/19/17 Secondary Mitral Regurgitation: When Should We Intervene? Robert O. Bonow, MD, MS, MACC Northwestern University Feinberg School of Medicine Bluhm Cardiovascular Institute Northwestern Memorial Hospital Editor-in-Chief JAMA Cardiology No Relationships to Disclose Stages of Secondary MR Stage A Definition Risk of valve disease Post MI, HF, DCM, AF B C D Mild - moderate asymptomatic disease Severe valve disease but asymptomatic C1: Normal LV function C: Depressed LV function Severe, symptomatic valve disease 1
/19/17 Mitral regurgitation Primary MR: primary valve disease Secondary MR: primary myocardial disease Mitral regurgitation Primary MR: primary valve disease Secondary MR: primary myocardial disease Diagnostic dilemmas Therapeutic dilemmas
Survival (percent) /19/17 Imprecision in grading severity of secondary MR What is severe secondary MR? 1 Survival After MI 8 6 4 p<.1 MI without MR ERO 1-19 ERO 61% 47% 9% 1 1 3 4 5 3 6 7 8 4 5 Time (years) Grigioni et al. Circulation 1;13:1759-1764 3
Hospital-Free Survival (%) /19/17 1 8 Ischemic or Nonischemic Cardiomyopathy 6 4 No FMR Mild-Mod FMR 51% ERO > p<.1 4% Severe FMR 11% 1 1 3 4 5 3 6 7 4 8 5 6 7 Time (years) Rossi et al. Heart 11;97:1675-168 Mitral regurgitation What is severe MR? RV (ml) ERO (cm ) Primary (degenerative) MR >6 >.4 Secondary (functional) MR >3 >. Does this help? 4
Mortality (percent) Hospital-Free Survival (%) /19/17 1 8 Ischemic or Nonischemic Cardiomyopathy EF 34% LVSD 51 mm 6 4 p<.1 No FMR EF 33% LVSD 53 mm Mild-Mod FMR EF 9% LVSD 57 mm Severe FMR 1 1 3 4 5 3 6 7 4 8 5 Time (years) 6 7 Rossi et al. Heart 11;97:1675-168 51% 4% 11% 8 6 4 p<.1 p<.1 Ischemic Cardiomyopathy EF 5% ESVI 9 ml/m EF 7% ESVI 8 ml/m EF 3% ESVI 73 ml/m Mod-Severe MR Mild MR No MR Functional MR: a marker of a sicker LV 1 3 4 5 6 1 3 4 5 6 7 8 Time (years) Deja et al. Circulation 1;15:639-648 Deja et al. Circulation 1 5
/19/17 Prevalence of MR in Patients with LV Dysfunction N Prevalence MR Yiu et al Circulation 18 63% Grigioni et al Circulation 1 33 64% Koelling et al Am Heart J 1436 49% Trichon et al Am J Cardiol 3 57 56% Robbins et al Am J Cardiol 3 1 59% Cleland et al N Engl J Med 4 65 5% Grayburn et al J Am Coll Cardiol 5 336 77% Bursi et al Circulation 5 33 5% Acker et al J Thorac CV Surg 6 3 66% Di Mauro et al Ann Thorac Surg 6 39 75% Rossi et al Heart 11 13 74% Deja et al Circulation 1 599 63% Onishi et al Circ Heart Fail 13 77 48% * Patients with moderate to severe MR * * * Secondary mitral regurgitation: a marker of a sicker LV - or - a contributor to a sicker LV? 6
ERO (cm ) /19/17 Secondary mitral regurgitation: a marker of a sicker LV - or - a therapeutic target? Therapies that produce beneficial reverse remodeling also reduce severity of functional MR β-blockade therapy in chronic heart failure: Diastolic function and mitral regurgitation improvement by carvedilol Soccorso Capomolla, MD, Oreste Febo, MD, Marco Gnemmi, md, Giorgio Riccardi, MD, Cristina Opasich, MD, Angelo Caporotondi, MD, Andrea Mortara, MD, GianDomenico Pinna, BME, and Franco Cobelli, MD, Pavia, Italy Am Heart J ;139:596-68 9.88 7.66 5.44 3. 1 ERO p<.1 Baseline 6 Months Carvedilol Baseline 6 Months Control Capomolla et al. Am Heart J ;139:596-68 7
Vena Contracta Width (cm) EROA (cm ) Tenting Area (cm ) LA Volunme (cm 3 ) Jet Area / LA Area (%) PA Systolic Pressure (mmhg) /19/17 Vena Contracta Vena Contracta Width Width EROA Tenting Area LA Volume Jet Area / LA Area EROA Tenting Area LA Volume Jet Area/LA Area PA Systolic PA Systolic Pressure Pressure 1.1 p<.1 p<.1 p<.1 p<.1 p<.1 p<.1.88 11 151 88 6 8.8 6.8.8 6 6.6.5.44.4.6 5.4.6 75.4 44 3 4... Baseline 6 Months Baseline 6 Months Baseline 6 Months Baseline 6 Months Baseline 6 Months Baseline 66 Months van Bommel et al. Circulation J 11;14:91-919 Secondary mitral regurgitation Guideline-directed medical therapy for heart failure, including CRT Indications for mitral valve surgery: Patients with severe MR undergoing CABG or AVR Severe MR, persistent symptoms despite optimal medical therapy, including CRT Patients with moderate MR undergoing CABG or AVR class I class IIa class IIb class IIb 8
/19/17 Baseline Optimized Medical Therapy and Biventricular Pacing 9
/19/17 Secondary mitral regurgitation Indications for transcatheter MV repair for severe secondary MR: Severe secondary MR Severely symptomatic Prohibited or high surgical risk Reasonable life expectancy class IIb Prevalence of MR in Patients with LV Dysfunction N Prevalence MR Yiu et al Circulation 18 63% Grigioni et al Circulation 1 33 64% Koelling et al Am Heart J 1436 49% Trichon et al Am J Cardiol 3 57 56% Robbins et al Am J Cardiol 3 1 59% Cleland et al N Engl J Med 4 65 5% Grayburn et al J Am Coll Cardiol 5 336 77% Bursi et al Circulation 5 33 5% Acker et al J Thorac CV Surg 6 3 66% Di Mauro et al Ann Thorac Surg 6 39 75% Rossi et al Heart 11 13 74% Deja et al Circulation 1 599 63% Onishi et al Circ Heart Fail 13 77 48% * Patients with moderate to severe MR * * * 1
Prevalence (percent) Prevalence (percent) /19/17 Prevalence of Heart Failure United States 16 Medicare 14 data 14 1 1 Average hospital mortality: 8.8% 1 8 Low volume centers: 13.% 6 High volume centers: 6.% 4 Men Women Data from national Medicare database 1994-1999 -34 35-44 45-54 55-64 65-79 8 86 87 88 9 684 hospitals Age Group (years) 14,488 AVRs Source: NHANES, CDC, and American Heart Association 1 Medicare data 1 Average hospital mortality: 8.8% 8 6 Low volume centers: 13.% 4 High volume centers: 6.% Prevalence of Atrial Fibrillation The ATRIA Study Men Women n=17,974 5-59 Data from national Medicare database 1994-1999 6-64 65-69 7-74 75-79 8-84 85 86 87 88 9 684 hospitals Age Group (years) 14,488 AVRs Go et al, JAMA 1;85:37-375 11
Percent with Valve Disease /19/17 Prevalence of Mitral Valve Disease 1 Medicare 9 data 8 Average 7 hospital mortality: 8.8% 6 5 Low volume centers: 13.% 4.9 3 High volume centers: 6.% 1 Olmstead County (n=16,51) CARDIA, ARIC, CHS (n=11,911) 8,41 subjects 6.4 Data from national Medicare database 1994-1999 <45 45-54 55-64 65-74 75 87 88 9 684 hospitals Age Group (years) 14,488 AVRs 7.3 9.6 Nkomo et al, Lancet 6;368:15-111 1