ICE VD or 2VD plus significant MR. G. Karavolias MD, FESC, FACC 2η Dept. of Cardiology Onassis Cardiac Surgery Center

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ICE 2011 3VD or 2VD plus significant MR G.

1 ICE VD or 2VD plus significant MR G. Karavolias MD, FESC, FACC 2η Dept. of Cardiology Onassis Cardiac Surgery Center

Causes of Mitral regurgitation Ø Ø Ø Ø Ø Ø Annulus Calcification Endocarditis (abcess) Valvular-leaflets Myxomatous MV Disease Rheumatic Endocarditis Congenital-clefts Chordae

2 Causes of Mitral regurgitation Ø Ø Ø Ø Ø Ø Annulus Calcification Endocarditis (abcess) Valvular-leaflets Myxomatous MV Disease Rheumatic Endocarditis Congenital-clefts Chordae Fused/inflammatory Torn/trauma Degenerative Endocarditis Papillary Muscles CAD (Ischemia, Infarction, Rupture) HCM Infiltrative disorders LV dilatation & functional regurgitation Trauma N Engl J Med 2001;345:740

3 Mitral regurgitation primary MR abnormalities of one or more of the components of the mitral valve cause it to leak LV volume overload LV remodeling myocardial dysfunction heart failure secondary MR mitral valve is usually normal LV damaged (MI, CAD, DCM) papillary muscle displacement and annular dilatation causing the mitral valve to leak

4 the presence of MR in ischemic and dilated cardiomyopathies worsens prognosis Ø interpretations (potentially very different): the volume overload created by the MR adds a greater pathologic? burden to an already adverse condition. the poorer ventricular function is the cause of the poorer prognosis and that the MR simply is an indicator of the poorer LV function. Ø the issue is central to the therapy for the condition. If secondary MR is a cause for worsened prognosis, it should represent a reasonable target for therapy. if secondary MR is simply a byproduct of disturbed LV geometry and function, correction of secondary MR may have little impact on outcome.

5 The patient Ø male, 42 years old Ø exertional dyspnea since last 3 months (NYHA class II III) Ø FH (+), DM (+), x-smoker Ø BP: 95/60 mmhg, HR: 98 bpm Ø S3 (+), holosystolic murmur (apex) Ø bibasilar rales Ø Med. Tx: ACE-inhibitors diuretics digitalis

6 HCG

7 X-ray

8 EF: 40% LVESD: 42 mm LVEDD: 56 mm IVS: 9 mm PWT: 8 mm LA: 46 mm MR: 3-4+/4+ ECHO

9 Angio LCA

10 Angio LCA

11 Angio RCA

12 SYNTAX Score

13 1. συντηρητική αγωγή 2. επαναιµάτωση 3. έλεγχος βιωσιµότητας 4. κάτι άλλο Επόµενο βήµα?

14 1. διαδερµική 2. χειρουργική 3. κάτι άλλο Επαναιµάτωση

15 Διαδερµική αντιµετώπιση 1. PCI 2. PCI + percutaneous mitral valve intervention 3. percutaneous mitral valve intervention

16 Χειρουργική αντιµετώπιση 1. CABG 2. CABG + αντιµετώπιση MR 3. αντιµετώπιση MR 4. κάτι άλλο

17 Χειρουργική αντιµετώπιση MR 1. αντικατάσταση µιτροειδούς 2. πλαστική µιτροειδούς

18 Επόµενο βήµα? 1. συντηρητική αγωγή 2. επαναιµάτωση 3. έλεγχος βιωσιµότητας 4. κάτι άλλο

19 In severe MR secondary to acute myocardial infarction Ø ruptured papillary muscle surgery on an emergency basis Ø papillary muscle displacement with leaflet tethering hemodynamic stabilization, usually with IABP ± surgery Ø annular dilatation from severe LV dilatation ACC/AHA 2008 Guidelines for the Management of Patients With Valvular Heart Disease

20 Functional MR and Survival in CHF Carabello B. et al, J Am Coll Cardiol 2008;52:319 26

21 Ischemic MR: Long-Term Outcome and Prognostic Implications With Quantitative Doppler Assessment Survival after diagnosis according to presence of IMR Survival after diagnosis accordig to degree of MR as graded by ERO <20 mm2 or >20 mm2 Grigioni F. et al, Circulation 2001, 103:

22 Symptoms + ischemia viability EF Revascularization ± Mitral Valve Surgery, in Pts With Ischemic MR vs. Medical Tx PCI: -31% (P<0.0001) CABG: -42% (P<0.0001) CABG+MV: -42% (P<0.0001) Trichon B, et al, Circulation. 2003;108[suppl II]:II-103-II-110

23 1. διαδερµική 2. χειρουργική 3. κάτι άλλο Επαναιµάτωση

24 symptoms or ischemia or viability PCI vs. CABG in Ischemic MR survival event free survival in-hospital death cardiac death hospitalization due to CHF Kang D.H. et al, Circulation, 2011;124[suppl 1]:S156 S162

25 PCI vs. CABG in Ischemic MR Ø Symptoms improvement: PCI: NS CABG: P<0.001 Ø EF improvement : (P<0.015) PCI: (1.9±9.3%) CABG: (6.2±13.1%) Ø MR improvement: P<0.001 PCI: (54% pts) CABG: (79% pts) Kang D.H. et al, Circulation, 2011;124[suppl 1]:S156 S162

26 Διαδερµική αντιµετώπιση 1. PCI 2. PCI + percutaneous mitral valve intervention 3. percutaneous mitral valve intervention

27 Pastorius C, Am J Cardiol 2007;100: Long-Term Outcomes of Patients With Ischemic MR Undergoing PCI N=711 Severity of MR is a potent independent predictor of survival nearly 25% of patients undergoing PCI do not have MR assessed!!!

28 MR Percutaneous Therapies leaflet repair using modifications of the surgical edge-to-edge technique mitral valve annulosplasty via either the coronary sinus

29 Leaflet Repair with the MitraClip (abbott vascular) N Engl J Med 2011;364:

30 EVEREST II N Engl J Med 2011;364:

31 Primary Efficacy End Point at 12 Months- Major Adverse Events at 30 Days (intention-to-treat analysis)

32 Subgroup Analyses for the Primary End Point at 12 Months

33 transcatheter valve annuloplasty with MONARC device (Edwards Lifesciences) J Am Coll Cardiol Intv 2011;4:115 22

34 EVOLUTION Phase I Study Probability of Event-Free Survival After MONARC Implantation The primary safety end point: freedom from death tamponade myocardial infarction J Am Coll Cardiol Intv 2011;4:115 22

35 Χειρουργική αντιµετώπιση 1. CABG 2. CABG + αντιµετώπιση MR 3. αντιµετώπιση MR 4. κάτι άλλο

36 Symptoms + ischemia viability EF Revascularization ± Mitral Valve Surgery, in Pts With Ischemic MR vs. Medical Tx PCI: -31% (P<0.0001) CABG: -42% (P<0.0001) CABG+MV: -42% (P<0.0001) Trichon B, et al, Circulation. 2003;108[suppl II]:II-103-II-110

37 Ischemic MR: Survival After Coronary Revascularization, With and Without MV Surgery Trichon B, et al, Circulation. 2003;108[suppl II]:II-103-II-110

38 symptoms + ischemia (-) viability (-) Results of Mitral Surgery in CHF CABG vs. CABG + mitral annuloplasty survival NYHA functional class N= 390 Mihaljevic T, J. Am. Coll. Cardiol. 2007;49;

39 Symptoms or ischemia or viability CABG vs CABG+MVP survival event free survival in-hospital death cardiac death hospitalization due to CHF Kang D.H. et al, Circulation, 2011;124[suppl 1]:S156 S162

40 Symptoms or ischemia or viability CABG vs CABG+MVP 7 years FU Ø δef: (P:NS) Ø MR improvement (P<0.001) Ø LVESV volume: (P<0.05) Ø LVEDV volume: (P<0.05) Ø cardiac events (P<0.05) Kang D.H. et al, Circulation, 2011;124[suppl 1]:S156 S162

Provocative intraoperative testing with TEE guidance preload and afterload challenges Ø No MV repair: both tests are negative regurgitation is induced but

41 Provocative intraoperative testing with TEE guidance preload and afterload challenges Ø No MV repair: both tests are negative regurgitation is induced but is associated with new wall motion abnormalities or ECG changes Ø MV repair: tests are positive and the regurgitation is not episodic Lancet 2000;355:

42 Χειρουργική αντιµετώπιση MR 1. αντικατάσταση µιτροειδούς 2. πλαστική µιτροειδούς

43 Mitral valve replacement with and without chordal preservation Circulation 1992, 86:

44 Mitral Valve Replacement Versus Repair Ann Thorac Surg 2007;84:

45 The patient Ø male, 42 years old Ø exertional dyspnea since last 3 months (NYHA class II III) Ø FH (+), DM (+), x-smoker Ø BP: 95/60 mmhg, HR: 98 bpm Ø S3 (+), holosystolic murmur (apex) Ø bibasilar rales Ø Med. Tx: ACE-inhibitors diuretics digitalis

46 IABP

47 Th201

48 CABG

49 Take home message Ø clinical management focuses on treatment of the causal disease process, rather than on direct attempts to decrease regurgitant severity Ø more options for intervention available: medical therapy percutaneous intervention surgical valve repair or replacement Ø all must be considered!!! Ø a patient-centered approach to decision making Ø review of each case by a heart team: a nonprocedural valve-disease specialist an interventional cardiologist cardiologist a cardiac surgeon N Engl J Med 2011; 364:

50 Επόµενο βήµα? 1. συντηρητική αγωγή 2. επαναιµάτωση 3. έλεγχος βιωσιµότητας 4. κάτι άλλο Επαναιµάτωση 5. διαδερµική 6. χειρουργική 7. κάτι άλλο Διαδερµική επαναιµάτωση 1. PCI 2. PCI + percutaneous mitral valve intervention 3. percutaneous mitral valve intervention Χειρουργική αντιµετώπιση 8. CABG 9. CABG + αντιµετώπιση MR 10. αντιµετώπιση MR 11. κάτι άλλο Χειρουργική αντιµετώπιση 12. αντικατάσταση µιτροειδούς 13. πλαστική µιτροειδούς

51 thank you

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