Treatment options in ischaemic mitral regurgitation: surgery, clips, devices?

Transcription

1 Treatment options in ischaemic mitral regurgitation: surgery, clips, devices? Francisco Leyva Conflicts of interest: FL has received advisory board fees from Medtronic Inc, Sorin, St Jude Medical and Abbot. His research fellows have received sponsorship from Medtronic Inc, St Jude Medical and Sorin. He is a member of the Advisory Board on MitraClip, Abbot Laboratories. ESC 2011 University of Birmingham Queen Elizabeth Hospital

2 Ischaemic MR following myocardial infarction Prevalence: Echocardiography 30 days post-mi (n = 773) Ischemic MR in 50% Mild in 38% Severe in 12% A murmur was reported in only 32% of patients with MR Bursi et al. Circulation 2005;111:

3 Prognosis in FMR All cause mortality and heart failure hospitalisation for FMR in patients with ischaemic or non-ischaemic cardiomyopathy Rossi A et al. Heart doi: /hrt

4 Retrospective study N = 126 undergoing MVA N= 293 not undergoing MVA LVEF ~ 20% Event-free survival (CHD and non-chd) Event-free survival for patients without CHD Non-MVA Non-MVA MVA MVA Conclusion: No mortality benefit conferred by MVA Wu AH., et al. JACC 2005:45:

5 Mitral valve valvuloplasty with GABG n = 390, from 1991 to 2003 Propensity matched for baseline variables 5 year survival: CABG alone: 75% CABG + MVA: 74% (p = 0.6) Mortality increased in: Wall motion abnormalities ST elevation Longer QRS duration Conclusions: CABG + MVA reduces MR and improves symptoms, but it does not improve survival. MVA, without addressing LV pathology, is unsufficient to improve long-term outcomes Mihaljevic, T. et al. J Am Coll Cardiol 2007;49:

6 Chordal cutting techniques Chordal cutting techniques. Messas E et al. Circ Cardiovasc Imaging 2010;3:

7 ESC guidelines on surgery for FMR c

8 MitraClip Delgado V et al. Heart 2011;97:

9 MitraClip EVEREST II study 279 patients with 3+ or 4+ mitral regurgitation Randomised in a 2:1 ratio to MitraClip or surgery Primary efficacy composite end point : Freedom from death, from surgery and from grade 3+ or 4+ mitral regurgitation at 12 months Primary safety end point: Composite of MACE within 30 days Conclusions: MitraClip is safer than surgery. Surgery provides more complete reduction in MR. 78% of MitraClip patients are free from surgery at 2 yrs. Feldman T, et al. NEJM 2011

10 Indirect mitral valvuloplasty Imaging techniques for indirect mitral annuloplasty procedure guidance. Delgado V et al. Heart 2011;97:

11 Case 61 year old man May 2010: First hospitalization for acute heart failure Treated with diuretics, discharged on Bisoprolol 1.25 mg od June 2010: NYHA II Persistent, uncontrolled AF: high rates up to 150 bpm Normal QRS duration (92 ms) Drug therapy: Bisoprolol 10 mg od, Digoxin 250 mcg od Examination: AF: bpm MR +++

12 Case 1: Echocardiography LVEF: 15% Leyva & Steeds BCIS 2011

13 Case 1 March 2011: CRT-P (10 months) April 2011: TOE post-crt NYHA class II Leyva & Steeds BCIS 2011

14 Post-AVJA and CRT June 2011: Post AVJN ablation NYHA class I Leyva & Steeds BCIS 2011

15 MitraClip Interpapillary muscle activation delay and FMR after CRT Kanzaki, H. et al. J Am Coll Cardiol 2004;44:

16 Mitral regurgitation: mechanisms Modified from Levine R A, Schwammenthal E Circulation 2005;112: Reproduced from Cleveland Clinic

17 Management of FMR Mitral regurgitation (ERO > 20 mm 2 ) Assessment of MR, LV function and aetiology TTE / TOE Cath LGE-CMR Structural abnormalities Functional abnormalities SURGERY MitraClip CRT ( ± ABLATION)

18 Conclusions Surgery (repair or replacement): MitraClip: CRT: Is best for patients with structural MR Promising role in patients with functional MR who are candidates surgery Role in patients who are not candidates for surgery remains unexplored Reduces FMR in patients with conventional indications for CRT Role of CRT in reducing MR in patients without conventional indications for CRT remains unexplored

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20 Carpentier s classification of functional mitral regurgitation Normal leaflet motion Increased leaflet motion (leaflet prolapse) Restricted leaflet motion In diastole and systole Restricted leaflet motion predominantly in systole Ischaemic MR:T ype I and Type IIIb

21 Management of patients with severe functional ischaemic mitral regurgitation. Lancellotti P et al. Heart 2008;94: by BMJ Publishing Group Ltd and British Cardiovascular Society

22 Management of patients with moderate functional ischaemic mitral regurgitation. Lancellotti P et al. Heart 2008;94: by BMJ Publishing Group Ltd and British Cardiovascular Society

23 Case: dyssynchrony assessment Leyva. ESC 2011

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25 Prevalence and severity of MR in CHF 221 patients (111 inpatients and 110 outpatients) with heart failure and LVEF <40% 74% of in patients and 45% of outpatients had moderate to severe MR (Robbins. Am J Cardiol. 2003;91:360-2)

26 Characterisation of mitral valve lesion before transcatheter edge-to-edge mitral valve repair. Delgado V et al. Heart 2011;97: by BMJ Publishing Group Ltd and British Cardiovascular Society

27 Mechanisms of FMR A, Balance of forces applied to mitral valve Otsuji, Y. et al. Circulation 1997;96: