What Degree of MR Deserves

Surgical or Transcatheter Intervention,

and How Should It Be Assessed?

Robert J. Siegel, M.D., FACC

Nov. 14-15, 2017, Beverly Hills

Director, Cardiac Non-Invasive Laboratory

Cedars-Sinai Medical Center, Los Angeles

Professor of Medicine, UCLA & Cedars-Sinai

Robert Siegel, M.D.

As a faculty member for this program, I disclose the following relationships

with industry:

(GRS): Grant/Research Support (C): Consultant (SB): Speaker’s Bureau

(MSH): Major Stock Holder (AB): Advisory Board (E): Employment

(O):Other Financial or Material Support

Name of company: Philips Ultrasound;

Nature of Relationship: Speaker’s Bureau

What Degree of MR Deserves Surgical or Transcatheter Intervention,

and How Should It Be Assessed?

Mechanism of MR – Degenerative v. Functional

• Important for grading MR severity

• Important Management –

Surgical, Catheter Intervention, or Medical

Functional v. Degenerative MR FMR:

Structurally normal MV but LV dysfunction

and dilation leads to MR

DMR:

A diseased MV causes severe MR

which leads to LV dysfunction

Severe Functional MR JACC 2015 MVARC & ACC/AHA*

Qualitative

MV Morphology Leaflet tenting, restriction, ↓coaption

Color jet Large, aliasing, deep into LA

Flow convergence zone Large

CW signal Dense; Holosystolic; Low velocity

Semiquantitative

Vena contracta (mm) ≥7mm

Pulm vein flow reversal Present +

Mitral Inflow E –wave dominant

Quantitative*

EROA (cm2) (PISA) ≥0.4* (0.4 specific, 0.2 more sensitive)

Regurgitant Vol (ml) (PISA) ≥30

LV dysfunction / LV dilation (as present not helpful in grading) Patients with any secondary MR have a worse prognosis –

MV repair may improve symptoms but not yet shown to ↑ survival

FMR very dependent on SBP and LV volume

2009 → went for a Mitraclip

55 y.o. woman

Functional MR

LVEF 27%

↑↑ LVESD 53mm

DOE: NYHA Class III

on ACE-I / Beta-blockers

F/U Echo in 2017-

8 yrs post MitraClip

Asymptomatic – very active

Minimal MR

LVEF pre Mitraclip- 27%

LVEF 8 yrs postclip- 57%

LV size normalized

Severe Functional Mitral Regurgitation

Surgery : If LVEF <55%- Post-op LV dysfunction 38%, no survival benefit, ↑↑failure MV repair failure(CAD) Matsumura 2004, Acker 2014

MitraClip: Several studies show good results

↓ MR, ↑ Cardiac output, ↓filling pr, ↑NYHA Class

• Procedural mortality ≈ 0%; no data on ↑ing survival

• Post-clip LV dysfunction/low C.O rare (> 60,000 pts)

• ↑ 6MWT, ↓BNP & ↑QOL

• ↓ LV size, ↑LVEF D’Ascenzo 2015 , Pighi 2016,Scotti 2017, Van De Heyning 2016

Schimdt 2017,Plegers 2013;Auricchio 2011; Franzen 2011, Siegel, Biner, Kar 2011;2012 Mendirichaga 2016

COAPT TRIAL: Clinical Evaluation of the Safety and Effectiveness of the MitraClip® System

for the Treatment of Functional Mitral Regurgitation in Symptomatic Heart Failure Subjects

Severe Degenerative MR – JACC MVARC 2015 ≈ ACC/AHA 2014

Color jet Significant penetration; holosystolic

Flow convergence zone Large; holosystolic MR

CW signal Dense; holosystolic MR

Semiquantitative

Vena contracta (mm) ≥7mm

Pulm vein flow reversal Present +

Mitral inflow E –wave dominant > 1.2 - 1.5cm/s

TVI mitral/TVI aortic >1.4

Quantitative:

Regurgitant vol (ml) (PISA) ≥60

EROA (cm2) (PISA) ≥0.4

LA / LV size* Enlarged

Qualitative

MV Morphology Flail, pap rupt, retraction, perforation

Severe MR very unlikely if LV and LA size are normal

Beware of “color flowitis”

MR Quantification

• “PISA strongly recommended but inherent

limitations”(MVARC) (reproducibility poor Biner/Siegel JACC 2010)

• Each echo parameter has limitations & lack of

precision→ use integrated approach

• Quantitation better than qualitative assessment

but may lead to false sense of accuracy

• NO ECHO GOLD STANDARD for MR severity

How does echo integrated approach compare

with a reference standard - MRI?

r=12mm

Uretsky et al. JACC 2015

• If severe MR on echo - only 22% severe on MRI

• In 34% severe MR on echo – MR was mild by MRI

-MRI - Severe MR strongly correlated with

post-op LV remodeling (r = 0.85; p < 0.0001)

-Echo - No correlation with post-op LV remodeling

& “Severe MR” (r = 0.32; p = 0.1) “Integrated approach”

Only 36% concordance!

ROC analysis area under curve - LV EDD was predictive for concordance - MR severity by TTE & MRI

LV EDD cut-off of 5.5 cm:

Very good sensitivity & specificity for TTE & MRI concordance

Must integrate LV size into MR assessment!

Chronic severe volume overload → LV dilation

If still uncertain of MR severity consider getting an MRI

Rafique & Siegel JACC 2015

AUC 0.86 (95% CI 0.75-0.98

p <0.001)

Y.M. 76y, asymptomatic M. Echo 05/10/06 – flail posterior MV leaflet

Prior guidelines equated flail mitral leaflet & severe MR

But still need an integrated approach – this not severe

MV inflow: E/A Reversal; Normal LV size, PASP 11 yrs later Normal LV size, EF, PASP,Exercise Capacity

Degenerative MR

A diseased MV with severe MR

→ Has adverse consequences

→ LV volume overload

→ LA dilation & increased LAP

When to intervene:

• Progressive LV Dilation → ≥ 40mm LVID (s)

• Decline in LVEF towards ≤ 60%

• Increase in PASP to ≥ 50 mmHg

• Symptoms – even “mild” symptoms (DOE)

Stress Echo in MR to Assess:

• Symptomatic status

• Functional capacity

• Heart rate recovery

• Contractile reserve

• Exercise induced pulmonary hypertension

• Worsening of MR

All have been shown to be prognostic and facilitate

timing surgery

What Degree of MR Deserves Surgical

or Transcatheter Intervention • Know your patient

Are they symptomatic, are they going to be compliant

with regular f/u echos and visits

• Know your surgeon

What is their repair rate? What are their morbidity

and mortality rates?

• Know your practice and yourself

Are you able to follow your patients?

Can you do step care? Do your patients “fly-in”?

Thank you

Adjunctive testing

• Serial Echo Doppler studies

• TEE if MR jet is eccentric

• BNP

• Strain

• MRI

• Stress echo

Management of patients with MR is based

not only on MR severity but on -

Consequences:

• - Clinical findings

• - LV function

• - LV size

• - PA pressure

Thanks!

William Osler

• DMR & FMR are different entities

• Guidelines- “Integrate findings” but no data on how to

weight a parameter

• Using integrated method in DMR, to diagnose chronic

severe MR, LV needs to be dilated

Optimal assessment of MR requires incorporating

symptoms, LV size & function- to assess impact of MR

volume overload on the LV and on the patient

Take home

messages

Caveats to Be Considered in Echo

Doppler evalautaion of MR

• 60% LA (severe) DCM Large central jets may be

present in patients with DCM and only mild MR

• Late systolic MR (MVP) ERO >0.4 cm2

Overestimation of the severity of MR by PISA with

late systolic jets

• Cannot have severe chronic MR with normal LV size

Is 3D Echo the Answer for MR Grading?

• Direct 3D planimetry of MV ROA

• 3D VC

• 3D PISA

These 3D methods reported to be more

accurate than 2D

However ….

TTE

*

Importance of “MR

severity”-

is the effect of MR on

patient & heart.

Chronic Severe MR

Results in LV dilation

(volume overload)

Grading of MR Severity

3D Echo is New

• Limited temporal/spatial resolution

• EROA variation during systole

• Artifacts

• Technical difficulties

• No gold standard for 3D MR validation

• To date - no validated guidelines or reference

standards on 3D quantification

POTENTIAL LIMITATIONS

MitraClip vs

Optimal Medical Therapy

(OMT) for FMR Giannini, AJC 2016 ( N=120) Overall survival

Survival free from CVD

Survival free from

rehospitalization

Months f/u

Months f/u

Months f/u

CLIP

OMT

LVEF 34%; NYHA Class 3-4;

60 vs 60 age matched

MC vs OMT(BiV) (f/u 515 days)

MitraClip vs OMT > overall survival (p=0.007)

> CV survival (p=0.002)

Survival 1 & 3 yrs MC 90% 61 %

OMT 64% 35 %

Functional v. Degenerative MR

FMR:

Structurally normal MV but

LV dysfunction leads to MR

DMR:

A diseased MV where severe

MR leads to LV dysfunction

FMR: LV Dysfxn

MV leaflets normal

but motion restricted

from

• Annular dilation • Tethering (apical / posterior displacement

of papillary muscles)

15% CHF pts have

significant FMR*

3D MV from LA from LV

13 mo f/u- post clip NYHA I

LVEDD normalized

Pre: 62 mm - Post: 49 mm

LVESD normalized

Pre: 52 mm - Post: 39 mm

LVEF improved

Pre: 27% - post: 45%

F/U Echo in 2017-

8 yrs post MitraClip

Asymptomatic – very active

MR- trivial

CFD- trivial

PW:

E/A

Reversal

Pulm V

S Dom

Multiparameter MR Severity Assessment

CFD CW PW- MV Inflow PW- PV flow

Vena Contracta 9 mm

PISA - EROA

12 mm

>40% Holosystolic* E≥120cm/s Blunted/reversed

≥ 7mm EROA ≥ 0.4cm2

Beware of “color flowitis”

• Normal PASP: 28 mmHg

• Severe = multiple parameters

• MV inflow: E/A Reversal

• CW Doppler: Not holosystolic signal – low intensity

Echo 05/10/2006

Flail posterior leaflet

but MR is not severe

Because:

• LV size normal LVEDD: 5.0 cm; LVESD: 3.1 cm

• Spectral Doppler very helpful

MV inflow:

E/A Reversal

11 yrs later Exercise Stress Echo:

LV size, LVEF still normal LVEDD: 5.0 cm; LVESD: 3.1 cm

PASP: 32-34 mmHg

Excellent functional capacity

MR not severe in spite of

flail MV leaflet