2018-01-09

1

Indicator Mild Moderate Severe

Jet velocity (m/s) 2.0-2.9 3.0 - 3.9 ≥ 4.0

Mean gradient (mmHg) < 20 20 - 39 ≥ 40

Valve area (cm2) ≤ 1.0

Valve area index (cm2/m2)

≤ 0.6

2018-01-09

2

Abnormal AV with Reduced Systolic Opening

Vmax 3.0 - 3.9 m/sec∆Pmean 20 - 39 mmHg

Severe ASVmax 4 m/sec

∆Pmean 40 mmHg

Symptomatic(stage D1)

Asymptomatic(stage C)

LVEF < 50%(stage C2)

Other cardiacsurgery

Abnormal ETT

Vmax 5 m/sec∆Pmean 60mmHgLow surgical risk

∆Vmax 0.3 m/s/yLow surgical risk

Symptomatic Asymptomatic

LVEF<50% Other cardiacsurgery

DSE withAVA 1 cm2 and

Vmax 4m/sec(stage D2)

AVA 1 cm2

andLVEF 50%(stage D3*)

AS likely cause of symptoms

AVR(Class IIa)

AVR(Class IIb)

AVR(Class IIa)

AVR(Class I)

Yes No

2018-01-09

3

Case. Asymptomatic Severe AS

Case. Asymptomatic Severe AS

AV Vmax = 4.6 m/sec

AV Vmax = 5.5 m/sec

2018-01-09

4

Case. Asymptomatic Severe AS

0.785 2

0.785 2.1 2 21154

.

Vmax = 5.5 m/secAV TVI 154 cm

LVOT TVI 21 cmLVOT diameter 2.1 cm

ComparisonofEarlySurgeryversusConventionalTreatmentinAsymptomatic

VerySevereAorticStenosis

Duk-Hyun Kang, Sung-Ji Park*, Ji Hye Rim,

Dae-Hee Kim, Jong-Min Song, Kee-Joon Choi,

Seung Woo Park*, Jae-Kwan Song,

Jae-Won Lee, Pyo-Won Park*

Division of Cardiology, Cardiac Surgery

Asan Medical Center, Samsung Medical Center*

Seoul, South Korea

KangDH,etal.Circulation2010;121:1502

2018-01-09

5

SurvivalFreeofCardiacDeathOP versus CONV group

OP 102 96 48 29 CONV 95 82 54 32

No at Risk

OP

CONV

years

OP 6-year survival rate 100%CONV 6-year survival rate 76±5%

P<0.001

0 2 4 60

40

60

80

100

Car

dia

c m

ort

alit

y fr

ee s

urv

ival

(%

)

Abnormal AV with Reduced Systolic Opening

Vmax 3.0 - 3.9 m/sec∆Pmean 20 - 39 mmHg

Severe ASVmax 4 m/sec

∆Pmean 40 mmHg

Symptomatic(stage D1)

Asymptomatic(stage C)

LVEF < 50%(stage C2)

Other cardiacsurgery

Abnormal ETT

Vmax 5 m/sec∆Pmean 60mmHgLow surgical risk

∆Vmax 0.3 m/s/yLow surgical risk

Symptomatic Asymptomatic

LVEF<50% Other cardiacsurgery

DSE withAVA 1 cm2 and

Vmax 4m/sec(stage D2)

AVA 1 cm2

andLVEF 50%(stage D3*)

AS likely cause of symptoms

AVR(Class IIa)

AVR(Class IIb)

AVR(Class IIa)

AVR(Class I)

Yes No

2018-01-09

6

Indicator Mild Moderate Severe

Jet velocity (m/s) < 3.0 3.0 - 3.9 > 4.0

Mean gradient (mmHg) < 20 20 - 39 > 40

Valve area (cm2) ≤ 1.0

Valve area index (cm2/m2) ≤ 0.6

2018-01-09

7

Minners J,etal.Eur HeartJ2008;29:1043‐48

< 50%

“Classical”LF LG AS

“Paradoxical”LF LG AS

Normal-flowLG AS

≤35 >35

Clavel MAetal.,EurHeartJ,2016

≥ 50%

LVEF

AVA ≤ 1.0cm2 & Mean PG < 40mmHg

SV index (mL/m2)

2018-01-09

8

67‐year‐old female with exertional dyspnea

0.785 2

0.785 2.0 2 12.573.7

.

LVOT TVI 12.5cm

AV Vmax 3.7m/sMean PG 35mmHg

Case: low‐gradient AS with depressed LVEF

LVOT diameter 2.0 cm

2018-01-09

9

Pibarot PandDumesnil JG.JAmColl Cardiol 2012;60:1845‐53

LVOT TVI 13.2cm

LVOT TVI 13.8cm

LVOT TVI 14.4cm

Vmax 3.6m/secPG 51/32mmHg

AVA 0.52cm2

Vmax 4.1m/secPG 66/41mmHg

Vmax 4.8m/secPG 93/54mmHg

AVA 0.50cm2

Baseline

Dobutamine 5㎍

Dobutamine 10㎍

2018-01-09

10

• Low-gradient severe AS with depressed LVEF- Low LVEF (<40%) causing low stroke volume

- True severe AS versus pseudosevere AS

• Paradoxical Low-flow, Low-gradient severe AS with preserved LVEF- Severe concentric LVH and smaller LV cavity size

- High valvuloarterial impedance

and low stroke volume

Pibarot PandDumesnil JG.JAmColl Cardiol 2012;60:1845‐53

2018-01-09

11

Low-Flow, Low gradient AS with Preserved LVEF

Reduced Transvalvular

flow rate

Reduced Forward

Stroke Volume

PronouncedConcentricRemodeling

ImpairedDiastolic

Filling

ImpairedLongitudinal

Systolic functionAtrial Fibrillation

MitralRegurgitation

MitralStenosis

TricuspidRegurgitation

Pibarot P,Dumesnil JG.Circulation2013:1729

PLF surgical

PLF medicalP<0.001

100

80

60

40

20

00 1 2 3 4 5

Sur

viva

l (%

)

Hachicha Z,etal.Circulation2007;115:2856‐64

NF group

PLF group

P=0.006

100

80

60

40

20

00 1 2 3 4 5

Sur

viva

l (%

)

Follow-up (year)

NF surgical

NF medical

Follow-up (year)

2018-01-09

12

Su

rviv

al

(%)

1.0

0.8

0.6

0.4

0.2

0.0

Follow –up, (month)

AVR

Standard

0 12 24 36 48 60

1.0

0.8

0.6

0.4

0.2

0.0

Follow –up, (month)

AVR

Standard

0 12 24 36 48 60

Su

rviv

al

(%)

Ozkan etal.Circulation2013;128:622‐631

Log rank P<0.001 HR: 2.03, P=0.013

Unadjusted Adjusted

Herrman HCetal,Circulation,2013

• PARTNER-I B (inoperable): Medical vs. TAVR

0

10

20

30

40

50

60

70

80

0 60 120 180 240 300 360 420 480 540 600 660 720

2-Y

ear

Dea

th (

%)

Time in DaysNo. at RiskB-TAVR 85 74 65 58 55 50 47 46 46B-MM 95 78 60 47 39 35 26 25 18

Log Rank P<0.001 Log Rank P=0.047

No. at RiskB-TAVR 23 21 19 17 15 13 11 10 10B-MM 29 22 15 10 9 9 6 5 4

76.2%

45.9%

76.9%

56.5%

LF-Cohort B-TAVRLF-Cohort B-MM

LF,NEF and-LG-Cohort B-TAVRLF,NEF and LG-Cohort B-MM

0

10

20

30

40

50

60

70

80

90

0 60 120 180 240 300 360 420 480 540 600 660 720

2-Y

ear

Dea

th (

%)

Time in Days

2018-01-09

13

Pibarot Petal.JAmColl Cardiol 2016:2359‐2363

AVA < 1.0 cm2

Low gradient (severe?) AS

▪ Confirm AS severity:2D echo, DSE, MDCT▪ Assess surgical risk

≥ 50%Preserved LVEF

Classical Low-Flow,Low-gradient AS

D2 Stage

AVR-Class IIaTAVR > SAVR?

< 50%Low LVEF

Flow SVi

Paradox, Low Flow,Low-gradient AS

D3 Stage

< 35 mL/m2

Low Flow

▪Confirm AS severity:2D echo, MDCT

▪Assess surgical risk

AVR-Class IIaTAVR > SAVR?

AVR?SAVR or TAVR

▪ Confirm AS severity:2D echo, MDCT

Normal Flow,Low-gradient AS

? Stage

≥ 35 mL/m2

Normal Flow

LVEF

< 50%

“Classical”LF LG AS

“Paradoxical”LF LG AS

Normal-flowLG AS

≤35 >35

Clavel MAetal.,EurHeartJ,2016

≥ 50%

LVEF

AVA ≤ 1.0cm2 & Mean PG < 40mmHg

SV index (mL/m2)

2018-01-09

14

Case: 70‐year‐old male with low‐gradient AS and dyspnea

LVOT TVI 25 cmLVOT 2.08 cm

AV Vmax 3.7 m/smeanPG 35 mmHgAV TVI 90 cm

AVA LVOT 0.785

2.08 0.7852590

0.94cm

BSA = 1.77 m2

AVAI = 0.53 cm2/m2

Stroke Volume = 80.0 ml

SVI = 45.2 ml/m2

Case: low‐gradient AS with preserved LV ejection fraction

2018-01-09

15

• Paradoxical Low-flow, Low-gradient severe AS

- Severe concentric LVH and smaller LV cavity size

- High valvuloarterial impedance and low stroke volume

• Normal-flow, Low-gradient severe AS

- Measurement error

- Small body surface area

- Inconsistency between cutoff values

of AVA and gradient

Aortic valve area (cm2) Mean gradient (mmHg)

3.0 2.92.0 6.61.0 260.9 320.8 410.7 530.6 73

Carabello BA.NEngl JMed2002;346:677

2018-01-09

16

Pibarot Petal.JAmColl Cardiol 2016:2359‐2363

AVA < 1.0 cm2

Low gradient (severe?) AS

▪ Confirm AS severity:2D echo, DSE, MDCT▪ Assess surgical risk

≥ 50%Preserved LVEF

Classical Low-Flow,Low-gradient AS

D2 Stage

AVR-Class IIaTAVR > SAVR?

< 50%Low LVEF

Flow SVi

Paradox, Low Flow,Low-gradient AS

D3 Stage

< 35 mL/m2

Low Flow

▪Confirm AS severity:2D echo, MDCT

▪Assess surgical risk

AVR-Class IIaTAVR > SAVR?

AVR?

▪ Confirm AS severity:2D echo, MDCT

Normal Flow,Low-gradient AS

? Stage

≥ 35 mL/m2

Normal Flow

LVEF

WatchfulObservationVersusEarlyAortic

ValveReplacementforPatientswithNormal

flow,Low‐GradientSevereAorticStenosis

Duk-Hyun Kang, Jeong Yoon Jang, Sung-Ji Park,

Dae Hee Kim, Jong-Min Song, Seung Woo Park,

Jae-Kwan Song, Jae Won Lee, Seung-Jung Park

Asan and Samsung Medical Center

Seoul, Korea

KangDH,etal.Heart2015;1375‐81

2018-01-09

17

StudyFlow

Normal flow LG AS(n = 284)

Early AVR Group

(n = 98, 35%)

Clinical and Echocardiographic follow-up until June 2014

Referred for late AVR Symptoms worsened

Aortic jet velocity > 4 m/sMean gradient > 40 mmHg

Watchful Observation Group(n = 186, 65%)

Early elective AVR within 6 monthsafter initial echocardiography

KangDH,etal.Heart2015;1375‐81

0 2 4 6 80

20

40

60

80

100

No. at Risk

WatchfulObservation

Early AVR

186

98

74

38

178

90

123

64

39

22

Early AVRWatchful Observation

Time after baseline, years

Ov

era

ll m

ort

alit

y ra

te, % 8 year overall mortality rate

17 ± 5 %27 ± 5%

p = 0.840

2018-01-09

18

0 2 4 6 80

20

40

60

80

100

No. at Risk

WatchfulObservation

Early AVR

186

98

74

38

178

90

123

64

39

22

Early AVRWatchful Observation

Time after baseline, years

CV

mo

rtal

ity

rate

, %8 year CV mortality rate

11 ± 4 %18 ± 4 %

p = 0.806

0 2 4 6 80

20

40

60

80

100

No. at Risk

WatchfulObservation

Early AVR

83

83

30

34

80

75

54

54

16

21

Early AVRWatchful Observation

Time after baseline, years

Ov

era

ll m

ort

alit

y ra

te, % 8 year overall mortality rate

20 ± 5%22 ± 7 %

p = 0.741

2018-01-09

19

AVA . .

.

BSA = 1.57 m2

AVAI = 0.43 cm2/m2

SVI = 39.2 ml/m2

LVOT 1.96 cm

AV Vmax 3.8 m/sAV TVI 89 cm

LVOT TVI 20.4 cm

75‐year‐old female with exertional dyspnea

Case. What is your diagnosis ?

1) Moderate AS

2) High-gradient Severe AS

3) Normal-flow, Low-gradient Severe AS

4) Low-flow, Low-gradient Severe AS

2018-01-09

20

AV Vmax 4.2 m/s

AV Vmax 3.8 m/s

75‐year‐old female with high‐gradient, severe AS

Case. What is your diagnosis ?

1) Moderate AS

2) High-gradient Severe AS

3) Normal-flow, Low-gradient Severe AS

4) Low-flow, Low-gradient Severe AS

2018-01-09

21

• Flow‐gradient pattern, AVA, ejection fraction, symptoms and operative risk should be considered in a decision for AVR in severe AS

• Clinical trials are required to evaluate benefit of surgical AVR or TAVR for symptomatic patients with LG severe AS and asymptomatic patients with very severe AS