Valvular Heart Disease and Imaging

Prof. Fausto J. Pinto, FESC, FACC President, ESC

University Hospital Sta Maria University of Lisbon, Portugal

TOPIC 1 Epidemiology and prognosis in aortic stenosis

TOPIC 2 ESC and global registries

TOPIC 3 ESC and ACC/AHA VHD guidelines compared

VALVULAR HEART DISEASE

Epidemiological projections & new risk factors in AS

AGES-Reykjavik AS sub-study (1967-1994, n=30,795)

Prevalence of severe AS: echo (AVA<0.6cm2)/CT (Ca2+ score >500)

Future projection using population data

Age group Echo

(n=685)

CT

(n=5256)

< 70 years 0.92% 0.80%

70 – 79 years 2.44% 4.00%

≥ 80 years 7.33% 9.50%

R. Danielsen (IS) / 4115

Predicted number of individuals with severe AS

Adjusted hazard ratios for aortic valve stenosis

1.0 2.0

Severe psoriasis

Mild psoriasis

1.60

1.11

Hazard ratios

Incidence rates per 10000 person-years for aortic valve stenosis

Entire Danish population aged ≥ 18 years 1st January 1997 – 31st December 2011

Follow-up using population health care records

1.0

Mild psoriasis

20.0

Severe psoriasis

Reference

Incidence rates per 10000 person-years

15.4

19.3

7.60

U. Khalid (DK) / P5855

Predicting outcome in aortic stenosis

Plasma level of Troponin I is associated with increased LV mass and replacement fibrosis

C.W.L Chin (UK) / P5857

Cohort 1 (n=122) Stable AS undergoing CMR/LGE

Plasma level of Troponin I predicts cardiovascular mortality and need for AVR

Independent of age, gender, LVEF, coronary calcium score or severity of AS

Freedom from death/AVR

Cohort 2 (n=131) Stable AS randomised in SALTIRE trial Median FU 10.6 yrs (1178 patient-yrs)

Survival at 1 year

Mid and long-lerm follow-up after TAVI – What have we learnt so far? International trials and registries

TAVI RCTs and Registries now encompass >10,000 patients

5 year outcomes (small numbers)

Demographics and comorbidity determine long term outcomes (not procedural complications)

Durability - limited data - no worrying signals

Future data - treatment of patients at lower risk

0

20

40

60

80

100

Surv

ival

(%

)

Survival at 5 year

0

10

20

30

40

50

60

70

80

90

1 Year 2 Year 3 Year 4 Year 5 year

Surv

ival

(%

)

Belgium

France

Germany

Source

Source XT

ADVANCE

Partner A

UK

Italy

Canada

STS/ACC

CoreValve CE

P. Ludman (UK) / 967

Pregnancy in women with prosthetic heart valves

ESC Registry Of Pregnancy And Cardiac disease: ROPAC

0102030405060708090

100

Mechanical valve

Tissue valve No prosthetic valve

% p<0.001

p=0.571

0

20

40

60

80

100

120

Hemorrhagic events

Thrombotic events

Live Birth

VKA-VKA-VKA VKA-VKA-LMWH/UHLMWH-LMWH-LMWH UH-UH-UHLMWH-VKA-LMWH/UH UH-VKA-LMWH/UH

p = 0.366 p = 0.013 p = 0.272

Women with a mechanical prosthesis have adverse outcome cf. other cardiac patients (event-free pregnancy & live birth 58% vs 78%, p<0.001)

A wide variety of anticoagulation regimes is in use

Vitamin K antagonists are associated with high offspring mortality (miscarriage)

Heparin use in the first trimester is associated with valve thrombosis

No single regime is clearly optimal J.W. Roos-Hesselink (NE) / 4742

Global rheumatic heart disease registry: REMEDY

Rheumatic heart disease in low and middle income countries

2 2 6 7 6 5 5 14

57

34 19 14 13 15 14

21

11

11

16 19 22 22 12

14 2

3 2 2 3

8

0 0 1 1 1

3

7

30

51 56 58 57 54 58 43

0

10

20

30

40

50

60

70

80

90

100

< 10 years 10-20 years 21-30 years 31-40 years 41-50 years 51-60 years,108 cases

61-70 years,42 cases

71-80 years

% o

f ca

ses

Pure MS Pure MR MMVD Isolated AVD MAVD MMAVD

Pattern of native valve involvement n=2475

Suboptimal use of penicillin for secondary prophylaxis

Inadequate monitoring and control of oral anticoagulant therapy

Extremely limited use of contraception by women with RHD

Disparities in the use of percutaneous and surgical intervention

L.J. Zuhlke (ZA) / 4743

AHA/ACC versus ESC valve guidelines Where do we differ?

C.M. Otto (US) / 4805

2014 AHA/ACC valve guidelines

What’s New ? Key concepts

Heart Valve Team

Integrative Approach to Procedural Risk Assessment

Valve Disease Stages

• More data on natural history

• Better imaging and quantitation

• Better outcomes from intervention

• Less invasive interventions

• Stronger evidence for recommendations

• Lower thresholds for interventions

• Extend treatments to sicker populations

C.M. Otto (US) / 4805

Valve disease staging – A new concept

Stage Definition Description

A At risk Patients with risk factors for development of VHD

B Progressive Patients with progressive VHD

(mild-to-moderate severity and asymptomatic)

C

Asymptomatic severe

Asymptomatic patients who have reached the criteria for severe VHD

C1: Asymptomatic patients with severe VHD in whom the LV and RV remain compensated

C2: Asymptomatic patients who have severe VHD, with LV or RV decompensation

D Symptomatic severe Patients who have developed symptoms

as a result of VHD

C.M. Otto (US) / 4805

TAKE HOME MESSAGE

Top priorities in patients with valvular heart disease

End-stage VHD Right Intervention Right Patient Right Time

Future improvements Identify VHD early (Stage A/B) Prevent disease progression Intervene before end-stage

VALVULAR HEART DISEASE

TOPIC 1 New 2014 ESC guidelines

TOPIC 2 Imaging Atherosclerosis

TOPIC 3

Evaluation

LV function assessment

Risk marker

IMAGING

# esccongress www.escardio.org/esc2014

Imaging in new 2014 guidelines

IMAGING

2014 ESC/EACTS Guidelines on myocardial revascularization: Indications for imaging

Symptomatic patients (Intermediate risk) Stress imaging IA CT Angiography IIa A Hybrid Imaging IIa B

Knuuti, (FI) / Zamorano, (ES) / S. Windecker, (CH)

2014 ESC guidelines on the diagnosis and treatment of aortic diseases: Imaging of aorta

R.Erbel (DE) / 1119

+++ only for follow-up after aortic stenting (metallic struts), otherwise limit radiation

Advantages/Limitations

TTE TOE CT MRI Angio

Ease of use +++ ++ +++ ++ +

Diag. Reliability + +++ +++ +++ ++

Serial examinations ++ + ++(+) +++ -

Repetitive imaging of the aorta diameter over time to assess change in diameter Use the same imaging modality IC Use similar method of measurement IC Lowest iatrogenic risk imaging IC

2014 ESC Guidelines on diagnosis/Management of Hypertrophic Cardiomyopathy: CMR indications

Echocardiography is central to the diagnosis and monitoring of HCM (IA in all pts.)

Diagnosis: detection of increased LV wall thickness

Disease phenotype: • myocardial fibrosis, • abnormal MV apparatus • coronary microcirculatory function • ECG

P.M. Elliott (GB)

LGE CMR

EURObservational research programme cardiomyopathy registry: Use of CMR/LGE

P.M. Elliott (GB)

1115 consecutive patients who fulfilled conventional criteria for cardiomyopathy (26 centres)

HCM HCM

2014 ESC Guidelines on diagnosis/management of acute pulmonary embolism: Central role of CT/Added value of Echo in unstable patients

S.V. Konstantinides᷂ (GR)

Suspected Acute PE with shock/hypotension

No YES

RV Overload/Dysfunction

Reperfusion therapy

Echo Class IC

CT available Class IC

+ +

-

# esccongress www.escardio.org/esc2014

Imaging Atherosclerosis

IMAGING

Systemic atherosclerotic inflammation following Acute Myocardial Infarction: Increased 18F-FDG PET uptake in remote atheroma

In murine models, acute MI exacerbates atherosclerotic inflammation and progression : is it the same in humans?

18F-FDG PET study

40 pts. with recent MI -

40 pts. with stable angina

1.5

2.0

2.5

3.0

Stable Angina (n=40) NSTEMI (n=14) STEMI (n=26)18

F-F

DG

tis

sue

to b

ack

gro

un

d r

atio

s

P<0.0001 P=0.03

1.5

2.0

2.5

3.0

Stable Angina (n=40) NSTEMI (n=14) STEMI (n=26)

18F

-FD

G t

issu

e to

bac

kg

rou

nd

rat

ios

P<0.0001 P=0.03

In MI patients, 18F-FDG PET activity correlated with the size of the infarct (troponin level) (r=0.43) p=0.01)

Regions of interests around aorta 18F-FDG in stable angina and myocardial infarction

N.V. Joshi, (UK) /ESC Hot line session 2014

Epicardial Adipose Tissue: Relationship with plaque characteristics/vulnerability

Y. Morimitsu (JP) / P2549

EAT was assessed in 406 patients referred

for 64-slice CT

Vulnerable coronary plaque components: presence of non-calcified plaque (NCP)

Factors

EAT (>5.6mm)

Gender (male)

Diabetes

Multiple logistic analysis after adjustment of age, hypertension, dyslipidemia

High risk plaques and EAT thickness

Epicardial Adipose Tissue: Predicts progression of coronary artery calcification (CAC)

A.A. Mahabadi (DE) / 3839

Fat Volume

EAT quantification To determine the association of EAT volume with progression of

CAC-score in the general population (Heinz Nixdorf Recall

Study) without known CAD

CAC score at enrollment and after 5 years of follow-up in

3367 subjects

Age Groupe

MV-adjusted**

% progression

in CAC+1 (95% Cl)

p-value

All participants 6.1 (1.2-

11.2) 0.01

<55 (n=1136) 19.8 (8.9-

31.7) 0.0002

≥55-<65 (n=1372)

2.5 (-4.8-10.4)

0.5

≥65 (n=859) 3.9 (-7.2-7.9) 0.98

# esccongress www.escardio.org/esc2014

LV Function assessment

IMAGING

40 women with left sided breast cancer, treated by lumpectomy without chemotherapy,

undergoing only adjuvant RT (mean cumulative dose 58.9±9.5 Gy)

Standard and 2D STE was obtained at baseline, during RT and 6 weeks

post RT

2D speckle-tracking after chest radiation: Detection of subclinical LV dysfunction

Q. Lo (AU) / P644

Acute adverse effects of RT on cardiac function are not well characterised

Parameter Baseline During RT 6 wks post RT P value

LVEF (%) 63 ± 5 62 ± 4 62 ± 4 NS

Global Long S -20.44 ± 2.66 -18.60 ± 2.70 * -18.34 ± 2.86 * <0.05

Global Cir S -18.52 ± 3.45 -19.20 ± 3.30 -19.30 ± 2.86 NS

Global Rad S 56.66 ± 18.57 46.93 ± 14.56 * 49.22 ± 15.81 * <0.05

Global Long Strain is modestly correlated with radiation dosage

These findings may have implications in breast cancer patients receiving additional cardiotoxic chemotherapy

41 asymptomatic pts. with severe primary MR and LVEF >

60%

Clinical F-Up at 18 months

Composite end-point (n=8): new onset of dyspnea, admission for

heart failure

3D STE is a promising tool for predicting the development of symptoms

Management of asymptomatic pts. with primary MR remains controversial

Log rank test p=0.033

3D speckle-tracking Echo (STE): Area strain but not LVEF predicts outcome in primary mitral regurgitation

E. Casas Rojo, (SP) / 226

TAKE HOME MESSAGE

Imaging plays a major role in diagnosis and decision-making in cardiology

Acute MI exacerbates systemic atherosclerotic inflammation and disease progression (18F FDG PET)

Epicardial fat is a confirmed marker of advanced atherosclerosis

LVEF underestimates the extent of LV dysfunction whereas 2D/3D strain imaging accurately detects LV impairment at an earlier stage (e.g., in breast cancer and in primary mitral regurgitation)