Optimal Treatment of Functional MR Steven F Bolling Professor of Cardiac Surgery University of Michigan
Functional MR
Functional MR in Ischemia Badhwar, Bolling, chapter in: Advances in Heart Failure, 2004
FMR : Ventricular Problem!! Badhwar, Bolling, chapter in: Advances in Heart Failure, 2004
Optimal Medical Therapy of FMR 1.0 : survival is not optimal! 0.8 surv vival 0.6 0.4 0.2 0.0 MR grade No. None 9,405 Mild 2,062 Moderate 210 Severe 171 0 1 2 3 4 5 Years Hickey et al: Circulation 78:1-51, 1988
In fact, even with small amounts of FMR it s terrible!! ERO RVol Grigioni et al: Circulation 103:1759, 2001
In 2012, with the modern testing & treatment they still do very badly! Szymanski et al Am J Cardiol 2011 Sep 21.
MR - Prognostic value 1300 CHF / FMR Mean age 67, mean EF 32% NYHA I 150 (15%) II 500 (49%) III 316 (31%) IV 57 (6%) Mean fu 2.7y Severe MR 24% Mild or Moderate MR 49% No MR 27% Rossi et al Heart 2011; 97:1675-80
More MR is worse! Ischemic or Dilated Rossi A et al. Heart 2011;97:1675-1680 2011 by BMJ Publishing Group Ltd and British Cardiovascular Society
FMR Not just a late marker! FMR worsened odds ratio of death Rossi A et al. Heart 2011;97:1675-1680 2011 by BMJ Publishing Group Ltd and British Cardiovascular Society
CRT for FMR : Less than half eligible, of which less than half respond van Bommel R J et al. Circulation 2011;124:912-919 Residual MR is still BAD!! Copyright American Heart Association
Undersized Mitral Repair for FMR Nyah, Nyah! Surgeons can fix FMR!!
Mitral Repair for FMR in CHF Bolling Chen Bishay Calafiore Buffolo Bitran Dreyfus Suma ACORN JTCVS 1995 200 pts Circ 1998 81 pts Eur JCTS 2000 44 pts Ann TS 2000 49 pts Ar Br Card 2000 80 pts J Card Surg 2001 21 pts JHLT 2000 45 pts JTCVS 2001 44 pts JTCVS 2006 193 pts 30 day mortality 1-5 %
Undersized Mitral Repair Feasible Low mortality Relief of MR Better Quality of life
Mitral Repair and CHF : benefit? Yikes - No mortality benefit!
Mitral Repair and CHF : benefit? Why - No mortality benefit?
FMR : residual / recurrent MR Progression of 3 or 4+ MR post-undersized annuloplasty (585) McGee, Gillinov et al, JTCVS, 2004;128:916-24
MVR and CHF Even a good operation, when done badly will not help a sick patient! recurrent FMR is still bad
Do a Better Operation : Surgical Predictors of Recurrent MR Flexible = 5x recurrent MR! Use rigid complete! Spoor, Geltz, Bolling : Circulation, 11/06
Flexible and/or partial bands don t provide a durable solution for FMR Magne et al. Cardiology 2009;112:244-259259
Strongest predictor of recurrent MR AP dia > 3.7 cm Recurrent MR Failed Repair AP diameter reduction!!! Kongsaerepong V et al. Am J Cardiol 2006;98:504-8
IMR-FMR ring designs Disproportionate AP dimension reduction Bothe W, Swanson J, et al., JTCVS 2010
MV repair 30 day mort 1.6% 1.6% Freedom from >1+ MR = 90%!! JTCVS 2006
FMR Surgery LV reverse remodeling
Braun J, et al., Leiden Ann Thorac Surg 2008;85:430 437
FMR : Ventricular Problem!! LVEDD < 65 mm! Braun J, et al., Leiden Ann Thorac Surg 2008;85:430 437
CHF Mitral Repair - Kron
CHF Mitral Repair - Hvass J Thorac Cardiovasc Surg. 2010 Feb;139(2):418-23. The papillary muscle sling for ischemic mitral regurgitation.hvass U, Joudinaud T.
CorCap only
Randomized FMR trial JTCVS Fatouch 2009
FMR - survival
FMR exercise MR
Randomized CABG + MVr for mod IMR Mitral regurg volume - 69% vs 14% LV end systolic volumes - 24% vs 10% LV sphericity - 18% vs + 1.7 % Peak oxygen capacity + 3.0 vs 1.0 Brain natriuretic peptide - 76% vs 59% All p < 0.01! Mitral Valve Annuloplasty in Addition to Coronary Artery Bypass Grafting in Moderate Functional Ischemic Mitral Regurgitation Reverses Left Ventricular Remodelling and Restores Left Ventricular Geometry: Chan et al, CIRC March 2012
Functional MR - 2012 Rigid, complete, undersized ring: Overall 6.5 year survival 86% DeBonis et al Eur J of CVTS, April 18, 2012 134 prospective propensity matched pts CHF / severe MR Editorial : SF Bolling : Mitral repair for functional mitral regurgitation in idiopathic dilated cardiomyopathy : A good operation done well may help!
Mitral Repair and IMR Repair vs. Just Replace it!
100 High Risk 100 Medium Risk 80 80 60 60 40 20 I Worst 20%!! 0 0 1 2 3 4 5 6 7 0 0 1 2 3 4 5 6 7 40 20 II 100 Low Risk Survival 80 60 Replace Repair 40 20 0 0 III - V 1 2 3 4 5 6 7 Gillinov et al, JTCVS 2001;122:1125-41
Valve sparing replacement vs repair Survival for 4+ IMR Al Radi et al, Ann Thorac Surg, 2005;79:1260-7
Mt Sinai - High risk CABG/MVr
Severe Ischemic Mitral Regurgitation - repair vs replacement
Mitral Repair and IMR Good repair Replacement Bad repair
Catheter-Based Mitral Valve Repair MitraClip System
LV Volumes by MR Etiology Reduction in LV volumes, BUT CLIP LEAVES MR!! p<0.0001 Baseline 12 Months p=0.0005 160 153 130 160 160 143 Volume (ml) 120 80 p=0.0042 55 51 Volume (ml) 120 80 p=0.0829 82 75 40 40 0 LVEDV LVESV LVEDV LVESV Degen MR Subgroup n=88 0 FMR Device Subgroup n=30
Septal-Lateral Annular Dimension Baseline vs 12 Months, 3.9 3.8!! 6 End Systole End Diastole Dimension (cm) 5 4 3 2 p=0.6716 3.3 3.3 p=0.0163 3.9 3.8 1 0 Baseline 12 Months Baseline 12 Month n=111 n=111 p-value compares baseline to 12 month measurements within device Septal-Lateral Annular Dimension not collected in Control group due to the presence of annuloplasty ring or replacement valve
Re-Inventing a Failed Surgical technique? The Importance of Annuloplasty Annuloplasty No annuloplasty 260 pts Overall freedom reop 90% (68% without ring) Alfieri O, et al. JTCVS 2001;122:674-81
Mitraclip Functional MR Results high risk EF - 55 % 8% mort @ 30 d 25% mort @ 1 yr DMR / FMR No controls Not random Left 2-4+ MR!
50 pts > 3+ MR CRT failed - 21 Age 70; euroscore 34; LVEDD 70mm; LVEDV 252 ml; LVEF 19% Franzen et al Eur J Heart Fail 2011; 13:569-76
Mitral regurgitation at baseline, discharge and 6 months Almost half had significant Residual MR! Franzen O et al. Eur J Heart Fail 2011;13:569-576
Mitral Clip in FMR 17 % mortality! Franzen O et al. Eur J Heart Fail 2011;13:569-576
Franzen O et al. Eur J Heart Fail 2011;13:569-576 LV Remodeling??
Optimal treatment of FMR Find MR! Fix MR! OMT, CRT, Clip (COAPT)
Optimal treatment for FMR GOOD SURGERY! Careful patient selection Beware the big LV and the bad RV! Repair - use complete rigid ring Replacement - selective RCT!
FMR is still a HEADACHE!!