Robert O. Bonow, MD, MS

Stages of Mitral Regurgitation

Northwestern University Feinberg School of Medicine

Bluhm Cardiovascular Institute

Northwestern Memorial Hospital

Mitral regurgitation

Degenerative MR: primary valve disease

Functional MR: primary myocardial disease

Stages of Valvular Heart Disease

Stage Definition

A Risk of valve disease

B Mild - moderate asymptomatic disease

C Severe valve disease but asymptomatic

C1: Normal LV function

C2: Depressed LV function

D Severe, symptomatic valve disease

Stages of Degenerative MR

Stage Definition

A Risk of valve disease

B Mild - moderate asymptomatic disease

C Severe valve disease but asymptomatic

C1: Normal LV function

C2: Depressed LV function

D Severe, symptomatic valve disease

(MVP, FED, RHD)

Stages of Functional MR

Stage Definition

A Risk of valve disease

B Mild - moderate asymptomatic disease

C Severe valve disease but asymptomatic

C1: Normal LV function

C2: Depressed LV function

D Severe, symptomatic valve disease

(MI, DCM, HF, AF)

Imprecision in grading severity of secondary MR

What is “severe”

secondary MR?

0

20

40

60

80

100

1 2 3 4 5 6 7 8

Surv

ival (p

erc

ent)

40

20

0

Grigioni et al. Circulation 2001;103:1759-1764

Time (years)

0 1 2 3 4 5

61%

47%

p<0.001

29%

Survival After MI

MI without MR

ERO 1-19

80

60

ERO ≥20

100

0

20

40

60

80

100

1 2 3 4 5 6 7 8

Surv

ival (p

erc

ent)

40

20

0

Grigioni et al. Circulation 2001;103:1759-1764

Time (years)

0 1 2 3 4 5

p<0.001

Survival After MI

MI without MR80

6061%

47%

29%

100

ERO ≥20

ERO 1-19

0

20

40

60

80

100

1 2 3 4 5 6 7 8

Surv

ival (p

erc

ent)

40

20

0

Grigioni et al. Circulation 2001;103:1759-1764

Time (years)

0 1 2 3 4 5

61%

47%

p<0.001

29%

Survival After MI

MI without MR

ERO 1-1960

ERO ≥20

100

n=109

n=194

80

n=83

n=111

0

20

40

60

80

100

1 2 3 4 5 6 7 8

100H

ospital-

Fre

e S

urv

ival (%

)

40

20

0

Time (years)

0 1 2 3 4 5

51%

24%

11%

No MR

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

6 7

Ischemic or Nonischemic Cardiomyopathy

Mild-Mod MR

Severe MR

60

80

p<0.001

n=965

n=304

n=661

n=335

ERO >20

Deja et al. Circulation 2012

p<0.001

0

200

400

600

800

1 2 3 4 5 6 7 8

Ischemic Cardiomyopathy80

0

Time (years)

0

60

40

20Mort

alit

y (

perc

en

t)

1 2 3 4 5 6

p<0.00155%

47%

30%

Deja et al. Circulation 2012;125:2639-2648

No MR

Mild MR

Mod-Severe MR

n=116

n=261

n=222

n=377

Average hospital mortality: 8.8%

• Low volume centers: 13.0%

• High volume centers: 6.0%

Data from national Medicare database 1994-1999

684 hospitals

142,488 AVRs

Medicare data

0

2

4

6

8

10

12

14

16

86 87 88 90Age Group (years)

16

0

Pre

vale

nce (

perc

ent)

20-34

10

8

45-54 55-64 65-7935-44 ≥80

4

Men

Women

6

2

14

12

Prevalence of Heart Failure

United States

Source: NHANES, CDC, and American Heart Association

Average hospital mortality: 8.8%

• Low volume centers: 13.0%

• High volume centers: 6.0%

Data from national Medicare database 1994-1999

684 hospitals

142,488 AVRs

Medicare data

0

2

4

6

8

10

12

86 87 88 90Age Group (years)

12

0

Perc

enta

ge w

ith A

F

50-59

Prevalence of Atrial FibrillationThe ATRIA Study

10

8

Go et al, JAMA 2001;285:2370-2375

65-69 75-79 80-8460-64 70-74 ≥85

4

Men

Women

6

2

n=17,974

Average hospital mortality: 8.8%

• Low volume centers: 13.0%

• High volume centers: 6.0%

Data from national Medicare database 1994-1999

684 hospitals

142,488 AVRs

Medicare data

0

1

2

3

4

5

6

7

8

9

10

87 88 90Age Group (years)

10

0

Perc

ent

with V

alv

e D

isease

<45

Prevalence of Mitral Regurgitation

8

Nkomo et al, Lancet 2006;368:1005-1011

55-6445-54 65-74 ≥75

4

CARDIA, ARIC, CHS (n=11,911)

Olmstead County (n=16,501)

6

2

28,412 subjects 6.4

2.9

9.6

7.3