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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
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Page 1: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

La patologia valvolare

dell’anziano: problemi

decisionali complessi

Ottavio Alfieri

S.Raffaele University Hospital

Milan

61° CONGRESSO NAZIONALE SIGG, Napoli, 2016

Page 2: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

Bulk of Population Growth

The Economist, May 14th 2011

Page 3: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

Longevity

Page 4: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

Nkomo, Lancet 2006

Page 5: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

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

Page 6: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

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

Page 7: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE
Page 8: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

Poor value:

•Patient

•Purchaser

•Physician

Optimum

Value

Surgical Risk

Clinical Benefit

Limited

Value ?

Increasing age, comorbidities,LV dysf,frailty

Surgical Risk vs Benefit

Page 9: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

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

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

European Journal of Cardio-Thoracic Surgery 2012 -

doi:10.1093/ejcts/ezs455).

Page 10: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

Treatment of Valve

disease

SURGEONSCARDIOLOGISTS

Imaging specialists (Echo, CT, MRI)

Anesthesiologists

The « Heart Team »

Other specialists:

Geriatricians ……

Page 11: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

Heart Team

• Complexity of the disease

• Complexity of the patient

• Expansion of the therapeutic options

Page 12: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE
Page 13: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

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).

Page 14: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

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%

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

European Journal of Cardio-Thoracic Surgery 2012 -

doi:10.1093/ejcts/ezs455).

Page 15: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

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

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).

Page 16: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

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

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).

Page 17: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

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

Iung et al. Eur Heart J 2005;26:2714-2720

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

European Journal of Cardio-Thoracic Surgery 2012 -

doi:10.1093/ejcts/ezs455).

Page 18: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

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

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

European Journal of Cardio-Thoracic Surgery 2012 -

doi:10.1093/ejcts/ezs455).

Page 19: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

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

Page 20: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

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

Page 21: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

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

Page 22: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

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

2015,66(2):169-183

TAVI OPTIONS

Page 23: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

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

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

European Journal of Cardio-Thoracic Surgery 2012 -

doi:10.1093/ejcts/ezs455).

Page 24: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE
Page 25: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

Published April 2012

Page 26: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE
Page 27: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

Published April 2012

Page 28: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE
Page 29: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

US CoreValve High-Risk Trial

2014

Page 30: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE
Page 31: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

All-Cause Mortality STS ≤7%

312015

Page 32: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE
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Page 35: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

Transfemoral rather than

Transapical

Page 36: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

Procedural Recovery Non-procedure related

Gaudiani et al. presented at the AATS, 2016

Page 37: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

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

Performance

Safety (mortality ,stroke)

Vascular complications

Perivalvular leaks

Conduction defects

Durability

Page 38: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

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

Page 39: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE
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Page 41: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

– 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

Page 42: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE
Page 43: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

Neochord Inc.

Page 44: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE
Page 45: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

Mitra Clip

Page 46: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

MitraClip Therapy Current Global Adoption

investigational special accesscommercial

Page 47: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

Transcatheter Annuloplasty

Coronary sinus remodeling

SL dimensions cinching

RF/Ultrasound remodeling

External compression

Direct annuloplasty

Page 48: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

How Does Cardioband Work?

48

Page 49: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

Fully Percutaneous Mitral Repair

Page 50: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

Transcatheter Mitral Valve Replacement

CardiAQ Tendyne Tiara

Fortis Cephe

a

Cardiovalve High Life

Twelve

Page 51: decisionali complessi - sigg.it · La patologia valvolare dell’anziano: problemi decisionali complessi Ottavio Alfieri S.Raffaele University Hospital Milan 61° CONGRESSO NAZIONALE

Tiara case done in San Raffaele

Fully successful case perform in less than 40 min

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/

• 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