Transcript Document

Asymptomatic Aortic Regurgitation
Elie Chammas, MD.FESC
Clemenceau Medical Center & Lebanese University
Introduction
• Despite Significant Volume and Pressure Overload on the Left Ventricle
(LV), patients with Aortic Regurgitation (AR) Typically Remain
Asymptomatic For Extended Periods of Time.
• Symptoms of Dyspnea, Orthopnea, Nocturnal angina and Syncope
Develop Relatively Late in the Course of the Disease.
• Aortic Valve Replacement (AVR) has Clearly been Shown to Prolong
Survival and Improve Functional Class in Patients (Pts) with Severe
Symptoms.
• The Optimal Timing for Valve Replacement in Asymptomatic Pts is
Less Concrete.
• Should Prophylactic AVR be Performed to Preserve LV Contractile
Function ?
• The Benefits of Preserving Contractile Function must be Weighted
against the Immediate Operative Risks Associated with Prosthetic
Valves.
Natural History of Medically Treated Patients
• Long asymptomatic phase, Followed by by a symptomatic phase with a
relatively rapid progressive deterioration in clinical function.
• Asymptomatic Patients with normal LV pump function have an
excellent long-term prognosis : 90% of pts are Asymptomatic at
3 years, 81% at 5 years and 75% at 7 years.
The percentage of Pts requiring AVR was < 4% per year.
• Asymptomatic Patients with impaired LV ejection performance:
66 % require surgery within 3 years.
• Vasodilator Therapy (nifedipine, ACE Inh), reduces LV dilatation in
Asymptomatic Pts with AR who have normal LV systolic function,
delaying the need for AVR
• Symptomatic Pts have a poor prognosis under medical TT (4% of
survival after 10 y FU, NYHA III-IV.
Natural History of Surgically Treated Patients
• No randomized trials comparing Medical
therapy with Surgery.
• Surgical Intervention appears to improve
survival and functional class in patients
with AR.
• LV pump function improves after aortic
valve replacement with correction of the
volume after load.
Indices of LV performance in
Asymptomatic patients with AR
• 1) Ejection Phase Indices:
Asymptomatic Pts with normal LV function have an excellent long-term
survival rate, and < 4% of pts per year require AVR.
Asymptomatic pts with impaired LV function, have a considerably more
aggressive clinical course and should be referred for elective AVR to avoid
progression to irreversible contractile dysfunction.
• 2) End-Systolic Dimension:
1) 80% of asymptomatic pts with an end-systolic dimension > 55 mm
required surgery within 34 months compared with 20% of pts with an endsystolic dimension < 55 mm.
2) No pt with an end-diastolic dimension <= 40 mm required aortic valve
replacement at 4 years, whereas 65% of pts with an end-systolic dimension
>= 50 mm required surgery within the follow up period
International Guidelines
European Guidelines
Guidelines on the Management of Valvular Heart Disease
ESC 2007 Guidelines
• Asymptomatic Patients with Severe Aortic
Regurgitation:
LVEF <= 50 % or
EDD > 70 mm or
ESD > 50 mm (or 25 mm/m2 BSA)
No : Follow up
Yes : Surgery
A Vahanian, European Heart Journal 2007, 28, 230-268
American Guidelines
Management strategy for patients with chronic severe aortic regurgitation
ACC/AHA Guidelines 2006
Bonow, R. O. et al. J Am Coll Cardiol 2006;48:e1-e148
Copyright ©2006 American College of Cardiology Foundation. Restrictions may apply.
Recommendations Françaises
Recommendations de la Société Française de Cardiologie
sur la prise en charge des Valvulopathies.
(C Tribouilloy Archives des Maladies du Coeur 98, 2, Fev 2005)
Indications Opératoires dans les Insuffisances Aortiques Chroniques Asymptomatiques.
1) Indications Formelles:
a. IA volumineuse avec dysfonction du VG : DTS du VG > 25mm/m2 (ou > 50mm) et / ou
FE < 50%
b. IA avec dilatation de l’aorte ascendante (Diamètre maximal > 55 mm)
2) Indications Admises:
a. IA du syndrome de Marfan ou bicuspidie avec dilatation de l’aorte Ascendante
(Diamètre maximal > 55 mm), surtout si progression rapide de ce diamètre au cours du
suivi ou si antécédants familiaux de dissection aortique
b. IA volumineuse et indication d’une autre intervention de chirurgie cardiaque
3) Indications Discutées:
a. IA volumineuse avec dilatation du VG importante (DTD du VG > 70 mm) ou FE
comprise entre 50 et 55%
b. IA du syndrome de Marfan ou bicuspidie avec diamètre aortique compris entre 45 et
50 mm, en fonction des possibilités de chirurgie conservatrice , de la notion
d’évolutivité, de l’âge et de la stature.
c. IA du syndrome de Marfan et désir de grossesse si diamètre de l’aorte ascendante >
40 mm
d. IA de sévérité moyenne et indication d’une chirurgie cardiaque associée
Recommendations de la Société Française de Cardiologie
sur la prise en charge des Valvulopathies.
(C Tribouilloy Archives des Maladies du Coeur 98, 2, Fev 2005)
Traitement Médical dans les Insuffisances Aortiques Chroniques Asymptomatiques
1) Traitement vasodilatateur:
La Nifédipine a un effet favorable sur les diamètres et la FE du VG, et permet de retarder
l’heure de la chirurgie .
Les IEC semblent entraîner une diminution de la fraction de régurgitation, de la masse et
des volumes du VG.
Les vasodilatateurs (IEC / Nifédipine ) ne sont pas recommendées en présence d’une IA
modérée sans dysfonction VG ni HTA associée.
Ils trouvent leur place: pour retarder la chirurgie chez les patients asymptomatiques
ayant une IA volumineuse dont le diamètre télésystolique est inférieur a 25 mm/m2 et la
FE du VG supérieure à 55%.
2) Traitement B-bloquant
Les BB sont indiqués quand l’IA n’est pas sévère pour prévenir la dissection aortique
dans le syndrome de Marfan
Algorithm for the Timing of
Surgery in Asymptomatic Pts
with Aortic Regurgitation
Algorithm for the Timing of Surgery in Asymptomatic
Pts with Aortic Regurgitation
LV Function
LV Size
Points
Clinical
Ejection
Fraction (%)
End Systolic
Dimension
(mm)
Exercise
Capacity
0
None
> 60%
< 45
Preserved
1
1
50-60%
45-55
2
2 or more
< 50%
> 55
Decreased
Clinical: Age > 65, Cardiothoracic ratio >= 0,58, LVH on ECG,
Cardiac index <=2.5 l/m/m2, LV ED Pressure > 20 mmHg.
Exercise Capacity: 8 METS on graded exercise treadmill
Algorithm for the Timing of Surgery in Asymptomatic
Pts with Aortic Regurgitation
Total Points
Decision Regarding Surgical
Intervention
0-1
Delay Surgery; Clinical and
Echocardiographic follow-up at 12 mo
2
Borderline; Recommend Clinical and
Echocardiographic follow-up at 6 mo
>=3
Proceed with Surgery.
Algorithm for the Timing of Surgery in
Asymptomatic Pts with Aortic Regurgitation
(Part C)
Additional Predictors of Adverse Outcome in Aortic Regurgitation
Percentage Fractional Shortening
< 29%
End-Systolic Volume Index
> 60 ml/m2
End-Systolic Wall Stress
> 235 mmHg
End-Diastolic Dimension
> 80 mm
End-Diastolic Dimension (Radius) R
End-Diastolic Wall Thickness Th
>= 3,2
Clinical Case
• 45 y old man, construction worker, Addressed
for echo : systolic and diastolic murmur
• Symptoms: No Symptoms
• Echo: Ejection Fraction : 55%, the LV endsystolic dimension measured 45 mm, Bicuspid
Aortic valve with grade III aortic regurgitation.
• Stress test: Complete stage III of a Bruce
protocol Without symptoms.
Clinical Case
What to do ?
•
•
•
•
•
1. No Treatment,Only prophylaxis.
2. Medical Treatment (Nifedipine)
3. Surgical Treatment (AVR)
4. I Need more Data (TEE…)
5. I Don’t know.
Algorithm for the Timing of Surgery in Asymptomatic
Pts with Aortic Regurgitation
LV Function
LV Size
Points
Clinical
Ejection
Fraction (%)
End Systolic
Dimension
(mm)
Exercise
Capacity
0
None
> 60%
< 45
Preserved
1
1
50-60%
45-55
2
2 or more
< 50%
> 55
Decreased
Clinical: Age > 65, Cardiothoracic ratio >= 0,58, LVH on ECG,
Cardiac index <=2.5 l/m/m2, LV ED Pressure > 20 mmHg.
Exercise Capacity: 8 METS on graded exercise treadmill
Algorithm for the Timing of Surgery in Asymptomatic
Pts with Aortic Regurgitation
Total Points
Decision Regarding Surgical
Intervention
0-1
Delay Surgery; Clinical and
Echocardiographic follow-up at 12 mo
2
Borderline; Recommend Clinical and
Echocardiographic follow-up at 6 mo
>=3
Proceed with Surgery.
Clinical Case
What to do ?
• According to the Algorithm, the patient would be assigned
Two points, Justifying medical therapy with serial clinical
and echocardiographic follow-up.
• The patient was treated with Nifedipine and followed every
6 months for 1 year, and then yearly thereafter.
• At 5 years after the initial diagnosis, although the patient
remained Asymptomatic, Echocardiography revealed an
increase in the end-systolic dimension to 55 mm and a
decrease in the Ejection Fraction to 48%, resulting in a total
of Three points.
• The patient was then referred for successful aortic valve
replacement.
What about Patients with
Aortic Regurgitation and
LV dysfunction ?
Improved outcomes after aortic valve
surgery for chronic aortic regurgitation
with severe left ventricular dysfunction
Bhudia SK, McCarthy PM, Kumpari GS
J Am Coll Cardiol 2007; 49: 1465-71
Improved outcomes after aortic valve surgery for chronic
aortic regurgitation with severe left ventricular dysfunction
• Background: Patients with chronic AR and severe LVD have been
considered high risk for aortic valve surgery, with limited prognosis.
Transplantation is considered for some.
(How to manage patients with severe left ventricular dysfunction and
valvular regurgitation. Acar J, Michel PL, Luxereau P.J Heart Valve Dis
1996; 5: 421-9)
• Methods: 724 Pts underwent surgery for chronic AR, 12% had severe
LVD.They were propensity matched to patients with non severe LVD to
compare hospital mortality and late survival.
• Results: Survival was lower (p=0.04. 91% vs 96%, 30 D) among patients
with severe LVD than among matched patients with non severe LVD.
However, survival of Pts with severe LVD improved dramatically across
the study time frame (p=0.0004)
• Conclusion: Neutralizing risk of severe LVD has improved early and
late survival such that aortic valve surgery for chronic AR and
cardiomyopathy is no longer a high-risk procedure for which
transplantation is the best option.
Conclusion
• After a long Asymptomatic period, Severe Aortic
Regurgitation eventually lead to reduced LV pump
performance.
• The development of irreversible contractile dysfunction is
associated with increased risk for post operative LV pump
failure and death from congestive heart failure.
• To justify the risk of surgery, the ideal timing for surgical
intervention in patients with aortic regurgitation is
therefore at the onset of contractile dysfunction, yet early
enough to prevent the development of irreversible
contractile dysfunction.
Conclusion
• Echocardiography in conjunction with a thorough history
and physical examination, provides accurate, reproducible,
and cost-effective methodology for the serial assessment
of contractile dysfunction in patients with aortic
regurgitation.
• The use of guidelines and the development of algorithms
for timing of surgery in patients with aortic regurgitation
guide operative intervention to preserve contractile
function, thereby improving long-term post operative
outcome and minimizing unnecessary risk.
Thank You