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Mitral RegurgitationMitral RegurgitationBrett Carlson, MDEssentia Health Heart and Vascular Conference May 18, 2012
Mitral Regurgitation (MR)
• ObjectivesDefinition– Definition
• Most common valvular heart disease• Systolic Flow Reversal LV->LA• Severe organic MR associated with excess mortality
– Anatomic Review• Etiologies of Mitral Regurgiation (MR)g g g ( )
– Clinical and Echo Findings (Chronic MR)– Role of Cardiac Cath Lab– Surgical Indications & Treatment Options
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Mitral Valve Anatomy
Kuwahara, et al. Circulation 2006;114;I-529-I-534
Mitral Valve Anatomy
Jouan, et al. Eur J Cardiothorac Surg 2004;26:1112-1117
Fig 1. Site of ischemic mitral valve prolapse (n=44). The posteromedialcommissure was involved in the majority of cases. The A3 portion of the anterior leaflet was prolapsed in one-third of the cases.
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Etiology of Mitral Regurgitation
• EtiologyDegenerative– Degenerative
– Functional – Inflammatory – SBE – Congenital
N l t
Figure 1: Carpentier’s functional classification. Type I, normal leaflet motion; Type II, increased leaflet motion (leaflet prolapse); Type IIIa restricted
Zoghbi, et al. Journal of the American Society of EchocardiographyVolume 22 Number 9, pp.978-9.
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Treatment Options
• Mitral Valve Repair– Better outcomes vs MVR
• Mitral Valve Replacement (MVR)– Age-dependent
• Not a Surgical Candidate?Mitral Clip– Mitral Clip
– Medical Management
MitraClip Criteria
• Sufficient leaflet tissue for mechanical coaptation
• Non-rheumatic/endocarditic valve morphology
• Protocol exclusions:
Flail gap >10mm
Flail width >15mm
LVIDs > 55mmLVIDs > 55mm
Coaptation depth >11mm
Coaptation length < 2mm
Grayburn et al, Am J Cardiol, Volume 108, Issue 6, Pages 882-887
mm
>15mm
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MitraClip
3-D Transesophageal Echo Guidance
Grayburn et al, Am J Cardiol, Volume 108, Issue 6, Pages 882-887
Grayburn et al, Am J Cardiol, Volume 108, Issue 6, Pages 882-887
3D TEE is essentialPercutaneous valve repair has advantagesOption for patients who are not ideal for surgeryActually increased surgical volume
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Summary
• Clinical Pearls– Early Operation for Severe MR
• Asymptomatic and EF <60% or LV dilation
• Asymptomatic and Afib, PHTN
• Symptomatic
• Flail Leaflet
– Correlation of clinical, echo, cath lab
– Repair > MVR > Medical Mgmt• Mitral Clip
Questions??
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References• Kuwahara, et al. Circulation 2006;114;I-529-I-534• Jouan, et al. Eur J Cardiothorac Surg 2004;26:1112-1117• Carpentier A. Cardiac valve surgery--the "French correction". J Thorac Cardiovasc Surg, 1983
September;86(3):323-37• Barlow JB, Pocock WA. The significance of late systolic murmurs and mid-late systolic clicks. Md , g y y
State Med J 1963 February;12:76-7• Photograph courtesy of Dr. Edward Woods, Geisinger Medical Center, Danville, PA• Cohn, et al. Cardiac Surgery in the Adult, 3rd Edition• ASE guideline J Am Soc Echocardiogr 2003;16:777-802• Enriquez-Sarano M et al. N Engl J Med 2005; 352(9): 875-83• Enriquez-Sarano M et al. Circulation 2010, 121:804-812• Enriquez-Sarano M et al. Circulation 2010, 121:804-812• Wisenbaugh T et al. Circulation 89,1994• Ling LH, NEJM 1996;335:1417-23• Lim E et al. Circulation 2001, 104:I-59-I-63• Rosenhek, R. et al. Circulation 2006;113:2238-2244Rosenhek, R. et al. Circulation 2006;113:2238 2244• Enriquez-Sarano M , Sundt T M Circulation 2010;121:804• Ling LH, NEJM 1996;335:1417-23• David TE, JTCVS 2005; 130(5):1242-9• ACC/AHA 2006 Guidelines• Townsend: Sabiston Textbook of Surgery 18th Edition• Volume 22 Number 9, pp.978-9.• Zoghbi, et al. Journal of the American Society of Echocardiography• Grayburn et al, Am J Cardiol, Volume 108, Issue 6, Pages 882-887• www.uptodate.com/contents/etiology-clinical-features-and-evaluation-of-chronic-mitral-