Bad LV and severe MR: How to proceed and how to predict LV ... · Preoperative predictors of secondary recurrent MR after undersized annuloplasty: LVEDD > 65mm Post. Mitral leaflet

Bad LV and severe MR:

How to proceed and how to

predict LV improvement?

Jan Vontobel, MD

Heart Failure/Transplant

St Paul‘s Hospital, Vancouver

Canada

Conflict of interest

Travel Grant by St. Jude Medical

outline

Different Treatment options

Unresolved Questions

Impact of MR on prognosis

Etiologies of MR

Prevalence of valvular heart disease

Mitral Valve Anatomy

Mitral valve anatomy

Prevalence of valvular heart disease

V. Nkomo. Lancet 2006;368:1005-11

Etiology of MR

Mechanism:Carpentier II

(Exessive leafletmotion or prolaps)

Mechanism:Carpentier I + III

(anular dilatation andrestrictive leaflet

motion)

Echo criteria of severe MR

Vahanian. Eur Hear J 2012;33:2451-2496

Survival Probability in CHF

according to the degree of MR

B. Trichon. Am J Car 2003;91:538-543

Survival free of heart failure

according to the degree of MR

F. Bursi. Circ. 2005;111:295-301

35% free of

HF

84%

74%

Medical Therapy of Mitral Regurgitation

H. Levine. J Am Coll Cardiol. 1996;28:1083-91

Volume

Pre

ssu

re

∆V

∆P

EF 50% EF 30%

Medical Therapy of FMR

H. Levine. J Am Coll Cardiol. 1996;28:1083-91

Medical Therapy of FMR

H. Levine. J Am Coll Cardiol. 1996;28:1083-91

Medical Therapy of FMR

B. Lowes. Am J Cardiol. 1999;83:1201-1205

N. Bellenger, Heart 2004;90:760-765

CRT in FMR

R. van Bommel. Circ. 2011;124:912-919

LVEF 23% ±7%

MR improvers

MR non-improvers

Surv

ival

Follow-up (months)

Guidelines in FMR

Indications for mitralValve surgery in chronicsecondaryMitral regurgitation

European Heart Failure Guidelines, 2016

Surgery in FMR

A.Ciarka, Am J Cariol. 2010;106:395-401

Preoperative predictors of secondary recurrent MR after undersized

annuloplasty:

LVEDD > 65mm

Post. Mitral leaflet angle > 45°

Distal anterior mitral leaflet angle > 25°

Systolic tenting area > 2.5cm2

Coaptation distance > 10mm

End-systolic interpapillary muscle distance > 20mm

Systolic spericity index > 0.7

Surgery in FMR

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

Surgery in FMR

Severe MR

Moderate MR30%

20%

10%

2.3%

28.4%

4.2%

32.6%

repair Replacement at 12months

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

Euro Heart Survey

M. Mirabel, Eur Heart J. 2007; 28:1358-1365

5001 patients with valvular heart disease included:

- 33.6% Mitral regurgitation

51.3% of symptomaticpatients with severe MR were

denied surgery

Mitra Clip anatomical Considerations

Wunderlich, Eur Heart J. CVI 2013

Current evidence for Mitra Clip use

M. Taramasso, Cardiovasc. Med. 2015; 18:333-339

FIRST-

IN-MAN

RCT’S

REGIS-

TRIES

META-

ANA-

LYSES

EVEREST IN=55

TRAMI n=1,064

Pilot Eur.SentinelN=628

ACCESS-Europe†n=567

EVEREST HRR†N=78

Vakil

N=2,980

REALISM† (ongoing) n>300

GRASP n>117 (ongoing)

MitraSwiss n>500

CE Mark (march 2008)

EVEREST II roll-inN=52

EVEREST II N=279

RESHAPE

COAPT

D’Ascenzo

N=875

Philip

N=3,198

Wan

N=349

Munkholm

N=878

MATTER-

HORN

MITRA-FRHIRIDE

**for degenerative MR with prohibitive surgical risk

† industry-sponsored registries

ǀ ǀ ǀ ǀ ǀ ǀ ǀ ǀ ǀ ǀ ǀ ǀ ǀ

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

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Reduction in MR and LV/LA Remodeling

P. Grayburn, Circ. 2013; 128:1667-1674

Usefulness of MitraClip in FMR

F. D’Ascenzo, Am J Cardiol. 2015; 116:325-331

Unanswered Questions

Does MitraClip compared to Optimal Medical Treatment improve the prognosis of thepatients?

Is the Mitral Regurgitation itself independently and prognostically causative relevant or isit just a Bystander?

Randomized Controlled Trials are needed - COAP Trial

Predictive parameters of outcome in medical as well as interventional treatmentsTime of referral?

At present what to do in FMR

Optimal Medical Therapy

CRT where indicated

Surgery if CABG and LVEF>30%; LVEF 1year

M. Taramasso, Cardiovasc. Med. 2015; 18:333-339

Guidelines in FMR

European Guidelines on the management of valvular heart disease, 2012

Indications for mitralValve surgery in chronicsecondaryMitral regurgitation

European Guidelines on myocardial revascularization, 2014

European Heart Failure Guidelines, 2016

EVEREST II HRR or REALISM HR

D. Glower, JACC. 2014; 64:172-81

Medical Therapy of FMR

H. Okura. Heart. 2016;10

EF≥50% EF≤50%