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