The difficult patient with mitral regurgitation

Transcription

1 Clinical pathways The difficult patient with mitral regurgitation Stress echo can be the best tool Challenging cases Maria João Andrade, Lisbon PT

2 Management of Severe Chronic Organic MR Echo Exercise Echo ESC Guidelines 2006

3 Parameters Mild Moderate Severe Qualitative MV morphology Normal/abnormal Normal/abnormal Flail leaflet/ruptured PMs large coaptation defect Colour flow MR jet Small, central Intermediate Very large central jet / eccentric jet adhering, swirling, and reaching the posterior wall of the LA Flow convergence zone No or small Intermediate Large CW signal of MR jet Faint /Parabolic Dense /Parabolic Dense /Triangular Semi-quantitative VC width (mm) <3 Intermediate 7 (>8 for biplane) Pulmonary vein flow Systolic dominance Systolic blunting Systolic flow reversal Mitral inflow A wave dominant Variable E wave dominant (>1.5 M/s) TVI mit /TVI Ao <1 Intermediate >1.4 Quantitative Grading the Severity of Organic MR EROA (mm2) < ; R Vol (ml) < ; LV and LA size and the systolic pulmonary pressure Lancellotti P et al. EAE Recommendations for the assessment of valvular regurgitation. Eur J Echocardiogr 2010; 11:

4 Actual application of guidelines Mirabel M, et al. EHJ 2007;28;

5 Role of exercise echo in organic MR Exercise Doppler echocardiography is reasonable in asymptomatic patients with severe MR to assess exercise tolerance and the effects on pulmonary artery pressure (>60 mm Hg) and MR severity ACC/AHA Class IIa Level of Evidence: C ESC guidelines: not included

6 Role of exercise echo in organic MR EAE Recommendations 2010 In asymptomatic patients with severe organic MR exercise stress echo may help identify patients with unrecognized symptoms or subclinical latent LV dysfunction Lancellotti P et al. EAE Recommendations for the assessment of valvular regurgitation. Eur J Echocardiogr 2010; 11:

7 Role of exercise echo in organic MR Symptom status Assist in the evaluation of symptoms and determine functional capacity Identification of patients with unrecognized symptoms Evaluate patients with equivocal symptoms LV function Assist in the identification of subclinical latent LV dysfunction Contractile reserve Severity of MR Exercise-changes in MR severity Evaluate the dynamic behaviour of MR Exercise-induced pulmonary hypertension to help optimize the timing of surgical intervention

8 Exercise-induced changes in degenerative MR RV ERO Degenerative MR might be dynamic and increases during exercise in 1/3 of patients. Marked changes in MR severity are associated with exercise-induced changes in systolic PAP and reduced symptom-free survival. Magne J et al. JACC 2010;56;300-9

9 Predictors of Post-operative LV Dysfunction in Degenerative MR by 2D 2D strain speckle tracking at Rest and after Exercise Lancellotti P et al. JASE 2008

10 Predictors of Post-operative LV Dysfunction in Degenerative MR by 2D Speckle Tracking Lancellotti P et al. JASE 2008

11 Clinical case 40 year-old asymptomatic

12 EROA =48 mm2 RV=50 ml

13 More data... ESDI 18 mm s/m E PeakV 1,7 M/s EROA =48 mm2 RV=50 ml EF%=63 EDV=170 ml ESV=64 ml LA ESVI 64 ml s/m RV/RA PG 25 mm Hg

14 More data... GLS= -28%

15 Question Should this patient be referred for MV repair? What would be the feasibility? Should the patient be asked to come back in 6 months for clinical and echo evaluation? Should an exercise echo help?

16 Exercise Doppler echo Symptom-limited graded bicycle exercise test in a tilting exercise table Initial load of 25W for 3 minutes with 25W increases every 2 minutes BP and 12-leads ECG every 2 minutes 2D and Doppler recordings throughout the test, stored in digital format 11 minutes 125 W Stop because of fatigue BP: 115/66 180/90 HR: No arrhythmias or ST changes

17 Exercise Doppler echo

18 Exercise Doppler echo More data... Rest Ex change EF (%) EDV (ml) ESV (ml) LVOT VTI (cm) MV EROA (mm 2 ) MV RV (ml) RV/RA PG (mm Hg) 25 --?

19 Clinical case 69 year-old female Long history of hypertension Dilated cardiomyopathy known from 4 years (35% EF) Normal coronary arteries ICD implanted from 3 years (primary prevention no shocks) One episode of PAF Under optimal medical therapy (β-blockers, ACEI, furosemide, spironolactone, nitrates) Referred for repetitive (4) episodes of hypertensive acute pulmonary oedema over the last 3 months

20 Clinical case ECG

21 Echo -Rest LVDD -71 mm LVSD -56 mm FS=22% Systolic tenting area=2,8 cm 2 Coaptation distance=1,4 cm

22 Echo -Rest EF%=32 EDV=117 ml ESV=79 ml EROA = 9mm2 RV=13 ml LA ESVI =37 ml/sm E/E = 12 RV/RA PG not possible AV dyssynchrony No Inter-V dyssynchrony No Intra-V dyssynchrony borderline (50 ms delay)

23 Exercise Doppler echo On full therapy 6 minutes 20 W (3 ), 40W (2 ), 50W(1 ) Stop because of dyspnea BP: 120/67 160/84 HR: No arrhythmias or ST changes Symptom-limited graded bicycle exercise test in a tilting exercise table BP and 12-leads ECG every 2 minutes 2D and Doppler recordings throughout the test, stored in digital format

24 Exercise Doppler echo EROA = 9mm2 RV=13 ml EROA = 24mm2 RV= 36 ml

25 Question Should this patient be referred for MVR? Should the patient be referred for CRT? Should she keep on going on medical therapy?

26 Role of exercise echo in functional MR In patients with systolic dysfunction and only mild MR at rest in whom acute pulmonary edema occurs without an obvious cause, exercise Doppler echo may be useful to unmask haemodynamically significant dynamic MR identify patients at higher risk for heart failure and death EAE Recommendations 2010 Lancellotti P et al. EAE Recommendations for the assessment of valvular regurgitation. Eur J Echocardiogr 2010; 11: