mitral regurgitation: the past … the present the …...in patients with secondary mitral...

Mitral Regurgitation: The Past … The Present ... The Future

Sean R. Wilson, MD

Disclosure

None

Setting the Foundation

Aortic Valve

Mitral Valve

Epidemiology: Mitral RegurgitationPatients with Mitral Valve Regurgitation

– US and EU 2016Mitral Valve Regurgitation – Patient Segmentation

Indications for Surgery for Mitral Regurgitation

*MV repair is preferred over MV replacement when possible.

Chronic Secondary Mitral Regurgitation: Medical Therapy

Recommendations COR LOEPatients with chronic secondary MR (stages B to D) and HF with reduced LVEF should receive standard GDMT therapy for HF, including ACE inhibitors, ARBs, beta blockers, and/or aldosterone antagonists as indicated

I A

Noninvasive imaging (stress nuclear/positron emission tomography, CMR, or stress echocardiography), cardiac CT angiography, or cardiac catheterization, including coronary arteriography, is useful to establish etiology of chronic secondary MR (stages B to D) and/or to assess myocardial viability, which in turn may influence management of functional MR

I A

Two Year Outcomes of Surgical Treatment of Moderate Ischemic MR

Michler RE. NEJM 2016; 374:1932

Two Year Outcomes of MV Repair Versus Replacement of Severe Ischemic MR

Goldstein D. NEJM 2016 374:344

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

Mitral - FR

ObadiaNEJM 2018

Mitral - FR

ObadiaNEJM 2018

MITRA-FR: Change in NYHA Class in Surviving Patients

COAPT Trial Exclusion criteria:

American College of Cardiology/American Heart Association stage D HF, hemodynamic instability, or cardiogenic shock

Untreated clinically significant coronary artery disease requiring revascularization

Chronic obstructive pulmonary disease (COPD) requiring continuous home oxygen or chronic oral steroid use

Severe pulmonary hypertension or moderate or severe right ventricular dysfunction

Aortic or tricuspid valve disease requiring surgery or transcatheter intervention

Mitral valve orifice area <4.0 cm2 by site-assessed transthoracic echocardiography

Life expectancy <12 months due to noncardiac conditions

COAPT: Characteristics of Patients

Prior myocardial infarction: 51%, prior percutaneous coronary intervention: 46%, prior coronary artery bypass grafting: 40%, COPD: 23%

Society of Thoracic Surgeons Predicted Risk of Mortality score (STS PROM) for replacement: 8.1%, ≥8%: 42%

High surgical risk: 69% Ischemic HF: 61% HF hospitalization within 1 year: 57% Prior CRT: 36% Echo (mean): effective regurgitant orifice area (EROA): 0.41

cm2, LVESD: 53 mm, LV end-diastolic dimension: 62 mm, LVEF: 31.3%

Beta-blockers: 91%, angiotensin-converting enzyme inhibitor/angiotensin-receptor blocker/angiotensin receptor–neprilysin inhibitor: 66%, mineralocorticoid receptor antagonist: 50%

COAPT Trial

COAPT Trial

COAPT Trial

Functional Mitral Regurgitation Trials

Functional Mitral Regurgitation TrialsKey Differences Between the 3 RCTs

Functional MR is One of Many Components of the Heart Failure Syndrome

Clinical Course/Treatment of Heart Failure in Mitral Regurgitation Patients

Referral Algorithm for Mitral Regurgitation

Increasing Complex Environment Various Heart Teams

Increasing Complex Environment Various Heart Teams

Increasing Complex Environment Various Heart Teams

Multidisciplinary Mitral Valve Heart Team

Heart Team meetings to discuss the indications for and timing of intervention together with necessary procedural details.

In collaboration with members of a heart failure service and electrophysiology specialists is needed in patients with secondary mitral regurgitation to ensure that medical therapy (and cardiac resynchronization if indicated) has been optimized before considering surgical or transcatheterintervention

Patients with heart failure and valve disease may be better cared for in a heart failure clinic (rather than a heart valve clinic) if no invasive intervention is planned

European Heart Journal (2017) 38, 2177–2183

Aortic Percutaneous Valve Marketplace

Percutaneous Valve Marketplace

Monthly TAVR Revenue By Brand 2012-2016

Portfolio and Revenue of Key Transcatheter Companies

Current Landscape of Percutaneous Mitral Valve Treatment

Future Issues To Ponder

Health care is transitioning from a volume-based to value-based payment system

Hospitals in general—and high-cost, high-volume procedures in particular—have been a focus for reform, since one-third of US health care spending accrues in such settings

Future Issues To Ponder

An aging population, concerns about rising drug costs, and the rapid changes to the US health care system serve as the backdrop for this issue

In the foreground, managed care decision-makers, policy experts, clinicians, and others grapple with economic and quality of life questions related to a host of diseases and conditions in an era of limited resources

All These Options – What Do We Do

We are not yet in a position of trying to determine who is likely to benefit the most Society is not ready for that Basically, if the patient meets the criteria, whether

they just minimally meet those criteria or are the best candidate possible, they are eligible for coverage

The economic realities may ultimately drive us to reconsider how and on whom resources should be allocated This needs to be a societal decision that payers

will then likely support

Thank You