DECISION MAKING DEL CARDIOCHIRURGO NELL INSUFFICIENZA MITRALICA: ISTRUZIONI D USO D CARDIOLOGO

Transcription

1 DECISION MAKING DEL CARDIOCHIRURGO NELL INSUFFICIENZA MITRALICA: ISTRUZIONI D USO D PER IL CARDIOLOGO GUIDELINES IN ASYMPTOMATIC MR ACC/AHA ESC Antonio Miceli Heart Hospital Monasterio Foundation NATURAL/ MEDICAL MR HISTORY Organic MR is a condition with adverse events Under medical management MR due to flail leaflets display excess mortality compared with the genaral population 3% 9% 6% 12% In patients with organic MR, surgery is almost unavoidable High likelihood of developing symptoms or LV dysfunction in 6-1 years. Patients in their 5s, rate of surgical indication is 7-1% per year Patients in their 6s, rate of death or cardiac surgery is % per 1 years after diagnosis, 9% of patients either are dead or surgery Mortality rate in patients with severe MR with flail leaflets is 6-7% per year. Sudden death.8% per year THE QUESTION IS NOT IF BUT WHEN SURGERY SHOULD BE PERFORMED Sarano. Lancet 9;373:

2 RATIONALE FOR EARLY SURGERY Class I indications are associated with worse outcomes EARLY SURGERY VS WATCHFUL WAITING Tribouilloy C et al. Circulation 1999;99:-5 RATIONALE FOR EARLY SURGERY Class I indications are associated with worse outcomes RATIONALE FOR EARLY SURGERY Class I indications are associated with worse outcomes Tribouilloy C et al. Circulation 1999;99:-5 Tribouilloy C et al. JACC 9;54:1961-8

3 RATIONALE FOR EARLY SURGERY ATRIAL FIBRILLATION RATIONALE FOR EARLY SURGERY ERO ERO>mm is associated with : - doubling of the mortality risk - quadrupling of the risk of cardiac events Sarano et al. Circulation 1;121: Sarano et al. Circulation 1;121: RATIONAL FOR EARLY SURGERY Survival in asymptomatic severe MR: the MIDA registry B-TYPE NATRIURETIC PEPTIDE Sarano et al. Circulation 1;121:

4 Study design Design Murmur detected Echo - Flail leaflet Initial medical management MIDA Registry: 97 consecutive patients with flail mitral valve regurgitation (198-4). Mean follow-up is 1.3 year and is 98% complete. Routine cardiac practice at six tertiary centers (France, Italy, Belgium and USA) Mitral surgery within 3 Months 616 MIDA Registry International Sites Participants Rochester, MN, USA Amiens, France Marseille, France Brussels, Belgium Bologna, Italy Modena, Italy One-thousand-and-twenty-one patients with mitral regurgitation and without class I triggers pt underwent mitral valve surgery within 3 months following detection pt initially medically managed Association between treatment strategy and survival, heart failure, and new-onset atrial fibrillation

5 Exclusion criteria Ischemic mitral regurgitation Significant concomitant aortic valve disease, congenital heart disease, mitral stenosis, and previous valve surgery Current heart failure symptoms due to mitral regurgitation as defined per Framingham criteria Overt left ventricular dysfunction defined as either ejection fraction<6 % or end-systolic diameter mm Contraindication to surgery due to comorbidity Baseline Characteristics Characteristic (%) management n=575 Overall n=446 Total n=1,21 Age, mean (SD) (yr) 67 (13) 62 (13) 65 (13) <.1 Men Charlson index, mean (SD).9 (1.2).8 (1.1).8 (1.2).5 Minimal subjective manifestation Ejection fraction, mean (SD) (%) 68.6 (6) 68.7 (6) 68.7 (6).65 Hypertension Atrial fibrillation Pulmonary hypertension Class II indication Heart rate, mean (SD) (bpm) 75 (14) 74 (16) 74 (15).28 LVEDD, mean (SD) (mm) 56. (6.1) 57.7 (5.9) 56.7 (6.1) <.1 LVESD, mean (SD) (mm) 32.2 (4) 33.5 (4) 32.8 (4) <.1 LVESD/BSA mean (SD) (mm/m 2 ) 17.6 (2.5) 17.9 (2.6) 17.7 (2.6).4 LA diameter, mean (SD) (mm) 48. (8.) 49.2 (7.6) 48.5 (7.9).3 Flail posterior P 616 Baseline Characteristics: Propensity scorematched cohort Characteristic (%) management n=324 Propensity score-matched cohort n=324 Total n=648 P Age, mean (SD) (yr) 64 (12) 64 (12) 64 (12).75 Men >.99 Charlson index, mean (SD).8 (1.2).8 (1.2).8 (1.2).79 Minimal subjective manifestation Ejection fraction, mean (SD) (%) 68.5 (6) 68.2 (6) 68.3 (6).46 Hypertension Atrial fibrillation Pulmonary hypertension Class II indication Heart rate, mean (SD) (bpm) 74 (14) 74 (16) 74 (15).48 LVEDD, mean (SD) (mm) 56.1 (6) 57.6 (6) 56.9 (6).4 LVESD, mean (SD) (mm) 32.6 (4) 33.7 (4) 33.1 (4).1 LVESD/BSA mean (SD) (mm/m 2 ) 17.5 (2.5) 18. (2.4) 17.8 (2.5).3 LA diameter, mean (SD) (mm) 48. (7.4) 49.3 (7.7) 48.7 (7.6).4 Flail posterior Unmatched survival in the MIDA registry Survival (%) Log rank p <

6 Matched survival in the MIDA registry Unmatched chronic heart failure in the MIDA registry Survival (%) Log rank p = Heart failure (%) Log rank p < Matched chronic heart failure in the MIDA registry Unmatched atrial fibrillation in the MIDA registry Heart failure (%) Log rank p < Atrial fibrillation (%) Log rank p =

7 Matched atrial fibrillation in the MIDA registry Atrial fibrillation (%) Log rank p = Summary Early-surgery was not associated with excess short term (3 months) mortality or heart failure, but does carry a small increased risk of early atrial fibrillation Long-term results are coherent regardless of the statistical methods employed (direct comparison, adjusted comparison, propensity-matching, Inverse-probability weighting) and demonstrate : a net survival benefit (total mortality decrement of approximately %) A diminished risk of heart failure (reduction of approximately 6%) What is new in Mitral Surgery?

8 Heart Hospital 1year Experience in MIMVS Baseline Characteristics October 3 - April Patients underwent MIMVS throu Overall Logistic EuroSCORE (%) 7 (4-15) Results Baseline Characteristics of 978 repair Central Aortic Cannulation 118 pts (8%) Femoral Artery Cannulation 287 pts (%) Direct Aortic Cross-Clamp Endoaortic Ballon Ventricular Fibrillation / Beating Heart 1189 pts 148 pts 55 pts Conversion to sternotomy 49 patients (3.5%)

9 Principles of Reconstruction Results Preserve or restore full leaflet motion Create a large surface of coaptation Remodel and stabilize the annulus Results Freedom from Reoperation 98% ±5% Median Follow-up 3 (1-5 years)

10 TAKE HOME MESSAGES 1.EARLY SURGICAL INDICATIONS 1.ADVANTAGES OF MIMVS