prof. fausto j. pinto, fesc, facc president, esc affairs... · valvular heart disease and imaging...
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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)