Mitral Regurgitation: Updates and MitraClip - Mitral Regurgitation...30% of patient with CHF and up...

Mitral Regurgitation: Updates and MitraClip©

Ailin Barseghian El-Farra, MD |November 3, 2018

Disclosures

Cardiology | November 3, 2018

MITRAL REGURGITATION GUIDELINES

Zoghbi WA, et al. J Am Soc Echocardiogr 2017;30(4):303-371.

ANATOMY OF THE MITRAL VALVE

Zoghbi WA, et al. J Am Soc Echocardiogr, 2018;30(4):303-371.

Nyman CB, et al. J Am Soc Echocardiogr 2018;31:434-53.

PRIMARY vs SECONDARY MITRAL REGURGITATION

6 Cardiology | November 3, 2018

Nyman CB, et al. J Am Soc Echocardiogr, 2018;31(4):434-53.

PROLAPSED LEAFLET

FLAIL LEAFLET

BACKGROUND

• Mitral regurgitation is one of the most common valve lesions

• The most common type of mitral regurgitation is primary mitral regurgitation due to myxomatous degeneration, causing leaflet prolapse or flail of the middle scallop of the posterior leaflet.

CLINICAL RELEVANCE • Moderate MR is present in 6.4% of

population ≥ 65 yo

• Moderate to Severe MR is present in 15-30% of patient with CHF and up to 12% of patients within 1 month of myocardial infarction (MI)

• Even asymptomatic patients with severe MR have higher 5 year rates of death, HF and atrial fibrillation

Rogers JH, et al. European Heart Journal 2011;32:2350-2357.

OPERATIVE REPORT Findings:

• Severe bileaflet myxomatous mitral valve changes. Ruptured primary chord of medial aspect of P1 causing prolapse but also prolapsing P2 segment of posterior leaflet of mitral valve

Operation:

• Minimally invasive mitral valve repair via right thoracotomy approach

• P2 triangular resection

• 34mm Medtronic Future Band annuloplasty Ring

Pathology of Mitral Valve P2 tissue:

• Valvular tissue with myxoid degeneration

MITRAL VALVE CLEFT

• A 16 year old female with a history of ostium primum atrial septal defect (ASD) and cleft anterior mitral valve repair at 14 months of age was being followed with echocardiography for residual postoperative mitral regurgitation.

• Over the past year, she developed cough and decreased exercise tolerance.

• Auscultation revealed a high frequency, holosystolic murmur with II/VI intensity harshest at the apex.

Intra-operative transesophageal echocardiogram confirmed the centrally directed severe mitral regurgitation jet.

Real-time 3D transesophageal echocardiogram demonstrated a large cleft in the anterior mitral leaflet (another cleft of the posterior leaflet)

Barseghian, et al. J Thorac and Cardiovasc Surg, 2012;143(2):503-4.

Robot-Assisted Surgical Correction of Dual Mitral Valve Clefts

Barseghian, et al. J Thorac and Cardiovasc Surg, 2012;143(2):503-4.

POSTERIOR MITRAL VALVE CLEFT

CASE: POST-OPERATIVE TEE

SECONDARY or “FUNCTIONAL” MITRAL REGURGITATION

Capoulade R, et al. J Thorac Dis 2017;9(Suppl 7):S640-S660.

MITRAL REGURGITATION SEVERITY

MITRAL REGURGITATION GRADING ALGORHYTHM

www.asecho.org/vrcases Zoghbi WA, et al. J Am Soc Echocardiogr 2017;30(4):303-371.

QUALITATIVE PARAMETERS

SEMIQUANTITATIVE

Ender J, et al. Ann Cardiothorac Surg 2013;2(6):796-802.

Quantification of Regurgitation by EROA, 2D PISA

MITRAL REGURGITATION QUANTIFICATION

Zoghbi, et al. JASE, Apr 2017

Mitral Regurgitation Continuous Wave (CW) Doppler

Mitral Regurgitation Assessment: ASE Guidelines Principles

1. Measure every component of mitral regurgitation

2. Quantify mitral regurgitation 3. Severe and moderate mitral regurgitation

-> important

MITRAL REGURGITATION MANAGEMENT WITH TRANSCATHETER EDGE-TO-EDGE CLIP

AKA: MITRACLIP©

MITRACLIP DEVICE

MitraClip device (Abbot Vascular Structural Heart, Menlo Park, CA, USA) Image Adapted from UW Medicine

Mitral Regurgitation – Decision Pathway

JACC 2017

ROLE of ECHO IMAGING BEFORE TRANSCATHETER MV PROCEDURES

MacKensen, et al. JASE April 2018

TTE in Mitral Valve Assessment

Nyman CB, et al. JASE, 2018;31 (4):434-53.

Transgastric 2 Chamber Basal Short Axis

Midesophageal 4 Chamber Mitral Commissural

2 Chamber Long Axis

Ender J, et al. Ann Cardiothorac Surg 2013;2(6): 796-802.

3D “SURGICAL VIEW”

Delgado V, et al. Eur Heart J Suppl 2010;12:E10-E23

Rogers JH, et al. European Heart Journal 2011;32:2350-2357.

EDGE-TO-EDGE MITRACLIP THERAPY

MitraClip can be used to approximate leaflets at different locations along the leaflet coaptation surface.

ALFIERI STICH

Alfieri O. (2015) The Genesis of the Edge-to-Edge Technique. In: Alfieri O., De Bonis M., La Canna G. (eds) Edge-to-Edge Mitral Repair. Springer, Cham

MitraClip

Delgado V, et al. Eur Heart J Suppl 2010;12:E10-E23.

Intra-atrial septum variations

Atrial Septal Aneurysm

Lipomatous Hypertrophy

Tugue, et al. JASE 2007

JASE 2018:31;434

ROLE OF ECHO in ASSESSING INTRA-ATRIAL SEPTUM

TRANSEPTAL PUNCTURE

Cardiology | November 3, 2018 Adapted from UW Medicine

SUMMARY

• Echocardiography is key to determining mitral valve pathology

• Echocardiography is invaluable for MitraClip procedural guidance, confirming success, and exclusion of complications.

• Interventional echocardiography will increase with the development of new devices.

THANK YOU

Mitral Regurgitation: Updates and MitraClip - Mitral Regurgitation...30% of patient with CHF and up...

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