What Degree of MR Deserves Surgical or Transcatheter Intervention, and How Should It Be Assessed?

Transcription

1 What Degree of MR Deserves Surgical or Transcatheter Intervention, and How Should It Be Assessed? Robert J. Siegel, M.D., FACC Nov , 2017, Beverly Hills Director, Cardiac Non-Invasive Laboratory Cedars-Sinai Medical Center, Los Angeles Professor of Medicine, UCLA & Cedars-Sinai

2 What Degree of MR Deserves Surgical or Transcatheter Intervention, and How Should It Be Assessed? Robert Siegel, M.D. As a faculty member for this program, I disclose the following relationships with industry: (GRS): Grant/Research Support (C): Consultant (SB): Speaker s Bureau (MSH): Major Stock Holder (AB): Advisory Board (E): Employment (O):Other Financial or Material Support Name of company: Philips Ultrasound; Nature of Relationship: Speaker s Bureau

3 Mechanism of MR Degenerative v. Functional Important for grading MR severity Important Management Surgical, Catheter Intervention, or Medical

4 Functional v. Degenerative MR FMR: Structurally normal MV but LV dysfunction and dilation leads to MR DMR: A diseased MV causes severe MR which leads to LV dysfunction

5 Severe Functional MR JACC 2015 MVARC & ACC/AHA* Qualitative MV Morphology Leaflet tenting, restriction, coaption Color jet Large, aliasing, deep into LA Flow convergence zone Large CW signal Dense; Holosystolic; Low velocity Semiquantitative Vena contracta (mm) 7mm Pulm vein flow reversal Present + Mitral Inflow E wave dominant Quantitative* EROA (cm 2 ) (PISA) 0.4* (0.4 specific, 0.2 more sensitive) Regurgitant Vol (ml) (PISA) 30 LV dysfunction / LV dilation (as present not helpful in grading) Patients with any secondary MR have a worse prognosis MV repair may improve symptoms but not yet shown to survival FMR very dependent on SBP and LV volume

6 55 y.o. woman Functional MR LVEF 27% LVESD 53mm DOE: NYHA Class III on ACE-I / Beta-blockers 2009 went for a Mitraclip

7 F/U Echo in yrs post MitraClip Asymptomatic very active Minimal MR LVEF pre Mitraclip- 27% LVEF 8 yrs postclip- 57% LV size normalized

8 Severe Functional Mitral Regurgitation Surgery : If LVEF <55%- Post-op LV dysfunction 38%, no survival benefit, failure MV repair failure(cad) Matsumura 2004, Acker 2014 MitraClip: Several studies show good results MR, Cardiac output, filling pr, NYHA Class Procedural mortality 0%; no data on ing survival Post-clip LV dysfunction/low C.O rare (> 60,000 pts) 6MWT, BNP & QOL LV size, LVEF D Ascenzo 2015, Pighi 2016,Scotti 2017, Van De Heyning 2016 Schimdt 2017,Plegers 2013;Auricchio 2011; Franzen 2011, Siegel, Biner, Kar 2011;2012 Mendirichaga 2016 COAPT TRIAL: Clinical Evaluation of the Safety and Effectiveness of the MitraClip System for the Treatment of Functional Mitral Regurgitation in Symptomatic Heart Failure Subjects

9 Severe Degenerative MR JACC MVARC 2015 ACC/AHA 2014 Qualitative MV Morphology Flail, pap rupt, retraction, perforation Color jet Significant penetration; holosystolic Flow convergence zone Large; holosystolic MR CW signal Dense; holosystolic MR Semiquantitative Vena contracta (mm) 7mm Pulm vein flow reversal Present + Mitral inflow E wave dominant > cm/s TVI mitral/tvi aortic >1.4 Quantitative: Regurgitant vol (ml) (PISA) 60 EROA (cm 2 ) (PISA) 0.4 LA / LV size* Enlarged Severe MR very unlikely if LV and LA size are normal Beware of color flowitis

10 MR Quantification r=12mm PISA strongly recommended but inherent limitations (MVARC) (reproducibility poor Biner/Siegel JACC 2010) Each echo parameter has limitations & lack of precision use integrated approach Quantitation better than qualitative assessment but may lead to false sense of accuracy NO ECHO GOLD STANDARD for MR severity How does echo integrated approach compare with a reference standard - MRI?

11 Uretsky et al. JACC 2015 Only 36% concordance! If severe MR on echo - only 22% severe on MRI In 34% severe MR on echo MR was mild by MRI -MRI - Severe MR strongly correlated with post-op LV remodeling (r = 0.85; p < ) -Echo - No correlation with post-op LV remodeling & Severe MR (r = 0.32; p = 0.1) Integrated approach

12 AUC 0.86 (95% CI p <0.001) Rafique & Siegel JACC 2015 ROC analysis area under curve - LV EDD was predictive for concordance - MR severity by TTE & MRI LV EDD cut-off of 5.5 cm: Very good sensitivity & specificity for TTE & MRI concordance Must integrate LV size into MR assessment! Chronic severe volume overload LV dilation If still uncertain of MR severity consider getting an MRI

13 Y.M. 76y, asymptomatic M. Echo 05/10/06 flail posterior MV leaflet Prior guidelines equated flail mitral leaflet & severe MR But still need an integrated approach this not severe MV inflow: E/A Reversal; Normal LV size, PASP 11 yrs later Normal LV size, EF, PASP,Exercise Capacity

14 Degenerative MR A diseased MV with severe MR Has adverse consequences LV volume overload LA dilation & increased LAP When to intervene: Progressive LV Dilation 40mm LVID (s) Decline in LVEF towards 60% Increase in PASP to 50 mmhg Symptoms even mild symptoms (DOE)

15 Stress Echo in MR to Assess: Symptomatic status Functional capacity Heart rate recovery Contractile reserve Exercise induced pulmonary hypertension Worsening of MR All have been shown to be prognostic and facilitate timing surgery

16 What Degree of MR Deserves Surgical or Transcatheter Intervention Know your patient Are they symptomatic, are they going to be compliant with regular f/u echos and visits Know your surgeon What is their repair rate? What are their morbidity and mortality rates? Know your practice and yourself Are you able to follow your patients? Can you do step care? Do your patients fly-in?

17 Thank you

18 Adjunctive testing Serial Echo Doppler studies TEE if MR jet is eccentric BNP Strain MRI Stress echo

19 Management of patients with MR is based not only on MR severity but on - Consequences: - Clinical findings - LV function - LV size William Osler - PA pressure Thanks!

20 Take home messages DMR & FMR are different entities Guidelines- Integrate findings but no data on how to weight a parameter Using integrated method in DMR, to diagnose chronic severe MR, LV needs to be dilated Optimal assessment of MR requires incorporating symptoms, LV size & function- to assess impact of MR volume overload on the LV and on the patient

21 Caveats to Be Considered in Echo Doppler evalautaion of MR 60% LA (severe) DCM Large central jets may be present in patients with DCM and only mild MR Late systolic MR (MVP) ERO >0.4 cm2 Overestimation of the severity of MR by PISA with late systolic jets Cannot have severe chronic MR with normal LV size

22 Is 3D Echo the Answer for MR Grading? Direct 3D planimetry of MV ROA 3D VC 3D PISA These 3D methods reported to be more accurate than 2D However.

23 TTE * Importance of MR severity - is the effect of MR on patient & heart. Chronic Severe MR Results in LV dilation (volume overload)

24 Grading of MR Severity 3D Echo is New POTENTIAL LIMITATIONS Limited temporal/spatial resolution EROA variation during systole Artifacts Technical difficulties No gold standard for 3D MR validation To date - no validated guidelines or reference standards on 3D quantification

25 MitraClip vs Optimal Medical Therapy (OMT) for FMR Giannini, AJC 2016 ( N=120) Overall survival CLIP LVEF 34%; NYHA Class 3-4; 60 vs 60 age matched MC vs OMT(BiV) (f/u 515 days) MitraClip vs OMT > overall survival (p=0.007) > CV survival (p=0.002) Survival 1 & 3 yrs MC 90% 61 % OMT 64% 35 % OMT Months f/u Survival free from CVD Months f/u Survival free from rehospitalization Months f/u

26 Functional v. Degenerative MR FMR: Structurally normal MV but LV dysfunction leads to MR DMR: A diseased MV where severe MR leads to LV dysfunction

27 FMR: LV Dysfxn MV leaflets normal but motion restricted from Annular dilation Tethering (apical / posterior displacement of papillary muscles) 15% CHF pts have significant FMR* 3D MV from LA from LV

28 13 mo f/u- post clip NYHA I LVEDD normalized Pre: 62 mm - Post: 49 mm LVESD normalized Pre: 52 mm - Post: 39 mm LVEF improved Pre: 27% - post: 45%

29 F/U Echo in yrs post MitraClip Asymptomatic very active MR- trivial CFD- trivial PW: E/A Reversal Pulm V S Dom

30 Multiparameter MR Severity Assessment >40% Holosystolic* E 120cm/s Blunted/reversed CFD CW PW- MV Inflow PW- PV flow 7mm EROA 0.4cm 2 9 mm Vena Contracta PISA - EROA 12 mm Beware of color flowitis

31 Echo 05/10/2006 Flail posterior leaflet but MR is not severe Because: LV size normal LVEDD: 5.0 cm; LVESD: 3.1 cm MV inflow: E/A Reversal CW Doppler: Not holosystolic signal low intensity Normal PASP: 28 mmhg Severe = multiple parameters Spectral Doppler very helpful

32 11 yrs later Exercise Stress Echo: LV size, LVEF still normal LVEDD: 5.0 cm; LVESD: 3.1 cm PASP: mmhg MV inflow: E/A Reversal Excellent functional capacity MR not severe in spite of flail MV leaflet