Disclosures. ESC Munich 2012 Bernard Iung, MD Consultancy: Abbott Boehringer Ingelheim Bayer Servier Valtech

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1 Disclosures ESC Munich 2012 Bernard Iung, MD Consultancy: Abbott Boehringer Ingelheim Bayer Servier Valtech Speaker s fee Edwards Lifesciences Sanofi-Aventis

2 Decision Making in Patients with Multivalvular Disease A Symptomatic Patient with Aortic, Mitral and Tricuspid Valve Disease Bernard Iung Bichat Hospital, Paris, France

3 Clinical History 66-year old woman Hypertension, diabetes, overweight (BMI 37) Sleep apnea Percutaneous mitral commissurotomy in 1999 Progressive dyspnea for 3 years, currently NYHA class III Atrial fibrillation for 5 years Clinical examination Double aortic murmur 2/6 Mitral opening snap, diastolic murmur 1/6 No signs of congestive heart failure

4 Valve area 1.0 cm² Mean gradient 9 mm Hg MR grade1/4 Cormier class 2

5 Vena contracta 6 mm End-diastolic velocity in descending aorta 15 cm/sec Mean gradient < 10 mm Hg

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7 Echocardiography: Summary Mitral valve Severe stenosis, trivial regurgitation Valve thickening, no calcification (fluoroscopy), bicommissural fusion Aortic valve Moderate regurgitation, no gradient Tricuspid valve Moderate functional regurgitation, annulus diameter 45 mm Left ventricle LVEDD 60 mm, LVESD 38 mm, LVEF 55% Enlarged left atrium (140 ml), no thrombus in TEE Systolic PAP 45 mmhg

8 Components of Decision Making Severe symptomatic valvular disease: need for intervention In favour of PMC Low risk Good expected results on the mitral valve Slow progression of moderate rheumatic AR Possible decrease of TR severity after PMC, but risk of redo intervention (mitral restenosis, progression of AR/TR) In favour of surgery Complete and durable treatment of all valvular diseases, but higher risk of intervention and prosthesis-related complications Importance of patient wishes

9 Operative Mortality Euro Heart Survey STS Database

10 Percutaneous Mitral Commissurotomy Inoue stepwise technique Progressive inflation 26 to 32 mm under TTE monitoring Opening of postero-medial commissure, valve area 1.5 cm², increase in MR severity No complication, stable haemodynamics TTE at day 1 Valve area 1.5 cm², Mean gradient 13 mmhg Severe MR originating from the opened commissure ERO 0.30 cm², vena contracta 5-6 mm Systolic PAP 60 mmhg

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12 Indication for Surgery Justified by poor immediate results of PMC No criteria for severe MS / MR but increase in gradient and PAP Poor tolerance of acute MR: do not delay intervention Pre-operative evaluation Normal coronary angiography FEV1: 80% of predicted value No comorbidity Euroscore I 6.8%, Euroscore II 4.8%, STS score not applicable Intervention performed 09/07/2012 Aortic valve replacement (ON-X 23) Mitral valve replacement (ON-X) Tricuspid annuloplasty (Carpentier ring 30 mm)

13 Indications for surgery in tricuspid disease Class Surgery is indicated in symptomatic patients with severe TS. I C Surgery is indicated in patients with severe TS undergoing left-sided valve intervention. Surgery is indicated in patients with severe primary, or secondary, TR undergoing left-sided valve surgery. Surgery is indicated in symptomatic patients with severe isolated primary TR without severe right ventricular dysfunction. Surgery should be considered in patients with moderate primary TR undergoing leftsided valve surgery.. Surgery should be considered in patients with mild or moderate secondary TR with dilated annulus ( 40 mm or > 21 mm/m²) undergoing left-sided valve surgery. Surgery should be considered in asymptomatic or mildly symptomatic patients with severe isolated primary TR and progressive right ventricular dilation or deterioration of right ventricular function. After left-sided valve surgery, surgery should be considered in patients with severe TR who are symptomatic or have progressive right ventricular dilatation/dysfunction, in the absence of left-sided valve dysfunction, severe right or left ventricular dysfunction, and severe pulmonary vascular disease. I I I IIa IIa IIa IIa Level C C C C C C C European Heart Journal doi: /eurheartj/ehl428

14 Post-Operative Evaluation Uneventful post-operative course Discharge at D + 14 Echocardiography (D + 12) Mean aortic gradient 10 mmhg Mean mitral gradient 5 mmhg Mild tricuspid regurgitation and mean gradient 3 mmhg LVEDD 59 mm, EF 50% Systolic PAP 45 mmhg

15 Conclusion (I) Assessment of Multivalve Disease Quantitation of the severity of each valve disease Adapted methods, interactions Assessment of etiology and mechanisms Progression, feasibility of conservative techniques Consequences (symptoms, left ventricle, PAP) Do not forget the tricuspid valve Anatomy, quantitation, annular diameter Assessment of the risk of interventions Single vs. double valve surgery, percutaneous techniques General risk factors

16 Conclusions (II) Indications for Interventions In symptomatic patients, the decision should be individualised: Predominance of one valve disease Feasibility of conservative techniques Partial vs. complete treatment Risk of different approaches Prosthesis-related complications Risk of further interventions Patient wishes Limitations of guidelines Heterogeneity, lack of data

17 Valvular Heart Disease ESC Working Group