Dr. Bernard David Prendergast,
Aortic stenosis (AS) is a hot topic as the population ages and transcatheter valve technology dawns. In a lively and stimulating session “Difficult Aspects of Aortic Stenosis” were addressed by a world class faculty. Anne Rossebo (Oslo, NO) emphasised the frequency of mild-moderate AS in ageing subjects and its relatively benign nature (approximately 30% of subjects require aortic valve replacement over 5 year follow up). Factors predictive of adverse outcome include heavy valve calcification and peak trans-valve velocity >3m/s, though wide inter-individual variability mandates careful clinical and echocardiographic follow up. The need for attention to technical detail in echocardiographic assessment was emphasised by Catherine Otto (Seattle, US). Common pitfalls include confusion with associated mitral and tricuspid disease, inaccuracy of beam alignment, measurement errors undermining the continuity equation, and failure to account for the effects of left ventricular impairment, hypertension or variation in body surface area. Specialist assessment and sonographer education are vital. The difficult concept of low flow-low gradient AS was explored by Jean-Luc Monin (Creteil, FR). Patients in this setting (who form approximately 10% of those with AS) have adverse prognosis, particularly when medical therapy is pursued without recourse to surgery. Again, careful echocardiographic assessment is vital with particular reference to assessment of left ventricular function (using novel techniques, such as speckle tracking), valve calcification and use of biomarkers, such as BNP. Systematic underprovision of aortic valve replacement in high risk elderly patients was highlighted by Thierry Lefevre (Masssy, FR). Transcatheter aortic valve implantation (TAVI) is now a valid treatment option in these patients and over 20,000 patients have been treated worldwide with >95% procedural success rates, acceptable short- and medium term mortality (8-10% one month, 20% one year), and excellent impact on symptoms and quality of life. The procedural learning curve demonstrated in early series has now been overcome, although vascular complications remain an important predictor of adverse outcome. Wider application following presentation of the first RCT versus high risk surgery (PARTNER) later this year seems likely.
Difficult aspects of aortic stenosis
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