Σεμινάρια Ομάδων Εργασίας 2017 Ανεπάρκεια μιτροειδούς μυξωματώδους αιτιολογίας

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1 Σεμινάρια Ομάδων Εργασίας 2017 Ανεπάρκεια μιτροειδούς μυξωματώδους αιτιολογίας Μυτάς Δημήτρης MD, PhD Επιμ Α ΕΣΥ Σισμανόγλειο Γενικό Νοσοκομείο Αττικής

2 Δηλώνω υπεύθυνα ότι η παρούσα ομιλία δεν επιχορηγείται ή δεν υποκρύπτει οποιαδήποτε οικονομική σχέση με φαρμακευτική εταιρεία

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4 Etiology of MVR Disease in Euro Heart Survey 60%

5 MVR classification Organic or primary (Due to intrinsic valvular disease) Functional or secondary (Regional and/or global LV remodeling without MV structural abnormalities) - Degenerative disease MVP syndrome: Barlow, Fibroelastic degeneration, Marfan, Ehler Danlos syndrome Annular calcification, - Rheumatic disease - Endocarditis - Ruptured papillary muscle (AMI) - Ischaemic heart disease - Dilated cardiomyopathy

6 Mitral valve anatomy LAA TRV

7 MV: Shape and function (3D) LA view LA A P LV view LV 3D Parametric map

8 MV Prolapse spectrum Fibroelastic deficiency Barlow disease

9 Differences between Barlow Disease & Fibroelastic Deficiency ASE s Comprehensive Echocardiography 2 nd edition ELSEVIER 2016

10 MVP signs and symptoms Signs Systolic click & mid to late systolic murmur Asthenic with low body weight, skeletal abnormalities Low/normal blood pressure Symptoms Asymptomatic or nonspecific symptoms (fatigability, anxiety, autonomic nervous dysfunction) Palpitations >>>> syncope >>>> sudden cardiac death (very rarely) Atypical chest discomfort Embolic events (ie TIA, retinal artery occlusion) Endocarditis Heart failure

11 MVP diagnosis: 2D ECHO criteria Superior displacement of one or both mitral leaflets 2mm above the plane of mitral annulus in long axis echo view Billowing Other minor echo criteria: diffuse leaflet thickening >5mm/redundancy excessive chordal length and motion evidence of rupture chords Doppler mitral regurgitation Carpentier s classification: Type II

12 M-Mode diagnostic signs Mid-late systolic posterior movement of one or both valve leaflets >2mm posterior to CD segment (white arrows) Hammock-shaped pansystolic posterior movement of one or both valve leaflets >3mm posterior to CD segment (black arrows)

13 Transthoracic ECHO - (2D & 3D) MV views TRV P2 A2 P1 A1 P3 A3

14 Transesophageal ECHO 2D MV views POST COM

15 3D MVP Normal subject. Saddle-shaped annulus Mild posterior leaflet billowing with mild MVR Fibroelastic deficiency Flail P2 scallop due to ruptured chord, severe eccentric MVR Barlow disease Bileaflet multi-scallop prolapse with severe MVR Lee et al. Circulation. 2013;127:

16 ECHO assessment of MVR

17 (PISA method)

18 LVEF <60% LVESD >45mm S TDI <10cm/s Global Strain <18% LA diam >50mm LAVI >40ml

19 Myxomatous MV - Fibroelastic deficiency Severe eccentric MR due to flail P2 scallop

20 Myxomatous MV - Fibroelastic deficiency Severe eccentric MR due to flail P2 scallop

21 Myxomatous MV - Fibroelastic deficiency Severe eccentric MR due to flail P2 scallop

22 Myxomatous MV - Fibroelastic deficiency Severe eccentric MR due to flail P2 scallop

23 Myxomatous MV - Barlow disease severe symptomatic MVR

24 Myxomatous MV - Barlow disease severe symptomatic MVR

25 Myxomatous MV - Barlow disease severe symptomatic MVR

26 Myxomatous MV - Barlow disease: severe symptomatic MVR MV Reg Volume 160ml MV Reg fraction 60% TVI ratio = VTI MV / VTI LVOT 1,4 Vena Contracta = 0,8cm PISA Radius = 1,1cm E 1,5m/s

27 Central Jet MVR Doppler quantitavive analysis : excellent agreement between 2D 3D - CMR

28 Eccentric Jet MVR Doppler quantitative analysis : 2D underestimates MR volume compared to 3D Choi et al. Circ Cardiovasc Imaging. 2014;7:

29 Accessing MVR severity: Vena contracta MVR Functional MVR Organic MVR

30 Accessing MVR severity: syst pulm flow reversal

31 Assessing Right heart RV / RA dimensions S TDI RV 10cm/s TAPSE 17cm RV Systolic function FAC 35% TVR IVC RV pressures PVR

32 Therapy

33 Severity Essential questions in the evaluation of a patient for MVR intervention Symptoms / correlation with MVR Patient s life expectancy / expected life quality Benefits vs. risks Patient s wishes Optimal local resources for planned intervention

34 Class I C LVEF > 30% and LVESD < 55mm Class IIa C IIaC flail leaflet and LVESD 40 mm IIbC LAVI 60 ml/m²bsa & sinus rhythm or PASP on exercise 60 mmhg

35 Predictors of unsuccessful repair in organic/primary MV Large central MVR jet Severe annular dilatation >50mm 3 scallops, especially if anterior leaflet is involved Extensive valve calcification Lack of valve tissue (rheumatic disease/endocarditis)

36 3D quantification of MVP (parametric maps) 3D accurate estimates: prolapsing height anterior leaflet surface area mitral annular dimensions Normal subjects have early-systolic anteroposterior area contraction increased annular height larger saddle shape depth unchanged intercommissural diameter MVP patients have mostly unchanged annular dimensions significant intercommissural dilation

37 3D contribution in preoperative approach Tailored rather than standard surgical approach based to Carpentier classification. Saddle-shaped MV annuloplasty with prior use of 3D TEE to measure the annular height to commissural width ratio Risk estimation of SAM after MV repair Song Wan et al. Ann Cardiothorac Surg 2015;4(3):

38 Mitral valve posterior leaflet repair: Basic surgical concepts A: a, P2 segment of the posterior leaflet without support due to chord rupture; outline of triangular resection (dotted line); b, triangular resection of P2; c and d, apposition and suturing of free edges. B: suturing of a 63 mm band (standard at the Mayo Clinic) to the fibrous trigones of the mitral ring (a and b), followed by integrity test with saline solution (c) Michelena H et al. Rev Esp Cardiol. 2010;63(7):820-31

39 Mitral valve anterior leaflet repair: Basic surgical concepts leaflet folding plasty and resection-suture chordal transposition chordal shortening artificial chordae Carpentier A et al. Carpentier s Reconstructive Valve Surgery. From Valve Analysis to Valve Reconstruction Saunders Elsevier.

40 Mitral valve replacement Both leaflets prolapse 3 scallops Calcified MV Infected cusps with severe destruction (endocarditis)

41 Percutaneous Mitral Valve interventions: Mitraclip system High-risk patients with secondary mitral valve regurgitation and poor left ventricular function that remain symptomatic despite optimal medical treatment Patients with primary MVR in high surgical risk or very old pts The MitraClip interventional treatment is still at an early stage of clinical development. Vahanian A et al. Presse Med 2014 P. Boekstegers et al. Clinical Research in Cardiology 2014

42 Conclusions Clinicians must be aware of MVP disease severity to early intervene Echocardiography is the principal investigation tool of MVR. Echo study must includes an assessment of severity, mechanisms of MVR, repairability and its consequences Surgical treatment is a decision that must be individualized and depends on : clinical signs/symptoms, echo findings, hemodynamic data, repairability vsoperative risk. Promising percutaneus new techniques are rapidly developing

43 Σας ευχαριστώ Dimitris Mytas Photography