mitral valve disease, when to intervene - fumed · mitral valve disease, when to intervene swedish...

Ming Zhang MD PhD Interventional Cardiology Structure Heart Disease

Mitral Valve Disease, When to

Intervene

Swedish Heart and Vascular Institute

Structural Heart ProgramSwedish Heart & Vascular Institute

Conflict of Interest

None


3

• Current ACC/AHA guideline

• Stages of Heart Valve Disease

• Evaluation of Surgical and Interventional Risk

• Evidence based management of mitral valve disease

• The transcatheter valve therapy, MitraClip and valve implantation

Objective


Stages of Progression of Valvular Heart Disease


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Abnormal structure and/or function of 1 or more of

the 4 components of the mitral apparatus

Leaflets, annulus,

Chordae tendineae,

Papillary muscles

Left ventricular myocardium


Carpentier’s functional classification. Type I, normal leaflet motion; Type II,increased leaflet motion (leaflet prolapse); Type IIIa restricted leaflet motion during diastoleand systole; Type IIIb restricted leaflet motion predominantly during systole


Mitral regurgitation (MR) is the most common type of heart valve insufficiency in the US1,2

1. Heart Disease and Stroke Statistics 2010 Update: A Report From the American Heart Association. Circulation.2010;121:e46-e215.

2. Nkomo et al. Burden of Valvular Heart Diseases: A Population-based Study, Lancet, 2006; 368: 1005-11.

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Prevalence of Valvular Heart Disease by Age

Prevalence increases from 0.5% for 18-44 year olds to 9.3% for ≥75 year olds (p<.0001)


1. U.S. Census Bureau, Statistical Abstract of the U.S.

2. Nkomo et al. Burden of Valvular Heart Diseases: A Population-based Study, Lancet, 2006; 368: 1005-11.

3. Patel, et al. Mitral Regurgitation in Patients with Advanced Systolic Heart Failure, J of Cardiac Failure, 2004.

4. Rankin, et al, J of Thoracic and Cardiovascular Surgery, March 2006

* Note: High-Risk Patients are defined as any patient with an EF<35% or an age of 75+.

49%High-Risk

Patients*,1-3

(860K)

49%Surgical

Candidates

(850K)

2%Surgical Patients (30K)Factors prohibiting

surgery include4:

• Impaired LVEF

• High operative risk

• Multiple comorbidities

• Advanced age

Nearly half of MR patients not considered appropriate for mitral valve surgery 4


Comparison of Early Surgery Versus Conventional Treatment in Asymptomatic Severe Mitral Regurgitation

Comparison of event-free survival rates between the operated (OP) and conventional treatment (CONV) groups in propensity-matched pairs.

Circulation. 2009;119:797-804

Structural Heart ProgramSwedish Heart & Vascular InstituteRecommendations for Chronic Primary MR


Pathogenesis of Right Ventricle in Mitral Valve Disease


Prevalence of Mild, Moderate, and Severe PH According to Left-Sided VHD


Tricuspid Regurgitation in Mitral Valve Disease Incidence, Prognostic Implications, Mechanism, and Management

J Am Coll Cardiol 2009;53:401–8


Right Versus Left Ventricular Failure Differences, Similarities, and Interactions

1. Embryological and Physiological Differences

2. Does the RV Differ From the LV in Its (Mal) Adaptation to Adverse Loading

3. How Does the RV Adapt to Chronically Increased Afterload

4. Mechanical and Functional Interdependence Between the RV and LV


Differences Between the Left and Right Ventricles Under Normal Conditions


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Intermediate Risk (Top 33% Surgical Risk)

STS ≥ 4

High Risk (Top 10% Surgical Risk)

STS ≥ 8

Cohort CDo not treat

Extreme RiskInoperable

Low Risk SAVR

80% of patients in STS Database* 14% 6%

* Thourani, Annals of Thoracic Surgery, 2015


ACCESS TO ABBOTT'S MITRACLIP® SYSTEM EXPANDS IN THE U.S. WITH MEDICARE NATIONAL COVERAGE DETERMINATION

- MEDICARE WILL PROVIDE NATIONAL COVERAGE FOR PEOPLE WITH SEVERE DEGENERATIVE MITRAL REGURGITATION DEEMED TOO SICK FOR SURGERY

- IN ADDITION, APPROVAL OF NEW TECHNOLOGY ADD-ON PAYMENT RECOGNIZES THE SUBSTANTIAL CLINICAL BENEFITS OF MITRACLIP THERAPY

ABBOTT PARK, Ill., Aug. 12, 2014 /


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The surgical mitral repair procedure introduced in 1991 by the Italian

surgeon Ottavio Alfieri who successfully treated a patient with anterior

leaflet prolapse.

In the largest surgical series from this same group, including 260

patients who underwent such repair, 80% of the cohort had

additional MV annuloplasty that was associated with reduced

reoperation at a mean follow-up of 5 years.

J Thorac Cardiovasc Surg 2001;122:674–81


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The MitraClip System

Gripper

Arm

MitraClip Device

(Clip)

Clip Delivery SystemMitraClip System

Delivery

Catheter

Handle

Stabilizer

Steerable

Guide Handle

Steerable Guide, Steerable

Sleeve, and Delivery Catheter

MitraClip Device

(Clip)


Current Status of MitraClip

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J Am Coll Cardiol 2014;64:172–81


Outcomes of the Initial Experience with Commercial TranscatheterMitral Valve Repair in the United States study,

The U.S. National TVT Registry 2015

This study included data from 564 high-risk patients with primary mitral regurgitation (MR)

Procedural success rate of 91.8% and a procedural complication rate of 7.8%. Procedural stroke rate was 1.8% The major bleeding rate was 3.9%.

Pre-implantation MR grade was 3 in 94% of patientsPost-implantation MR grade was 2 in 93% of patients and 1 in 63.7% of patients.

In hospital mortality was 2.3% and 30-day mortality was 5.8%.


Q&A


Pressure overload

Left-sided HF (most common cause)Pulmonary embolism (common)Other causes of PHRV outflow tract obstructionPeripheral pulmonary stenosis

Volume overload

Tricuspid regurgitationPulmonary regurgitationAtrial septal defectAnomalous pulmonary venous returnSinus of valsalva rupture into the RACoronary artery fistula to RA or RVCarcinoid syndromeRheumatic valvulitis


Ischemia and infarctionRV myocardial infarctionIschemia may contribute to RV dysfunction in CHD and RV overload states(especially pressure overload)Intrinsic myocardial processCardiomyopathy and heart failureArrhythmogenic RV dysplasiaSepsisInflow limitationTricuspid stenosisSuperior vena cava stenosisComplex congenital defectEbstein’s anomalyTetralogy of FallotTransposition of the great arteriesDouble-outlet RV with mitral atresiaPericardial diseaseConstrictive pericarditis

mitral valve disease, when to intervene - fumed · mitral valve disease, when to intervene swedish...

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