MD Conference Express ESC 2012 - (Page 10)
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Guidelines for Management of Severe AS Bernard Iung, MD, Hôpital Bichat, Paris, France, reviewed the latest guidelines on the management of valvular heart disease. The European Society of Cardiology (ESC)/ European Association for Cardio-Thoracic Surgery (EACTS) Guidelines recommend evaluating severity of disease, presence of symptoms, life expectancy, QoL, intervention benefits versus risks, patient wishes, and available resources. Severe AS is defined as aortic valve area (AVA) <1.0 cm2, indexed AVA <0.6 cm2, mean gradient >40 mm Hg, maximum jet velocity >4.0 m/s, and velocity ratio <0.25 [Vahanian A et al. Eur Heart J 2012]. While the guidelines do provide the listed criteria, these parameters have been shown to perform inconsistently in patients with normal LV function in whom use of AVA criteria results in a greater proportion of patients being classified as having severe AS [Minners J et al. Eur Heart J 2008]. These inconsistencies should be considered when evaluating patients with AS. The guidelines recommend TAVI for eligible patients with contraindications to surgical AVR [Vahanian A et al. Eur Heart J 2012] (Figure 1). In the PARTNER trials, EuroSCOREs and STS scores were 26.4% and 11.2%, respectively, in patients with contraindications for surgery [Leon MB et al. N Engl J Med 2010] and 29.3% and 11.8% in high-risk operable patients [Smith CR et al. N Engl J Med 2011]. Risk scores have good discrimination (low- vs high-risk) but poor calibration (predicted vs observed risk). EuroSCORE II has improved calibration, but there are no specific data in high-risk patients. The ESC Working Group reported that risk scores have limitations in high-risk patients and that patients with comorbidities require an individualized approach. In the absence of a more precise quantitative score, risk assessment should mostly rely on the clinical judgment of a comprehensive heart team as was used in the PARTNER trials [Leon MB et al. N Engl J Med 2010; Makkar RR et al. N Engl J Med 2012]. Figure 1. Management of Severe AS.
Severe AS Symptoms
No LVEF <50% No Physically active No Yes Exercise test Symptoms or fall in blood pressure below baseline No Presence of risk factors and low/intermediate individual surgical risk No Re-evaluate in 6 months Yes AVR AVR or TAVI Yes Yes No High risk for AVR Contraindication for AVR Yes Short life expectancy No No Yes TAVI Med Rx Yes Yes
TAVI should be considered for patients with severe symptomatic AS who are deemed to be high-risk for traditional SAVR. Risk assessment is a key issue, and a better definition of contraindications to SAVR is needed. Risk scores in patients with AS have limitations, and there is a need for better identification of patients who should not have any intervention. Clinical judgment through a multidisciplinary approach is essential for optimal patient selection. TAVI in the “Real World” Based on a review of data from TAVI registries, Martyn R. Thomas, MD, St. Thomas’ Hospital, London, United Kingdom, concluded that TAVI is rapidly being adopted in the real world but penetration varies widely from country to country. Outcome results for the Sapien and CoreValve devices are the same except for higher permanent pacemaker rates with the CoreValve. Mortality is 4% to 8% at 30 days and 15% to 25% at 1 year after TAVI, and stroke rates are 3% to 4% [Toggweiler S et al. J Am Coll Cardiol 2012; Wendler O. TCT 2012; Meridith IT. TCT 2010]. Moderate to severe paravalvular leak is associated with worse outcomes, as was shown in the PARTNER trials. The registries contain only limited QoL data. Comparison between transfemoral and alternative access outcomes is difficult because the patient populations are different, as shown in the SOURCE XT registry (Table 1). Table 1. TF Versus Non-TF: SOURCE XT.
Characteristic NYHA III/IV (%) LVEF (mean ± SD) CAD (%) Previous MI (%) Previous PCI (%) Previous CABG (%) Atrial Fibrillation (%) Previous Pacemaker (%) Previous AO Bioprosthesis (%) Transfemoral Transapical n=1694 n=906 77.2 55.3±17.0 40.2 12.2 27.2 12.3 22.8 10.0 1.8 75.9 53.5±12.4 51.8 20.9 36.7 24.4 29.9 12.7 4.0 p value 0.5 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 0.03 <0.0001
AO=thoracic aorta; CABG=coronary artery bypass graft; CAD=coronary artery disease; LVEF=left ventricular ejection fraction; MI=myocardial infarction; NYHA=New York Heart Association; PCI=percutaneous coronary intervention; TF=transfemoral. Reproduced with permission from M. Thomas, MD.
AS=aortic stenosis; AVR=aortic valve replacement; LVEF=left ventricular ejection fraction; TAVI=transcatheter aortic valve implantation. Reproduced with permission from the European Society of Cardiology. All rights reserved. Copyright © 2012.
Overall, novel interventional options for patients with AS who need AVR continue to evolve. These therapies provide an opportunity to improve patient outcomes. Importantly, adoption of these new therapies should be based primarily on clinical outcome data rather than enthusiasm, finances, and healthcare systems. Optimal outcomes can only be achieved through sensible use governed by current data and caution should be used with regard to performing TAVI in lower-risk patients.
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Table of Contents for the Digital Edition of MD Conference Express ESC 2012
MD Conference Express ESC 2012
Contents
ESC 2012 Clinical Practice Guidelines
TAVI: 10 Years After the First Case
PARAMOUNT Trial Results
TRILOGY ACS Outcomes
Results from the ALTITUDE Trial
Results of the WOEST Trial
Results from the Aldo-DHF Trial
FAME 2 Results
Results from the IABP-SHOCK II Trial
STEMI Mortality Decreases in France While Some Key Risk Factors Increase
Results from the PURE Study
PURE: Treatment and Control of Hypertension
Genetic Determinants of Variability in Dabigatran Exposure
The RE-LY AF Registry
TRA 2°P-TIMI 50 Results
Rivaroxaban of Benefit in STEMI: ATLAS ACS 2-TIMI 51
Ivabradine Effect on Recurrent Hospitalization for HF
CLARIFY: Similar 1-Year Outcomes for Men and Women with Stable CAD
HPS2-THRIVE Study Results
PRoFESS Study Results
Outcomes from the CARDia Trial
Hypertension
Atrial Fibrillation
Heart Failure
MD Conference Express ESC 2012
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