insuffisance mitrale organique cas clinique mis à disposition par claire bouleti
TRANSCRIPT
Insuffisance mitrale organique
Cas clinique mis à disposition par Claire BOULETI
Mitral Regurgitation
(Iung et al. Eur Heart J 2003;24:1244-53)
(Nkomo et al. Lancet 2006;368:1005-11)
Euro Heart Survey
Population-Based Series
Case study: Mitral regurgitation (MR)
• 52 years old man, no medical history, no CV risk factors
• Follow-up for degenerative MR since1995
• Asymptomatic
• Clinical examination: BP 150/80 HR 66/min
– Systolic heart murmur (3/6), heard at the apex (maximal), radiates to
left side of the sternum and to the axilla.
– No other abnormalities
• Chest x-rays: no LV enlargement, no fluid accumulation in the lungs.
• ECG: Sinus rhythm 66/min. No abnormalities
TTE
Echocardiogram results
• Mitral regurgitation
• Internal P2 prolapse
• Severe MR: Regurgitant volume 98 ml/beat
ERO: 0,5 cm²
• LV 56/32 mm
• Preserved LV function
• LA dilation at 130 ml
• sPAP 36 mmHg
Stress Echocardiography
Maximal stage of exercise tolerance test reached (96% of TMHB, 150W).
Stress test stopped for muscular exhaustion.
Asymptomatic patient
Maximal stress sPAP: 50 mmHg
Novembre 2010
52 years old man, no comorbidity
Severe degenerative MR,
Truely symptomatic,
No impact on LV function
But LA dilation.
How to manage this patient?
Management of asymptomatic MR
Natural history
Quantification
Mechanisms
Anatomy (segmental analysis)
Guidelines
Natural History of MR
Years
Survival(%) Observed
57%
Expected
P = 0.016
65%
(Avierinos et al. Circulation 2002;106:1355-61)
Primary predictors• EF ≤ 50%
• MR ≥ moderateExcess Mortality
Quantification of MR and Prognosis
(Enriquez-Sarano et al. N Engl J Med 2005;352:875-83)
Cardiac Deaths Cardiac Events
456 asymptomatic patientsQuantification of the degree of MR
Outcome under Medical Management
Criteria Mitral RegurgitationSpecific signs of severe regurgitation
• Vena contracta width 0.7 cm with large central MR jet (area > 40% of LA) or with a wall impinging jet of any size, swirling in LA
• Large flow convergence• Systolic reversal in pulmonary veins prominent flail
mitral valve or ruptured papillary muscle
Supportive signs • Dense, triangular CW Doppler MR jet• E-wave dominant mitral inflow (E > 1.2m/s) • Enlarged LV and LA size (particularly when normal LV
function is present)
Quantitative parameters
Reg. Vol (ml/beat) 60
RF (%) 50
ERO (cm²) 0.40
(Adapted from Zoghbi et al. J Am Soc Echocardiogr 2003;16:777-802)
Definition of Severe Mitral Regurgitation
Mechanism of MR
• Functional Classification (Carpentier)
• Etiology
Feasability of repair
Etiology of MR
• Infective endocarditis
Repair is feasible in experienced hands
• Rheumatic MR
Less good late results
(Deloche et al. J Thorac Cardiovasc Surg 1990; 99:990-1002)
Etiology of MR
• Degenerative MR Repair is frequently feasible
Valve prolapse is the main mechanism
Wide spectrum of anatomic presentations
Does anatomy influence the quality of late results ?
Lesions
Chordae : rupture, lenghtening
Leaflets : thin or tissue excess, pliable
Annular dilatation
(Monin et al. J Am Coll Cardiol 2005;46:302-9)
Functional Analysis of MR
• 279 patients operated on for severe MR• Valve repair: 237, valve replacement: 42
• Good concordance between TTE and surgical findings• Prognostic impact
Functional Analysis of MR Using 3D-Echo
(La Canna et al. Am J Cardiol 2011;107:1365-74)
Class
Asymptomatic patients with LV dysfunction (ESD > 45 mm* and /or LV EF 60%)
IC
Asymptomatic patients with preserved LV function and AF or pulmonary hypertension (sPAP >50 mmHg at rest)
IIaC
Asymptomatic patients with preserved LV function, high likelihood of durable repair, and low risk for surgery
IIbB
* Lower values can be considered for patients of small stature.
Guidelines: Indications for Surgery in Severe Chronic Asymptomatic Organic Mitral Regurgitation
Class
Asymptomatic patients with LV dysfunction (ESD > 45 mm* and /or LV EF 60%)
IC
Asymptomatic patients with preserved LV function and AF or pulmonary hypertension (sPAP >50 mmHg at rest)
IIaC
Asymptomatic patients with preserved LV function, high likelihood of durable repair, and low risk for surgery
IIbB
* Lower values can be considered for patients of small stature.
Guidelines: Indications for Surgery in Severe Chronic Asymptomatic Organic Mitral Regurgitation
Septembre 2011
AsymptomaticFollow-up of its MR
Clinical examination: unchanged
Septembre 2011
AsymptomaticFollow-up of its MR
Clinical examination: unchanged
TTE/TEE: severe MR, ERO= 50 mm2 P2 posterior leaflet prolapse and tendinous cord rupture
on degenerative mitral valve VG 66/45 mmLVEF > 60%
LA Dilation: 130 ml sPAP: 35 mmHg
Management of the patient?
In favor of MR treatment
• Natural history of MR due to flail leaflets
• Early LV dysfunction: ESD 45 mm
Class
Asymptomatic patients with LV dysfunction (ESD > 45 mm* and /or LV EF 60%)
IC
Asymptomatic patients with preserved LV function and AF or pulmonary hypertension (sPAP >50 mmHg at rest)
IIaC
Asymptomatic patients with preserved LV function, high likelihood of durable repair, and low risk for surgery
IIbB
* Lower values can be considered for patients of small stature.
In favor of MR treatment
• Natural history of MR due to flail leaflets
• Early LV dysfunction: ESD 45 mm
Class
Asymptomatic patients with LV dysfunction (ESD > 45 mm* and /or LV EF 60%)
IC
Asymptomatic patients with preserved LV function and AF or pulmonary hypertension (sPAP >50 mmHg at rest)
IIaC
Asymptomatic patients with preserved LV function, high likelihood of durable repair, and low risk for surgery
IIbB
* Lower values can be considered for patients of small stature.
(Enriquez-Sarano et al. Circulation 1994;90:830-7)
> 60 %
409 patients undergoing MR surgery
Facteurs prédictifs p
FEVG 0.0004Age 0.003Créatinine 0.006Coronaropathie 0.024HTA 0.016
Do not wait for LVEF < 60%
Treatment of degenerative MR
Medical treatment: no option
Mitral valve repair
or
MVR
(Mohty et al. Circulation 2001;104(suppl.I):I-1-7)
Mitral valve repair or valve replacement? Long-term Results
(Hammermeister et al. J Am Coll Cardiol 2000;36:1152)
Valve Repair is the Treatment of Choice
(Enriquez-Sarano et al. Circulation 1995:1022-8)
Results of Surgery in Patients with Severe Mitral Regurgitation in NHYA Class I-II
n Valve Repair (%)
Degenerative origin
(%)
Operative mortality
(%)
Maximum FU
(years)
Late survival
(%)
Tribouilloy 199 79 79 0.6 10 80
Sousa Uva 175 99 73 1 5 98
Garbarz 109 100 80 1 7 87
Management of Asymptomatic Severe Chronic Organic Mitral Regurgitation LVEF > 60% andLVEF > 60% and
LVESD < 45 mmLVESD < 45 mm
NoNoYesYes
Atrial fibrillation orAtrial fibrillation orsPAP > 50 mmHg at sPAP > 50 mmHg at
restrest
NoNo YesYes
* valve repair can be considered when there is a high likelihood of
durable valve repair at a low risk
Surgery Surgery (repair whenever possible)(repair whenever possible)Follow-up*Follow-up*
Severe asymptomatic organic MRSevere asymptomatic organic MR
Management of Asymptomatic Severe Chronic Organic Mitral Regurgitation LVEF > 60% andLVEF > 60% and
LVESD < 45 mmLVESD < 45 mm
NoNoYesYes
Atrial fibrillation orAtrial fibrillation orsPAP > 50 mmHg at sPAP > 50 mmHg at
restrest
NoNo YesYes
* valve repair can be considered when there is a high likelihood of
durable valve repair at a low risk
Surgery Surgery (repair whenever possible)Follow-up*Follow-up*
Severe asymptomatic organic MRSevere asymptomatic organic MR
Management of Symptomatic Severe Chronic Organic Mitral Regurgitation
LVEF > 30%
NoYes
Valve repair is likelyand low comorbidity
NoYes
* valve replacement can be considered in
selected patients
Surgery (repair whenever
possible) Medical therapy*Transplantation
Refractory to medical therapy
Yes No
Medical therapy
Severe symptomatic organic MR
Class
Symptomatic patients with LV EF >30% and ESD < 55 mm* IB
Asymptomatic patients with LV dysfunction (ESD > 45 mm* and /or LV EF 60%)
IC
Asymptomatic patients with preserved LV function and AF or pulmonary hypertension (sPAP >50 mmHg at rest)
IIaC
Patients with severe LV dysfunction (LV EF < 30% and/or ESD > 55 mm*) refractory to medical therapy with high likelihood of durable repair and low comorbidity
IIaC
Asymptomatic patients with preserved LV function, high likelihood of durable repair, and low risk for surgery
IIbB
Patients with severe LV dysfunction (LV EF < 30% and/or ESD > 55 mm*) refractory to medical therapy with low likelihood of repair and low comorbidity
IIbC
** Lower values can be considered for patients of small stature.
Indications for Surgery in SevereChronic Organic Mitral Regurgitation
Percutaneous Mitral Valve Repair ? Edge-to-Edge Technique: Mitraclip
Everest II Randomized n=279 (Mitraclip 184/ Surgery 95)
EVEREST II Randomized Clinical Trial
279 Patients enrolled at 37 sites
Randomized 2:1
Control GroupSurgical Repair or Replacement
N=95
Significant MR (3+-4+)
Device GroupMitraClip System
N=184
MR etiology: Degenerative/functional (%): 73/27 in both groups (p=0.81)
SafetyMajor Adverse Events
30 days
EffectivenessClinical Success Rate*
12 months
EVEREST II
Device Group, n=180
Control Group, n=94
Met superiority hypothesisMet superiority hypothesis• Pre-specified margin =2%
• Observed difference = 32.9%
Control Group, n=89
Device Group, n=175
Met non-inferiority hypothesisMet non-inferiority hypothesis• Pre-specified margin = 25% • Observed difference = 7.3%
66.9%
74.2%
15.0%
47.9%
pSUP <0.0001 pNI =0.0005
* Freedom from the combined outcome of death, MV surgery or re-operation for MV dysfunction >90 days post Index procedure, MR
>2+ at 12 months
SafetyMajor Adverse Events
30 days
EffectivenessClinical Success Rate*
12 months
EVEREST II
Device Group, n=180
Control Group, n=94
Met superiority hypothesisMet superiority hypothesis• Pre-specified margin =2%
• Observed difference = 32.9%
Control Group, n=89
Device Group, n=175
Met non-inferiority hypothesisMet non-inferiority hypothesis• Pre-specified margin = 25% • Observed difference = 7.3%
66.9%
74.2%
15.0%
47.9%
pSUP <0.0001 pNI =0.0005
* Freedom from the combined outcome of death, MV surgery or re-operation for MV dysfunction >90 days post Index procedure, MR
>2+ at 12 months
SafetyMajor Adverse Events
30 days
EffectivenessClinical Success Rate*
12 months
EVEREST II
Device Group, n=180
Control Group, n=94
Met superiority hypothesisMet superiority hypothesis• Pre-specified margin =2%
• Observed difference = 32.9%
Control Group, n=89
Device Group, n=175
Met non-inferiority hypothesisMet non-inferiority hypothesis• Pre-specified margin = 25% • Observed difference = 7.3%
66.9%
74.2%
15.0%
47.9%
pSUP <0.0001 pNI =0.0005
* Freedom from the combined outcome of death, MV surgery or re-operation for MV dysfunction >90 days post Index procedure, MR
>2+ at 12 months
MAE : All tr
ansfusions ≥
2 Units
EVEREST II : MR Reduction
Device Group Control Group
≤2+
n=137 n=119 n=80 n=67
3+/4+
≤2+
3+/4+
81.5%
18.5%3+/4+
97.0%
Feasible Can be safely performed in experienced hands Can decrease the severity of MR at mid-term
BUT
• No long-term results• Only 1 randomized trial: 1-year results, residual MR in 18%.• Very good results of mitral valve repair.
for patients with contra-indications to or at high risk for surgery
Waiting for thorough evaluation of results (randomized trials, long-term FU)
Back to Mr G
• Mitral valve repair
• P2 prolapse
• Repair of 2 cords on A2
• And of 4 cords on P2,
• Surgical repair of incision between P2 and P3,
• Annuloplasty with implantation of a Duran flexible ring n°35
Per-operatory TEE: no prolapsus, negligible central MR
Results
• Favourable immediate evolution
• Post-operative echocardiography at D13 (TTE+TEE)
• No residual MR
• Mean gradient 4 mmHg
• LV 52/34 mm LVEF 65%
• At 3 months: Asymptomatic + normal examination/TTE
Post-operative TTE
• MR is the 2nd most frequent valvular disease. Mainly of degenerative origin and the most frequent mechanism is valve prolapse.
• TTE is the key exam to assess MR mechanism, severity and anatomy (impact on the feasibility of valve repair).
• The prognosis of MR depends on LV function, which is not a reliable criterion for indicating surgery: do not wait for LVEF<60%.
Conclusion (I)
• There is a trend towards earlier interventions, but which needs to take into account the operative risk and the feasibility of valve repair.
• Intervention can be considered in asymptomatic patients without waiting for ESD > 45 mm or LVEF < 60%, provided: MR is severe Operative risk is low There is a high likelihood of durable valve repair (IIB)
• In other cases, “watchful waiting” is a valid alternative, with directing patients to surgery in case of early signs of LV dysfunction.
Conclusion (II)