DEPARTMENT OF CARDIOLOGY

Aortic Valve Stenosis with Hypertension. The double loaded ventricle

Javier Bermejo

I have no financial relationships to disclose

The Problem

Hypertension

CAD

AS

- AS is present in 1-3 % of pts. with HT

- HT is present in 30-60 % of pts. with AS

- HT is a “risk factor” for degenerative AS

- Common findings are disruption of elastic fibers

Aortic Valve

Arterial Bed

The double loaded ventricle

AS & Hypertension

Diagnostic implications

Physiological consequences

Impact on outcome

Therapeutic issues

In the Echo-Lab:

Measure BP in all pts. with AS

Reassess severity if extreme values

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JACC 2005

Briand et al JACC 2005

Hachicha Circulation 2007

Rosebbo N Engl J Med 2008

Carmaruic JACC Img 2009

Jander et al Circulation 2011

Rieck et al Hypertension 2012

Rieck et al Hypertension 2012

Rieck et al Hypertension 2012

Treat Hypertension!

Target for drug therapy

brain/ kidney

other vascular beds

brain/ kidney

other vascular beds

Courtesy of MF O’Rourke

• N= 20 pts. with severe AS & HT

• 73 years old (87 – 29)

• 13 male / 7 female

• AVA= 0.7 ± 0.3 cm2

• Normal EF

• Stress Echocardiography

• Randomized with/without - test/retest

Jiménez Candil et al. Heart 2005

Jiménez Candil et al. Heart 2005

Nadir et al. JACC 2011

Nadir et al. JACC 2011

Treat Aortic Valve Stenosis… (if symptomatic)

Circulation Research 1992

Pre-TAVI Post-TAVI p* Valvular and Ventricular

Aortic Valve Area (cm2) 0.7 ± 0.1 1.8 ± 0.6 0.007

Mean Transvalvular Pressure Gradient (mm Hg) 39 ± 18 11 ± 4 0.005

Stroke Volume (ml) 75 ± 13 64 ± 17 0.14

Ejection Fraction (%) 47 ± 21 55 ± 17 0.038

LV End-systolic Elastance (mm Hg/ml) 0.76 ± 0.2 1.3 ± 0.7 0.09

LV pressure (mmHg) 128 ± 18 115 ± 25 0.12

Vascular

Mean Blood Pressure (mmHg) 62 ± 14 74 ± 17 0.05

Pulse Pressure (mmHg) 39 ± 13 52 ± 14 0.005

Systemic Vascular Resistance (dynes/s/cm-5) 820 ± 259 1137 ± 597 0.08

Aortic Input Impedance Z1 (mmHg/ml) 337 ± 142 510 ± 188 0.028

Characteristic Impedance (dynes/s/cm-5) 147 ± 78 207 ± 109 0.14

Aortic Compliance (·10-3 cm5/dynes) 1.47 ± 0.78 0.80 ± 0.27 0.08

Ea (mmHg/ml) 1.05 ± 0.30 1.61 ± 0.63 0.023

Ea/Ees 1.38 ± 0.37 1.38 ± 0.23 0.92

Non-Invasive Valvuloarterial Impedance (mmHg/ml) 2.1 ± 0.5 1.9 ± 0.9 0.5

Wave Intensity Analysis

Wave Speed (m/s) 2.48 ± 1.18 4.06 ± 1.76 0.01

Peak dIw FCW (· 106 W·m-2·s-2) 0.91 ± 0.49 1.52 ± 0.78 0.012

Reflexion Distance (m) 0.06 ± 0.03 0.08 ± 0.12 0.81

*Wilcoxon test

Yotti et al AHA 2012

Valve and the Arterial Bed:

More than simple lumped-model

LV load interaction after valve intervention

complementary

competititive

Effects of Load in AS

Dahl et al Am J Cardiol 2010

Treat them both!

Dahl et al Am J Cardiol 2010

Conclusions (1/2)

AS & HT are two highly prevalent diseases, with important interactions regarding pathophysiology, diagnosis, LV function, and outcome.

In case of severe HT, reassess severity after controlling BP.

Increased load reduces cardiac output and modifies LV remodelling response.

Conclusions (2/2)

HT in pts. with AS doubles the risk of hard CV events.

HT should be aggressively treated

ACEI and ARB are the drugs of choice.

HT after AVR blunts the acute and chronic benefits of valvular interventions.

Treatment is advocated for the long-term after AVR.