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Prise en Charge des Valvulopathies Aortiques et Mitrales en 2014

Prise en Charge des Valvulopathies Aortiques et Mitrales en 2014. Bernard Iung Hôpital Bichat, Paris, France Marrakech, 29 mars 2014. European Heart Journal doi:10.1093/eurheartj/ehs109. Guidelines on the management of valvular heart disease (version 2012).

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Prise en Charge des Valvulopathies Aortiques et Mitrales en 2014

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  1. Prise en Charge des Valvulopathies Aortiques et Mitralesen 2014 Bernard Iung Hôpital Bichat, Paris, France Marrakech, 29 mars 2014

  2. European Heart Journal doi:10.1093/eurheartj/ehs109 Guidelines on the management of valvular heart disease (version 2012) The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Authors/Task Force Members: Alec Vahanian (Chairperson) (France), Ottavio Alfieri (Chairperson) (Italy), Felicita Andreotti (Italy), Manuel J. Antunes (Portugal), Gonzalo Barón-Esquivias (Spain), Helmut Baumgartner (Germany), Michael Andrew Borger (Germany),Thierry P. Carrel (Switzerland), Michele De Bonis (Italy), Arturo Evangelista (Spain), Volkmar Falk (Switzerland), Bernard Iung (France), Patrizio Lancellotti (Belgium), Luc Pierard (Belgium), Susanna Price (UK), Hans-Joachim Schäfers (Germany), Gerhard Schuler (Germany), Janina Stepinska (Poland), Karl Swedberg (Sweden), Johanna Takkenberg (The Netherlands), Ulrich Otto Von Oppell (UK), Stephan Windecker (Switzerland), Jose Luis Zamorano (Spain), Marian Zembala (Poland) ESC Committee for Practice Guidelines (CPG): Jeroen J. Bax (Chairperson) (The Netherlands), Helmut Baumgartner (Germany), Claudio Ceconi (Italy), Veronica Dean (France), Christi Deaton (UK), Robert Fagard (Belgium), Christian Funck-Brentano (France), David Hasdai (Israel), Arno Hoes (The Netherlands), Paulus Kirchhof (United Kingdom), Juhani Knuuti (Finland), Philippe Kolh (Belgium), Theresa McDonagh (UK), Cyril Moulin (France), Bogdan A. Popescu (Romania),ŽeljkoReiner (Croatia), Udo Sechtem (Germany), Per Anton Sirnes (Norway), Michal Tendera (Poland), Adam Torbicki (Poland), Alec Vahanian (France), Stephan Windecker (Switzerland) Document Reviewers: Bogdan A. Popescu (ESC CPG Review Coordinator) (Romania), Ludwig Von Segesser (EACTS). Review Coordinator) (Switzerland), Luigi P. Badano (Italy), MatjažBunc (Slovenia), Marc J. Claeys (Belgium), Niksa Drinkovic (Croatia), Gerasimos Filippatos (Greece), Gilbert Habib (France), A. Pieter Kappetein (The Netherlands), Roland Kassab (Lebanon), Gregory Y.H. Lip (UK), Neil Moat (UK), Georg Nickenig (Germany), Catherine M. Otto (USA), John Pepper, (UK), Nicolo Piazza (Germany), Petronella G. Pieper (The Netherlands), Raphael Rosenhek (Austria), Naltin Shuka (Albania), Ehud Schwammenthal (Israel), Juerg, Schwitter (Switzerland), Pilar Tornos Mas (Spain), Pedro T.Trindade (Switzerland), Thomas Walther (Germany). European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  3. Changing Pattern of Valvular Disease in Industrialised Countries Age-adjusted prevalence 2.5% [95% CI 2.2-2.7] (Soler-Soler J, Galve E (Nkomo et al. Heart 2000;83:721-5) Lancet 2006;368:1005-11)

  4. Distribution of Valvular Heart Diseases in the Euro Heart Survey 5001 patients Previous ValvularIntervention 28% NativeValve Disease 72% AS 34% AR 10% MS 10% MR 25% Right 1% ValveRepair 18% ValveReplacement 82% Multiple 20% Iung et al. Eur Heart J 2003;24:1244-53 European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  5. Patient Evaluation European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  6. Essential questions in the evaluationof a patient for valvular intervention • Is valvular heart disease severe? • Does the patient have symptoms? • Are symptoms related to valvular disease? • What are patient life expectancy and expected quality of life? • Do the expected benefits of intervention (versus spontaneous outcome) outweigh its risks? • What are the patient's wishes? • Are local resources optimal for planned intervention? European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  7. Echocardiographic criteria for the definition ofsevere valve stenosis: an integrative approach Adapted from Baumgartner, EAE/ASE recommendations. Eur J Echocardiogr. 2010;10:1-25 European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  8. Echocardiographic criteria for the definition of severe valve regurgitation: an integrative approach Adapted from Lancellotti, EAE Recommendations. Eur J Echocardiogr. 2010;11:223-244 and 307-332 European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  9. Echocardiographic criteria for the definition of severe valve regurgitation: an integrative approach Adapted from Lancellotti, EAE recommendations. Eur J Echocardiogr. 2010;11:223-244 and 307-332 European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  10. Other Techniques • Exercise testing • Objective assessment if equivocal or no symptoms. • Prognosis in asymptomatic AS. • Stress echocardiography • Low dose dobutamine echocardiography in AS with low gradient andLV dysfunction. • Exercise echocardiography may provide additional information in AS, MR, MS. • Magnetic resonance imaging • To assess regurgitation/LV function if echocardiography is inadequate. • As a reference method for evaluation of RV. • Multislice CT • For imaging of thoracic aorta. • For work-up before TAVI. • Cardiac catheterisation (to evaluate valve function) • Only if non-invasive findings inconsistent or discordant with clinical assessment. European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  11. Aortic Regurgitation European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  12. AR with significant enlargementof ascending aorta No Yes AR severe No Yes Symptoms No Yes LVEF ≤ 50% or LVEDD > 70 mm orLVESD > 50 mm (or > 25 mm/m2 BSA) No Yes Follow-up Surgery Management of aortic regurgitation European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  13. Indications for surgeryin severe aortic regurgitation European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  14. Indications for surgery in aortic root disease (whatever the severity of AR) European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  15. Aortic Stenosis European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  16. Consistency between indices of AS severity • 3483 echocardiographic studies in 2427 pts with AS ( 2 cm²) with normal LV function (shortening fraction  30%) • (Minners et al. Eur Heart J 2008;29:1043-8)

  17. Consistency between indices of AS severity • Low-flow low-gradient AS with decreased EF • Low-dose dobutamine echocardiography • Low-flow low-gradient AS with preserved EF • Paradoxical low-flow low-gradient AS • Frequent in the elderly • Eliminate first causes of errors of measurement • Underestimation of transaortic flow • Underestimation of the LVOT diameter • Usefulness of quantitative assessment of valve calcification

  18. Indications for aortic valve replacementin symptomatic aortic stenosis European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  19. Management of severe aortic stenosis Severe AS Symptoms No Yes Contraindication for AVR LVEF < 50% No Yes Physically active No Yes No Yes High risk for AVR Short life expectancy Exercise test No Yes Symptoms or fall in bloodpressure below baseline No Yes No Yes Presence of risk factors and low/intermediate individual surgical risk TAVI Med Rx No Yes AVR Re-evaluate in 6 months AVR or TAVI European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  20. Indications for transcatheter aortic valve implantation « In the absence of a perfect quantitative score, the risk assessment should mostly rely on the clinical judgement of the ‘heart team’, in addition to the combination of scores. » European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  21. Indications for aortic valve replacement in asymptomatic aortic stenosis European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  22. Aortic Jet VelocityPredictor of Outcome in AS 116 pts. AV Vel >5m/s Median FU 41 mo 96 events: AVR (90) Sudden death (1) Deaths possibly cardiac related (5): mean age 83yrs MCI (1) Sepsis / multiorgan failure (3) CHF (1) Rosenhek R et al. Circulation 2010;121:151-156

  23. Mitral Regurgitation European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  24. Indications for surgeryin symptomatic severe primary MR European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  25. Operative mortality after surgery for MR

  26. Indications for surgeryin asymptomatic severe primary MR European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  27. Symptoms No Yes LVEF ≤ 60% orLVESD ≥ 45 mm LVEF > 30% Yes No No Yes Refractory to medical therapy New onset of AF or SPAP > 50 mmHg Yes No No Yes Durable valve repair is likely and low comorbidity High likelihood of durable repair,low surgical risk, and presence of risk factors Yes No No Yes Surgery(repair whenever possible) Extended HFtreatment Medicaltherapy Follow-up Management of severe chronic primary mitral regurgitation European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  28. Background in the Management (Moderate-Severe) Secondary MR • Operative mortality is higher than in primary MR • Long-term prognosis is worse (comorbidities) • No evidence that surgery prolongs life (5-yrs death 50%) • CABG alone does not correct MR in most patients • Untreated MR is associated with recurrent HF and death • Functional improvement uniformly reported after MVS • Persistence and high recurrence rate of MR after MV repair Non randomized observational trials for most Retrospective trials One randomized study not powered to evaluate the outcome has compared CABG with CABG/MVRepair in moderate ischemic MR  Improvement in class/LV function Fattouch JTCVS 2009

  29. Indications for mitral valve surgery in secondary mitral regurgitation European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  30. Percutaneous techniques • The percutaneous mitral clip procedure may be considered in patients with symptomatic severe secondary MR despite optimal medical therapy (including CRT if indicated), who fulfil the echo criteria of eligibility, are judged inoperable or at high surgical risk by a team of cardiologists and cardiac surgeons, and who have a life expectancy > 1 year (Class IIb Level C) “These findings have to be confirmed in larger series with longer follow-up and with a randomized design”

  31. Mitral Stenosis European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  32. Percutaneous Mitral Commissurotomy Long-Term Results After PMC (Bouleti et al. Circulation 2012; 125:2119-27)

  33. Indications for percutaneous mitral commissurotomy European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  34. Management of clinically significant mitral stenosis MS≤1.5 cm2 Symptoms Yes No Cl to PMC High risk of embolism or haemodynamic decompensation No Yes Yes No Cl or high riskfor surgery Exercise testing No Yes Symptoms No symptoms Favourable anatomical characteristics Unfavourable anatomical characteristics Cl to or unfavourable characteristics for PMC No Yes Favourable clinical characteristics Unfavourable clinicalcharacteristics PMC Surgery PMC Follow-up European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  35. "The Loop of Knowledge " Research Clinical Trials Guidelines Evaluationof Practices by Surveys Education based on Guidelines European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  36. Pocket Guidelines European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455). www.escardio.org/guidelines

  37. Contraindications for transcatheteter aortic valve implantation European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 - doi:10.1093/ejcts/ezs455).

  38. 33% of asymptomatic pts with LVESD >40mm 10 3.2 1.0 0.3 Hazard Ratio 40 or 22 mm/m² 30 35 40 45 50 LV ESD (mm) Impact of LV Dilatation on Survival MIDA registry 739 patients with flail leaflet, follow-up: 6.1±3.7 years Conservative treatment Tribouilloy et al. JACC, 2009;54:1961–8

  39. Limitations of risk scores in high-risk patients • Population characteristics • Change in techniques • (surgery, percutaneous techniques, anaesthesia) • Choice and coding of variables • Relative or absolute contraindications for surgery • Porcelain aorta • Chest radiation • Hepatic insufficiency • Complex conditions requiring an individual approach • Active endocarditis • Cancer • Frailty (Rosenhek et al. Eur Heart J 2012;33:822-8)

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