Club 35 - The best in heart valve disease - Functional Mitral Regurgitation Steven Droogmans, MD, PhD UZ Brussel, Jette, Belgium 08-12-2011 Euroecho & other Imaging Modalities 2011 No conflicts of interest
Functional Mitral Regurgitation Definition Anatomy & mechanisms Echocardiographic assessment Prognostic implications Treatment options Summary: the role of echo
Definition Secondary MR < LV-disease: global dilated cardiomyopathy of any cause regional LV-dysfunction ( ischemic MR ) Distortion of LV geometry and function: imbalance tethering and closing forces Normal mitral valve apparatus Frequent: 50% post AMI or dilated CMP
Prognostic implications Grigioni F et al. Circulation 2001;103:1759-1764
Anatomy & mechanisms Reduced closing forces Increased tethering forces decreased LV-function change annular contraction synchronicity PM LV dyssynchrony Apical displacement PM Annular dilatation Ischemic MR: regional WMA - eccentric jet Global LV dilatation: central jet
Anatomy & mechanisms Functional Ischemic MR
Functional Ischemic MR WM abnormalities and PM displacement: asymmetric MR
Global LV dilatation Altered geometry sphericity annular dilatation structural normal leaflets
Echocardiographic assessment Mitral valve morphology success of repair Severity of MR - prognostic implications LV morphology and function: LV volume, EF Dyssynchrony WMA scar? Viability (dobu) Dynamic changes of MR Prognosis and management of functional MR
Echocardiographic assessment
Mitral Valve Watanabee JACC 2006 Grewal Circulation 2010 Mor-Avi Circulation 2009 Maruo, Abstract ESC 2011
Mitral valve and LV parameters
LV geometry and function
Mitral valve closing force Piérard L A, Carabello B A Eur Heart J 2010;31:2996-3005
Unfavourable parameters of MV repair
Severity of MR Semi-quantitative Colour flow mapping Vena contracta width Limitations Technical factors (Gain settings, PRF) Eccentric jets Loading conditions Left atrial size Limitations Lateral resolution Phasic changes Multiple jets Non-circular orifice
Severity of MR Semi-quantitative Colour flow mapping Vena contracta width Usefull for diagnosis indirect estimation of severity Two orthogonal planes VC < 0.3 cm: mild MR VC 0.7 cm: severe MR
Severity of MR: PISA Severe functional MR: EROA 20 mm 2 or a R Vol 30 ml
Severity of MR: pitfalls Non-circular orifices Phasic change of MR during cardiac cycle
Severity of MR: additional parameters Pulsed Doppler CW Doppler MI/AO TVI Pulm. vein
Integrating indices of severity Severe functional MR: EROA 20 mm 2 or a R Vol 30 ml
Dynamic aspect of MR Severity of functional MR at rest does not predict does not reflect severity during exercise Unmask significant MR when rest MR is mildmoderate: 1. Exertional dyspnoea out of proportion MR and LV-function at rest 2. Pulmonary oedema without a cause 3. CABG planned for patients with moderate MR Prognostic relevance
Dynamic aspect of MR Picano, E. et al. J Am Coll Cardiol 2009;54:2251-2260
Exercise-induced dynamic MR ischemic MR Lancellotti et al. Eur Heart J 2005
LV viability: biphasic response
Treatment of functional MR Medical therapy Revascularisation ± Mitral valve surgery Cardiac resynchronisation therapy (CRT) Percutaneous treatment
Medical therapy Medical therapy for heart failure if indicated ACE-inhibitor beta-blocker aldactone Reduction of morbidity/mortality Diuretics symptom reduction
Surgical treatment Mitral valve annuloplasty preferably: probably better outcome preservation mitral (sub) valvular apparatus - maintaining LV geometry preservation LV systolic function reduction LV volume But, high frequency of MVP-failure reported in some series. 28% moderate MR at 6 months and stable thereafter
Surgical treatment Limited study data and controversy about long-term prognosis
Surgical treatment Limited study data and controversy about long-term prognosis????
CABG ± MVP in moderate MR CABG + MVP Better outcome on LV geometry function NYHA No survival benefit after 32 month follow-up (underpowered) Fattouch, JTSC 2009
CABG ± MVP in moderate MR CABG CABG + MVP 35% of patients evolved towards moderate to severe MR Better outcome on LV geometry function NYHA MR improved in all patients No survival benefit after 32 month follow-up (underpowered) Fattouch, JTSC 2009
Predictors of improvement of unrepaired moderate ischemic MR after CABG MR Improvement ( ) and failure ( ) group: 5 dysfunctional viable segments PPM dyssynchrony < 60 ms Penicka M et al. Circulation 2009;120:1474-1481
Preoperative left ventricular dimensions predict reverse remodelling following restrictive mitral annuloplasty in ischemic mitral regurgitation Braun, EJTS 2007
Acute reduction of MR by CRT Kanzaki, JACC 2004
Chronic reduction of MR in DCMP by CRT Matsumoto, AJC 2011
Chronic reduction of MR in DCMP by CRT Chronic Acute effect Matsumoto, AJC 2011
CRT as alternative for moderate to severe MR in inoperable HF? van Bommel R J et al. Circulation 2011;124:912-919
CRT as alternative for moderate to severe MR in inoperable HF? van Bommel R J et al. Circulation 2011;124:912-919
MitraClip
MitraClip
Conclusion: Central role of echocardiography Severity of MR and anatomy mitral valve Risk stratification: EROA > 20 mm 2 in rest Dynamic component EROA > 13 mm 2 increase LV remodelling: LVEDD > 65 mm Success of surgical repair Management: Mitral valve annuloplasty CRT Mitraclip