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La patologia valvolare

dell’anziano: problemi

decisionali complessi

Ottavio Alfieri

S.Raffaele University Hospital

Milan

61° CONGRESSO NAZIONALE SIGG, Napoli, 2016

Bulk of Population Growth

The Economist, May 14th 2011

Longevity

Nkomo, Lancet 2006

The Burden of Valve Disease

Survival

100

80

60

40

20

0

0 1 2 3 4 5 6 7 8

Su

rviv

al

(%)

Expected

Observed

P < 0.001

Years

European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 &

European Journal of Cardio-Thoracic Surgery 2012 -

doi:10.1093/ejcts/ezs455).

Treament of severe valve desease

has a favorable impact on survival

at any age

Frailty

Frailty is a Phenotype

Physical Function Fatigue

Weakness Muscle Wasting

Limited Life Space Isolation

Cognition Depression

Nutrition Weight Loss

Comorbidity (>2 conditions)

Disability (>1 ADL) 25% 66%

27%

Courtesy Karen Alexander

Poor value:

•Patient

•Purchaser

•Physician

Optimum

Value

Surgical Risk

Clinical Benefit

Limited

Value ?

Increasing age, comorbidities,LV dysf,frailty

Surgical Risk vs Benefit

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), Željko Reiner (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), Matjaž Bunc (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

doi:10.1093/eurheartj/ehs109




Treatment of Valve

disease

SURGEONSCARDIOLOGISTS

Imaging specialists (Echo, CT, MRI)

Anesthesiologists

The « Heart Team »

Other specialists:

Geriatricians ……

Heart Team

• Complexity of the disease

• Complexity of the patient

• Expansion of the therapeutic options

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?




Aetiologies of Single Valvular Heart Diseasesin the Euro Heart Survey

Iung et al. Eur Heart J 2003;24:1244-53

0%

20%

40%

60%

80%

100%

Other

Ischemic

Congenital

Inflammatory

Endocarditis

Rheumatic

Degenerative

AS

43%

AR

13%

MR

32%

MS

12%




Patient Characteristics inthe Euro Heart Survey

Age(years)

70 years(%)

1 comorbidity(%)

AS 69±12 56 36

AR 58±16 25 26

MS 58±13 18 22

MR 65±14 44 42





Aortic Stenosis 75 years

(n=398)

No Severe AS

(n=114)

Severe AS

(n=284)

No Symptoms

(n=68)

Symptoms

(n=216)

Intervention

(n=144) 67%

No Intervention

(n=72) 33%

Current Management of Severe SymptomaticAS in the Elderly





Isolated MR > 75 years

(n=887)

No Severe MR

(n=347)

Severe MR

(n=540)

No Symptoms

(n=144)

Symptoms

(n=396)

Intervention

(n=203) 51%

No Intervention

(n=193) 49%

Current Managementof Severe MR

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




Sources: 1 S.J. Lester et al., “The Natural History and Rate of Progression of Aortic

Stenosis,” Chest 1998

2 C.M. Otto, “Valve Disease: Timing of Aortic Valve Surgery,” Heart 2000

Chart: Ross J Jr, Braunwald E. Aortic stenosis. Circulation. 1968;38 (Suppl 1):61-7.

…Aortic stenosis is life-threatening and

progresses rapidly…

40 50 60 70 800

20

40

60

80

100

Age

Years

Survival

Percent Onset

severe

symptoms

Avg. survival

Years

Angina

Syncope

Failure

Latent

Period

(Increasing

Obstruction,

Myocardial

Overload)

0 2 4 6

LIFE EXPECTANCY AFTER AVR

Life expectancy for men in normal populations versus life expectancy after

implantation of a prosthetic valve

0

5

10

15

20

25

30

35

45 50 55 60 65 70 75 80

Age (yrs)

Life e

xpecta

ncy (

yrs

)

LE normal BC population

LE normal Dutch population

LE normal UK population

LE normal US population

LE (US) with MECH

LE (US) with BIO

Patient outcome after AVR with mechanical or bioprostheses: weighing lifetime anticoagulant-related event risk against reoperation

risk Martijn W.A. van Ge§ldorp1, W.R. Eric Jamieson2, Jian Ye2, Guy J. Fradet2, A. Pieter Kappetein1, Marinus J.C. Eijkemans3, Gary

L. Grunkemeier4, Ad J.J.C. Bogers1, Johanna J.M. Takkenberg1

Aortic Valve Implantation

The Evolving ProcessConventional through midline sternotomy

Surgical through minimal incision

On pump, arrested heart sutureless valve replacement

Surgical apico-aortic valved conduit

Transaortic delivery

Transapical delivery

Transaxillary delivery

Transcarotid delivery

Percutaneous transfemoral

Invasiveness

TAVI

Ruiz et al. J Am Coll Cardiol. July 14,

2015,66(2):169-183

TAVI OPTIONS

Indications for transcatheter aortic valve

implantationClass Level

TAVI should only be undertaken with a multidisciplinary “heart team” including

cardiologists and cardiac surgeons and other specialists if necessary.I C

TAVI should only be performed in hospitals with cardiac surgery on-site. I C

TAVI is indicated in patients with severe symptomatic AS who are not suitable for

AVR as assessed by a “ heart team” and who are likely to gain improvement in their

quality of life and to have a life expectancy of more than 1 year after consideration

of their comorbidities.

I B

TAVI should be considered in high risk patients with severe symptomatic AS who

may still be suitable for surgery, but in whom TAVI is favoured by a “heart team”

based on the individual risk profile and anatomic suitability.IIa B




Published April 2012

US CoreValve High-Risk Trial

2014

All-Cause Mortality STS ≤7%

312015

Transfemoral rather than

Transapical

Procedural Recovery Non-procedure related

Gaudiani et al. presented at the AATS, 2016

Alec Vahanian MD,Bichat Hospital, Paris,University Paris VII

Performance

Safety (mortality ,stroke)

Vascular complications

Perivalvular leaks

Conduction defects

Durability

Alec Vahanian MD,Bichat Hospital, Paris,University Paris VII

Surgical AVR will be limited to contraindications to TAVI

and to pts requiring combined cardiac or aortic surgery

– If a good and durable repair is carried out before

symptoms, LV dysfunction, LA dilatation, PH and AF,

normal life expectancy is expected at any age

Detaint, et al. Circulation. 2006;114:265-

272

Degenerative MR

Neochord Inc.

Mitra Clip

MitraClip Therapy Current Global Adoption

investigational special accesscommercial

Transcatheter Annuloplasty

Coronary sinus remodeling

SL dimensions cinching

RF/Ultrasound remodeling

External compression

Direct annuloplasty

How Does Cardioband Work?

48

Fully Percutaneous Mitral Repair

Transcatheter Mitral Valve Replacement

CardiAQ Tendyne Tiara

Fortis Cephe

a

Cardiovalve High Life

Twelve

Tiara case done in San Raffaele

Fully successful case perform in less than 40 min

/

• Stand-alone annuloplasty: earlytreatment FMR /symmetrictethering

• Stand-alone Mitraclip: FMR with asymmetric tethering (IMR)

DMR with little annular dilatation

• Combined Annuloplasty and MitraClip: DMR with importantannular dilatation and advancedFMR

• MV Replacement: advancedorganic MR and advanced FMR

The complementary role of

transcatheter techniques

annuloplasty

mitraclipreplacement

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