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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