What to do with a Patient with Recurrent MR after Intervention
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1 What to do with a Patient with Recurrent MR after Intervention James D. Thomas, MD, FACC, FASE Director, Center for Heart Valve Disease Bluhm Cardiovascular Institute Professor of Medicine, Feinberg School of Medicine, Northwestern University Chicago, Illinois Conflicts of interest: GE, Abbott, Edwards (honoraria)
2 Limited Data on Clip after Surgery and Vice Versa 2 pts post MVr treated successfully with MC 6 pts post MVr, 4 treated successfully with MC 18 pts w/ MR post MC: 13 MVR, 2 MVr, 3 LVAD
3 Case 1: 84F w/ Recurrent MR After MVr Remote LCx occlusion severe functional MR 2007: MVr w/ #27 Duran annuloplasty 2013: Recurrent MR and Class III sx persist despite GDMT, BNP 431
4 Severe Functional MR w/ Annuloplasty Large LCx scar Multicomponent complex jet
5 No Wonder She s Short of Breath! RVSP = 98 mmhg ROA = 0.8 cm 2 MRV ~ 100 ml Marked PV sys reversal Mean MV gradient 6 mmhg
6 Severe Functional MR w/ Annuloplasty Broadly arising, anteriorly directed jet without flail or prolapse MVA = 5.34 cm 2
7 What to Do? 1. Redo sugery 2. Med management 3. MitraClip 4. Valve-in-valve TMVR
8 What s the Impact of MitraClip on MVA? Reduces valve area by half, but should be OK 27 mm annuloplasty ring 2 inscribed circles 5.7 cm cm 2
9 What to Do? 1. Redo surgery: Pretty high risk 2. Med management: Already doing it 3. MitraClip: Hmmm maybe 4. Valve-in-valve TMVR: Consider if clip not feasible
10 MitraClip Intervention in COAPT Poor leaflet coaptation Steering clip into position 46 mmhg V-wave
11 Grasping Leaflets Clip advanced into LV Grasping leaflets 23 mmhg V-wave Post clip release
12 Dual Orifice Valve Partly Obscured by Ring
13 Pre-Clip Post-Clip
14 Excellent Result at F/U ROA = 0.12 cm 2 MRV ~ 15 ml PV S>D RVSP = 45 mmhg
15 Case #2 60ish yo Man with Dyspnea History: Born with Tetralogy of Fallot 1954: Systemic-pulmonary shunt 1962: VSD closure/pv repair 2002: SCD ICD 2006: Bioprosthetic PVR 2012: Transcatheter valve-in-valve PVR for PR 5/2015: Sensed a pop in chest, then severe DOE COPD from smoking (FEV1 1.2 L), PAF Meds: Bumetidine, spironolactone, coumadin, metoprolol, home O 2 PE: BP 108/60, HR 92 reg, CVP~7, clear lungs, 3/6 HSM
16 Transthoracic Echo 60ish yo Man with Dyspnea Flail posterior leaflet, worst medially
17 Tall E RVSP>70 mmhg Severe MR, P2-3 flail
18 Transesophageal Echo Proximal Convergence Analysis 1.0 cm ROA > 1.0 cm 2
19 Transesophageal Echo 3D Rendering P2 and P3 flail
20 Clinical Course Summary of MitraClip Procedure High risk for surgery so referred for percutaneous clip Baseline: ROA >1 cm 2, mean p = 4 mmhg Clip 1 (lateral A2-P2): ROA 0.3 cm 2, mean p = 4mmHg Clip 2 (medial A2-P2): ROA 0.15 cm 2, mean p = 5mmHg Clip 3 (lateral A3-P3): ROA 0.06 cm 2, mean p = 9mmHg Gradient unacceptable, Clip 3 removed Final: ROA 0.1 cm 2, mean p = 5mmHg
21 One Month Follow-up Echocardiogram I feel great. I went dancing last weekend!
22 3 Days Later I can t breath Clip dislodged, severe MR Clip lodged in posteromedial LV
23 What to do?? A. Redo MitraClip B. Redo-redo-redo-redo surgery C. Just a bit more bumex, he ll be fine
24 What to do?? A. Redo MitraClip B. Redo-redo-redo-redo surgery C. Just a bit more bumex, he ll be fine
25 To the OR Mitral Leaflet Too Mascerated to Repair s/p MVR Good LV function
26 Case 3: 71M w/ Recurrent MR After MVr 1989: RCA occlusion 2001: CABG x 3, VT ICD placed 2007: Functional MR noted but Asx 2012:?subtle symptoms, ring annuloplasty at another Midwestern heart center 2013: Recurrent MR 2016: Referred back for redo surgery. States he feels pretty good, able to go hunting. Outside cath with patent grafts.
27 Severe Functional MR w/ Annuloplasty Large IPMI Very eccentric jet ROA 0.3 cm 2 RVSP 30 mmhg
28 What to Do? 1. Redo redo sugery 2. Med management 3. MitraClip 4. Stress echo
29 What to Do? 1. Redo redo sugery 2. Med management 3. MitraClip 4. Stress echo
30 10.1 METs, RCA Scar, No Ischemia
31 10.1 METs, RCA Scar, No Ischemia
32 10.1 METs, Stopped for Fatigue MR similar RVSP 45 mmhg
33 What to Do? 1. Redo redo sugery 2. Med management 3. MitraClip 4. MRI
34 What to Do? 1. Redo redo sugery 2. Med management 3. MitraClip 4. MRI
35 71M w/ Recurrent MR After MVr One Year Later A little tougher hunting this season, not feeling quite himself Echo suggests worsening MR Repeat exercise echo to assess functional capacity Cruising through stage III without difficulty when
36
37 Yikes!
38 71M w/ Recurrent MR After MVr VT on ETT Cath negative It was determined SOMETHING needed to be done But what? TEE to better assess anatomy
39 EF~30% w/ IPMI, Ring Dehiscence ROA 0.4 cm 2
40 Using X-Plane to Define MV Anatomically A1-P1 A2-P2 X-C view A-P view X-C view A-P view A3-P3 Main pathology A1 & A2 X-C view A-P view
41 Preeeety Small PML, 6 mm
42 OK, Now What to Do? 1. Redo redo sugery 2. Med management 3. MitraClip 4. Just keep echoing him 5. Plug the dehisced ring
43 OK, Now What to Do? 1. Redo redo sugery 2. Med management 3. MitraClip 4. Just keep echoing him 5. Plug the dehisced ring
44 Intraoperative Echo, Bioprosthetic MVR
45 Post-Op Echo, Doing Well
46 Case 4: 80M w/ Recurrent MR After Alfieri 1997: Severe AS Ross procedure 2011: Severe PS Melody valve 2014: Severe AR/MR consideration for surgery
47 Severe AR A2 prolapse ROA 0.35 cm 2 Pat McCarthy: This was one of my toughest cases. #25 CE AVR and (quick!) Alfieri stitch on circulatory arrest
48 3 Years Later: Recurrent Class III dyspnea Well-functioning AVR (1.2 m/sec) Mild prosthetic PS (2.8 m/sec) Moderately severe, very eccentric MR arising medially with ROA 0.4 cm 2
49 What to Do? 1. Redo redo sugery 2. Med management 3. MitraClip 4. TMVR
50 What to Do? 1. Redo redo sugery: No way!!! 2. Med management: Already doing it 3. MitraClip: Hmmm maybe 4. TMVR: Unproven with prior Alfieri
51 MitraClip Undertaken A3 Flail w/ Flow Reversal Severe MR Flow reversal Medial clip placement Normalized
52 Post-Procedure Echo Truly Mild MR
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