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Neil J. Weissman, MD

Asymptomatic Valvular Disease:

MedStar Health Research Inst atMedStar Washington Hospital Center

&Professor of MedicineGeorgetown University

Washington, D.C.

Can Echocardiography Help You Decide When to Intervene?

Disclosures

Academic Echo Core Lab with multiple

pharmaceutical and device commercial sponsors

No direct COI with this lecture

www.EchoCoreLab.org

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Valvular Heart Disease

• General Agreement

– Operate for symptomatic severe valve stenosis

or regurgitation

• General Disagreement

– Operate for severe valve

stenosis or regurgitation

asymptomatic

Chronic Severe MR - When to Operate

What You Need to Know

• Etiology

• Pathphysiology

• Echocardiographic findings

• Natural history

• Surgical morbidity, mortality

• Expertise of surgeon

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What You Need To Know 20142017

Aortic vs Mitral Regurgitation

MR AR

Pure volumeoverload

Volume &pressureoverload

Normal to

Pathophysiology

Preload

Afterload

4

Aortic vs Mitral Regurgitation

MR AR

Pure volumeoverload

Volume &pressureoverload

Normal to

Pathophysiology

Preload

Afterload

Aortic vs Mitral Regurgitation

MR AR

Pure volumeoverload

Volume &pressureoverload

Normal to

Pathophysiology

Preload

Afterload

EF after surgery =

5

Mitral Regurgitation

Major Challenge

1. Identify contractile LV dysfunction

2. Correct MR before irreversibleLV dysfunction develops

Aortic vs Mitral Regurgitation

EF reflects (closer to) true

LV performance

EF is overestimation of true

LV performanceMR

AR

6

Enriquez-Sarano Circulation 90:830(1994)

0 2 4 6 80

20

40

60

80

100

p = 0.0001

Su

rviv

al (

%)

10

72%

53%

32%

EF 60%

EF 50-60%

EF <50%

Years

Late Survival of Operative Survivors

Pre-op Echo EF vs Postop Survival

MR Due to Flail Leaflet

Long-Term Survival with Medical Therapy

Ling (Mayo Clinic) NEJM 335:1417(1996)

Su

rviv

al (

%) Expected

Observed

p = 0.016annual mortality = 6.3%/yr

65%

57%

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10

Years after Diagnosis

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Enriquez-Sarano, M. et al. N Engl J Med 2005;352:875-883

ERO > 40 mm2

ERO < 20 mm2

ERO 20-39 mm2

Su

rviv

al

(%)

50

100

531

The more severe the regurgitation the

poorer the prognosis

Years

8

Recommendations for MV Operation in Chronic Severe MR

Indication Class

MV surgery is beneficial for asymptomatic patients

with chronic, severe MR and mild to moderate LV

dysfunction, EF 30-60% and/or end-systolic

dimension > 40mm

(Level of evidence: B)

I3.

Bonow ACC/AHA Practice Guidelines JACC 48:e1(2006)

B

I IIa IIb III

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Recommendations for MV Operation in Chronic Severe MR

Indication Class

MV repair is reasonable in experienced surgical centers for

asymptomatic pts with chronic severe MR with preserved LV

function (ejection fraction greater than 0.60 and end-systolic

dimension less than 40 mm) in whom the liklihood of

successful repair without residual MR is greater than 90% 95%

and mortality <1% with Heart Valve Center

(Level of evidence: B)

IIa5.

6.IIa

MV surgery is reasonable for asymptomatic pts with chronic

severe MR with preserved LV function, and new onset atrial

fibrillation.

(Level of evidence: C)

Bonow ACC/AHA Practice Guidelines JACC 48:e1(2006)

B

I IIa IIb III

C

I IIa IIb III

2017 Updated Guidelines

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2017 Updated Guidelines

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Asymptomatic

AR

12

AR patients with decreased EF or

LVIDs > 40mm progress to develop

symptoms and need AVR within 3

years (25%/yr develop symptoms)

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14

AS

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Asymptomatic Severe AS:

Is It Time to Operate ?

Pro: All patients should be operated

Con: Truly asymptomatic patients

do not need surgery now

Carabello N Engl J Med 2002;346(9)

AVR Should be Performed in Symptomatic AS

0 1 2 3 4 50

20

40

60

80

100

125 87 51 35 9 019 8 2 1 0 0

Valve replacement

No surgery

No. at Risk Year

Su

rviv

al

(%

)

p<0.05 p<0.001

p<0.001Chi-square = 23.5

Valve Replacement

No surgery

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17

The only class I indication for valve

replacement in severe AS is development

of symptoms or in conjunction with other

CV surgery or EF < 50%

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Rosenhek Circulation 2010;121:151-6

Severe Aortic Stenosis

p < 0.0001

Years

Event-

Fre

e S

urv

ival (

%) 100

90

80

70

60

50

40

30

20

10

0

0 1 2 3

AV-Vel

4.0 to 5.0 m/s

AV-Vel

5.0 to 5.5 m/s

AV-Vel

≥ 5.5 m/s

Very

2017 Updated

Guidelines -

“TAVR not studied

in asymptomatic

patients” so not

considered as an

option for Asx AS

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