Whom to refer for mitral valve repair and whom not

Raphael Rosenhek

Department of CardiologyMedical University of Vienna

Mitral Regurgitation in Heart Failure

Whom to Refer to Valve Repair, and Whom Not

EuroHeart Failure 2015Sevilla, May 24th 2015

Mitral RegurgitationMechanism

• Organic mitral regurgitation

• Functional mitral regurgitation

• imbalance between tethering forces (annular dilatation, LV dilatation, papillary muscle displacement, LV sphericity)

• and closing forces (reduction of LV contractility, global LV dyssynchrony, papillary muscle dyssynchrony, altered mitral systolic annular contraction)

• Ischaemic mitral regurgitation– Acute ischaemic mitral regurgitation (papillary muscle rupture) (rare)

– True ischaemic MR (rare)

– Chronic ischaemic MR

Functional Mitral RegurgitationMechanism

Levine R. and Schwammenthal E. Circulation 2005;112:745-758

• The valve is structurally normal – MR is due to LV dysfunction

• Mitral regurgitation begets mitral regurgitation

Grigioni, F. et al. Circulation 2001;103:1759-1764

Ischaemic Mitral RegurgitationOutcome

Trichon, BH. et al. Am J Cardiol 2003;91:538-43

Functional Mitral RegurgitationSeverity of MR and Outcome

Adjusted survival in ischemic cardiomyopathies Adjusted survival in non-ischemic cardiomyopathies

Treatment of Patients with CardiomyopathiesEstablished Therapies

• Medical Therapy– Beta-blockers, ACE-inhibitors, Aldosterone antagonists

• Evaluate for Revascularization in pts with CAD

• CRT-Therapy

Symptomatic Improvement

Survival Benefit

Kanzaki, H. et al.J Am Coll Cardiol 2004;44:1619-25

Functional Mitral RegurgitationEffect of CRT on MR Severity

Breithardt, O. et al.J Am Coll Cardiol 2003;41:765-70

Castleberry AW et al. Circulation 2014 (online first)

Ischemic Mitral RegurgitationBenefit of Revascularization

Mitral valve annuloplasty

Medical therapy

Observational non randomized 4989 patients

Medical: older, more comorbidities

CABG: more ischemic burden

CABG + MVR: more MR and symptoms

Medical

CABG onlyPCI

CABG + MVR

Wu, AH. et al. J Am Coll Cardiol 2005;45:381-7

Functional Mitral RegurgitationSurvival: Mitral Annuloplasty vs Medical Therapy

Mitral valve annuloplasty

Medical therapy

University of Michigan

Retrospective

Pts with reduced LVF

126 pts undergoing mitral annuloplastyNo survival benefit

Mihajlevic, T et al. J Am Coll Cardiol 2007;49:2191-201

Ischemic Mitral RegurgitationSurvival: CABG ± Mitral Annuloplasty

390 pts with ischemic MRCABG vs. CABG + Annuloplasty

Mihajlevic, T et al. J Am Coll Cardiol 2007;49:2191-201

Ischemic Mitral RegurgitationSymptoms: CABG ± Mitral Annuloplasty

Acker M et al. N Engl J Med 2014;370:23-32

Ischemic Mitral RegurgitationMitral Repair vs Replacement

Mitral valve annuloplasty

Medical therapy

Randomized Trial

Acker M et al. N Engl J Med 2014;370:23-32

Ischemic Mitral RegurgitationMitral Repair vs Replacement

Mitral valve annuloplasty

Medical therapy

Dayan V et al. Ann Thor Surg 2014;97:758-766

Ischemic Mitral RegurgitationMetaanalysis - Mitral Repair vs Replacement

Mitral valve annuloplasty

Medical therapy

Operative Mortality

Global Survival

Dayan V et al. Ann Thor Surg 2014;97:758-766

Ischemic Mitral RegurgitationMitral Repair vs Replacement

Mitral valve annuloplasty

Medical therapy

Recurrence of Mitral Regurgitation

Reoperation

Lee A P et al. Circulation. 2009;119:2606-2614

Copyright © American Heart Association, Inc. All rights reserved.

Functional Mitral RegurgitationPredictors of Recurrence

Secondary MRUnfavorable Characteristics for Repair

Mitral valve deformation• Coaptation distance ≥1 cm• Tenting area >2.5–3 cm2

• Complex jets originating centrally and posteromedially• Postero-lateral angle >45° (high posterior leaflet tethering)Local LV remodelling• Interpapillary muscle distance >20 mm• Posterior papillary-fibrosa distance >40 mm• Lateral wall motion abnormalityGlobal LV remodelling• EDD >65 mm, ESD >51 mm (ESV >140 mL) (low likelihood of• reverse LV remodelling after repair and poor long-term outcome)• Systolic sphericity index >0.7

EACVI Guidelines. EHJCI 2013;14:611-44

http://dx.doi.org/10.1016/j.amjcard.2010.03.042

Functional Mitral RegurgitationPredictors of Recurrence

Ciarka A et al. Am J Cardiol 2010;106:395-401

Chan J et al. Circulation 2012;126:2502-2510

Moderate Functional Mitral RegurgitationRIME Trial: CABG ± Mitral Annuloplasty

Medical therapy

Randomized Trial73 pts with moderate ischemic MR

Treatment of Patients with CardiomyopathiesSummary

• Mitral regurgitation is a marker of poor prognosis

• But the problem is the ventricle!!!

• Role for Medical Therapy (symptoms, survival)

• Role for CRT (symptoms, survival, MR)

• Surgery– Feasible?

– Surgical risk?

– Durability / Recurrence of MR?

– Long-term outcome (Symptoms, LV function, mortality)?

Clinical Situation Indication for MV Surgery

Indications for Surgery in Ischaemic MRESC Recommendations

• Patients with severe IMR• Ruptured papillary muscle due to acute MI

• LV EF ≥30% undergoing CABG

• LV EF <30% and option for CABG

• LV EF ≥30% no option for CABG

• Patients with moderate IMR• Undergoing CABG

• No option for CABG or undergoing PCI

• Patients with trace IMR• Undergoing CABG

ImmediateRecommended (IC)Reasonable if sympt (IIaC) (viability)Consider if sympt + low morb (IIbC)

Reasonable if repair feasible (IIaC)Uncertain

Not recommended

“The percutaneous mitral clip procedure may be considered in patients with symptomatic severe secondary MR despite optimal medical therapy (including CRT if indicated), who fulfill the echo criteria of eligibility, are judged inoperable or at high surgical risk by a team of cardiologists and cardiac surgeons, and who have a life expectancy greater than 1 year (IIbC)”

“Percutaneous edge-to-edge procedure may be considered in patients with symptomatic severe primary MR who fulfill the echo criteria of eligibility, are judged inoperable or at high surgical risk by a‘heart team’, and have a life expectancy greater than 1 year (IIbC)”

Indication in primary MR

Indication in secondary MR

ESC/EACTS Guidelines Valvular Heart Disease Edge-to-Edge Repair

Vahanian A et al. Eur Heart J 2012

• The choice of treatment in ischemic MR is controversial. Surgery can improve symptoms and quality of life, and reverse LV remodelling. No clear prognostic benefit in comparison to optimal medical therapy demonstrated

• Undersized annuloplasty might offer a durable result if performed before the onset of severe LV dilatation and in the absence of echocardiographic predictors of postoperative residual or recurrent MR. Pts with moderate ischemic MR should undergo MV surgery at the time of CABG surgery

• Otherwise, mitral valve replacement with preservation of the subvalvular apparatus may be considered

• Transcatheter edge to edge repair is a lower risk option for high-risk patients to reduce symptoms and induce reverse LV remodelling but is commonly associated with residual and recurrent MR

• Randomized studies are needed to clarify whether correction of MR in high risk patients provides clinical and prognostic benefit in comparison with optimal medical therapy

Summary*Surgery in Functional Mitral Regurgitation

*Adapted from position paper ESC WGs Cardiac Surgery and VHD