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
– Institutional: Presence of Multidisciplinary Care
Team with Excellent Outcomes
– Estimate Risks: STS, NYS, Euroscore, etc
– Family/Social Support
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
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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
• 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
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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!
• STS Risk Calculator
– CABG/AVR – Mortality Risk – 33.8%
– AVR Alone – Mortality Risk – 27.9%
• Logistic EuroSCORE
– CABG/AVR – Mortality Risk – 78.8%
Case 1
What Would You Do?
1.BAV
2.TAVI
3.Surgical AVR – surgeons refused
4.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
• 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
• 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
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Severe AS
Peak velocity 4.3
AVA 0.7 cm2
EF normal
Case 2: Cardiac Catheterization
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RA 7 mmHg
PA 32/7 mmHg
PCWP 12 mmHg
PA Sat 68%
Mean AV gradient 40
mmHg
• AVA 0.68 cm2
• Coronary angiography:
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Patent LIMA to LAD
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Patent SVG to OM
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Occluded SVG to RCA
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Severe native 3VD
Case 2
Risk Calculator
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STS 2.9% mortality, 20% morbidity
Euroscore 26.8% mortality
What Would You Do?
1.BAV
2.TAVI – not a PARTNER candidate
3.Surgical AVR – surgeons refused
4.Palliative Care
Case 2: Balloon Aortic Valvuloplasty
• Post BAV:
– gradient 8 mmHg
– AVA 1.4 cm2
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
• 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
• Moderate to severe MR is present in 10%
of adults over 75.
• Degenerative
• Functional
–Ischemic
–Dilated cardiomyopathy
Goals of Treatment
• Degenerative MR:
– Eliminate
symptoms
– Maintain normal
survival
• Functional MR:
– Improve symptoms
– Improve QOL
– Decrease
hospitalizations for
CHF
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
O'Gara, P. et al. J Am Coll Cardiol Img 2008;1:221-237
Degenerative MR
Surgical Indications
• Severe MR prior to consequence (IIa)
• Severe MR with consequence
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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 Indications
• Severe MR prior to consequence (IIa)
• Severe MR with consequence
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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
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%
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
Nioga L, Euro J CT Surg, 39
(2011) 875-880
Functional MR
• 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
Papillary
muscle
traction
Increased
tethering
Decreased
closing force
Bulging
MR
Annular dilatation
Degree of MR predicts Survival in CHF
(Ischemic and Dilated Cardiomyopathy)
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
• 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
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
Percutaneous Mitral Valve Repair: 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
• 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
• 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
• Labs: BUN 60/Cr 1.9
• EKG: BiV paced
• CXR: enlarged heart and bilateral pleural
effusions
Cardiac Catheterization
• Coronary angiography: Patent LIMALAD, 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
• 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
• 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
• 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
Reasons for Treatment Allocation
Wenaweser, P. et al. J Am Coll Cardiol 2011;58:2151-2162