Which patients should undergo Ischemic MV repair in 2017 · 2017-10-17 · Which patients should undergo Ischemic MV repair in 2017 ? Steven F. Bolling, M.D. Professor of Cardiac

Which patients should undergoIschemic MV repair in 2017 ?

Steven F. Bolling, M.D.Professor of Cardiac Surgery

University of Michigan

Functional MR : Ventricular Problem!

Badhwar, Bolling , chapter in: Advances in Heart Failure, 2004

Asymmetric FMR in Ischemia

Badhwar, Bolling , chapter in: Advances in Heart Failure, 2004

Traditional cardiology view of FMR

©2011 by BMJ Publishing Group Ltd and British Cardiovascular Society

FMR…Not “just a late marker” !

It’s also a CAUSE ! FMR - worsens odds ratio of death

Rossi A et al. Heart 2011;97:1675-1680

FMR makes you die !Ischemic or Dilated FMR

Rossi A et al. Heart 2011;97:1675-1680©2011 by BMJ Publishing Group Ltd and British Cardiovascular Society

FMR is bad

Untreated State

MR grade No.None 9,405Mild 2,062Moderate 210Severe 171

0.0

0.2

0.4

0.6

0.8

1.0

0 1 2 3 4 5

surv

ival

Years

FMR survival is bad

Hickey et al: Circulation 78:1-51, 1988

Despite GD medical therapy/CRT !

Even with small amounts of FMR …survival is terrible !

Grigioni et al: Circulation 103:1759, 2001

ERO RVol

2014 Guidelines -“Small” FMR is bad

ERO > 20 cm2R Vol > 30 ml

Small FMR is bad

Untreated StateGDMT

Bolling JTCVS 1995 200 ptsChen Circ 1998 81 ptsBishay Eur JCTS 2000 44 ptsCalafiore Ann TS 2000 49 ptsBuffolo Ar Br Card 2000 80 ptsBitran J Card Surg 2001 21 ptsDreyfus JHLT 2000 45 ptsSuma JTCVS 2001 44 ptsACORN JTCVS 2006 193 pts

30 day mortality 1 - 5 %

Mitral Repair for FMR in CHF

“Undersized” Mitral RepairFeasible / low mortality

Relief of MRBetter QOL / less CHF

It works!...it doesn’t work !

Not getting rid of FMR ! small amounts of FMR hurts patients

McGee, Gillinov et al, JTCVS, 2004;128:916-24

Progression of 3 or 4+ MR post-undersized annuloplasty (585)

McGee EC et al. JTCVS 2004;128:916-24Mihaljevic et al. J Am Coll Cardiol 2007;49:2191-201Crabtree TD et al. Ann Thorac 2008;85:1537-43 Surg

Residual / recurrent FMR if we do repair badly

FMR patients do badly !

Bothe W, Swanson J, et al., JTCVS 2010

IMR-FMR rings

SMALL, RIGID and COMPLETE“ re-normal sizing ”

Small FMR is bad

Untreated StateGDMT

Postop Recurrence

Catheter-Based FMR Mitral Repair - MitralClip

Franzen et al Eur J Heart Fail 2011; 13:569-76

50 pts > 3+ FMR CRT failed - 21Age 70; euroSCORE 34;LVEDD 70mm; LVEDV 252 ml;

LVEF 19%

Mitral regurgitation at 6 months

45 % had significant residual >2+ MR !

Franzen O et al. Eur J Heart Fail 2011;13:569-576

Small FMR is bad

Untreated StatePostop Recurrence

Post Clip Recurrence

Randomized Moderate iFMR trial– JTCVS Fatouch 2009

3% rMR

iFMR - survival

Math: the absence of proof,is not the proof of absence

iFMR – exercise MR

Results: Secondary endpointsMitral regurgitation at 1 Year

CABG CABG + MVR

Mitral regurgitation was less followingCABG + MV repair compared to CABG only.

9

74

41

22

47

43 0

605040302010

0

100908070

(%)No MRMild MR Mod MR

Mod-severe MR

P

Results: Primary endpointFunctional Capacity at 1 Year

Peak VO2 (% change) 5 22

Improvement in functional capacity was greaterfollowing CABG + MV repair compared to CABG alone.

CABG CABG + MVR-2

3

8

13

18

28

23

CABGCABG + MVR

P

Severe Ischemic Mitral Regurgitation

Mortality sameCV events sameFunctional status sameLVESI (size/remodeling) same

NEJM 2014 : 251 CABG + MV repair vs replacement

SMR - Operative MortalityMitral repair -1.6%

vs “total valve sparing” MVR - 4.2%

Severe Ischemic Mitral Regurgitation

Different!32% repairs - recurrent FMR

FMR is bad !

…FMR patients do poorly slowly !

1 Year Mortality: 14% (Repair) vs. 18% (Replacement),

p =0.47

2 Year Mortality: 19% (Repair) vs. 23% (Replacement),

p =0.42

Mortality

MR Recurrence (≥ moderate)

0

10

20

30

40

50

60

70

80

90

100

MV Repair MV Replacement

Perc

ent (

%)

SevereModerate

P

FMR : 1 Year RemodelingLVESI 67 mm

“Good” repair - 46 mm **

Replacement - 61 mm *

“Bad” repair - 63 mmKron et al JTCVS 2015

p < 0.001

Repair

LVESVI (ml/m2)Recurrence No Recurrence

62.6 ± 26.9 42.7 ± 26.4

Post Hoc Analysis: 2 yearRecurrence vs. No Recurrence

Good repair :67 to 46 to 42 !

FMR - JACC 2016 Nappi

14% FMR Recurrence !

FMR - ACC 2016

“Good repair”,Higher survival ?

FMR is bad

Untreated stateGDMT

Postop recurrenceRandomized trials

Good repair is good…

Good repair

Replacement

Bad repair

FMR 2017 - Surgery

Posterior leaflet angle >45°post/basal dyskinesia !

BIG LV !– LVEDD > 65 mm– Sphericity index > 0.7

– End systolic interpap muscle >20 mm

– LVESV ≥ 145 ml (or ≥ 100 ml/m2)

– Coaptation depth >1 cm

Mild annular dilatation

Predictors of “Bad iFMR Repair”

Lancellotti et al. Eur J Echo 2010 EAE recommendations for the assessment of valvular regurgitation

CorCap only

http://jtcs.ctsnetjournals.org/content/vol135/issue6/images/large/1384.S0022522308000822.gr2.jpeg

How are pts with FMR ACTUALLY treated? Duke: 1,538 pts 3-4+ FMR LVEF ≥20%, 2000-2010

not much surprise, NOT MUCH SURGERY !

LVEFN=1538 N=440 N=298 N=313 N=479

Chart1

All ptsAll pts

20%-30%20%-30%

30%-40%30%-40%

40%-50%40%-50%

50%-60%50%-60%

Conservative management

Isolated MV surgery

11.4%

5.9%

8.4%

11.8%

18.4%

88.6

11.4

94.1

5.9

91.6

8.4

88.2

11.8

81.6

18.4

Sheet1

Conservative managementIsolated MV surgery

All pts88.611.4

20%-30%94.15.9

30%-40%91.68.4

40%-50%88.211.8

50%-60%81.618.40

To resize chart data range, drag lower right corner of range.

Perc MV replacement

BIG ! : LVOTO, LV distortion, apical

Functional MR :Ventricular Geometry

Badhwar, Bolling , chapter in: Advances in Heart Failure, 2004

Percutaneous Mitral Annuloplasty Rings

CARDIOBAND - MR Grade at Endpoints

47

3-4+

3-4+3-4+

2+

2+2+

0-1+0-1+

N=30 N=28 N=27

93% MR ≤ 2+at Discharge

N=16

88% MR ≤ 2+at 6 Month

0-1+

2+3-4+

89% MR ≤ 2+at 1 Month

40% > 2+MRat 6 and 12

months

Chart1

BaselineBaselineBaseline

DischargeDischargeDischarge

1 month1 month1 month

6 months6 months6 months

3-4+

2+

0-1+(None/Mild)

70

30

0

7.14

17.86

75

11.11

18.52

70.37

12.5

25

62.5

Sheet1

BaselinePost-opDischarge1 month6 months

3-4+70.000.007.1411.1112.50

2+30.0032.0017.8618.5225.00

0-1+(None/Mild)0.0068.0075.0070.3762.50

100.0092.8688.8987.50MR ≤ 2+

70.00%0.00%7.14%11.11%12.50%

30.00%32.14%17.86%18.52%25.00%

0.00%46.43%67.86%66.67%56.25%

0.00%21.43%7.14%3.70%6.25%

Indications for Surgery for Mitral Regurgitation (Modified)

*MV repair is preferred over MV replacement when possible.

Chronic Severe Secondary Mitral Regurgitation: Intervention

Recommendations COR LOEMV surgery is reasonable for patients with chronic severe secondary MR (stages C and D) who are undergoing CABG or AVR

IIa C

New: It is reasonable to choose chordal-sparing MVR over downsized annuloplasty repair if operation is considered for severely symptomatic patients (NYHA class III to IV) with chronic severe ischemic MR (stage D) and persistent symptoms despite GDMT for HF

IIa B-R

MV surgery may be considered for severely symptomatic patients (NYHA class III-IV) with chronic severe secondary MR (stage D) who have persistent symptoms despite optimal GDMT for HF

IIb B

Modified: In patients with chronic, moderate, ischemic MR (stage B) undergoing CABG, the usefulness of mitral valve repair is uncertain

IIb B-R

2017 FMR is bad

Good mitral repair - good

Replace - big LV, post / basilar dys

Fix TR

Avoid - bad RV However…

Find MR, Fix MR well!

it’s the LV !

FMR 2017

For Ischemic MR 20171. REPAIR2. REPLACE

Which patients should undergo� Ischemic MV repair in 2017 ?Slide Number 2Slide Number 3Slide Number 4Slide Number 5Slide Number 6 FMR is bad � FMR survival is bad� Slide Number 92014 Guidelines -“Small” FMR is bad Small FMR is bad Mitral Repair for FMR in CHF“Undersized” Mitral RepairSlide Number 14Slide Number 15Slide Number 16Slide Number 17Small FMR is bad Slide Number 19Slide Number 20Slide Number 21Slide Number 22Small FMR is bad Slide Number 24 iFMR - survival�iFMR – exercise MR�Results: Secondary endpoints�Mitral regurgitation at 1 YearResults: Primary endpoint�Functional Capacity at 1 YearSevere Ischemic Mitral Regurgitation SMR - Operative Mortality� Mitral repair -1.6% �vs “total valve sparing” MVR - 4.2% Severe Ischemic Mitral Regurgitation Slide Number 32Slide Number 33Slide Number 34FMR : 1 Year Remodeling� LVESI 67 mm Slide Number 36FMR - JACC 2016 Nappi FMR - ACC 2016 FMR is bad FMR 2017 - Surgery Predictors of “Bad iFMR Repair”Slide Number 42How are pts with FMR ACTUALLY treated? �Duke: 1,538 pts 3-4+ FMR LVEF ≥20%, 2000-2010 �not much surprise, NOT MUCH SURGERY !��Perc MV replacement Slide Number 45Percutaneous Mitral Annuloplasty RingsCARDIOBAND - MR Grade at Endpoints Slide Number 48Chronic Severe Secondary Mitral Regurgitation: Intervention 2017 FMR is bad FMR 2017 For Ischemic MR 2017