Functional Mitral Regurgitation

Transcription

1 Club 35 - The best in heart valve disease - Functional Mitral Regurgitation Steven Droogmans, MD, PhD UZ Brussel, Jette, Belgium Euroecho & other Imaging Modalities 2011 No conflicts of interest

2 Functional Mitral Regurgitation Definition Anatomy & mechanisms Echocardiographic assessment Prognostic implications Treatment options Summary: the role of echo

3 Definition Secondary MR < LV-disease: global dilated cardiomyopathy of any cause regional LV-dysfunction ( ischemic MR ) Distortion of LV geometry and function: imbalance tethering and closing forces Normal mitral valve apparatus Frequent: 50% post AMI or dilated CMP

4 Prognostic implications Grigioni F et al. Circulation 2001;103:

5 Anatomy & mechanisms Reduced closing forces Increased tethering forces decreased LV-function change annular contraction synchronicity PM LV dyssynchrony Apical displacement PM Annular dilatation Ischemic MR: regional WMA - eccentric jet Global LV dilatation: central jet

6 Anatomy & mechanisms Functional Ischemic MR

7 Functional Ischemic MR WM abnormalities and PM displacement: asymmetric MR

8 Global LV dilatation Altered geometry sphericity annular dilatation structural normal leaflets

9 Echocardiographic assessment Mitral valve morphology success of repair Severity of MR - prognostic implications LV morphology and function: LV volume, EF Dyssynchrony WMA scar? Viability (dobu) Dynamic changes of MR Prognosis and management of functional MR

10 Echocardiographic assessment

11 Mitral Valve Watanabee JACC 2006 Grewal Circulation 2010 Mor-Avi Circulation 2009 Maruo, Abstract ESC 2011

12 Mitral valve and LV parameters

13 LV geometry and function

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15 Mitral valve closing force Piérard L A, Carabello B A Eur Heart J 2010;31:

16 Unfavourable parameters of MV repair

17 Severity of MR Semi-quantitative Colour flow mapping Vena contracta width Limitations Technical factors (Gain settings, PRF) Eccentric jets Loading conditions Left atrial size Limitations Lateral resolution Phasic changes Multiple jets Non-circular orifice

18 Severity of MR Semi-quantitative Colour flow mapping Vena contracta width Usefull for diagnosis indirect estimation of severity Two orthogonal planes VC < 0.3 cm: mild MR VC 0.7 cm: severe MR

19 Severity of MR: PISA Severe functional MR: EROA 20 mm 2 or a R Vol 30 ml

20 Severity of MR: pitfalls Non-circular orifices Phasic change of MR during cardiac cycle

21 Severity of MR: additional parameters Pulsed Doppler CW Doppler MI/AO TVI Pulm. vein

22 Integrating indices of severity Severe functional MR: EROA 20 mm 2 or a R Vol 30 ml

23 Dynamic aspect of MR Severity of functional MR at rest does not predict does not reflect severity during exercise Unmask significant MR when rest MR is mildmoderate: 1. Exertional dyspnoea out of proportion MR and LV-function at rest 2. Pulmonary oedema without a cause 3. CABG planned for patients with moderate MR Prognostic relevance

24 Dynamic aspect of MR Picano, E. et al. J Am Coll Cardiol 2009;54:

25 Exercise-induced dynamic MR ischemic MR Lancellotti et al. Eur Heart J 2005

26 LV viability: biphasic response

27 Treatment of functional MR Medical therapy Revascularisation ± Mitral valve surgery Cardiac resynchronisation therapy (CRT) Percutaneous treatment

28 Medical therapy Medical therapy for heart failure if indicated ACE-inhibitor beta-blocker aldactone Reduction of morbidity/mortality Diuretics symptom reduction

29 Surgical treatment Mitral valve annuloplasty preferably: probably better outcome preservation mitral (sub) valvular apparatus - maintaining LV geometry preservation LV systolic function reduction LV volume But, high frequency of MVP-failure reported in some series. 28% moderate MR at 6 months and stable thereafter

30 Surgical treatment Limited study data and controversy about long-term prognosis

31 Surgical treatment Limited study data and controversy about long-term prognosis????

32 CABG ± MVP in moderate MR CABG + MVP Better outcome on LV geometry function NYHA No survival benefit after 32 month follow-up (underpowered) Fattouch, JTSC 2009

33 CABG ± MVP in moderate MR CABG CABG + MVP 35% of patients evolved towards moderate to severe MR Better outcome on LV geometry function NYHA MR improved in all patients No survival benefit after 32 month follow-up (underpowered) Fattouch, JTSC 2009

34 Predictors of improvement of unrepaired moderate ischemic MR after CABG MR Improvement ( ) and failure ( ) group: 5 dysfunctional viable segments PPM dyssynchrony < 60 ms Penicka M et al. Circulation 2009;120:

35 Preoperative left ventricular dimensions predict reverse remodelling following restrictive mitral annuloplasty in ischemic mitral regurgitation Braun, EJTS 2007

36 Acute reduction of MR by CRT Kanzaki, JACC 2004

37 Chronic reduction of MR in DCMP by CRT Matsumoto, AJC 2011

38 Chronic reduction of MR in DCMP by CRT Chronic Acute effect Matsumoto, AJC 2011

39 CRT as alternative for moderate to severe MR in inoperable HF? van Bommel R J et al. Circulation 2011;124:

40 CRT as alternative for moderate to severe MR in inoperable HF? van Bommel R J et al. Circulation 2011;124:

41 MitraClip

42 MitraClip

43 Conclusion: Central role of echocardiography Severity of MR and anatomy mitral valve Risk stratification: EROA > 20 mm 2 in rest Dynamic component EROA > 13 mm 2 increase LV remodelling: LVEDD > 65 mm Success of surgical repair Management: Mitral valve annuloplasty CRT Mitraclip

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