Mitral Valve prolapse: What s new? Which indications of early surgery? Input of new 2017 ESC/EACTS guidelines. Christophe Tribouilloy Amiens, France

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1 Mitral Valve prolapse: What s new? Which indications of early surgery? Input of new 2017 ESC/EACTS guidelines Christophe Tribouilloy Amiens, France

2 I have no financial relationships to disclose related to this presentation.

3 ESC/ EACTS September 2017

4 50 yo, male with MR

5 Primary Mitral Regurgitation Post-operative LVD after valve repair Series pre-op EF late post-op EF post-oplv (%) (%) Dysfunction Leung % Tribouilloy % Witkowski % Repair reduces the rate of post-op LVD compared to MV replacement but does not suppress post-op LVD

6 Asymptomatic MR : Operative Mortality is Low Operative Mortality (%) Tribouilloy et al Circulation % 12.7% 2.5% Severe symptoms (class III-IV) 0.5% 3.6% Overall 75 <75 0 No or minimal symptoms (class I-II)

7 MR Postoperative Outcome Long-term Survival P< P=0.18 % Observed Expected 20 0 NYHA III-IV Years NYHA I-II Years Tribouilloy et al Circulation 1999

8 Asymptomatic Severe MR due to MV prolapse The essential questions Is the patient really asymptomatic? Is MR really severe? Can valve repair be performed? What are the repercussions of MR on LV and LA? What are the repercussions of MR on PAP? Does the patient have AF? What are the patient s wishes Does the expected benefits of intervention (versus spontaneous outcome) outweigh its risks?

9 ERO 0.42 cm², RV 64 ml Is MR really severe?

10 Survival, % Asymptomatic MR: Natural History (n=456; EF > 50%) ±3 % ±6 % P<0.01 ERO 1-19 mm2 ERO mm2 ERO 40 mm2 58±9 % Years Enriquez Sarano et al NEJM 2005

11 Can valve repair be performed?

12 Lazam et al Circulation 2017

13 Mitral valve repair improves surgical result Lazam et al Circulation 2017

14 Mitral Valve Repair ESC / EACTS 2017

15 What are the repercussions of MR on LV function? MR due to Flail Leaflets Mortality on conservative management according to EF Tribouilloy et al Circ Cardiovasc Imaging 2014

16 What are the repercussions of MR on LV function? MR due to Flail Leaflets Long-term survival according to LV-ESD n=739 Cut-off: 40mm or 22 mm/m² HR: 1.95 overall mortality, HR: 3 CV mortality Tribouilloy et al JACC 2009

17 Mitral Valve Prolapse Echocardiographic prediction of LVD after MV repair Tribouilloy et al Eur J of Echocardiography 2011

18 What are the repercussions of MR on Left Atrial? MR due to Flail Leaflets Long-term survival according to LA diameter/volume 100% 90±3% P < LA diam < 55mm LA diam >55mm P < LA-index < 40 ml/m² LA-index ml/m² LA-index 60 ml/m² 84±5% 53±9% Years Rusinaru et al Circulation Imaging 2011 Letourneau et al JACC 2010

19 ESC / EACTS 2017

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21 Overall Survival, % 100 Does the patient have atrial fibrillation? Preoperative AF: A key determinant of outcome in severe MR due to mitral valve prolapse ±3% 70±6% 59±6% SINUS RHYTHM PAROXYSMAL AF PERMANENT AF p< years Szymanski et al Am J cardiol 2015

22 What are the repercussions of MR on PAP? MR due to Flail Leaflets Long-term survival according to PAP Survival according to rest systolic PAP Survival according to rest pre-operative systolic PAP n= 437 PH: Syst. PAP > 50mmHg Barbieri et al, Eur Heart J 2010 Le Tourneau, Heart 2010; 96:

23 Right catheterism ESC / EACTS 2017

24 ESC / EACTS 2017 PH during exercise > 60mmHg ESC 2017 guidelines: no recommandation for surgery in primary MR based on exercise echocardiography Magne et al Circulation 2010 Class II B

25 EF > 60% End point = CHF, left ventricular dysfunction (EF<60%) or death ESC 2017 guidelines: «low plasma BNP has a high negative predictive value as predictor of symptom onset and may be helpful in the follow-up of asymptomatic patients»

26 Global longitudinal strain (GLS) Asymptomatic MR due to MVP with preserved EF (n=135) N=135 ESC 2017 guidelines: «global longitudinal strain could be of potential interest for the detection of subclinical LV dysfunction» Cardiac event-free survival stratified according to median global longitudinal strain ( 20%) Magne et al Heart 2012; 98: 584

27 Chronic MR due to mitral valve prolapse Higher rate of events on conservative management in pts with absence of increase of GLS of 2% or more. left ventricular EF global longitudinal strain Δ EF < 4 % Δ GLS < 2% Cardiac events: cv death, MV surgery, LV dysfunction Magne J et al. Eur Heart J 2014

28 Mitral Regurgitation due to MV Prolapse - Asymptomatic severe MR - High probability of valve repair - EF> 60% and ESD < 40mm - LA Volume < 60ml/m² - PAP < 50mm Hg (at rest) - Sinus rhythm - Low operative risk

29 Women, 71 yo, asymptomatic, 1.65m, 62 kg, FEVG 73% DTD 62 mm DTS 34 mm

30 AHA/ACC 2017: likelihood of successful and durable repair without residual MR >95% with an expected operative mortality < 1% when performed at a Heart valve center of excellence (recommandation class IIa; B) ESC 2017: Watchful waiting is a safe strategy in asymptomatic patients with severe ESC primary MR 2012/ and 2017 none with none of the above indications for surgery

31 Watchful Waiting in Asymptomatic Dystrophic MR Rosenhek et al Circulation 2006 Surgery : symptoms, atrial fibrillation, PAPS > 50mmHg, EF < 60%, ESD > 45 mm (or 26 mm/m²) 132 pts, 55 yo surgery in 35 pts, MV repair in 83%, no operative mortality LV dimensions EDD 56 ± 6 mm ESD 34 ± 5 mm

32 Asymptomatic Severe Mitral Regurgitation Events leading to surgery Years new onset Afib/PHT asympt. LV-dysfunction symptoms any event Rosenhek et al. Circulation 2006;113:

33 Early surgery vs conservative treatment in asymptomatic severe degenerative MR Pts without LV dysfunction or dilatation, AF, PAH n=132 Effect of follow-up regularity and quality on outcome Early surgery defined as within 3 months of diagnosis 4 pts not operated despite class I or IIa indications Montant et al JTCVS 2009;1339

34 Prospective registry 610 pts, mean age 50 yo Kang et al JACC 2014

35 Asymptomatic Degenerative Severe MR Early Surgery vs Waiting for Symptoms A propensity analysis No significant difference in overall mortality Registry 610 pts, mean age 50 yo Excess cardiovascular mortality Kang et al JACC 2014

36 MR due to Flail leaflets: Early Surgery No heart failure symptoms, EF 60, LVESD<40mm Retrospective registry: - n=1021 without class I indication for surgery - Early surgery defined as within 3 months of diagnosis Suri al JAMA 2013;310:609

37 Survival in MR due to Flail Leaflets Early surgery versus initial medical management Propensity score matched cohort -pts without class I indication for surgery (n=1021) -22% with class IIa indication (AFib and/or PHT) Each patient in the conservative group had follow-up visits with a physician within each participating center or elsewhere HR 0.52, P< 0.03 Suri et al. JAMA 2013;310:609

38 CHF in severe MR due to Flail Leaflet Early surgery versus initial medical management HR 0.29, P< 0.01 HR 0.44, P< 0.03 Suri et al JAMA 2013

39 ESC EACTS 2017 Guidelines Etude REVERSE-MR (PHRC 2016) Randomized comparison of Early mitral ValvE Repair versus watchful waiting for asymptomatic SEvere degenerative Mitral Regurgitation due to leaflet prolapse.

40 Severe Asymptomatic Primary MR No Risk Factor Surgery delayed with regular FU Classical indications: -LV Dysfunction -AF -Pulm. hypertension Prompt surgery Risk factors LA 60 ml/m2 LVS mm EF 60-64% SPAP mmhg BNP activation -ERO > 40mm² -low operative risk -Valve repair (MVP) Early surgery

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