How does Pulmonary Hypertension Affect the Decision to Intervene in Mitral Valve Disease? NO DISCLOSURE

Transcription

1 How does Pulmonary Hypertension Affect the Decision to Intervene in Mitral Valve Disease? Prof. Patrizio LANCELLOTTI, MD, PhD GIGA Cardiovascular Sciences, Heart Valve Clinic, University of Liège, CHU Sart Tilman, BELGIUM NO DISCLOSURE

2 BACKGROUND Elevation of PA pressures is commonly observed in symptomatic patients with MV disease Elevated PA leads to a cascade of adverse effects on the pulmonary circulation and RV function PHT is a risk factor for poor outcome in MVD The presence of PHT in MVD is a key element in the decision making algorithm for intervention on the mitral valve

3 The Pathophysiology of PHT in MVD Harikrischnan et al, 2009

4 Mitral Stenosis Indications for Mitral Valve Treatment ESC Guidelines Class a Level b PMBV should be considered in asymptomatic patients with MVA 1.5 cm² without unfavourable characteristics* and high risk of haemodynamic decompensation (SPAP >50 mmhg at rest) IIa C AHA/ACC Guidelines PMBV is effective for asymptomatic patients with moderate or severe MS and valve morphology that is favorable for percutaneous mitral balloon valvotomy who have SPAP > 50 mm Hg at rest or > 60 mm Hg with exercise) I C PMBV may be considered for symptomatic patients (NYHA functional class II) with MV area >1.5 cm 2 if there is evidence of hemodynamically significant MS based on SPAP >60 mm Hg during exercise IIb Vahanian et al, Eur H J Bonow et al Circu 2007 C

5 Mitral Stenosis and Severe Pulmonary Hypertension Technical challenges for performing PMBV Less tolerance to the stress of the procedure because of the precarious hemodynamics Transeptal puncture being difficult given the larger right-sided chambers Tighter stenosis, leading to difficulty for the balloon to cross the valve. Susceptibility to tearing and development of MR Wisenbaugh et al, Am J Cardiol 1992

6 Mitral Stenosis PHT and Outcome after MV Surgery Operative mortality for MVR correlates with - Age - Functional class - Pulmonary hypertension - Presence of CAD Long-term survival is related to - Age, functional class, AF - Pulmonary hypertension - Preoperative LV/RV function - Prosthetic valve complications Vahanian A, The ESC Textbook of Cardiovascular Medicine

7 Mitral Stenosis and Mitral Valve Surgery Influence of Pre-op PHT Severity 43 patients with MVD (43% MVS) undergoing MVS PHT > Systemic Arterial Pressure Most of the reduction in PHT is observed during the first week after treatment Persistent PHT: residual MR, Iatrogenic ASD, restenosis, fixed PVR MVR is safe even in the presence of severe PHT as long as SAP is below systemic pressures Mubeen et al: Asian Cardiovasc Thorac Ann 2008

8 Mitral Stenosis Pulmonary Hypertension at exercise - 48 patients asymptomatic pts with MS - Exer reveals symptoms in 46% Despite similar peak values, dyspneic patients have different hemodynamic parameters during the first level of exercise compared with pts remaining asymptomatic

9 Primary Mitral Regurgitation Indications for Mitral Valve Treatment ESC Guidelines Class a Level b Surgery should be considered in asymptomatic patients with IIa C preserved function and pulmonary hypertension at rest (>50 mmhg) Surgery may be considered in asymptomatic patients with preserved function, high likelihood of durable repair, and low surgical risk and pulmonary hypertension on exercise (SPAP 60 mmhg at exercise) AHA/ACC Guidelines MV surgery is reasonable for asymptomatic patients with chronic severe MR,* preserved LV function, and pulmonary hypertension (> 50 mm Hg at rest or >60 mm Hg with exercise) IIb IIa C C Vahanian et al, Eur H J Bonow et al Circu 2007

10 Primary Mitral Regurgitation Pulmonary Hypertension and Outcome patients with chronic severe organic MR referred for surgery - 36% of NYHA class III-IV - 32 % PAPs > 50 mmhg - Post-op end points: death + CardioVx death patients with flail organic MR - 35% of NYHA class III-IV (MIDA) - 23 % PAPs > 50 mmhg - Event: Death + Heart failure Le Tourneau et al., Heart, 2010 Barbieri et al Eur H J 2011

11 Primary Mitral Regurgitation Any Grade of PHT affects the outcome after MVS patients with chronic severe degenerative MR referred for surgery - 39% of NYHA class III-IV (retrospective) - 17% SPAP mmhg and 15 % SPAP > 50 mmhg - Operative mortality was 0.8% 40 % SPAP > 40 mmhg at F-Up Predictor of Long-term mortality SPAP, Age, LVEF Ghoreishi et al, J Thorac Cardiovasc Surg 2011

12 Primary Mitral Regurgitation Pulmonary Hypertension and Post-Op LV dysfunction - 79 patients with chronic severe organic MR referred for surgery - 36 % PAPs > 50 mmhg By a stepwise multivariate regression analysis, preoperative PAPs and LVDs independently correlated with postoperative LVEF Yang H JASE 2006;19:1051

13 Primary Mitral Regurgitation (asymptomatic pts) PHT and Post-Op Survival after MVRepair Asymptomatic pts with severe MR 143 patients (Prospective) - SPAP > 50 mmhg: 12% (No LV Dysfunvtion) 12 % (18 with LV dysfunction) - Median F-up 8.5 years 8 years - Early surgery (<3 months after diagnosis) : n=125 Overall outcome after MVR versus conservative treatment PHT PHT PHT Post-MVRepair Outcome Montant et al, JTCVS 2009 Chenot Eur J CV Surg 2009

14 Secondary MR RV Function and Post-op Outcome 53 patients with severe primary MR undergoing MVS Hochreiter Circulation 1986

15 Primary Mitral Regurgitation Prediction of Pulmonary Hypertension + Severity of MR Le Tourneau et al., Heart, 2010

16 Primary Mitral Regurgitation Pulmonary Hypertension at Exercise in Asymptomatic Patients - 78 asymptomatic patients with moderate to severe degenerative MR - Symptom-Free Survival Magne,Lancellotti, Piérard Circulation 2010, 122: 33-41

17 Primary Mitral Regurgitation Pulmonary Hypertension at Exercise and Outcome Magne,Lancellotti, Piérard Circulation 2010, 122: 33-41

18 Secondary MR Indications for Mitral Valve Surgery: PHT is not a criterion Surgery is indicated in patients with severe MR* undergoing CABG, and LVEF >30% Class a Level b I C Surgery should be considered in patients with moderate MR undergoing CABG (Exercise echo is recommended to identify dyspnea, increase in severity of MR and in SPAP) Surgery should be considered in symptomatic patients with severe MR, LVEF <30%, option for revascularization, and evidence of viability IIa IIa C C Surgery may be considered in patients with severe MR, LVEF >30%, who remain symptomatic despite optimal medical management (including CRT if indicated) and have low comorbidity, when revascularization is not indicated IIb C Vahanian et al, Eur H J 2012

19 Secondary MR Impact of PHT in patients with Heart Failure Distribution of RV tricuspid pressure gradient in 510 patients with suspected HF + Age Using a definition of SPAP > 45 mmhg, 7% of the patients with HF have PAH, which is associated with worse LV function, MR, and prognosis Damy et al, EHJ 2010

20 Dynamic PHT on Exercise Man of 52 y old, History of inferior MI, PCMK NYHA III, Episodes of acute dyspnea REST EXER VC 6.1 mm VC 7.3 mm RV 41 ml RV 81 ml

21 Secondary MR Dynamic PHT in HF: relationship with symptoms - 46 HF pts with ischemic LV dysdunction HF pts with ischemic LV dysdunction - Determinants of SPAP at exercise - Determinants of dyspnea on exercise 103 fatigue 58 dyspnea LV EFand mitral ERO were independently associated with PASP at exercise Tumminello et al, Eur Heart J 2007 Patients with a SPAP > 60 mmhg interrupted more frequently exercise for dyspnea Piérard and Lancellotti N Engl J Med 2006

22 Secondary MR Dynamic PHT in HF and Outcome HF pts with ischemic LV dysdunction - SPAP > 61 mmhg at exercise: 38% of patients - Predictors of outcome: ERO diff, TTPG diff, ERO at rest AUC: 0.7 for 61 mmhg AUC 0.73 Lancellotti et al, 2012

23 Secondary MR Pulmonary Hypertension and Post-op Outcome 46 patients with severe MR and DCM undergoing restrictive mitral annuloplasty SPAP > mmhg SPAP > 60 mmhg SPAP > 60 mmhg Multivariate Cox regression analysis identified severe PH (systolic PAP> 60 mm Hg) as a significant predictor of adverse cardiac events, as well as LV remodeling after RMA Kainuma et al J Thorac Cardiovasc Surg 2011

24 Secondary MR RV Function and Post-op Outcome 111 patients with severe MR and DCM undergoing restrictive mitral annuloplasty ROC analysis identified TAPSE12 mm, TAPSV10 cm/s, and MVCD >10 mm as predictive cut-offs for early and late post-op outcome Di Mauro EHJ 2007

25 Take Home Messages - The prevalence of PHT depends on the etiology/symptoms - PHT is an indicator of poor outcome in MVD - PHT ( SPAP 50mmHg) is a criterion for surgical decisionmaking in patients with severe MVD. - Should we consider this threshold as a class I indication for referral in MS (When still < to systemic Arterial Pressure in MS) or in Flail MV? - Exercise PHT may develop in patients with MVD, even when resting SPAP is normal. It is associated with a poor prognosis in primary and secondary MR. Data are inexistent in MS