Debates en cardiología: Estenosis aortica degenerativa: punto de vista del clínico

Estenosis aortica degenerativa: punto de vista del clínico Dr Pilar Tornos Hospital Vall d’Hebron. Barcelona Congreso de la SEC. Valencia 2010

Estenosis aortica degenerativa Unidad de valvulopatías: Lineas de investigación clínica

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• Epidemiologia • Dificultades en la valoracion de la severidad • Tratamiento

Valvulopatías y edad

EA

EA Nkomo V et al. Lancet 2006

Age (years)

≥ 70 years (%)

≥1 comorbidity (%)

AS

69±12

56

36

AR

58±16

25

26

MS

58±13

18

22

MR

65±14

44

42

EURO HEART SURVEY Iung et al. Eur Heart J 2003

Epidemiologia: Que datos tenemos?

- Pocos estudios han valorado los patrones de esclerosis/estenosis aórtica a nivel poblacional.

- El mas reciente se llevó a cabo hace mas de una década - Ninguno está realizado en el área mediterránea - La mayoría no utilizaban ecografia con segundo harmónico - Solo 2 de ellos se centraban especificamente en >64 años - Prevalencia variable para esclerosis (18.2%-53%) y estenosis (1.3%-4.8%) - En relación a los factores de riesgo asociados: - Estercha correlacion esclerosis/estenosis y edad - Asociación plausible con el género - TProbable asociación con factores de riesgo de arteriosclerosis(LDL-c, Total-c, Lp(a), Dm…) - Podría haber asociación con factores constitucionales (BMI)

PEEADE STUDY Study sample selection Reference population: All population ≥ 65 years included in the list of nine Primary Care facilities of Barcelona metropolitan area (54,594 subjects ≥ 65; 16.5% of the total Barcelona population ≥ 65 years) Sample size: - Expected ASt prevalence in ≥ 65 years: 3% - Absolute precision: 1% (relative precision 33%) - 95% CI; N=1,118 Sampling: Age-stratified according with the Barcelona demographics census (3 strata: 65-74, 75-84, ≥ 85) Screening process: 2,800 people were randomly selected from the Primare Care list (eligible population). They were consecutively contacted by phone call and invited to participate until completing the study sample (1,118 cases).

PEEADE STUDY Results: Screening process

2,562 phone calls N=1,029 (40%) not localized 1,533 Invited to participate N=391 (25.5%) refused 1,142 agreed to participate N=6 (0.05%) with aortic prosthesis 1,136 underwent echocardiography N=155 (13.6%) with not high quality echo view for fine ASc assessment N=981

PEEADE STUDY Results: ASc and ASt prevalence 65-74 y (n=454; 46.3%)

75-84 y >84 y (n=409; 41.7%) (n=118; 12%)

GLOBAL (n = 981)

Aortic Sclerosis Mild to moderate Moderate to severe Any

Aortic Stenosis

1. Standardized Spain 2009

105 (23.1%)

140 (34.2%)

47 (39.8%)

292 (29.8%) 29.4%1 28.9%2

25 (5.5%)

73 (17.8%)

39 (33.1%)

137 (14%) 13.7%1 12.9%2

130 (28.6%)

213 (51.1%)

86 (72.9%)

429 (43.7%) 43%1 41.8%2

3 (0.7%)

21 (5.5%)

10 (8.5%)

34 (3.5%) 3.3%1 3.1%2

2. Standardized Europe 2008

Valoracion de la severidad de la EA • Click to edit Master text styles – Second level – Third level • Fourth level – Fifth level

Baumgartner H et al Eur J Echo, 2009

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Velocidad: 4.29 m/sec Gradiente medio 44 mmHg Area 0.75 cm2

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Estenosis aórtica severa

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Dificultades en la correcta catalogación de la severidad • Mala función ventricular

test dobutamina

• Función ventricular conservada, bajo gradiente y área reducida

Considerar los posibles problemas en el cálculo del área

Gradm: 26 mmHg

GC: 4.13 L/min

FÓRMULA DE GORLIN

ECOCARDIOGRAMA EN EL LABORATORIO DE HEMODINÁMICA

ECUACIÓN CONTINUIDAD: Área valvular aórtica: 0.66 cm2 Velocidad 3.3 m/S y gradiente medio 24 mm HG

BASAL TA 205/65, 59 x min Gradm: 26 mmHg

GC: 4.13 L/min

POST-NITROPRUSIATO 105/75, 74 x min Gradm: 32 mmHg

GC: 4.57 L/min

ECOCARDIOGRAMA BASAL

AVA 0.66

ECOCARDIOGRAMA POST-NITROPRUSIATO

AVA 0.9

Management of Severe Aortic Stenosis

Severe AS (< 1 cm² or < 0.6 cm²/m² BSA) Symptoms No

Yes

LV EF < 50%

No Yes

Markedly calcified valve and increase in peak jet velocity ≥ 0.3 m/sec within 1 year

No Yes

Patient physically active

Yes

Exercise test No Re-evaluate in 6 to 12 months or when symptoms occur

Normal

Abnormal Surgery

Haga clic para modificar el estilo GuidelinesSegundo ESC,2007 nivel ● Tercer nivel

• “Age is not a contraindication to surgery, with several series showing outcomes similar to age-matched normal subjects in the very elderly” Guidelines, 2006

ACC/AHA

• “Age per se should not be considered a contraindication for surgery. Decisions sould be made on an individual basis, taking into account patients’s wishes and cardiac and non cardiac factors.

In this population the need for an emergency operation, or, at the other end of the clinical spectrum, vey early intervention at an asymptomatic stage, should be avoided” Guidelines, 2007

European

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Decision-making in elderly patients with severe aortic stenosis: why are so many denied surgery?

Bernard Iung, Agnès Cachier, Gabriel Baron, David Messika-Zeitoun, François Delahaye, Pilar Tornos, Christa Gohlke-Bärwolf, Eric Boersma, Philippe Ravaud and Alec Vahanian

Eur Heart J 2005 26:2714-2720

REASONS THAT AORTIC VALVE REPLACEMENT WAS NOT PERFORMED AS during 2005 155 patients with severe AS In 75 surery was not performed 22 asymptomatic 53 symptomatic

Calculated operative risk was 11-13% Only 35% evaluated by a surgeon

Symptomatic pts (n = 53) Prohibitive comorbidities

30 (57%)

Symptoms felt due to another etiology

11 (21%)

Died before surgery Presented in cardiogenic shock

2 (4%)

Planned elective surgery

2 (4%)

Subvalvular obstruction

3 (6%)

Aortic stenosis unrecognized

3 (6%)

Patient declined intervention

2 (4%)

Bach, D. S. et al. J Am Coll Cardiol 2007;50:2018-2019

Cirugía de recambio valvular por estenosis aórtica severa en mayores de 80 años.

Experiencia de un centro en una serie de pacientes consecutivos David Calvo et al Rev Esp Cardiol 2007; 60: 720 - 726 137 pacientes con EA severa edades entre 80 y 87 años, media 81 MORTALIDAD QUIRURGICA: 3.8%

33 se rechazó

Haga clic para modificar el estilo de cirugía (24%) Segundo nivel ● Tercer nivel ● Cuarto nivel

> 30% de pacientes con EA sintomรกtica no se operan.

No Surgery Surgery

1. Bouma et al. To operate or not on elderly patients with aortic stenosis: the decision and its consequences. Heart 1999; 82: 143-148 2. Iung et al. A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease.

European Heart Journal 2003; 24: 1231- 1243 3. Pellikka et al. Outcome of 622 Adults with Asymptomatic, Hemodynamically Significant Aortic Stenosis During Prolonged Follow-Up. Circulation 2005 4. Charlson et al. Decision-making and outcomes in severe symptomatic aortic stenosis. J Heart Valve Dis 2006; 15: 312-321

La cirugía no se realiza en un número considerable de pacientes • Las razones para no enviar los pacientes a cirugía pueden deberse a desconocimiento de los resultados o a la dificultad en la estimación del riesgo quirúrgico • Las razones por las que los equipos quirúrgicos rechazan a los pacientes tampoco son uniformes

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Supervivencia de pacientes con EA no operada

Bach, D. S. et al. J Am Coll Cardiol 2007;50:2018-2019

Supervivencia en octogenarios con EAo

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Nkomo V et al. Lancet 2006

Nueva modalidad terapéutica: TAVI

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NEJM, 2010

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2010.Manejo apropiado de la EA • Reconocimiento de la lesión • Correcta catalogación de la severidad • Aconsejar cirugía con precocidad, según las indicaciones de las Guias • En caso de paciente de alto riesgo quirúrgico considerar Implantación de Protesis Transcateter •

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Management of Severe Aortic Stenosis

Severe AS (< 1 cm² or < 0.6 cm²/m² BSA) Symptoms No

Yes

LV EF < 50%

No Yes

Markedly calcified valve and increase in peak jet velocity ≥ 0.3 m/sec within 1 year

No Yes

Patient physically active

Yes

Exercise test No Re-evaluate in 6 to 12 months or when symptoms occur

Normal

Abnormal Surgery

Guidelines ESC,2007

PARA DISMINUIR EL RIESGO QUIRURGICO HAY QUE INTENTAR EVITAR LA CIRUGÍA URGENTE

OPTIMIZAR LA VALORACIÓN DEL PACIENTE “ASINTOMÁTICO”

Correcta evaluación de síntomas incipientes BNP Prueba de esfuerzo Progresión rápida EA críticas •

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Unidad de valvulopatias HGUVH Paciente con EA severa sintomática rechazado en sesión medico-quirúrgica Consulta externa específica. Evaluados 146 pts EcoTT o TE si dudas en la medición Anillo aortico>25mm

Anillo aortico<25mm

Reevaluar cirugía convencional Tratamiento médico <27 mm corevalve?

Coronariografía TAC Evaluación geriatrica SESION CLINICA

Transfemoral 32

Transapical

Tto médico

21

20

Mortalidad 5.6%

MERCI, Dr. Cribier!!!!!!

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2004

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Mas de 12.000 pts

partner

2010

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