Bicuspid valveのdilatationの理由は物理的と分子メカニズム的の２つ;
- Wall share stress Circulation 2014 129 673
- 分子メカニズム
AS進行のメカニズム
Risk factor for atherosclerosis was also risk factors for AS（JACC 2017 69 1523）
PET study ---- inflamationがASの進行に関連（Circulation 2012 125 76）
ASではLipoprotein associated phospholipase A2（LPA）がover expression
generic association with valvular calcification and AS (NEJM)
elevatied lipoprotein and AS (from JACC)
assocation of LPA
state of art paper about NHLBI working group for LPA and AS (JACC 2018 71 177-192)
ASのreview paper （NEJM 2014 371 744）must read for fellows!!
circ CQO 2009 2 533 現在のsymptomatic ASの自然歴
asymptomatic severe ASの自然歴 circ 1997 95 2262, NEJM 2000 343 611-617, circ 2010 121 151-156
management challenges
- Asymptimatic severe AS
- Low-flow, low-dradient AS
- Indication of TAVR
Asymptimatic severe AS
ACC/AHA
- Vmax >5m class2a
- Rapid progression and low surgical risk class2b
ESC class 2a
- Vmax >5,5
- severe AS calc
- elevated BNP (JACC 2014 83 2016-2025)
- PH
Exercise test results
- symptom: class1
- hypotension: class 2a
How are "symptoms" detemined?
- Everyone has symptoms on stress test
- Are the symptoms cardiac in origin?
- What level of exercise?
How is hypotension defined?
- less than 20 mmHg increase?
ではsymptomaticになるまで待つか？
難しいのが突然死が96名中1名
ただしAVR後30日以内に死亡も6名
Ann Throrac Surg 2006 82 116
JACC 2015 6 2827（Taniguchi et al）
AVR vs. conservative approach PS match → AVR
Low-flow, low-dradient AS
Heart 2010 96 1463-1468
1/3はmean gradient <40 and AVA <1.0
treat hypertension
cadiac cath
valve calc
advanced imaging
clinical skill set
→ this scenario can be under-diagnosed and over-diagnosed
Only if clinical anatomic and hemodynamic data support severe AS: class2a
TAVR indication
heart team class 1
TAVR for prohbittive surgical risk class 1
TAVR or SAVR for high risk class 1
TAVR or SAVR for intermediate risk class 2a
SAVR for low risk class 1
TAVR for LV dysfunction --- waiting
TAVR for asymptomatic AS --- waiting
Class 1 = should be performed, not must be done