Cathéterisme

Cardiaque
 Cathétérisme D + G
•  Indiqué seulement en cas de discordance
échographie et clinique (C’est de plus en plus rare)
•  Formule de Gorlin :
–  S Ao = Fc (Débit cardiaque, TES, Gradient)
•  Ventriculographie à éviter
•  évaluée en écho ou Scinti
•  FE diminuée par augmentation de la post-charge

Coronarographie +++
- Si angor
- Systématique è homme>40 ans, Femme>50 ans
Angio scanner
Cathétérisme Gauche
 Diagnosis: Classification

Bonow R, Carabello BA, et al. Circulation 2006; 114: e84-231.

5
 Traitement
•  Il n’y a pas de Ttt Médical du RA.
•  Ttt de l’IVG
–  attention aux digitaliques,
–  diurétiques, IEC
•  Valvuloplastie Per-Cutanée « exceptionnelle »
•  CHIRURGIE :
•  Valvuloplastie = valvulotomie des congénitaux
•  RVAo
–  Mécanique
è ± 65 ans (coronaropathie)
–  Biologique
•  Gestes associés
–  PAC,
–  Myectomie (septum > 18 mm, SAM, S ejection < 4 cm2)
 Modalités de Suivi
du RA non symptomatique

•  Réévaluation Clinique bi annuelle

è Echographie Annuelle

•  Si Calcifications importantes ou RA serré (V>4m/s)

è Echographie tous les 6 mois

+
* Information du patient,
* Prophylaxie EI,
* Recherche et traitement des facteurs de risque
HTA, Diabète, dyslipidémie, tabac…
Chirurgie des lésions acquises de la valve aortique ¶ 42-570

Figure 12. (Suite)

D, E. Mise en place d’une bioprothèse en poste
supra-annulaire selon Carpentier.

S’il convient de choisir la taille maxima

convient d’éviter tout surdimensionnem
Les bioprothèses aortiques percutanées
AVR versus TAVI
Les approches vasculaires Carotide R and L

Sub-clavian

Direct transAo

transapicale

Trans femoral
Que faire quand la voie fem. est impraticable ?

70,8 % 1) Sapiens 29,2 %

84,6 % 2) Corevalve 15,4 %

Navigation aortique
Navigation aortique
 Procédure interventionnelle

Gestion Interventionnelle et chirurgicale avec échographie

Chirurgien cardiaque et Cardiologues

interventionnistes

Anésthésiste-Réanimateur

Echographiste (ETT)
Mesures valvulaires et aortiques
Procédure RVAP - CoreValve®
Dilatation RA
Angiography
Ouverture
Ouverture
Ouverture
Ouverture
Basal Contrôle à 1 mois
 Etude PARTNER

September 22, 2010 on NEJM.org

26
 Two Individually Stratified and Powered
Cohorts
Symptomatic Severe Aortic Stenosis
Edward
s Yes ASSESSMENT: High-Risk AVR Candidate No
RetroFlex
3,105 Total Patients Screened
SAPIEN 1
THV
Cohort A 2Total = 1,058 patients
Parallel Trials: Cohort B Or
Nand
23 mm = 700 High Risk
Individually Inoperable
N Ascendra
= 358
26 mm valve 22 F and 24 F
ASSESSMENT: Powered ASSESSMENT:
sheath sizes
sizes Yes Transfemoral No Transfemoral
Access Access

High-Risk TF High-Risk TA Yes No

1:1 Randomization 1:1 Randomization 1:1 Randomization Not In Study

TAVI TAVI TAVI Standard

Surgical Surgical
Trans- Trans- Trans- Therapy
AVR AVR
femoral apical femoral (Usually BAV)
VS VS VS

Primary Endpoint: All-Cause Mortality (1 yr) Primary Endpoint: All-Cause Mortality Over
(Non-inferiority) Length of Trial (Superiority)
Co-Primary Endpoint: Composite of All-Cause Mortality
TA, transapical; TF, transfemoral; BAV, balloon aortic valvuloplasty. and Repeat Hospitalization (Superiority)
 20% Absolute Reduction in Mortality at 1 Year

100 Standard Therapy

All-Cause Mortality Edwards THV

80 ∆ at 1 yr = 20.0%
All-Cause Mortality, %

NNT = 5.0 pts

60 50.7%

40

30.7%
20
HR [95% CI] =
0.55 [0.40, 0.74]
P (log rank) < .001
0
0 6 12 18 24
Months
Numbers at Risk
Edwards THV 179 138 122 67 26
Standard Therapy 179 121 83 41 12
 24% Absolute Reduction in
Cardiovascular Mortality at 1 Year
100 Standard Therapy
Cardiovascular Mortality Edwards THV

∆ at 1 yr = 24.1%
Cardiovascular Mortality, %

80

NNT = 4.1 pts

60
44.6%

40

20
HR [95% CI] =
20.5%
0.39 [0.27, 0.56]
P (log rank) < .001
0
0 6 12 18 24
Months
Numbers at Risk
Edwards THV 179 138 122 67 26
Standard Therapy 179 121 83 41 12
 Significantly Reduced Mean Gradient

Mean Gradients Over Time Standard Therapy

70 Edwards THV

44.6 44.4
60
39.5
Mean Gradient, mm Hg

50 33.0

40

30
43.2 12.1
11.3
20 10.8

10
P < .001
0
Baseline 30 Days 6 Months 1 Year
n = 163 n = 143 n = 100 n = 89

Error bars = ± 1 standard deviation.

 Significantly Increased Aortic Valve Area

Aortic Valve Areas Over Time Standard Therapy

2.5
1.61 Edwards THV

1.53 1.57
2.0
AVA, cm2

1.5

0.77 0.68 0.70

1.0 0.64

0.5
0.65
P < .001
0
Baseline 30 Days 6 Months 1 Year
n = 163 n = 143 n = 100 n = 89

Error bars = ± 1 standard deviation.

Competitive Landscape
 Treatment: ACC / AHA Guidelines

33
 Guidelines on the management ESC/EACTS
of valvularGUIDELINES
heart
European
Page Heart Journal
16 of 46
ESC/EACTS
disease (version 2012)
doi:10.1093/eurheartj/ehs109 GUIDELINES ESC/EACTS Guidelines

The
Table 9 Joint Task
Indications Force
for aortic on the Management
valve replacement of Valvular Heart Disease
in aortic stenosis
of the European Society of Cardiology (ESC) and the European
Guidelines on the management of valvular heart Class Level Ref a b C

Association for Cardio-Thoracic Surgery (EACTS)

AVR is indicated in patients with severe AS and any symptoms related to AS. I B 12, 89, 94

disease(Chairperson)
(version 2012)
Authors/Task Force Members: Alec Vahanian (Chairperson) (France) , Ottavio Alfieri
AVR is indicated in patients with severe AS undergoing CABG, surgery of the ascending aorta or another valve.
(Italy), Felicita Andreotti (Italy), Manuel J. Antunes (Portugal),
*
AVR is indicated in asymptomatic patients with severe AS and systolic LV dysfunction (LVEF <50%) not due to another
*I C

management of valvular heart

I C
Gonzalo
cause.Barón-Esquivias (Spain), Helmut Baumgartner (Germany),
The Joint Task Force on the Management
Michael
AVR is indicatedAndrew
clearly related to
of Valvular Heart
Borger
in asymptomatic
AS.
Disease
(Germany),
patients with Thierry
severe AS and abnormal exerciseP.
(Italy), Arturo Evangelista (Spain), Volkmar Falk (Switzerland), Bernard Iung
testCarrel (Switzerland),
showing symptoms on exercise Michele De Bonis
I C

of the European Society of Cardiology (ESC) and the European

(France),
AVR Patrizio
should be considered in highLancellotti (Belgium),
risk patients with severe symptomatic ASLuc Pierard
who are suitable for(Belgium),
TAVI, but in whom Susanna Price (UK),
IIa B 97

12)
surgery is favoured by a ‘heart team’ based on the individual risk profile and anatomic suitability.
Hans-Joachim Schäfers (Germany), Gerhard Schuler (Germany), Janina Stepinska
Association for Cardio-Thoracic Surgery (EACTS)
(Poland),
AVR Karl Swedberg
should be considered (Sweden),
in asymptomatic patients Johanna
with severe AS and abnormalTakkenberg
exercise test showing(The Netherlands),
fall in blood
IIa C
pressure below baseline.
Ulrich Otto Von Oppell (UK), Stephan Windecker (Switzerland), Jose Luis Zamorano
Authors/Task
AVR
(Spain),Force
should
another valve.
Members:
be considered
Marian Alec
in patients with moderate
Zembala (Poland) Vahanian
ASd undergoing CABG, surgery (Chairperson)
of the ascending aorta or (France)
IIa *, Ottavio Alfieri
C

(Chairperson)
AVR should(Italy),
* be considered
ESC Committee
inFelicita
for Practice Guidelines
symptomatic Andreotti
(Italy),patients
(CPG): Jeroen J. Bax
with low (Italy),
flow,(France),
low gradient
(Chairperson)
(<40 mmHg) Manuel J.onlyFagard
(The Netherlands),
AS with normal EF Antunes (Portugal),
Helmut Baumgartner

e Management of Valvular Heart Disease

(Germany), Claudio Ceconi Veronica Dean Christi Deaton (UK), Robert (Belgium),
IIa C
Gonzalo Barón-Esquivias
after careful confirmation
(Spain),
of severe(France),
AS.
Helmut Baumgartner (Germany),
e
Christian Funck-Brentano David Hasdai (Israel), Arno Hoes (The Netherlands), Paulus Kirchhof
(United
AVR shouldKingdom),
be consideredJuhani Knuuti (Finland),
in symptomatic patients withPhilippe
severe AS, Kolh (Belgium),
low flow, low gradientTheresa McDonagh
with reduced EF, and (UK), Cyril Moulin (France),
Michael Andrew
Bogdan A.
evidence of flowBorger
Popescu
reserve. (Germany), Thierry P. Carrel (Switzerland),
(Romania),f Željko Reiner (Croatia), Udo Sechtem (Germany), Per Anton Sirnes Michele
IIa (Norway),
C De Bonis
Cardiology (ESC) and the European
Michal Tendera (Poland), Adam Torbicki (Poland), Alec Vahanian (France), Stephan Windecker (Switzerland)
(Italy), Arturo
AVR should Evangelista (Spain),
be considered in asymptomatic Volkmar
patients, with normal EF and none ofFalk (Switzerland),
the above mentioned
Document Reviewers:: Bogdan A. Popescu (ESC CPG Review Coordinator) (Romania), Ludwig Von Segesser (EACTS
exercise test Bernard Iung
abnormalities, if the surgical risk is low, and one or more of the following findings is present:
(France), Patrizio Lancellotti (Belgium),
velocity >5.5 m/s or, Luc Pierard (Belgium), Susanna Price (UK),
Review Coordinator) (Switzerland), Luigi P. Badano (Italy), Matjaž Bunc (Slovenia), Marc J. Claeys IIa
• Very severe AS defined by a peak transvalvular
Niksa Drinkovic (Croatia), Gerasimos Filippatos (Greece), Gilbert Habib (France), A. Pieter Kappetein (The Netherlands),
(Belgium), C

oracic Surgery (EACTS)

• Severe valve calcification and a rate of peak transvalvular velocity progression ≥0.3 m/s per year.
Hans-JoachimAVR
Schäfers
be considered
(Germany),
symptomatic (Germany),
patients
Gerhard
with severePetronella
AS low flow,G. lowPieper
Schuler
gradient,(The
(Germany),
Roland Kassab (Lebanon), Gregory Y.H. Lip (UK), Neil Moat (UK), Georg Nickenig (Germany), Catherine M. Otto (USA),
Johnmay Pepper, (UK),inNicolo Piazza and LVNetherlands),
Janina Stepinska
Raphael Rosenhek (Austria),
dysfunction without
IIb C
(Poland), Karl
Naltin
flow Swedberg
Shuka (Albania), Ehud
reserve. f
(Sweden),
Schwammenthal Johanna
Pedro T. Trindade (Switzerland), Thomas Walther (Germany)
Takkenberg
(Israel), Juerg Schwitter (Switzerland), Pilar (The TornosNetherlands),
Mas (Spain),

Ulrich Ottoexercise
AVR
Von
The may
Oppell
be considered
disclosure forms (UK),
in asymptomatic
of the authors Stephan
patients
and with severe AS,
reviewers are Windecker
normal EF andon
available none
theofESC (Switzerland),
the above mentioned
website
test abnormalities, if surgical risk is low, and one or more of the following findings is present:
Jose Luis Zamorano
www.escardio.org/guidelines

ecESCVahanian
(Spain), Marian
(Chairperson)
Zembala (Poland)
(France) *, Ottavio Alfieri
• Markedly elevated natriuretic peptide levels confirmed by repeated measurements and without other explanations IIb C
• Increase of mean pressure gradient with exercise by >20 mmHg
* Corresponding authors: Alec Vahanian, Service de Cardiologie, Hopital Bichat AP-HP, 46 rue Henri Huchard, 75018 Paris, France. Tel: +33 1 40 25 67 60; Fax: + 33 1 40 25 67 32.
• Excessive LV hypertrophy in the absence of hypertension.
Committee for Practice Guidelines (CPG): Jeroen J. Bax (Chairperson) (The Netherlands), Helmut Baumgartner
Email: alec.vahanian@bch.aphp.fr
Ottavio Alfieri, S. Raffaele University Hospital, 20132 Milan, Italy. Tel: +39 02 26437109; Fax: +39 02 26437125. Email: ottavio.alfieri@hsr.it
(Germany), Claudio Ceconi (Italy), Veronica Dean (France), Christi Deaton (UK), Robert Fagard (Belgium),
†Other ESC entities having participated in the development of this document:
 AVR versus TAVI

Jeune 60 ans Vieux 85 ans Haut Risque

Treatment: Surgical
•  Surgical treatment of AS has operative mortalities of less
than 5%

STS National Executive Summary 2009

Filsoufi F et al, J Am Geriatr Soc 2008, 56: 255-261.

36
 Treatment: Surgical
•  Surgical treatment of AS is underutilized
– Patients are believed to be too old?

Life expectancy for US population

•  Those expecting to
Years
live for more than 5
Age years are likely to
65 18,2 derive significant
benefit from AVR
70 14,7
•  For those who survive
75 11,5
6 months after their
80 8,8 operation, life
85 6,5 expectancy matches
that of age-matched
90 4,8
controls
Hornick et al. Clin Geriatr Med 2006; 22: 499-513.
From David H Adams MD, “Current Standard of Care for Treating Severe Aortic Stenosis: Surgical Treatment”
37
 Treatment : Surgical
•  Multiple studies quantify the extent of undertreatment

Severe Symptomatic AS: Percent of patients treated

30% 32% 41%

Untreated 60%

70% 68% 59%

Surgery 40%

Charlson1 Pellikka2 Iung3 Bouma4

US EU
From David H Adams MD, “Current Standard of Care for Treating Severe Aortic Stenosis: Surgical Treatment”

1Charlson E, Legedza AT, Hamel MB. J Heart Valve Dis 2006;15: 312-321. 3Iung B, Baron G, Butchart E, et al. Eur Heart J 2003; 24: 1231-1243.
2Pellika PA, Sarano ME, et al. Circulation 2005; 111: 3290-95. 4Bouma BJ, van den Brink, et al. Heart 1999; 82: 143-48.
38
 Treatment: Surgical

•  Mortality difference for

people with symptomatic
AS treated with Aortic Valve
Replacement (AVR) versus
those not undergoing this
procedure is one of the most
striking in medicine1
–  AVR can be withheld in such
patients only when compelling
contraindications exist

1Schwartz F, Bauman P, et al. Circulation 1982; 66: 1105-10.

39