Understanding the guidelines for Interventions in MR Ali AlMasood
Mitral regurgitation The most diverse from all acquired valve diseases About 50% of patients with an LVEF 35 percent had moderate to severe MR Am Heart J. 2002;144(3):524.r pre It is associated with progressive HF symptomatology and an increased mortality.
Prognostic importance of MR freedom from death any cause freedom from cardiac death survival without heart failure 404 pts with CHF and optimal medical treatment (76.5% ischemic) Mild: 166 patients (41.2%) Moderate:195 patients (48.1%) Severe: 43 patients (10.7%) Agricola E et al. Eur J Heart Fail 2009;11:581-7
Prognostic implications of MR 469 pts with CHF and optimal medical and device treatment Bursi F et al.. Eur J Heart Fail 2010;12:382-8
Mitral Regurgitation Abnormal valve function may results from Leaflets Supporting apparatus Left ventricle Two important categories of etiology Acute Chronic valence in elderly
Etiology of MR Valve related LV related
Etiology of primary MR Degenerated Rheumatic
Etiology of secondary MR Dilated Ischemic
Secondary MR It has worse prognosis complex treatment options optimized medical therapy biventricular pacing valve interventions (surgical vs percutaneous) long-term LV assist devices cardiac transplantation.
Mechanism of MR
Mechanism of MR
Surgical correction of FMR Low operative mortality Possible symptomatic and remodeling benefit There is no evidence that elimination of MR in HF patients conveys a survival benefit Surgery is challenging with inferior outcomes than in primary MR
Mitral valve repair for MR in heart failure improves symptoms Bach DS, Bolling SF. Am Heart J 1995; 129:1165
Mitral valve annuloplasty improves left ventricular function in heart failure
Impact of mitral valve annuloplasty on mortality risk in MR & LV dysfunction there is no clearly demonstrable mortality benefit conferred by MVA for significant MR with severe LV dysfunction. Wu AH et al. J Am Coll Cardiol 2005;45:381-7
Surgical correction of FMR Most major guidelines recommend against isolated mitral valve surgery in the setting of chronic severe secondary MR Surgery is only recommended in this setting if aortic valve or coronary artery bypass graft (CABG) surgery functional MR surgery, when performed with CABG, has yielded mixed results
ACC/AHA 2014 Guidelines Recommendations COR LOE MV surgery may be considered in symptomatic patients with chronic severe primary MR and LVEF IIb C 30% (stage D) MV repair may be considered in patients with rheumatic mitral valve disease when surgical treatment is indicated if a durable and successful repair is likely or if the reliability of long-term anticoagulation management is questionable IIb B
ACC/AHA 2014 Guidelines Recommendations COR LOE Percutaneous MV repair may be considered for severely symptomatic patients (NYHA class III-IV) with chronic severe primary MR (stage D) who have a reasonable life expectancy, but a prohibitive surgical risk because of severe comorbidities IIb B MVR should not be performed for the treatment of isolated severe primary MR limited to less than one half of the posterior leaflet unless MV repair has been attempted and was unsuccessful III: Harm B
ACC/AHA 2014 Guidelines Recommendations COR LOE Percutaneous MV repair may be considered for severely symptomatic patients (NYHA class III-IV) with chronic severe primary MR (stage D) who have a reasonable life expectancy, but a prohibitive surgical risk because of severe comorbidities IIb B MVR should not be performed for the treatment of isolated severe primary MR limited to less than one half of the posterior leaflet unless MV repair has been attempted and was unsuccessful III: Harm B
ACC/AHA 2014 Recommendations COR LOE MV surgery may be considered in symptomatic patients with chronic severe primary MR and LVEF IIb C 30% (stage D) MV repair may be considered in patients with rheumatic mitral valve disease when surgical treatment is indicated if a durable and successful repair is likely or if the reliability of long-term anticoagulation management is questionable IIb B
Percutaneous Mitral Valve Repair Mitral Clip System 30 000 implantations performed worldwide. approved for use in high risk or inoperable pts with severe MR suitable anatomic criteria
Percentage of patients with 2+ (MR)at base line and 12 M after percutaneous MitraClip
Percentage of pts with [NYHA] functional class at baseline and 12 months after MitraClip
Trial/Registry Composition by Functional vs Degenerative Etiology
ROLE (1) Don t send pts with FMR for Surgery
ESC/ EACTS guidelines & ESC focus update 2015 Percutaneous MitraClip therapy may be considered, after heart team discussion, in highrisk patients with either primary or secondary MR
Chronic Primary Mitral Regurgitation: Intervention (cont.) Recommendations COR LOE Percutaneous MV repair may be considered for severely symptomatic patients (NYHA class III- IV) with chronic severe primary MR (stage D) who have a reasonable life expectancy, but a prohibitive surgical risk because of severe IIb B comorbidities MVR should not be performed for the treatment of isolated severe primary MR limited to less than one half of the posterior leaflet unless MV repair has been attempted and was unsuccessful III: Harm B
ROLE (2) The Heart Team
The Heart Team A multidisciplinary Heart Team (interventional cardiologists, cardiac surgeons, anaesthetists, imaging, and heart failure specialists) Heart team role Evaluate all the options Assess the risk benefit ratio Comorbidities
The Heart Valve Team Recommendations COR LOE Patients with severe VHD should be evaluated by a multidisciplinary Heart Valve Team when intervention is considered I C
ROLE (3) Establish Heart Valve Centers of Excellence
Heart Valve Centers of Excellence Consultation with or referral to a Heart Valve Center of Excellence is reasonable when discussing treatment options for 1) asymptomatic patients with severe VHD, 2) patients who may benefit from valve repair versus valve replacement, or 3) patients with multiple comorbidities for whom valve intervention is considered IIa C
ROLE (4) Selection is essential for success in choosing the therapy
Key anatomic eligibility criteria for percutaneous edge-to-edge repair
Unfavorable anatomical conditions for percutaneous edge-to-edge repair
ROLE (5) Utilize the imaging techniques
Imaging assessment Severity assessment Anatomic suitability Procedure safety & success
MR severity assessment
Contrast-enhanced ECG-gated Cardiac CT
Echo vs. MRI Quantitative echo was compared with cardiac MRI in a prospective series of 103 patients with a majority (82%) of primary MR Agreement between the two methods was moderate for regurgitate volume r ¼ 0.6) (correlation 45 of 58 pts with severe MR according to echo were reclassified as mild or moderate using MRI 26 pts who had MRI after surgery, the correlation between reverse (LV) remodeling and indices of MR severity was much higher for MRI than for echo (r ¼ 0.85, P, 0.0001 vs. r ¼ 0.32, P ¼ 0.10, respectively Uretsky S, et al. Am Coll Cardiol 2015;65:1078 1088
ROLE (6) Be aware of potential limitation of available techniques
Potential Limitations of mitral clip Recurrent MR Need for reoperation Iatrogenic mitral stenosis
ROLE (7) Don t undervalue the role of medical therapy
Medical Therapy Medical therapy (ACE inhibitors, b-blockers, and aldosterone antagonists) Diuretics for fluid overload vasodilators for hemodynamic compromise Cardiac resynchronization therapy in appropriate candidate
Role (8) Stay tuned for the upcoming therapeutic options
Ongoing randomized trials COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) MITRA-FR ( percutaneous mitral valve repair compared with optimal medical management alone for severe secondary mitral regurgitation ) RESHAPE II-HF (Randomized Study of the MitraClip Device in Heart Failure Patients With Clinically Significant Functional Mitral Regurgitation )
Take Home Message & future direction