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• 95 y/o woman 95 y/o woman • History of hypertension and aortic stenosisHistory of hypertension and aortic stenosis• NYHA class IV symptomsNYHA class IV symptoms• Multiple admissions for heart failure in the past yearMultiple admissions for heart failure in the past year• Echo with critical AS and decreased LV function Echo with critical AS and decreased LV function • Most recent admission, treated with diuretics and Most recent admission, treated with diuretics and

discharged home due to advanced agedischarged home due to advanced age• Readmitted within one week with CHF and BNP Readmitted within one week with CHF and BNP

>5000>5000• Renal function: BUN/Cr 24/0.9Renal function: BUN/Cr 24/0.9

Case 1: Echocardiogram

• EF – 25%EF – 25%

• Severe AS Severe AS – Peak Velocity - 4.2 m/sPeak Velocity - 4.2 m/s– Mean Gradient - 45 mmHgMean Gradient - 45 mmHg– Valve Area - 0.6 cmValve Area - 0.6 cm22

• Moderate Pulm HTN ~ 50 mmHgModerate Pulm HTN ~ 50 mmHg

Case 1: Cardiac Catheterization• 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 CalculatorSTS Risk Calculator– CABG/AVR – Mortality Risk – 33.8%CABG/AVR – Mortality Risk – 33.8%– AVR Alone – Mortality Risk – 27.9%AVR Alone – Mortality Risk – 27.9%

• Logistic EuroSCORELogistic EuroSCORE– CABG/AVR – Mortality Risk – 78.8%CABG/AVR – Mortality Risk – 78.8%

Case 1What 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

• Severe AS

• Peak velocity 4.3

• AVA 0.7 cm2

• EF normal

Case 2: Cardiac Catheterization• RA 7 mmHg• PA 32/7 mmHg• PCWP 12 mmHg• PA Sat 68%• Mean AV gradient 40

mmHg• AVA 0.68 cm2

• Coronary angiography:• Patent LIMA to LAD• Patent SVG to OM• Occluded SVG to RCA• Severe native 3VD

Case 2Risk Calculator

• 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• Functional MR:

– Improve symptoms

– Improve QOL

– Decrease hospitalizations for CHF

• Degenerative MR:

– Eliminate symptoms

– Maintain normal survival

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 MRSurgical Indications

• Severe MR prior to consequence (IIa)

• Severe MR with consequence– 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 MRSurgical Indications

• Severe MR prior to consequence (IIa)

• Severe MR with consequence– 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

Detaint D et al. Circulation 2006;114:265-272DiGregorio, Annals of Thoracic Surgery, 2004

In patients over 807.7% stroke rate for MVR

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%

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

Decreased Decreased closing forceclosing force

MR

IncreasedIncreasedtetheringtethering

Bulging

Papillary muscle traction

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

Mirabel et al. Eur Heart Journal 2007;28:1358-1365

49% of patients in the Euro Heart Survey on valvular heart disease with symptomatic severe MR were not operated on.

n = 546

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

Whitlow, P. L. et al. J Am Coll Cardiol 2012;59:130-139

CHF hospitalizations reduced by 26%

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 LIMA-LAD, 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

Wenaweser, P. et al. J Am Coll Cardiol 2011;58:2151-2162

AS in older adultsReasons for Treatment Allocation