Post on 30-Jul-2015
QUOI DE NEUF? Dr SIHAM HALLAB
Service de cardiologie-Pr Rachida HabbalCHU Ibn Rochd casablanca
Recommandations ESC 2012sur les pathologies valvulaires
cardiaques
RETRECISSEMENT AORTIQUE
Rétrécissement aortique à bas débit et bas gradient malgré une fraction d’éjection normale
« low flow low gradient aortic stenosis » : faut-il opérer ?
• prévalence :25 à 35 %(selon plusieurs études)
• Se caractérise par: une surface valvulaire aortique ≤ 1cm², un gradient moyen transvalvulaire ≤ 40 mmHg, une FeVG préservée (≥ 50 %) et un volume d’éjection indexé par rapport à la surface corporelle ≤ 35 ml/m².
• concerne souvent les sujets âgés, de sexe féminin, HTA avec un remodelage concentrique prononcé (rapport paroi/cavité > 0,47), et une petite cavité ventriculaire gauche (DTDVG ≤ 47 mm), à l’origine d’une anomalie de remplissage diastolique.
• Entité Problème à la fois du diagnostic et de la prise en charge thérapeutique:
Discordance Surface<1 cm2
Et Gradient 40 mmHg
QUE FAIRE?
Éliminer les diagnostics différentiels
Minners and al. Eur Heart J. 2008
Autres techniques
• Calcifications: « look at the valve » ETT, scopie scanner: score
calcique• +/- Echo Dobutamine low
dose • +/- BNP• +/- KT: Gorlin
faut-il opérer ?ESC 2012
class level
AVR should be considered in symptomatic patients with low flow, low gradient (<40 mmHg) AS with normal EF only after careful confirmation of severe AS.
IIa C
TAVITranscatheter Aortic Valve Implantantion
1ère implantation :Rouen en avril 2002. Deux valves aortiques implantables
par voie percutanée sont commercialisées en Europe depuis 2007:
la valve Edwards (Edwards Lifesciences, Irvine, California)
la Corevalve (Medtronic, Irvine, California)
Voies d’abord: voie artérielle fémorale
2ème intention: voie transapicale, voie artérielle sous clavière
Plusieurs registres: PARTNER, France 2,
GARY (ESC 2012)
GARY(German Aortic Valve RegistrY)
TAVIGARY confirme
FRANCE 2
Indications for transcatheter aortic valve implantation
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
INSUFFISANCE AORTIQUE
Critères échographiques de la sévérité des régurgitations
INSUFFISANCE MITRALE
Mitraclipréparation « bord à bord »
• Introduite par Alfieri• peu diffusée et l’est
essentiellement dans l’IM dégénérative
• Le seul système utilisé en clinique est le système Mitraclip (Abbott Vascular,)• Plusieurs études: EVEREST,
REALISM,
ACCESS Europe
European Society of Cardiology Congress 2012Munich, Germany
ACCESS-EUROPE Phase IA Post Market Study of the MitraClip System for
the Treatment of Significant Mitral Regurgitation in Europe: Analysis of Outcomes
at 1 Year
Wolfgang Schillinger, MD on behalf of the ACCESS EU investigators
Baseline Demographics and Co-Morbidities
Demographics and Co-morbiditiesEVEREST II RCT Device Patients
N=178
EVEREST II High Surgical Risk Cohort
N=211
ACCESS EU – MitraClip PatientsN=567
Age (mean ± SD), years 67 ± 13 76 ± 10 74 ± 10
Logistic EuroSCORE, (%)
Mean ± SD NA NA 23 ± 18
Logistic EuroSCORE ≥ 20%, (%) NA NA 45
STS Mortality Risk, (%)
Mean ± SD 5 ± 4 12 ± 8 NA
STS Mortality Risk ≥ 12%, (%) 6 48 NA
Male Gender, (%) 64 61 64
Coronary Artery Disease, (%) 47 81 63
Previous Cardiovascular Surgery, (%) 23 58 37
Myocardial Infarction, (%) 22 49 32
Cerebrovascular Disease, (%) 8 21 13
Moderate to Severe Renal Failure, (%) 3 31 42
Atrial Fibrillation, (%) 33 64 68
NYHA Functional Class III or IV, (%) 50 86 85ACCESS EU-ESC2012
Site Reported Safety Events At 30 Days
1-Year Events*All Patients
N=567
Logistic EuroSCORE
≥20%N=253
Logistic EuroSCORE
<20%N=314
p-value
Death 19 (3.4%) 11 (4.3%) 8 (2.5%) ns
Stroke 4 (0.7%) 3 (1.2%) 1 (0.3%) ns
Myocardial Infarction
4 (0.7%) 2 (0.8%) 2 (0.6%) ns
Renal Failure 27 (4.8%) 16 (6.3%) 11 (3.5%) ns
Respiratory Failure
4 (0.7%) 3 (1.2%) 1 (0.3%) ns
Need for Resuscitation
10 (1.8%) 7 (2.8%) 3 (1.0%) ns
Cardiac Tamponade
6 (1.1%) 3 (1.2%) 3 (1.0%) ns
Bleeding Complications
22 (3.9%) 12 (4.7%) 10 (3.2%) nsACCESS EU-ESC2012
Site Reported Safety Events At 1 Year
1-Year Events*All Patients
N=567
Logistic EuroSCORE
≥20%N=253
Logistic EuroSCORE
<20%N=314
p-value
Death 98 (17.3%) 58 (22.9%) 40 (12.7%) <0.05
Stroke 6 (1.1%) 4 (1.6%) 2 (0.6%) ns
Myocardial Infarction
8 (1.4%) 5 (2.0%) 3 (1.0%) ns
Renal Failure 49 (8.6%) 29 (11.5%) 20 (6.4%) <0.05
Respiratory Failure
5 (0.9%) 4 (1.6%) 1 (0.3%) ns
Need for Resuscitation
12 (2.1%) 9 (3.6%) 3 (1.0%) <0.05
Cardiac Tamponade
7 (1.2%) 4 (1.6%) 3 (1.0%) ns
Bleeding Complications
27 (4.8%) 16 (6.3%) 11 (3.5%) nsACCESS EU-ESC2012
Mitral Regurgitation Grade*
N = 327 Matched Cases
79% MR ≤ 2+at 1 Year
0
20
40
60
80
100
Baseline 1 Year
Perc
ent
Pat
ients 3+
4+
3+
2+
1+
02+
4+
p<0.0001
ACCESS EU-ESC2012
NYHA Functional Class
72% NYHA Class I or IIat 1 Year
N = 343 Matched Cases
0
20
40
60
80
100
Baseline 1 Year
Perc
ent
Patie
nts
II
III
IV
II
III
IV
I
I
p<0.0001
ACCESS EU-ESC2012
Quality of Life Score (MLHFQ) and 6-Minute Walk Distance
41,6
28,1
0
15
30
45
60
Mea
n Q
oL S
core
(M
LHFQ
)
Baseline 1 Year
N = 264 Matched Cases
Mean improvement -13.5 points95% CI: (-16.0, -11.0)
p<0.0001
MLHFQ
275334
0
100
200
300
400
Mea
n M
eter
s W
alke
d
Baseline 1 Year
p<0.0001
N = 216 Matched Cases
Mean improvement 59.5 meters95% CI: (44.5, 74.6)
6MWT
ACCESS EU-ESC2012
principales approches percutanées pour le traitement de l’IM
Kardiovaskuläre Medizin 2008;11: Nr 6
RETRECISSEMENT MITRAL
PATHOLOGIE TRICUSPIDIENNE
Rétrécissement tricuspideInsuffisance tricuspide
PROTHESES VALVULAIRES
QUE CHOISIR?
MECHANICAL PROSTHESIS
ORBIOPROSTHESIS
Target international normalized ratio (INR) for mechanical prostheses
Overdose of vitK antagonist and bleeding
• The risk of major bleeding increases considerably when the INR exceeds 4.5 and increases exponentially above an INR of 6.0.
• An INR ≥6.0 therefore requires rapid reversal of anticoagulation because of the risk of subsequent bleeding.
• In the absence of bleeding, the management depends on the target INR, the actual INR, and the half-life of the vitamin K antagonist used. It is possible to stop oral anticoagulation and to allow the INR to fall gradually or to give oral vitamin K in increments of 1or 2 mg.
• If INR 10higher doses of oral vitamin K (5 mg). The oral route the intravenous route• If severe bleeding: Immediate reversal of anticoagulation Intravenous
+prothrombin complex concentrate +oral vitamin K, whatever the INR.
Merci pour votre attention