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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


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


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

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


    Trends in operative mortality for MR surgery by age at 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


    Mitral valve Surgical Outcomes in by age at surgery octoagenarians

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


    Functional mr
    Functional MR by age at surgery

    • Primary disease of LV:

      Local-ischemic MR

      Global-dilated cardiomyopathy

    • MR results from restricted valve leaflet motion

    • LV function is initially depressed


    Mechanisms of Ischemic Mitral Regurgitation by age at surgery

    Increased

    tethering

    Decreased

    closing force

    Bulging

    MR

    Papillary muscle traction

    Annular dilatation



    Functional mr current treatment options
    Functional MR - Cardiomyopathy)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 Cardiomyopathy)

    • 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 Cardiomyopathy)

    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 Cardiomyopathy)

    • 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 Cardiomyopathy)

    • 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 Cardiomyopathy)

    • 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 Cardiomyopathy)

    • Labs: BUN 60/Cr 1.9

    • EKG: BiV paced

    • CXR: enlarged heart and bilateral pleural effusions


    Cardiac catheterization
    Cardiac Catheterization Cardiomyopathy)

    • 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 Cardiomyopathy)

    • 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 Cardiomyopathy)

    • 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 Cardiomyopathy)

    • 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


    AS in older adults Cardiomyopathy)

    Reasons for Treatment Allocation

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


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