Mitral valve treatment in advanced heart failure: Repair, Replacement, MitraClip. Nicola Buzzatti, MD San Raffaele Scientific Institute Milan, Italy

Transcription

1 Mitral valve treatment in advanced heart failure: Repair, Replacement, MitraClip Nicola Buzzatti, MD San Raffaele Scientific Institute Milan, Italy

2 Disclosures I have nothing to disclose

3 FMR: a ventricular disease Trichon et al, Am J Cardiol 2003 FMR in 2057 pts with EF 40% and NYHA II-IV: 44% none 39% 1+ or 2+ Rossi et al, Heart 2011 FMR in 1256 pts with chronic HF due to DCM: 27% none 49% mild-to-moderate 24% severe 17% 3+ or 4+ 56% 73%

4 FMR matters Grigioni et al. Circulation 2001; 103: Rossi et al. Heart 2011; 97:

5 Repair Ring Ring + something else Replacement Transcatheter Repair MitraClip Ring Both/else Transcatheter Replacement LVAD/ HTx +/- tricuspid? +/- arrhythmia? What to do? which is the best?

6 Acute mortality of FMR surgery Study Year Number of patients + CABG Acute Mortality Wu yes 4.8% ACORN no 1.6% Braun yes 8.0% Fattouch yes 4.1% Ciarka yes 8.2% Acker yes 2.8% De Bonis yes 2.8%

7 Undersized annuloplasty: LV remodelling and symptoms improvement Mihaljevic et al. J Am Coll Cardiol 2007; 49: Bax et al. Circulation 2004; 110:

8 Undersized annuloplasty: survival benefit? Wu et al. J Am Coll Cardiol 2005; 45:

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10 Undersized annuloplasty: recurrent MR 30% after 1 year! McGee et al. J Thorac Cardiovasc Surg 2004; 128: Crabtree et al. Ann Thorac Surg 2008; 85:

11 Selection is key! PREDITORS OF ANNULOPLASTY FAILURE: - Absence of annular dilatation - Excessive leaflet tethering - Coaptation depth >10mm - Posterior leaflet angle > 45 - Distal anterior leaflet angle >25 - Systolic tenting area >2.5cm 2 - Advanced LV remodelling - systolic sphericity index >0.7, - LVEDD >65mm - LVESV 145 ml (or 100 ml/m2) - End-systolic interpapillary muscle distance >20mm - Basal aneurysm/dyskinesis Lee et al. Circulation 2009;119:2606

12 Added repair procedures

13 30.8±8.0% 10.3±4.1%

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15 Mean 2-year LVESVI: REPAIR: / ml/m 2 (change from baseline 9.0 ml). REPLACEMENT: / ml/m 2 (change from baseline 6.5 ml). REPAIR WITHOUT RESIDUAL MR: / (-16 ml) REPAIR WITH RECURRENT MR / P<0.001! Successful repair provides the greatest LV reverse remodeling!

16 Circulation is based on dynamism and crosstalk, actions and reactions play a game which principle is the preservation of energy Sir M. Yacoub, ATS 2009 Repair: LV vortex preserved Replacement: LV vortex lost

17 Associated procedures: tricuspid and AFib

18 FMR: a ventricular disease SURVIVAL at 4 years: Coapsys 74% Control 50% P=0.09 (unpublished data) Grossi EA et al, JACC 2010

19 Concerns about surgery for FMR in HF Acute morbidity and mortality not negligible Low-risk advanced-hf patient does not exist MR recurrence still an issue No proved survival benefit Early intervention (with good anatomy) is difficult Addressing the right target?

20 Patients with severe MR and HF at Cliveland Clinic 1095 pts ( ) Prevalence of MR mechanisms Outcomes in unoperated patients Goel SS et al. JACC 2014

21 Maisano et al. JACC 2011

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23 NYHA class MLHFQ

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26 Hospital mortality: MitraClip 0% (0/55) Surgery 3% (2/65, both LCOS) P=0.49 Survival

27 Symptoms and LV remodelling NYHA MitraClip Surgery Baseline FUP P Baseline FUP P III-IV, n(%) 45/55 (81.8) 9/55 (16.3) < /65 (86.1) 16/63 (25.3) <0.001 ECHO MitraClip Surgery Baseline FUP Δ P Baseline FUP Δ P LVEF, % 27.9 ± ± ± ± <0.001 LVEDD,mm 69.7 ± ± ± ± <0.001 spap,mmhg 47 ± ± ± ± <0.001

28 MR recurrence

29 Patients with initial good result Patients with good persistent result at 1 year

30 29.8% ± 8.2% 45.7% ± 4.5% 8.7% ± 3.0% 5.0% ± 2.2% 24 24

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32 Other transcatheter technologies are now arriving on the scene Annuloplasty Mitral Replacement Improved efficacy is expected!

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34 Severe FMR in HF SURGERY Anatomy Severe tethering Calcium Acceptable Surgical Risk +Tricuspid +AFib High TRANSCATHETER THERAPY Anatomy Severe tethering? Calcium? Good Bad Repair Ring Ring+other Replacement Transcath Repair MitraClip (MitraClip+Ring) (TMVR) Unapproachable valve Unapproachable patient LVAD/HTx Medical therapy

35 Heart-Team approach Individualized patient centred care Cardiac Surgeon Echocardiographist Patient Interventional Cardiologist HF Cardiologist Anesthesiologist

36 Mitral Repair: Art or Science? The wedding of the Virgin Raffaello Sanzio, Courtesy of Francesco Maisano

37 Cardiac surgeon Interventional cardiologist share your expertise, for patients sake!

38 Just a different suture, just a different needle holder just do it!

39 Thank you