Case 1HPI:• 78 yo attorney followed with known moderate AS had been followed

medically• In Jan 2017, routine echo showed worsening AS and he was referred

for TAVR evaluationPH:• skin issues• HTN• prostate Ca s/p prostatectomy and XRT• h/o TIA

• STS risk for AVR low (~2%)

Echo (March 2017):

Case 1 Echo (March 2017)

• EF 70%, mod diastolic dysfunction, trileaflet AV, mean grad 20 mmHg, AVA 1.6 cm2, “mild AS”

• Cath:• Mean grad 30 mmHg, normal CI 3

L/min/M2, AVA 1.3 cm2, “moderate AS”• Non-obstructive CAD

Case 1HPI:• 78 yo attorney followed with know asymptomatic moderate AS• Jan 2017, routine echo showed worsening AS and he was referred for

TAVR evaluationEcho (March 2017)• AVA 1.6 cm2, referred for cath: AVA 1.3 cm2• Medical management recommended

• He continued to be physically active, playing tennis 3X / wk without symptoms

• In June, he had an episode of SOB at rest that resolved spontaneously and he was started on furosemide (20 mg daily).

• He resumed walking, regular activity, can do several flights of stairs without symptoms at some times, but “feels winded” at other times. He was told to stop playing tennis and is unhappy about that.

• In July, he was hospitalized at OSH with SOB. Echo mean grad 20 mmHg, EF 60%, ? HOCM physiology, referred back to Penn

Case 1• Aug 2017: He described episodic SOB at rest, epigastric discomfort, but at other

times was able to walk 30 mins at a leisurely pace with no symptoms. No orthopnea or PND. No pre-syncope or syncope, edema.

Peak/Mean grads 43/27 mmHg, AVA 0.9 cm2, SVI sl low at ~34 ml/M2, preserved EF 58%, mild AR, c/w moderately-severe or PLF severe AS.

In summary, 78 yo with moderately severe AS, intermittent atypical symptoms, who wants to be physically active, but hemodynamics on echo and cath are not c/w severe AS.

What therapy would you offer this patient?

1. Medical management as he does not have either severe AS nor symptoms c/w AS (Stage B or C1)

2. Open AVR for moderate AS with some symptoms

3. TAVR as that is his preference

4. Further testing

Case 1 ETT• Based on his atypical symptoms and echo that was not quite c/w

severe AS, I was somewhat on the fence as to whether to recommend surgery.

• I also became newly aware that he had had a stress test locally in April. I asked him to not play tennis until I reviewed that study:

Stress Myoview:4 mins 11 sec Bruce protocolResting BP 147/71, HR 60Stress BP 154/61, HR 114 (80% PMHR)SOB and leg fatigue at peak exercise, no chest discomfortECG not diagnostic, freq PVCs notedSmall inferior defect with reperfusion, EF 62%

Does this change your therapy?

1. Medical management

2. Open AVR

3. TAVR

4. Further testing

Redfors et al, Circulation 2017;135:1956-1976

Significant arrhythmia or VEA

Case 1 Outcome

• AVR was recommended • He did not qualify for Partner 3 based on low gradients

and was referred for open surgical AVR

• During pre-op testing, found to be in new AF (asymptomatic) and hospitalized for heparin

• Uncomplicated AVR (#25 Magna Ease) and LAA excision

• Initial post op rhythm was SR, but AF developed he was started on IV heparin/warfarin

• POD #3, pathology on LAA suggested infiltrative disease and subsequent staining confirmed amyloid

Case 2• 78 yo man presenting March 2016 with multiple med problems:

H/o pul embolismH/o smokingH/o esophageal Ca with resection/XRTType II DMHTNChronic AFHLCAD s/p large inf/post MI 2002, EF 30%CKD with baseline creat 1.7

• He describes DOE ambulating ~100 ft. • Echo c/w AS and referred for TAVR vs SAVR eval

Case 2: Echo• EF 25%• Peak gradient 25-36 mmHg (in AF)• Mean gradient 15-19 mmHg• AVA 1.1-1.2 cm2 c/w moderate AS

STS risk of mortality: 4.075%

What therapy would you offer this 78 yo patient with moderate AS and severe LV dysfunction?

1. Surgical AVR

2. TAVR

3. Medical management

4. Further testing

78 yoH/o pul embolismH/o smokingH/o esophageal Ca with resection/XRTType II DMHTNChronic AFCAD s/p large inf/post MI 2002, EF 30%CKD with baseline creat 1.7

All Aortic Stenoses Are Not Created Equal

Anjan and Herrmann, JACC 2015;65:654-6

Practical Considerations for Diagnosis

• In most patients, the issue is a low AVA c/w severe AS with a gradient that is low raising the issue of whether it is truly severe AS

• Step 1 should be an assessment of EF and SVI, by echo and/or cath• Step 2 involves additional tests:

• Visualization of valve • Does it open on echo?• Dimensionless index (DI)• CT assessment of calcification

• Pharmacologic measures to restore normal SVI• Dobutamine stress echo if EF is low (DSE)• Nitroprusside in HTN

• Step 3 involves clinical integration and evaluation of the patient for other causes of symptoms: pulmonary, other valvular, HTN, coronary, ventricular

AlgorithmAVA < 0.8-1.0 cm2 and MG < 30-40 mmHg

Consider hydration status

Normal EF and Low SVILow EF and Low SVI Normal SVI

Step 1: Assess EF and SVI

Paradoxical LF Severe ASClassical LF Severe AS Probably Moderate AS

Step 2: Classification

Additional Clinical Assessment for Cause of Symptoms:

COPDComorbid Valve DiseasePulm/Systemic HTNHFpEF / HFrEFHydration Status

Step 3: Additional Testing

Additional Testing:

DSEDimensionless IndexValve calcium (CTA)

Additional Testing:

DSE or NiprideDimensionless IndexValve Calcium (CTA)Co-morbidityAssessment

If findings are equivocal, there is equipoise to err on the side of TAVR (assuming low procedural risk), but important to set appropriate patient expectations regarding symptom improvement

Saybolt, Fiorilli, Gertz, and Herrmann: Circ Cardiovasc Interv. 2017;10:e004838. DOI:10.1161/CIRCINTERVENTIONS.117.004838

InternationalMulticenter

Randomized

TAVR-UNLOAD Trial Design

Heart FailureLVEF < 50%

NYHA ≥ 2Optimal HF

therapy(OHFT)

Moderate AS

TAVR UNLOAD

Trial

R

TAVR + OHFT

OHFT Alone

Follow-up:1 month6 months

1 year

Clinical EndpointsSymptomsEcho QoL

Primary EndpointHierarchical occurrence of:

All-cause death Disabling stroke Hospitalizations for

HF, aortic valve disease, or non-disabling stroke

Change in KCCQ

Reduced AFTERLOADImproved LV systolic and diastolic function

Case 2• Medical management initiated with initially good clinical response• He returned 10 mos later with increasing DOE• Echo repeated: LV improved (EF ~35%), grads/AVA similar

Case 2: DSE performed at OSH

Baseline 20 mcgs/kg/min

EF 35% Augmented contractility

Peak gradient 36 70

Mean gradient 20 40

AVA 1.1 1.1

What therapy would you now offer this patient?

1. Surgical AVR

2. TAVR

3. Medical management

4. Further testing

Case 2: Procedure• TF TAVR under MAC• Sapien 3 #26• Fast track protocol, discharge POD #2• 1 month f/u:

Feels betterLVEF 45-50%Peak/mean grads 22/11 mmHgNo PVL