aortic valve stenosis with hypertension
TRANSCRIPT
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DEPARTMENT OF CARDIOLOGY
Aortic Valve Stenosis with Hypertension. The double loaded ventricle
Javier Bermejo
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I have no financial relationships to disclose
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The Problem
Hypertension
CAD
AS
- AS is present in 1-3 % of pts. with HT
- HT is present in 30-60 % of pts. with AS
- HT is a “risk factor” for degenerative AS
- Common findings are disruption of elastic fibers
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Aortic Valve
Arterial Bed
The double loaded ventricle
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AS & Hypertension
Diagnostic implications
Physiological consequences
Impact on outcome
Therapeutic issues
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In the Echo-Lab:
Measure BP in all pts. with AS
Reassess severity if extreme values
+
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JACC 2005
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Briand et al JACC 2005
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Hachicha Circulation 2007
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Rosebbo N Engl J Med 2008
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Carmaruic JACC Img 2009
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Jander et al Circulation 2011
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Rieck et al Hypertension 2012
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Rieck et al Hypertension 2012
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Rieck et al Hypertension 2012
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Treat Hypertension!
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Target for drug therapy
brain/ kidney
other vascular beds
brain/ kidney
other vascular beds
Courtesy of MF O’Rourke
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• N= 20 pts. with severe AS & HT
• 73 years old (87 – 29)
• 13 male / 7 female
• AVA= 0.7 ± 0.3 cm2
• Normal EF
• Stress Echocardiography
• Randomized with/without - test/retest
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Jiménez Candil et al. Heart 2005
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Jiménez Candil et al. Heart 2005
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Nadir et al. JACC 2011
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Nadir et al. JACC 2011
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Treat Aortic Valve Stenosis… (if symptomatic)
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Circulation Research 1992
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Pre-TAVI Post-TAVI p* Valvular and Ventricular
Aortic Valve Area (cm2) 0.7 ± 0.1 1.8 ± 0.6 0.007
Mean Transvalvular Pressure Gradient (mm Hg) 39 ± 18 11 ± 4 0.005
Stroke Volume (ml) 75 ± 13 64 ± 17 0.14
Ejection Fraction (%) 47 ± 21 55 ± 17 0.038
LV End-systolic Elastance (mm Hg/ml) 0.76 ± 0.2 1.3 ± 0.7 0.09
LV pressure (mmHg) 128 ± 18 115 ± 25 0.12
Vascular
Mean Blood Pressure (mmHg) 62 ± 14 74 ± 17 0.05
Pulse Pressure (mmHg) 39 ± 13 52 ± 14 0.005
Systemic Vascular Resistance (dynes/s/cm-5) 820 ± 259 1137 ± 597 0.08
Aortic Input Impedance Z1 (mmHg/ml) 337 ± 142 510 ± 188 0.028
Characteristic Impedance (dynes/s/cm-5) 147 ± 78 207 ± 109 0.14
Aortic Compliance (·10-3 cm5/dynes) 1.47 ± 0.78 0.80 ± 0.27 0.08
Ea (mmHg/ml) 1.05 ± 0.30 1.61 ± 0.63 0.023
Ea/Ees 1.38 ± 0.37 1.38 ± 0.23 0.92
Non-Invasive Valvuloarterial Impedance (mmHg/ml) 2.1 ± 0.5 1.9 ± 0.9 0.5
Wave Intensity Analysis
Wave Speed (m/s) 2.48 ± 1.18 4.06 ± 1.76 0.01
Peak dIw FCW (· 106 W·m-2·s-2) 0.91 ± 0.49 1.52 ± 0.78 0.012
Reflexion Distance (m) 0.06 ± 0.03 0.08 ± 0.12 0.81
*Wilcoxon test
Yotti et al AHA 2012
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Valve and the Arterial Bed:
More than simple lumped-model
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LV load interaction after valve intervention
complementary
competititive
Effects of Load in AS
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Dahl et al Am J Cardiol 2010
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Treat them both!
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Dahl et al Am J Cardiol 2010
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Conclusions (1/2)
AS & HT are two highly prevalent diseases, with important interactions regarding pathophysiology, diagnosis, LV function, and outcome.
In case of severe HT, reassess severity after controlling BP.
Increased load reduces cardiac output and modifies LV remodelling response.
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Conclusions (2/2)
HT in pts. with AS doubles the risk of hard CV events.
HT should be aggressively treated
ACEI and ARB are the drugs of choice.
HT after AVR blunts the acute and chronic benefits of valvular interventions.
Treatment is advocated for the long-term after AVR.