Mitral Valve Disease, When to Intervene

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1 Mitral Valve Disease, When to Intervene Swedish Heart and Vascular Institute Ming Zhang MD PhD Interventional Cardiology Structure Heart Disease

2 Conflict of Interest None

3 Current ACC/AHA guideline Stages of Heart Valve Disease Objective Evaluation of Surgical and Interventional Risk Evidence based management of mitral valve disease The transcatheter valve therapy, MitraClip and valve implantation 3

4

5 Stages of Progression of Valvular Heart Disease

6

7 Abnormal structure and/or function of 1 or more of the 4 components of the mitral apparatus Leaflets, annulus, Chordae tendineae, Papillary muscles Left ventricular myocardium 7

8 Carpentier s functional classification. Type I, normal leaflet motion; Type II, increased leaflet motion (leaflet prolapse); Type IIIa restricted leaflet motion during diastole and systole; Type IIIb restricted leaflet motion predominantly during systole

9 Mitral regurgitation (MR) is the most common type of heart valve insufficiency in the US 1,2 Prevalence of Valvular Heart Disease by Age 12 Prevalence increases from 0.5% for year olds to 9.3% for 75 year olds (p<.0001) 1. Heart Disease and Stroke Statistics 2010 Update: A Report From the American Heart Association. Circulation. 2010;121:e46-e Nkomo et al. Burden of Valvular Heart Diseases: A Population-based Study, Lancet, 2006; 368:

10 Nearly half of MR patients not considered appropriate for mitral valve surgery 4 Factors prohibiting surgery include 4 : Impaired LVEF High operative risk Multiple comorbidities Advanced age 2% Surgical Patients (30K) 49% High-Risk Patients*,1-3 (860K) 49% Surgical Candidates (850K) * Note: High-Risk Patients are defined as any patient with an EF<35% or an age of U.S. Census Bureau, Statistical Abstract of the U.S. 2. Nkomo et al. Burden of Valvular Heart Diseases: A Population-based Study, Lancet, 2006; 368: Patel, et al. Mitral Regurgitation in Patients with Advanced Systolic Heart Failure, J of Cardiac Failure, Rankin, et al, J of Thoracic and Cardiovascular Surgery, March 2006

11 Comparison of Early Surgery Versus Conventional Treatment in Asymptomatic Severe Mitral Regurgitation Comparison of event-free survival rates between the operated (OP) and conventional treatment (CONV) groups in propensity-matched pairs. Circulation. 2009;119:

12 Recommendations for Chronic Primary MR

13 Pathogenesis Structural of Heart Right Program Ventricle in Mitral Valve Disease

14 Prevalence of Mild, Moderate, and Severe PH According to Left-Sided VHD

15 Tricuspid Regurgitation in Mitral Valve Disease Incidence, Prognostic Implications, Mechanism, and Management J Am Coll Cardiol 2009;53:401 8

16 Right Versus Left Ventricular Failure Differences, Similarities, and Interactions 1. Embryological and Physiological Differences 2. Does the RV Differ From the LV in Its (Mal) Adaptation to Adverse Loading 3. How Does the RV Adapt to Chronically Increased Afterload 4. Mechanical and Functional Interdependence Between the RV and LV

17 Differences Between the Left and Right Ventricles Under Normal Conditions

18 Intermediate Risk (Top 33% Surgical Risk) STS 4 High Risk (Top 10% Surgical Risk) STS 8 Low Risk SAVR Extreme Risk Inoperable Cohort C Do not treat 80% of patients in STS Database* 14% 6% * Thourani, Annals of Thoracic Surgery,

19 ACCESS TO ABBOTT'S MITRACLIP SYSTEM EXPANDS IN THE U.S. WITH MEDICARE NATIONAL COVERAGE DETERMINATION - MEDICARE WILL PROVIDE NATIONAL COVERAGE FOR PEOPLE WITH SEVERE DEGENERATIVE MITRAL REGURGITATION DEEMED TOO SICK FOR SURGERY - IN ADDITION, APPROVAL OF NEW TECHNOLOGY ADD-ON PAYMENT RECOGNIZES THE SUBSTANTIAL CLINICAL BENEFITS OF MITRACLIP THERAPY ABBOTT PARK, Ill., Aug. 12, 2014 /

20 The surgical mitral repair procedure introduced in 1991 by the Italian surgeon Ottavio Alfieri who successfully treated a patient with anterior leaflet prolapse. In the largest surgical series from this same group, including 260 patients who underwent such repair, 80% of the cohort had additional MV annuloplasty that was associated with reduced reoperation at a mean follow-up of 5 years. 20 J Thorac Cardiovasc Surg 2001;122:674 81

21 MitraClip Device (Clip) Structural Heart Program The MitraClip System MitraClip System Clip Delivery System Steerable Guide Handle Arm Gripper Delivery Catheter Handle Steerable Guide, Steerable Sleeve, and Delivery Catheter Stabilizer MitraClip Device (Clip) 21

22 Current Status of MitraClip 22

23 J Am Coll Cardiol 2014;64:172 81

24 Outcomes of the Initial Experience with Commercial Transcatheter Mitral Valve Repair in the United States study, The U.S. National TVT Registry 2015 This study included data from 564 high-risk patients with primary mitral regurgitation (MR) Procedural success rate of 91.8% and a procedural complication rate of 7.8%. Procedural stroke rate was 1.8% The major bleeding rate was 3.9%. Pre-implantation MR grade was 3 in 94% of patients Post-implantation MR grade was 2 in 93% of patients and 1 in 63.7% of patients. In hospital mortality was 2.3% and 30-day mortality was 5.8%.

25 Q&A

26 Pressure overload Left-sided HF (most common cause) Pulmonary embolism (common) Other causes of PH RV outflow tract obstruction Peripheral pulmonary stenosis Volume overload Tricuspid regurgitation Pulmonary regurgitation Atrial septal defect Anomalous pulmonary venous return Sinus of valsalva rupture into the RA Coronary artery fistula to RA or RV Carcinoid syndrome Rheumatic valvulitis

27 Ischemia and infarction RV myocardial infarction Ischemia may contribute to RV dysfunction in CHD and RV overload states (especially pressure overload) Intrinsic myocardial process Cardiomyopathy and heart failure Arrhythmogenic RV dysplasia Sepsis Inflow limitation Tricuspid stenosis Superior vena cava stenosis Complex congenital defect Ebstein s anomaly Tetralogy of Fallot Transposition of the great arteries Double-outlet RV with mitral atresia Pericardial disease Constrictive pericarditis

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