking short distances indoors
case 2 additional history
Case 2: Additional History
  • Progressive short-term memory loss
  • Multiple TIA’s over the past 2 years
  • CNS Imaging shows multiple old

fronto-parietal infarcts

  • No significant extra-cranial vascular disease
case 2 echocardiogram
Case 2: Echocardiogram
  • Severe AS
  • Peak velocity 4.3
  • AVA 0.7 cm2
  • EF normal
case 2 cardiac catheterization
Case 2: Cardiac Catheterization
  • RA 7 mmHg
  • PA 32/7 mmHg
  • PCWP 12 mmHg
  • PA Sat 68%
  • Mean AV gradient 40 mmHg
  • AVA 0.68 cm2
  • Coronary angiography:
  • Patent LIMA to LAD
  • Patent SVG to OM
  • Occluded SVG to RCA
  • Severe native 3VD
case 21
Case 2

Risk Calculator

    • STS 2.9% mortality, 20% morbidity
    • Euroscore 26.8% mortality

What Would You Do?

  • BAV
  • TAVI – not a PARTNER candidate
  • Surgical AVR – surgeons refused
  • Palliative Care
case 2 balloon aortic valvuloplasty
Case 2: Balloon Aortic Valvuloplasty
  • Post BAV:
    • gradient 8 mmHg
    • AVA 1.4 cm2
case 22
Case 2
  • Wife reported resolution of dyspnea for approximately 2 months
  • 2 months later, repeat Echo showed peak velocity 3.9 mmHg, AVA 0.9 cm2
  • Underwent successful transfemoral TAVI with 26mm Edwards-Sapien Valve
case 2 post op course
Case 2: Post-op Course
  • Persistent somnolence, but no new infarct by CNS imaging
  • Discharged after 5 days
  • 2 years later
    • Wife reports dyspnea resolved
    • Severe dementia
mitral regurgitation in older adults
Mitral Regurgitation in Older Adults
  • Moderate to severe MR is present in 10% of adults over 75.
  • Degenerative
  • Functional
    • Ischemic
    • Dilated cardiomyopathy
goals of treatment
Goals of Treatment
  • Functional MR:
    • Improve symptoms
    • Improve QOL
    • Decrease hospitalizations for CHF
  • Degenerative MR:
    • Eliminate symptoms
    • Maintain normal survival
degenerative mr
Degenerative MR
  • Primary disease of the valve leaflets and chordea
    • Myxomatous
    • Diffuse calcific degeneration
  • Regurgitation results from either excess leaflet motion or restriction of leaflets and annular contraction
  • LV function is initially normal
degenerative myxomatous mr
Degenerative (myxomatous) MR

O\'Gara, P. et al. J Am Coll Cardiol Img 2008;1:221-237

degenerative mr surgical indications
Degenerative MRSurgical Indications
  • Severe MR prior to consequence (IIa)
  • Severe MR with consequence
    • Symptoms (I)
    • LV Dysfunction (I) (30< EF < 60)
    • Atrial Fibrillation (IIa)
    • Pulmonary Hypertension (IIa)
    • Severe MR with EF < 30 with structural mitral disease and high likelihood of repair (IIa) with NYHA III-IV
degenerative mr surgical indications1
Degenerative MRSurgical Indications
  • Severe MR prior to consequence (IIa)
  • Severe MR with consequence
    • Symptoms (I)
    • LV Dysfunction (I) (30< EF < 60)
    • Atrial Fibrillation (IIa)
    • Pulmonary Hypertension (IIa)
    • Severe MR with EF < 30 with structural mitral disease and high likelihood of repair (IIa) with NYHA III-IV
slide24

Survival of operative survivors after MR surgery stratified by age at surgery

Detaint D et al. Circulation 2006;114:265-272

slide25

Trends in operative mortality for MR surgery

Contemporary Results in Age > 80

30 day mortality 5%

3 month mortality 13%

Complications

Stroke: 5% repair, 7% replacement

Prolonged ventilation 50%

Acute renal failure 10%

Nioga L, Euro J CT Surg, 39 (2011) 875-880

In patients over 80

7.7% stroke rate for MVR

Detaint D et al. Circulation 2006;114:265-272

DiGregorio, Annals of Thoracic Surgery, 2004

slide26

Mitral valve Surgical Outcomes in octoagenarians

Chikwe et al. Eur Heart Journal 2010;32:618-626

functional mr
Functional MR
  • Primary disease of LV:

Local-ischemic MR

Global-dilated cardiomyopathy

  • MR results from restricted valve leaflet motion
  • LV function is initially depressed
slide28

Mechanisms of Ischemic Mitral Regurgitation

Increased

tethering

Decreased

closing force

Bulging

MR

Papillary muscle traction

Annular dilatation

functional mr current treatment options
Functional MR -Current Treatment Options
  • Medical
      • RAAS inhibition (ACE inhibition, ARB)
      • Beta-Blockers
  • Relieve ischemia
  • Cardiac resynchronization therapy
  • Surgical/Transcatheter techniques

- Reduction annuloplasty

    • Alfieri, Chordal, LV remodeling, LV restraint, posterior leaflet extension, mitral valve replacement
    • Catheter-based annuloplasty and restraint devices
surgical outcomes
Surgical Outcomes
  • Ischemic MR – in general
    • Operative mortality 5-10% overall
    • ~50% five year survival with surgery
    • Symptomatic benefit in many
    • Recurrence rate problematic
    • Effect on mortality unknown
  • Ischemic MR – paucity of data in elderly
    • Less than 50% 1 year survival in octogenarians1
    • Effect on symptoms and quality of life unknown

1Nioga L, Euro J CT Surg, 39 (2011) 875-880

decision not to operate in symptomatic severe mr
Decision Not To Operate In Symptomatic Severe MR

n = 546

49% of patients in the Euro Heart Survey on valvular heart disease with symptomatic severe MR were not operated on.

Mirabel et al. Eur Heart Journal 2007;28:1358-1365

mr high risk registry mitral clip
MR High Risk Registry: Mitral Clip
  • Mean age 76
  • 60% functional MR
  • Ejection fraction: 54%
  • STS Score 14%
  • In hospital mortality = 7.2%
  • No strokes

CHF hospitalizations reduced by 26%

Whitlow, P. L. et al. J Am Coll Cardiol 2012;59:130-139

older adult with mr case
Older Adult with MR Case
  • 75 y/o man with CAD s/p CABG 14 years ago after inferior MI
  • Post CABG noted to have progressively decreased LV function, MR, and CHF
  • 3 years ago CRT-D with marked improvement in symptoms
  • 6 months of progressive fatigue, dyspnea on exertion, orthopnea, edema, and ascites despite maximal medical therapy
  • Rapid loss of independence, yet still working
physical exam
Physical Exam
  • VS: BP 90/60, P 70
  • Ill appearing elderly man
  • JVP elevated to angle of the jaw with prominent V wave
  • Bilateral pleural effusions
  • PMI in anterior axillary line
  • Loud systolic murmur at the apex
  • Pulsatile liver and ascites
  • Pedal edema to the knees
studies
Studies
  • Labs: BUN 60/Cr 1.9
  • EKG: BiV paced
  • CXR: enlarged heart and bilateral pleural effusions
cardiac catheterization
Cardiac Catheterization
  • Coronary angiography: Patent LIMA-LAD, Patent SVG OM1-OM2, Occluded SVG-PDA and Occluded RCA
  • LVEF 35%, Moderate MR
  • Hemodynamics: RA 12, PA 45/26/32, PCWP 20, CI 2.2, PVR 5
  • With exercise: PA 60/36, mean PCWP 28, V wave to 45
referred for surgery
Referred for Surgery
  • Tissue MVR and Tricuspid Valve Repair
  • 1 month later, exercise tolerance had improved and orthopnea and edema had resolved
  • Lasix dose decreased from 80 mg bid to 80 mg daily
  • BUN and Cr normalized
3 year follow up
3 Year Follow-up
  • Patient had to cancel his last visit because he was too busy running a retailing business.
  • Patient works daily.
  • Patient lives independently.
  • Symptom free.
conclusions
Conclusions
  • Valvular disease is an important cause of morbidity and mortality in older adults
  • Treatment should focus on symptom relief and maintenance of functionality
  • Improvement in surgical outcomes and emerging percutaneous therapies make treatment available to more high risk patients
  • Optimizing the timing and selection of the appropriate therapies is evolving
slide42

AS in older adults

Reasons for Treatment Allocation

Wenaweser, P. et al. J Am Coll Cardiol 2011;58:2151-2162

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