Steven F Bolling Professor of Cardiac Surgery University of Michigan

Transcription

1 Optimal Treatment of Functional MR Steven F Bolling Professor of Cardiac Surgery University of Michigan

2 Functional MR

3 Functional MR in Ischemia Badhwar, Bolling, chapter in: Advances in Heart Failure, 2004

4 FMR : Ventricular Problem!! Badhwar, Bolling, chapter in: Advances in Heart Failure, 2004

5 Optimal Medical Therapy of FMR 1.0 : survival is not optimal! 0.8 surv vival MR grade No. None 9,405 Mild 2,062 Moderate 210 Severe Years Hickey et al: Circulation 78:1-51, 1988

6 In fact, even with small amounts of FMR it s terrible!! ERO RVol Grigioni et al: Circulation 103:1759, 2001

7 In 2012, with the modern testing & treatment they still do very badly! Szymanski et al Am J Cardiol 2011 Sep 21.

8 MR - Prognostic value 1300 CHF / FMR Mean age 67, mean EF 32% NYHA I 150 (15%) II 500 (49%) III 316 (31%) IV 57 (6%) Mean fu 2.7y Severe MR 24% Mild or Moderate MR 49% No MR 27% Rossi et al Heart 2011; 97:

9 More MR is worse! Ischemic or Dilated Rossi A et al. Heart 2011;97: by BMJ Publishing Group Ltd and British Cardiovascular Society

10 FMR Not just a late marker! FMR worsened odds ratio of death Rossi A et al. Heart 2011;97: by BMJ Publishing Group Ltd and British Cardiovascular Society

11 CRT for FMR : Less than half eligible, of which less than half respond van Bommel R J et al. Circulation 2011;124: Residual MR is still BAD!! Copyright American Heart Association

12 Undersized Mitral Repair for FMR Nyah, Nyah! Surgeons can fix FMR!!

13 Mitral Repair for FMR in CHF Bolling Chen Bishay Calafiore Buffolo Bitran Dreyfus Suma ACORN JTCVS pts Circ pts Eur JCTS pts Ann TS pts Ar Br Card pts J Card Surg pts JHLT pts JTCVS pts JTCVS pts 30 day mortality 1-5 %

14 Undersized Mitral Repair Feasible Low mortality Relief of MR Better Quality of life

15 Mitral Repair and CHF : benefit? Yikes - No mortality benefit!

16 Mitral Repair and CHF : benefit? Why - No mortality benefit?

17 FMR : residual / recurrent MR Progression of 3 or 4+ MR post-undersized annuloplasty (585) McGee, Gillinov et al, JTCVS, 2004;128:916-24

18 MVR and CHF Even a good operation, when done badly will not help a sick patient! recurrent FMR is still bad

19 Do a Better Operation : Surgical Predictors of Recurrent MR Flexible = 5x recurrent MR! Use rigid complete! Spoor, Geltz, Bolling : Circulation, 11/06

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21 Flexible and/or partial bands don t provide a durable solution for FMR Magne et al. Cardiology 2009;112:

22 Strongest predictor of recurrent MR AP dia > 3.7 cm Recurrent MR Failed Repair AP diameter reduction!!! Kongsaerepong V et al. Am J Cardiol 2006;98:504-8

23 IMR-FMR ring designs Disproportionate AP dimension reduction Bothe W, Swanson J, et al., JTCVS 2010

24 MV repair 30 day mort 1.6% 1.6% Freedom from >1+ MR = 90%!! JTCVS 2006

25 FMR Surgery LV reverse remodeling

26 Braun J, et al., Leiden Ann Thorac Surg 2008;85:

27 FMR : Ventricular Problem!! LVEDD < 65 mm! Braun J, et al., Leiden Ann Thorac Surg 2008;85:

28 CHF Mitral Repair - Kron

29 CHF Mitral Repair - Hvass J Thorac Cardiovasc Surg Feb;139(2): The papillary muscle sling for ischemic mitral regurgitation.hvass U, Joudinaud T.

30 CorCap only

31 Randomized FMR trial JTCVS Fatouch 2009

32 FMR - survival

33 FMR exercise MR

34 Randomized CABG + MVr for mod IMR Mitral regurg volume - 69% vs 14% LV end systolic volumes - 24% vs 10% LV sphericity - 18% vs % Peak oxygen capacity vs 1.0 Brain natriuretic peptide - 76% vs 59% All p < 0.01! Mitral Valve Annuloplasty in Addition to Coronary Artery Bypass Grafting in Moderate Functional Ischemic Mitral Regurgitation Reverses Left Ventricular Remodelling and Restores Left Ventricular Geometry: Chan et al, CIRC March 2012

35 Functional MR Rigid, complete, undersized ring: Overall 6.5 year survival 86% DeBonis et al Eur J of CVTS, April 18, prospective propensity matched pts CHF / severe MR Editorial : SF Bolling : Mitral repair for functional mitral regurgitation in idiopathic dilated cardiomyopathy : A good operation done well may help!

36 Mitral Repair and IMR Repair vs. Just Replace it!

37 100 High Risk 100 Medium Risk I Worst 20%!! II 100 Low Risk Survival Replace Repair III - V Gillinov et al, JTCVS 2001;122:

38 Valve sparing replacement vs repair Survival for 4+ IMR Al Radi et al, Ann Thorac Surg, 2005;79:1260-7

39 Mt Sinai - High risk CABG/MVr

40 Severe Ischemic Mitral Regurgitation - repair vs replacement

41 Mitral Repair and IMR Good repair Replacement Bad repair

42 Catheter-Based Mitral Valve Repair MitraClip System

43 LV Volumes by MR Etiology Reduction in LV volumes, BUT CLIP LEAVES MR!! p< Baseline 12 Months p= Volume (ml) p= Volume (ml) p= LVEDV LVESV LVEDV LVESV Degen MR Subgroup n=88 0 FMR Device Subgroup n=30

44 Septal-Lateral Annular Dimension Baseline vs 12 Months, !! 6 End Systole End Diastole Dimension (cm) p= p= Baseline 12 Months Baseline 12 Month n=111 n=111 p-value compares baseline to 12 month measurements within device Septal-Lateral Annular Dimension not collected in Control group due to the presence of annuloplasty ring or replacement valve

45 Re-Inventing a Failed Surgical technique? The Importance of Annuloplasty Annuloplasty No annuloplasty 260 pts Overall freedom reop 90% (68% without ring) Alfieri O, et al. JTCVS 2001;122:674-81

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47 Mitraclip Functional MR Results high risk EF - 55 % 8% 30 d 25% 1 yr DMR / FMR No controls Not random Left 2-4+ MR!

48 50 pts > 3+ MR CRT failed - 21 Age 70; euroscore 34; LVEDD 70mm; LVEDV 252 ml; LVEF 19% Franzen et al Eur J Heart Fail 2011; 13:569-76

49 Mitral regurgitation at baseline, discharge and 6 months Almost half had significant Residual MR! Franzen O et al. Eur J Heart Fail 2011;13:

50 Mitral Clip in FMR 17 % mortality! Franzen O et al. Eur J Heart Fail 2011;13:

51 Franzen O et al. Eur J Heart Fail 2011;13: LV Remodeling??

52 Optimal treatment of FMR Find MR! Fix MR! OMT, CRT, Clip (COAPT)

53 Optimal treatment for FMR GOOD SURGERY! Careful patient selection Beware the big LV and the bad RV! Repair - use complete rigid ring Replacement - selective RCT!

54 FMR is still a HEADACHE!!