David Stultz, MD, FACC Southwest Cardiology, Inc ...drstultz.com/Presentations/2010 09 28 Mitral valve disease.pdf · Mitral valve disease David Stultz, MD, FACC Southwest Cardiology,

Mitral valve diseaseMitral valve disease

David Stultz, MD, FACCDavid Stultz, MD, FACC

Southwest Cardiology, Inc.Southwest Cardiology, Inc.

September 28, 2010September 28, 2010

©2010 David Stultz, MD


ObjectivesObjectives

�� Identify the principle cause of mitral Identify the principle cause of mitral

stenosisstenosis

�� Name several mechanisms of mitral Name several mechanisms of mitral

regurgitationregurgitation

�� Identify how often mitral regurgitation Identify how often mitral regurgitation

should be followed by echocardiogramshould be followed by echocardiogram


This Conference is an OverviewThis Conference is an Overview

�� Many aspects cannot be covered in a 1 Many aspects cannot be covered in a 1

hour conferencehour conference

�� This is meant to serve as a framework for This is meant to serve as a framework for

further knowledgefurther knowledge


Outline of conferenceOutline of conference

�� Mitral StenosisMitral Stenosis

�� Mitral regurgitationMitral regurgitation

�� Mitral valve prolapseMitral valve prolapse

�� Surgical and endovascular repairSurgical and endovascular repair


Libby P, Bonow RO, Mann DL, Zipes DP. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, Saunders, 2007.


Surgical AnatomySurgical Anatomy

Fedak PW, McCarthy PM, Bonow RO. Evolving concepts and technologies in mitral valve repair. Circulation. 2008 Feb 19;117(7):963-

74.


Mitral StenosisMitral Stenosis�� Narrowing of the mitral valve orificeNarrowing of the mitral valve orifice

�� Restricts flow from left atrium to left Restricts flow from left atrium to left ventricle during diastoleventricle during diastole�� Rheumatic fever almost always the causeRheumatic fever almost always the cause

�� Senile Senile calcificcalcific (annular calcification)(annular calcification)

�� Anorectic drugs, carcinoidAnorectic drugs, carcinoid

�� Mitral valve area normally 4Mitral valve area normally 4--6cm6cm22

�� 2cm2cm22 is mild stenosisis mild stenosis

�� <1cm<1cm22 is critical stenosisis critical stenosisBonow RO, Carabello BA, Chatterjee K, de Leon AC Jr., Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O’Gara PT,

O’Rourke RA, Otto CM, Shah PM, Shanewise JS. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the

management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task

Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Valvular Heart Disease).

J Am Coll Cardiol 2008;52:e1–142.

Carabello BA. Modern management of mitral stenosis. Circulation. 2005 Jul 19;112(3):432-7.




Symptoms of Mitral StenosisSymptoms of Mitral Stenosis

�� Exertional Exertional dyspneadyspnea

�� HemoptysisHemoptysis

�� Chest painChest pain

�� Systemic Systemic embolizationembolization

�� Mostly due to atrial fibrillationMostly due to atrial fibrillation



Physical Examination for MSPhysical Examination for MS

�� Diastolic murmurDiastolic murmur

�� Low pitched rumble at apex with bellLow pitched rumble at apex with bell

�� Best heard in left lateral decubitus positionBest heard in left lateral decubitus position

�� Prominent S1 (If leaflets are pliable)Prominent S1 (If leaflets are pliable)

�� Opening snapOpening snap

�� Caused by a tension on the valve leaflets when the Caused by a tension on the valve leaflets when the valve opensvalve opens

�� Audible at apex, with bell of stethoscopeAudible at apex, with bell of stethoscope

�� Follows AFollows A22 by 40by 40--120ms120ms

�� Shorter AShorter A22--OS interval = more severe MSOS interval = more severe MS



PhonocardiogramsPhonocardiograms

http://en.wikipedia.org/wiki/File:Phonocardiograms_from_normal_and_abnormal_heart_sounds.png


Severity of Mitral StenosisSeverity of Mitral Stenosis

Carabello BA. Modern management of mitral stenosis. Circulation. 2005 Jul 19;112(3):432-7. (Adapted)

SeveritySeverity MVAMVA

cm2cm2

Gradient Gradient

mmHgmmHgPAPPAP SymptomsSymptoms SignsSigns TherapyTherapy

MildMild >1.8>1.8 22--44 NormalNormal Usually absentUsually absent SS22--OS > OS >

120ms; 120ms;

normal Pnormal P22

ModerateModerate 1.21.2--1.61.6 44--99 NormalNormal Class IIClass II SS22--OS OS

100100--

120ms; 120ms;

normal Pnormal P22

DiureticsDiuretics

Moderate Moderate

to Severeto Severe1.01.0--1.21.2 1010--1515 Mild Mild

pulmonary pulmonary

HTNHTN

Class IIClass II--IIIIII SS22--OS 80OS 80--

100ms; P100ms; P22

increaseincrease

BMV if BMV if

applicable or applicable or

surgery if more surgery if more

than mild than mild SxSx

SevereSevere <1.0<1.0 1515 Mild to Mild to

severe severe

pulmonary pulmonary

HTNHTN

Class IIClass II--IVIV SS22--OS OS

<80ms; P<80ms; P22

increase; increase;

RV liftRV lift

BMV or surgeryBMV or surgery


http://depts.washington.edu/physdx/heart/tech.html

MS MS

AuscultationAuscultation


Asymptomatic Mitral StenosisAsymptomatic Mitral Stenosis

Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr., Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O’Gara PT, O’Rourke RA, Otto CM, Shah PM, Shanewise JS. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Valvular Heart Disease). J Am Coll Cardiol 2008;52:e1–142.


Medical ManagementMedical Management

�� DiureticsDiuretics

�� Salt restrictionSalt restriction

�� Anticoagulation if indicatedAnticoagulation if indicated

�� Atrial fibrillationAtrial fibrillation

�� Treatment of atrial fibrillationTreatment of atrial fibrillation



Mitral StenosisMitral Stenosis

““Hockey StickHockey Stick””


Mean Pressure GradientMean Pressure Gradient

Mitral StenosisMitral Stenosis


Symptomatic Mitral StenosisSymptomatic Mitral Stenosis

Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr., Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O’Gara PT, O’Rourke RA, Otto CM, Shah PM, Shanewise JS. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Valvular Heart Disease). J Am Coll Cardiol 2008;52:e1–142.


Natural History of Mitral Valve Natural History of Mitral Valve

disease (1991)disease (1991)

Blue = Mitral Stenosis; Purple = Mitral RegurgitationSolid = Medical Management; Dashed = Surgical Management


Surgical ManagementSurgical Management

�� Indicated forIndicated for

�� Moderate (NYHA Class 2) symptomsModerate (NYHA Class 2) symptoms

�� PA pressure >60mmHgPA pressure >60mmHg

�� PCWP pressure >25mmHgPCWP pressure >25mmHg

�� Percutaneous balloon Percutaneous balloon valvotomyvalvotomy

�� Favored if echo showsFavored if echo shows�� High leaflet mobilityHigh leaflet mobility

�� Low calcification, thickening, and Low calcification, thickening, and subvalvularsubvalvular thickeningthickening

�� Open/Closed Surgical Open/Closed Surgical valvotomyvalvotomy

�� Mitral Valve replacementMitral Valve replacement

Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr., Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O’Gara PT,






Inoue method of balloon mitral Inoue method of balloon mitral

valvotomyvalvotomy ((transseptaltransseptal approach)approach)



Mean pressure gradient across Mitral ValveMean pressure gradient across Mitral ValvePrePre-- and Postand Post-- Balloon Balloon ValvotomyValvotomy



Why is mitral regurgitation so Why is mitral regurgitation so

complicated?complicated?�� Variable etiologiesVariable etiologies

�� Variable symptomsVariable symptoms�� Generally slow onsetGenerally slow onset

�� Symptoms often overlap with Symptoms often overlap with deconditioningdeconditioning and and aging aging

�� Variable Variable comorbitiescomorbities�� CardiacCardiac

�� Role of coronary & myocardial diseaseRole of coronary & myocardial disease

�� SystemicSystemic

�� Guidelines often based on specific numerical Guidelines often based on specific numerical cutoffs for various measurementscutoffs for various measurements


Symptoms of MRSymptoms of MR

�� Typically develop over a longer time Typically develop over a longer time

frame than mitral stenosisframe than mitral stenosis

�� Shortness of breathShortness of breath

�� Weakness/fatigueWeakness/fatigue

�� Development of atrial fibrillationDevelopment of atrial fibrillation


Physical Examination for MRPhysical Examination for MR

�� Systolic murmurSystolic murmur

�� HolosystolicHolosystolic

�� Constant intensityConstant intensity

�� Blowing, high pitchBlowing, high pitch

�� Loudest at apex, Loudest at apex,

radiates to radiates to axillaaxilla

http://en.wikipedia.org/wiki/File:Phonocardiograms_from_normal_and_abnormal_heart_sounds.png

http://depts.washington.edu/physdx/heart/tech.html


Causes of Chronic MRCauses of Chronic MR

�� InflammatoryInflammatory�� Rheumatic heart diseaseRheumatic heart disease

�� Systemic lupus Systemic lupus erythematosuserythematosus

�� SclerodermaScleroderma

�� DegenerativeDegenerative�� MyxomatousMyxomatous degeneration of mitral valve leafletsdegeneration of mitral valve leaflets (Barlow click(Barlow click--murmur syndrome, murmur syndrome, prolapsingprolapsing leaflet, leaflet,

mitral valve prolapse) mitral valve prolapse)

�� MarfanMarfan syndromesyndrome

�� EhlersEhlers--DanlosDanlos syndromesyndrome

�� PseudoxanthomaPseudoxanthoma elasticumelasticum

�� Calcification of mitral valve annulusCalcification of mitral valve annulus

�� InfectiveInfective�� Infective endocarditis affecting normal, abnormal, or prostheticInfective endocarditis affecting normal, abnormal, or prosthetic mitral valvesmitral valves

�� StructuralStructural�� Ruptured Ruptured chordaechordae tendineaetendineae (spontaneous or secondary to myocardial infarction, trauma, mit(spontaneous or secondary to myocardial infarction, trauma, mitral valve ral valve

prolapse, endocarditis) prolapse, endocarditis)

�� Rupture or dysfunction of papillary muscle (ischemia or myocardiRupture or dysfunction of papillary muscle (ischemia or myocardial infarction) al infarction)

�� Dilation of mitral valve annulus and left ventricular cavityDilation of mitral valve annulus and left ventricular cavity (congestive (congestive cardiomyopathiescardiomyopathies, , aneurysmalaneurysmaldilation of the left ventricle) dilation of the left ventricle)

�� Hypertrophic cardiomyopathy Hypertrophic cardiomyopathy

�� ParavalvularParavalvular prosthetic leakprosthetic leak

�� CongenitalCongenital�� Mitral valve clefts or fenestrationsMitral valve clefts or fenestrations

�� Parachute mitral valve abnormality in association with:Parachute mitral valve abnormality in association with:�� EndocardialEndocardial cushion defectscushion defects

�� EndocardialEndocardial fibroelastosisfibroelastosis

�� Transposition of the great arteriesTransposition of the great arteries

�� Anomalous origin of the left coronary arteryAnomalous origin of the left coronary artery



How often should I get an How often should I get an

echo?echo?�� Moderate to Severe MR (Asymptomatic)Moderate to Severe MR (Asymptomatic)

�� Every 6Every 6--12 months12 months

�� Moderate MRModerate MR

�� Not specified in Guidelines or appropriateness Not specified in Guidelines or appropriateness

criteriacriteria

�� Asymptomatic Mild MRAsymptomatic Mild MR

�� Not routinely recommendedNot routinely recommended

�� Echo is recommended for change in symptomsEcho is recommended for change in symptomsBonow RO, Carabello BA, Chatterjee K, de Leon AC Jr., Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O’Gara PT,





Douglas PS, Khandheria B, Stainback RF, Weissman NJ. ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR, 2007 appropriateness criteria

for transthoracic and transesophageal echocardiography. J Am Coll Cardiol 2007.


Managing Managing

Chronic Chronic

Severe Severe

MRMR

Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr., Faxon DP, Freed MD,

Gaasch WH, Lytle BW, Nishimura RA, O’Gara PT, O’Rourke RA, Otto CM, Shah PM,

Shanewise JS. 2008 focused update incorporated into the ACC/AHA 2006 guidelines

for the management of patients with valvular heart disease: a report of the American

College of Cardiology/American Heart Association Task Force on Practice Guidelines

(Writing Committee to Develop Guidelines for the Management of Patients With

Valvular Heart Disease). J Am Coll Cardiol 2008;52:e1–142.


EchocardiographyEchocardiography

�� Primary tool for assessing severity of Primary tool for assessing severity of

Mitral regurgitationMitral regurgitation


Mild Mitral RegurgitationMild Mitral Regurgitation


Moderate Mitral RegurgitationModerate Mitral Regurgitation


Moderate MR CW jetModerate MR CW jet


PISA PISA –– Moderate MRModerate MR


Severe Mitral RegurgitationSevere Mitral Regurgitation


Etiology of Mitral RegurgitationEtiology of Mitral Regurgitation

�� PrimaryPrimary�� Flail leafletFlail leaflet

�� Mitral valve prolapseMitral valve prolapse

�� Perforation (endocarditis)Perforation (endocarditis)

�� Chordal ruptureChordal rupture

�� SecondarySecondary�� Annular dilatationAnnular dilatation

�� Ischemic mitral regurgitationIschemic mitral regurgitation

�� Remodeling of papillary muscleRemodeling of papillary muscle


Simplified Mechanisms of Mitral Simplified Mechanisms of Mitral

RegurgitationRegurgitation

Normal

Prolapse

Flail leaflet

Perforated leaflet

Annular dilatation

Restricted leaflet motion


Carpentier ClassificationType I - normal leaflet length and motion but with either annular dilation or leaflet perforation

Type II MR is caused by leaflet prolapse or by papillary muscle rupture or elongation.

Type III MR is caused by restricted leaflet motion.

Type IIIa - rheumatic disease with subvalvular involvement.

Type IIIb – tethered and restricted leaflet motion due to ischemic or idiopathic cardiomyopathy with ventricular dilation.

Fedak PW, McCarthy PM, Bonow RO. Evolving concepts and technologies in mitral valve repair. Circulation. 2008 Feb 19;117(7):963-

74.


Flail posterior leaflet tipFlail posterior leaflet tip


Ischemic Mitral RegurgitationIschemic Mitral Regurgitation


Mitral valve leaflet perforationMitral valve leaflet perforation

EndocarditisEndocarditis


Dilated CardiomyopathyDilated Cardiomyopathy

((NonischemicNonischemic))

End SystoleFailure of coaptation

End Diastole


Mitral Valve ProlapseMitral Valve Prolapse

�� Defined as billowing of the mitral valve leaflet Defined as billowing of the mitral valve leaflet

2mm beyond the annular plane in the 2mm beyond the annular plane in the

parasternalparasternal long axis viewlong axis view

�� MyxomatousMyxomatous degeneration in younger patientsdegeneration in younger patients

�� FibroelasticFibroelastic tissue deficiency in elderlytissue deficiency in elderly

�� 11--2.5% prevalence2.5% prevalence

�� HeterogenousHeterogenous natural historynatural history

�� 55--10% progress to severe mitral regurgitation10% progress to severe mitral regurgitation



MyxomatousMyxomatous mitral valvemitral valve



Physical Exam in MVPPhysical Exam in MVP

�� Systolic ClickSystolic Click

�� Best heard with diaphragmBest heard with diaphragm

�� Occurs at least 140ms after S1Occurs at least 140ms after S1

�� Caused by sudden tensing of Caused by sudden tensing of chordaechordae during during

systolesystole

�� Maneuvers that decrease LV volume move Maneuvers that decrease LV volume move

click closer to S1click closer to S1

�� Maneuvers that increase LV volume move Maneuvers that increase LV volume move

click away from S1 and lower intensityclick away from S1 and lower intensity


http://www.texasheart.org/education/cme/explore/events/eventdetail_5469.cfm




Mitral Valve Prolapse Mitral Valve Prolapse

SyndromeSyndrome�� Cluster of symptomsCluster of symptoms

�� PalpitationsPalpitations

�� Chest painChest pain

�� TIA symptomsTIA symptoms

�� Guidelines base treatment onGuidelines base treatment on�� Cerebrovascular eventCerebrovascular event

�� Atrial fibrillationAtrial fibrillation

�� Severity of Mitral regurgitationSeverity of Mitral regurgitation


Mild MVPMild MVP

Diastole Systole


Severe MVPSevere MVP


Acute Severe Mitral RegurgitationAcute Severe Mitral Regurgitation

�� Usually Significant SymptomsUsually Significant Symptoms

�� Shortness of BreathShortness of Breath

�� HypotensionHypotension

�� Sudden change in valvular functionSudden change in valvular function

�� PerforationPerforation

�� Papillary muscle dysfunctionPapillary muscle dysfunction

�� Chordal ruptureChordal rupture


Causes of Acute MRCauses of Acute MR

�� Mitral Annulus DisordersMitral Annulus Disorders�� Infective endocarditis (abscess formation)Infective endocarditis (abscess formation)

�� Trauma (valvular heart surgery)Trauma (valvular heart surgery)

�� ParavalvularParavalvular leak caused by suture interruption (surgical technical problemsleak caused by suture interruption (surgical technical problems or infective endocarditis)or infective endocarditis)

�� Mitral Leaflet DisordersMitral Leaflet Disorders�� Infective endocarditis (perforationInfective endocarditis (perforation or interference with valve closure by vegetation)or interference with valve closure by vegetation)

�� TraumaTrauma (tear during percutaneous balloon mitral (tear during percutaneous balloon mitral valvotomyvalvotomy or penetrating chest injury)or penetrating chest injury)

�� Tumors (atrial Tumors (atrial myxomamyxoma))

�� MyxomatousMyxomatous degenerationdegeneration

�� Systemic lupus Systemic lupus erythematosuserythematosus ((LibmanLibman--Sacks lesion)Sacks lesion)

�� Rupture of Rupture of ChordaeChordae TendineaeTendineae�� Idiopathic (e.g., spontaneous) Idiopathic (e.g., spontaneous)

�� MyxomatousMyxomatous degeneration (mitral valve prolapse, degeneration (mitral valve prolapse, MarfanMarfan syndrome, Ehlerssyndrome, Ehlers--DanlosDanlos syndrome) syndrome)

�� Infective endocarditis Infective endocarditis

�� Acute rheumatic fever Acute rheumatic fever

�� Trauma (percutaneous balloon Trauma (percutaneous balloon valvotomyvalvotomy, blunt chest trauma), blunt chest trauma)

�� Papillary Muscle DisordersPapillary Muscle Disorders�� Coronary artery disease (causing dysfunction and rarely rupture)Coronary artery disease (causing dysfunction and rarely rupture)

�� Acute global left ventricular dysfunction Acute global left ventricular dysfunction Infiltrative diseases (Infiltrative diseases (amyloidosisamyloidosis, , sarcoidosissarcoidosis))

�� TraumaTrauma

�� Primary Mitral Valve Prosthetic DisordersPrimary Mitral Valve Prosthetic Disorders�� Porcine cusp perforation (endocarditis)Porcine cusp perforation (endocarditis)

�� Porcine cusp degenerationPorcine cusp degeneration

�� Mechanical failure (strut fracture)Mechanical failure (strut fracture)

�� Immobilized disc or ball of the mechanical prosthesisImmobilized disc or ball of the mechanical prosthesis



Diagnosis of Acute Severe MRDiagnosis of Acute Severe MR

�� Auscultation may not be remarkableAuscultation may not be remarkable

�� Echocardiography is primary diagnostic Echocardiography is primary diagnostic

modalitymodality

�� Medical management limitedMedical management limited

�� NitroprussideNitroprusside for for afterloadafterload reductionreduction

�� Surgical management usually indicatedSurgical management usually indicated



Surgical RepairSurgical Repair

�� Repair favored over valve replacementRepair favored over valve replacement

�� New endovascular techniques promisingNew endovascular techniques promising

�� EVEREST 2 trial for EVEREST 2 trial for MitraClipMitraClip

�� Other percutaneous methodsOther percutaneous methods


Repair of Posterior MVPRepair of Posterior MVP



AlferiAlferi Surgical RepairSurgical Repair

FedakFedak PW, McCarthy PM, PW, McCarthy PM, BonowBonow RO. Evolving concepts and technologies in mitral valve repair. RO. Evolving concepts and technologies in mitral valve repair. Circulation. 2008 Feb 19;117(7):963Circulation. 2008 Feb 19;117(7):963--

74.74.


4

Investigational Device only in the US; Not available for sale in the US

Catheter-Based Mitral Valve RepairMitraClip® System

Endovascular Valve Edge-to-Edge Repair Study (EVEREST 2) Randomized Clinical Trial: Primary Safety and Efficacy Endpoints. Ted

Feldman, Laura Mauri, Elyse Foster, Don Glower on behalf of the EVEREST 2 Investigators. ACC 2010 Annual Scientific Sessions,

March 14, 2010, Atlanta, GA


27

Investigational Device only in the US; Not available for sale in the US

� Safety & effectiveness endpoints met

• Safety: MAE rate at 30 days

– MitraClip device patients: 9.6%

– MV surgery patients: 57%

• Effectiveness: Clinical Success Rate at 12 months

– MitraClip device patients: 72%

– MV Surgery patients: 88%

� Clinical benefit demonstrated for MitraClip System and MV surgery patients through 12 months

– Improved LV function

– Improved NYHA Functional Class

– Improved Quality of Life

� Surgery remains an option after the MitraClip procedure

EVEREST II RCT: Summary

Endovascular Valve Edge-to-Edge Repair Study (EVEREST 2) Randomized Clinical Trial: Primary Safety and Efficacy Endpoints. Ted

Feldman, Laura Mauri, Elyse Foster, Don Glower on behalf of the EVEREST 2 Investigators. ACC 2010 Annual Scientific Sessions,

March 14, 2010, Atlanta, GA

©2010 David Stultz, MDOther investigational percutaneous Other investigational percutaneous

methodsmethods

Van Mieghem NM, Piazza N, Anderson RH, Tzikas A, Nieman K, De Laat LE, McGhie JS, Geleijnse ML, Feldman T, Serruys PW, de

Jaegere PP. Anatomy of the mitral valvular complex and its implications for transcatheter interventions for mitral regurgitation. J Am

Coll Cardiol. 2010 Aug 17;56(8):617-26.


Coronary Sinus DevicesCoronary Sinus Devices

Carillon (Cardiac Dimensions, Inc., Kirkland,

Washington)

Edwards MONARC

(Edwards Lifesciences, Irvine, California)

Percutaneous Transvenous Mitral Annuloplasty (PTMA)

(Viacor, Inc., Wilmington, Massachusetts)

Van Mieghem NM, Piazza N, Anderson RH, Tzikas A, Nieman K, De Laat LE, McGhie JS, Geleijnse ML, Feldman T, Serruys PW, de

Jaegere PP. Anatomy of the mitral valvular complex and its implications for transcatheter interventions for mitral regurgitation. J Am

Coll Cardiol. 2010 Aug 17;56(8):617-26.


Mitralign – retrograde catheter in LV anchors to AV junction and cinches togetherQuantumcor – thermal energy at AV junction to shrink orificeAmple PS3 – Left atrial T bar anchored by septal occluder/coronary sinusiCoapsys – Transventricular bridge to change LV geometry

Van Mieghem NM, Piazza N, Anderson RH, Tzikas A, Nieman K, De Laat LE, McGhie JS, Geleijnse ML, Feldman T, Serruys PW, de Jaegere PP. Anatomy of the mitral valvular complex and its implications for transcatheter interventions for mitral regurgitation. J Am Coll Cardiol. 2010 Aug 17;56(8):617-26.


ReferencesReferences�� CarabelloCarabello BA. Modern management of mitral stenosis. Circulation. 2005 JulBA. Modern management of mitral stenosis. Circulation. 2005 Jul

19;112(3):43219;112(3):432--7.7.

�� BonowBonow RO, RO, CarabelloCarabello BA, BA, ChatterjeeChatterjee K, de Leon AC Jr., K, de Leon AC Jr., FaxonFaxon DP, Freed DP, Freed MD, MD, GaaschGaasch WH, Lytle BW, Nishimura RA, OWH, Lytle BW, Nishimura RA, O’’Gara PT, OGara PT, O’’Rourke RA, Otto Rourke RA, Otto CM, Shah PM, CM, Shah PM, ShanewiseShanewise JS. 2008 focused update incorporated into the JS. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvACC/AHA 2006 guidelines for the management of patients with valvular ular heart disease: a report of the American College of Cardiology/Amheart disease: a report of the American College of Cardiology/American erican Heart Association Task Force on Practice Guidelines (Writing ComHeart Association Task Force on Practice Guidelines (Writing Committee to mittee to Develop Guidelines for the Management of Patients With Valvular Develop Guidelines for the Management of Patients With Valvular Heart Heart Disease). J Am Disease). J Am CollColl CardiolCardiol 2008;52:e12008;52:e1––142.142.

�� Douglas PS, Douglas PS, KhandheriaKhandheria B, B, StainbackStainback RF, RF, WeissmanWeissman NJ. NJ. ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR, 2007 appropriateness ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR, 2007 appropriateness criteria for criteria for transthoracictransthoracic and and transesophagealtransesophageal echocardiography. J Am echocardiography. J Am CollCollCardiolCardiol 2007.2007.

�� FedakFedak PW, McCarthy PM, PW, McCarthy PM, BonowBonow RO. Evolving concepts and technologies RO. Evolving concepts and technologies in mitral valve repair. Circulation. 2008 Feb 19;117(7):963in mitral valve repair. Circulation. 2008 Feb 19;117(7):963--74.74.

�� Libby P, Libby P, BonowBonow RO, Mann DL, RO, Mann DL, ZipesZipes DP. DP. Braunwald'sBraunwald's Heart Disease: A Heart Disease: A Textbook of Cardiovascular Medicine, Saunders, 2007. Textbook of Cardiovascular Medicine, Saunders, 2007.

�� Van Van MieghemMieghem NM, Piazza N, Anderson RH, NM, Piazza N, Anderson RH, TzikasTzikas A, A, NiemanNieman K, De K, De LaatLaatLE, LE, McGhieMcGhie JS, JS, GeleijnseGeleijnse ML, Feldman T, ML, Feldman T, SerruysSerruys PW, de PW, de JaegereJaegere PP. PP. Anatomy of the mitral valvular complex and its implications for Anatomy of the mitral valvular complex and its implications for transcathetertranscatheter interventions for mitral regurgitation. J Am interventions for mitral regurgitation. J Am CollColl CardiolCardiol. 2010 . 2010 Aug 17;56(8):617Aug 17;56(8):617--26.26.

David Stultz, MD, FACC Southwest Cardiology, Inc ...drstultz.com/Presentations/2010 09 28 Mitral valve disease.pdf · Mitral valve disease David Stultz, MD, FACC Southwest Cardiology,

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