eae - functional mitral regurgitation: medical therapy, surgical or
TRANSCRIPT
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Functional mitral regurgitation: medical therapy, surgical or percutaneous repair ?
De Bonis Michele, MDDepartment of Cardiac Surgery,
San Raffaele University Hospital, Milan, Italy
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Valvular heart disease: clinical imaging
pathways in challenging scenarios:
a clinical case-guided discussion
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Clinical Case
46 years old, male
Past medical history Hyperuricemia
Cardiac history Increasing SOB in the last 3 years
Permanent AF since 2010 (refractory to MT/DC Shock)
3 hospital admissions for CHF in the previous 6 months
NYHA IIIB-IV
ECG: AF + RBB block
Coronary angiography: no CAD
TEE: severe functional MR, EF 15-20%, LVEDD 83 mm
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Medical therapy
Warfarin
Carvedilol 6,25 mg bd
Frusemide 125 mg bd
Zofenopril 15 mg od
Amiodarone 200 mg od
Spironolactone 25 mg od
Digoxin 0.125 mg od
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Clinical Case
In the referring hospital
Only option HTX
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Cardiac Surgery Department San Raffaele Hospital
TTE +TEE
Severe LV remodeling and dysfunction (EF 20%)
Severe FMR (4+/4+), symmetric leaflet tethering +
annular dilatation
TR 2+/4+, tricuspid annulus > 40 mm
SPAP 35 mmHg
Mild RV dysfunction
LV dyssinchrony (no indication to CRT due to RBB
block)
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TEE during high rate AF Severe LV dysfunction + FMR
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LVEDD/LVESD
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LVEDV
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LVESV
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LVEF
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LV function and dimension improvement after AF rate control
EF 30%
LVEDD 75 mm
LVESD 68 mm
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Still severe MR after AF rate control
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Possible scenarios: medical therapy and HTX listing
- MV surgery + surgical AF ablation non
indicated
- Screening for HTx waiting list
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Possible scenarios:treating Functional MR
Mitraclip ?
MV surgery + surgical ablation of
permanent AF + tricuspid
annuloplasty?
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Mitraclip feasibility in Functional MR
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Coaptation length > 2 mm
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Coaptation depth 1 cm
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Regurgitant jet
Central origin
Eccentric direction
Extension <30%
(intercommissural
distance)
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Mean age 70 years
Euroscore 34
LVEDD 70 mm
LVEDV 252 mL
LVEF 19%
Hospital mortality 17%
MR post-Mitraclip
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Recurrent MR
No recurrent MR
Mortality in the follow-up is
strictly related to
residual/recurrent MR
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Possible scenarios:Mitraclip
……. Let’s try with the Mitraclip …..
It would be less risky for the
patient…. If it fails we will still
have the surgical option………………
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Is repair still feasible after Mitraclip implantation in FMR?
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Is repair or replacement the same?
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AATS Meeting San Francisco 28 april- 2 May 2012
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De Bonis M et al. Ann Thorac Surg. 2012 Mar 20
Repair might be better than replacement in FMR
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Possible scenarios: Mitraclip
PROS:
Lower procedural risk compared to surgery?
CONS:
AF and TR not addressed
Higher likelihood of residual/recurrent MR
Negative effect on reverse LV remodeling
If residual/recurrent MR surgical MV repair
unlikely
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- Replacement
- Good repair
- Bad repair
Possible scenarios: MV surgery
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- Replacement
- Good repair
- Bad repair
Possible scenarios: MV surgery
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Can we avoid bad repair?
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Can we avoid bad repair?
Complete rigid ring
Patient selection
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Can we avoid bad repair?
Complete rigid ring
Patient selection
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Is a good repair feasible in this patient?
YES
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MV parameters predicting residual/recurrent MR after undersized
annuloplasty
Absence of annular dilatation
Complex regurgitant jet
Coaptation depth > 10 mm
Distal anterior leaflet angle > 25o
Posterior leaflet angle > 45o
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Annular dilatation
Important annular dilatation in this patient
IC dimension43 mm
AP dimension47 mm
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Regurgitant jet
Central origin
Eccentric direction
Extension <30%
(intercommissural
distance)
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And what about tethering?
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Augmented PL tethering after undersized annuloplasty
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Augmented PL tethering after undersized annuloplasty
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Augmented PL tethering after undersized annuloplasty
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Lee et al. Circulation 2009;119:2606
Distal anterior leaflet angle
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Lee et al. Circulation 2009;119:2606
Distal anterior leaflet angle
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Lee et al. Circulation 2009;119:2606
Distal anterior leaflet angle
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Lee et al. Circulation 2009;119:2606
Distal anterior leaflet angle
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Lee et al. Circulation 2009;119:2606
Distal anterior leaflet angle
No MR
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Lee et al. Circulation 2009;119:2606
Distal anterior leaflet angle
No MR
Mild MR
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Lee et al. Circulation 2009;119:2606
Distal anterior leaflet angle
No MR
Mild MR
Severe MR
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Symmetric MV tethring
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MV leaflet tethering
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Posterior leaflet angle < 45°
30°
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Distal anterior leaflet angle < 20°
17°
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Possible scenarios:surgery (“good” MV repair)
PROS:
- Possibility to address all the pathophysiologic components of the disease
- Functional MR
- Tricuspid regurgitation
- Permanent AF
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Possible scenarios:surgery (“good” MV repair)
CONS:
- Surgical risk
- Reverse LV remodeling unpredictable
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Undersized annuloplasty
Clinical outcomes for different strata of LV dimensions
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….but what about the risk of no reverse LV remodeling?
According to baseline LV dimensions
- LV reverse remodeling unlikely
- However the real contribution of permanent AF to the severity of LV remodeling and dysfunction remains difficult to quantify
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Restoring sinus rhythm may significantly improve LV function and
promote reverse LV remodeling
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Univariate Multivariate
HR 95% CI p HR 95% CI p
NYHA >3 0.6 0.2-1.8 0.4
EF 0.9 0.8-1 0.1
SPAP 0.9 0.9-1.0 0.05 0.9 0.9-1 0.04
LVEDVI 0.9 0.9-1 0.3
LVESVI 0.9 0.9-1 0.4
MR at discharge 0.6 0.2-1.2 0.1
Edge-to-edge repair 2.3 0.9-6.1 0.07 1.8 0.6-4.8 0.2
AF ablation and/or CRT 2.7 1-7.6 0.04 3.4 1.2-9.7 0.02
Predictors of reverse LV remodeling
De Bonis M et al. European J Cardiothoracic Surgery, March 2012
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Is surgical ablation of AF going to
be effective in this patient?
Young pt ! (46 years)
Short AF duration (about 1 year)
but….
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Is surgical ablation of AF going to
be effective in this patient?
……. Large left atrium ….
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Classa Levelb
Surgery is indicated in patients with severe MR* undergoing CABG, and LVEF >30%
I C
Surgery should be considered in patients with moderate MR undergoing CABG**
IIa C
Surgery should be considered in symptomatic patients with severe MR, LVEF <30%, option for revascularization
IIa C
Surgery may be considered in patients with severe MR, LVEF >30%, who remain symptomatic despite optimal medical management (including CRT if indicated) and have low comorbidity, when revascularization is not indicated
IIb C
Indications for MV surgery in chronic secondary MR(ESC/EACTS Guidelines)
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Isolated undersized annuloplasty
Saddle St. Jude
Ring. N. 28
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Remodeling tricuspid annuloplastyEdwards MC3 tricuspid annuloplasty system n. 30
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Left pulmonary veins
MVLeft appendage
Right pulmonary veins
AF surgical ablation
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Postoperative TEENo residual MR
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Good postoperative MV coaptation length
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MV coaptation length 9 mm
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Postoperative TEENo residual tricuspid regurgitation
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Postoperative sinus rhythm
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Hospital discharge
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6 months follow-up
NYHA I-IIA
Major improvement in QoL
No CHF episodes
ECG: SR+RBB block
TTE: No MR, No TR, EF 40-45%
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Same patient but…
multiple comorbidities (renal, epatic, pulmonary …)
MITRACLIP
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Complementary role of Mitraclip and Surgery
SURGERY
Mitraclip
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Freedom from MR>2+ in FMR(HSR experience)
Mitraclip 58±9.3% at 1 year
Undersized annuloplasty88±3.7% at 1 year