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Mitral Regurgitation: Updates and MitraClip©
Ailin Barseghian El-Farra, MD |November 3, 2018
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Disclosures
None
Cardiology | November 3, 2018
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MITRAL REGURGITATION GUIDELINES
Cardiology | November 3, 2018
Zoghbi WA, et al. J Am Soc Echocardiogr 2017;30(4):303-371.
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ANATOMY OF THE MITRAL VALVE
Cardiology | November 3, 2018
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.
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PRIMARY vs SECONDARY MITRAL REGURGITATION
Cardiology | November 3, 2018
Zoghbi WA, et al. J Am Soc Echocardiogr 2017;30(4):303-371.
6 Cardiology | November 3, 2018
Nyman CB, et al. J Am Soc Echocardiogr, 2018;31(4):434-53.
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PROLAPSED LEAFLET
Cardiology | November 3, 2018
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FLAIL LEAFLET
Cardiology | November 3, 2018
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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.
Cardiology | November 3, 2018
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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
Cardiology | November 3, 2018
Rogers JH, et al. European Heart Journal 2011;32:2350-2357.
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CASE
Cardiology | November 3, 2018
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CASE
Cardiology | November 3, 2018
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CASE
Cardiology | November 3, 2018
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CASE
Cardiology | November 3, 2018
15 Cardiology | November 3, 2018
CASE
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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
Cardiology | November 3, 2018
17 Cardiology | November 3, 2018
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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.
Cardiology | November 3, 2018
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)
Cardiology | November 3, 2018
Barseghian, et al. J Thorac and Cardiovasc Surg, 2012;143(2):503-4.
CASE
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Robot-Assisted Surgical Correction of Dual Mitral Valve Clefts
Cardiology | November 3, 2018
Barseghian, et al. J Thorac and Cardiovasc Surg, 2012;143(2):503-4.
POSTERIOR MITRAL VALVE CLEFT
CASE: POST-OPERATIVE TEE
Cardiology | November 3, 2018
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SECONDARY or “FUNCTIONAL” MITRAL REGURGITATION
Cardiology | November 3, 2018
Capoulade R, et al. J Thorac Dis 2017;9(Suppl 7):S640-S660.
MITRAL REGURGITATION SEVERITY
Cardiology | November 3, 2018
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MITRAL REGURGITATION SEVERITY
Cardiology | November 3, 2018
Zoghbi WA, et al. J Am Soc Echocardiogr 2017;30(4):303-371.
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MITRAL REGURGITATION GRADING ALGORHYTHM
Cardiology | November 3, 2018
www.asecho.org/vrcases Zoghbi WA, et al. J Am Soc Echocardiogr 2017;30(4):303-371.
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QUALITATIVE PARAMETERS
Cardiology | November 3, 2018
Zoghbi WA, et al. J Am Soc Echocardiogr 2017;30(4):303-371.
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SEMIQUANTITATIVE
Cardiology | November 3, 2018
Ender J, et al. Ann Cardiothorac Surg 2013;2(6):796-802.
28 Cardiology | November 3, 2018
Quantification of Regurgitation by EROA, 2D PISA
Zoghbi WA, et al. J Am Soc Echocardiogr 2017;30(4):303-371.
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MITRAL REGURGITATION QUANTIFICATION
Cardiology | November 3, 2018
30 Cardiology | November 3, 2018
31 Cardiology | November 3, 2018
Zoghbi, et al. JASE, Apr 2017
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Mitral Regurgitation Continuous Wave (CW) Doppler
Cardiology | November 3, 2018
33 Cardiology | November 3, 2018
34 Cardiology | November 3, 2018
35 Cardiology | November 3, 2018
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Mitral Regurgitation Assessment: ASE Guidelines Principles
1. Measure every component of mitral regurgitation
2. Quantify mitral regurgitation 3. Severe and moderate mitral regurgitation
-> important
Cardiology | November 3, 2018
37 Cardiology | November 3, 2018
MITRAL REGURGITATION MANAGEMENT WITH TRANSCATHETER EDGE-TO-EDGE CLIP
Cardiology | November 3, 2018
AKA: MITRACLIP©
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MITRACLIP DEVICE
MitraClip device (Abbot Vascular Structural Heart, Menlo Park, CA, USA) Image Adapted from UW Medicine
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Mitral Regurgitation – Decision Pathway
Cardiology | November 3, 2018
JACC 2017
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ROLE of ECHO IMAGING BEFORE TRANSCATHETER MV PROCEDURES
Cardiology | November 3, 2018
MacKensen, et al. JASE April 2018
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TTE in Mitral Valve Assessment
Cardiology | November 3, 2018
Nyman CB, et al. JASE, 2018;31 (4):434-53.
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TEE
Cardiology | November 3, 2018
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.
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3D “SURGICAL VIEW”
Cardiology | November 3, 2018
Delgado V, et al. Eur Heart J Suppl 2010;12:E10-E23
45 Cardiology | November 3, 2018
Rogers JH, et al. European Heart Journal 2011;32:2350-2357.
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EDGE-TO-EDGE MITRACLIP THERAPY
Cardiology | November 3, 2018
MitraClip can be used to approximate leaflets at different locations along the leaflet coaptation surface.
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ALFIERI STICH
Cardiology | November 3, 2018
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
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MitraClip
Cardiology | November 3, 2018
Delgado V, et al. Eur Heart J Suppl 2010;12:E10-E23.
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Intra-atrial septum variations
Cardiology | November 3, 2018
Atrial Septal Aneurysm
Lipomatous Hypertrophy
Tugue, et al. JASE 2007
50 Cardiology | November 3, 2018
JASE 2018:31;434
ROLE OF ECHO in ASSESSING INTRA-ATRIAL SEPTUM
51 Cardiology | November 3, 2018
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TRANSEPTAL PUNCTURE
Cardiology | November 3, 2018 Adapted from UW Medicine
53 Cardiology | November 3, 2018
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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.
Cardiology | November 3, 2018
THANK YOU
Cardiology | November 3, 2018