ΕΝΔΕΙΞΕΙΣ ΑΝΤΙΚΑΤΑΣΤΑΣΗΣ ΑΟΡΤΙΚΗΣ ΚΑΙ ΜΙΤΡΟΕΙΔΟΥΣ ΒΑΛΒΙΔΑΣ ΜΑΥΡΟΥΔΗ ΜΕΛΑΧΡΙΝΗ ΚΑΡΔΙΟΛΟΓΟΣ

Οι οδηγίες προσανατολίζονται στην αντιμετώπιση βαλβιδοπαθειών των ενηλίκων Έλλειψη στοιχείων μεγάλων τυχ. μελετών Συστάσεις είναι αποτέλεσμα συναινετικής γνώμης Αποκλείσεις από κατευθυντήριες οδηγίες σε συγκεκριμένες κλινικές καταστάσεις

Απόφαση για χειρουργική επέμβαση Ανάλυση κινδύνου οφέλους με πολυμεταβλητά συστήματα βαθμονόμησης (EuroScore>20%, STS Score>10%) Προσδόκιμο επιβίωσης του ασθενή Ποιότητα ζωής Κόστος Επιθυμία του

Ανεπάρκεια αορτικής βαλβίδας

Ενδείξεις για χειρουργική διόρθωση ανεπάρκειας αορτής (ΑR) Η σοβαρότητα ορίζεται: Κλινική εκτίμηση Υπερηχοκαρδιογραφική εκτίμηση Ασυμπτωματικοί ασθενείς : επαναλαμβανόμενες υψηλής ποιότητας μετρήσεις πριν τη χειρουργική επέμβαση

Στένωση αορτικής βαλβίδας

2 τύποι διακαθετηριακής αορτικής βαλβιδικής πρόθεσης (TAVI) : 1. H εκπτυσσόμενη με μπαλόνι βιοπροσθετική βαλβίδα Edwards SAPIEN 2. H αυτοεκτεινόμενη βαλβίδα της Medronic Core Valve

Mitral Valve Aortic Valve Complex Simple

Ανεπάρκεια μιτροειδούς βαλβίδας

BACKGROUND Assessment of Mitral Regurgitation is a complex process that requires integration of clinical and echocardiographic skills Quantification of MR is of prognostic significance The degree of severity is directly linked to the pathology and the anatomy of the valve The decision for intervention is based on the severity of MR but also on the estimation of LV function, likelihood of repair, clinical parameters etc.

Role of echocardiography- repair or replacement? Quantify the severity of MV disease Identify MV pathology, anatomy and mechanism of MR and communicate that with the surgeon Assess LV function Predict the feasibility of repair Facilitate surgical planning Monitor immediate MV repair outcome in OR Assess potential complications and the mechanisms of failed repair Assist in planning further management of these patients

TEE is superior to TTE in assessing MV 3DTEE offers a unique combination of excellent resolution and live 3D imaging of MV Permits assessment

What is the reason for the MR?

Degenerative mitral disease with large posterior leaflet prolapse imaged by real-time threedimensional transoesophageal echocardiography. De Bonis M, Bolling S F Eur Heart J 2013;34:13-19 Published on behalf of the European Society of Cardiology. All rights reserved. The Author 2012. For permissions please email: journals.permissions@oup.com.

Quantification of MR

Types and Mechanisms of MR 1. Primary (organic or degenerative) MR: Intrinsic valve disease 2. Secondary (functional) MR: Structurally nl valve - Ischemic or idiopathic dilated cardiomyopathy: Left ventricular remodeling resulting in papillary muscle displacement, choral traction, leaflet tethering and abnormal coaptation; annular dilation is mild and occurs late - Lone atrial fibrillation: LA dilatation (with nl LV size and fxn) may result in MR by: 1. Exerting tension on the posterior leaflet 2. Altering the planarity of the mitral annulus 3. Impairing the timing of valve closure 4. Increased annular size and geometry 5. Direct effects of loss of atrial Hoit BD. JACC 2011;58;1482-1484

Οργανική MR H πρωτοπαθής παθολογία των γλωχίνων είναι η πρωταρχική αιτία της νόσου Περιλαμβάνει : Εκφυλιστική μυξωματώδη MR Ρευματική MR

Λειτουργική ΜR H MR είναι η συνέπεια νόσου της LV Περιλαμβάνει : Μη ισχαιμική MR (διατατική μυοκαρδιοπάθεια, τελικό στάδιο ΧΝΑ, βηματοδότοση της RV) Ισχαιμική νόσο MR με σοβαρή δυσλειτουργία της LV (οξεία, χρόνια, συνδυασμό των δύο)

Εκφυλιστική MR Ινοελαστική ανεπάρκεια : ανεπάρκεια της φιμπριλλίνης, λεπτές γλωχίνες, ρήξη λεπτών και επιμηκυσμένων χορδών, συνήθως μεσαίο τμήμα οπισθίας γλωχίν., φυσιολογική διάμετρο του δακτυλίου, ασθενείς>60ετών, βραχύ ιστορικό

Νόσος του Barlow μεγάλο μέγεθος βαλβίδας διάχυτη περίσσεια ιστών, αφορά πολλά τμήματα γλωχίνων διάχυτη επιμήκυνση των χορδών και ρήξη σοβαρή διάταση δακτυλίου με ασβεστοποίηση υποβαλβιδική ίνωση και ασβεστοποίηση των θηλοειδών μυών ασθενείς<60ετών, μακρύ ιστορικό φυσήματος

Spectrum of degenerative mitral disease There is a spectrum of degenerative disease ranging from fibroelastic deficiency (FED) to Barlow's disease Adams D H et al. Eur Heart J 2010;31:1958-1966 Published on behalf of the European Society of Cardiology. All rights reserved. The Author 2010. For permissions please email: journals.permissions@oxfordjournals.org

Echocardiographic differentiation of degenerative mitral disease Adams D H et al. Eur Heart J 2010;31:1958-1966 Published on behalf of the European Society of Cardiology. All rights reserved. The Author 2010. For permissions please email: journals.permissions@oxfordjournals.org

Grading of Severity of Primary MR Parameters Mild Moderate Severe Qualitative MV morphology Colour flow MR Jet Normal/Abnormal Small, central Normal/Abnormal Intermediate Flail leaflet/ruptured PMs Very large central jet or eccentric jet adhering, swirling and reaching the posterior wall of the LA Flow convergence zone CW signal of MR jet No or small Faint/Parabolic Intermediate Dense/Parabolic Large Dense/Triangular Semi-quantitative VC width (mm) Pulmonary vein flow Mitral inflow VTI mit/vti Ao <3 Systolic dominance A wave dominant <1 Intermediate Systolic blunting Variable Intermediate 7 (> 8 for biplane) Systolic flow reversal E wave dominant (> 1.5 cm/s) > 1.4 Quantitative EROA (mm2) R Vol (ml) < 20 < 30 20-29;30-39 30-44;45-59 40 60 LV and LA size and the systolic pulmonary pressure (Lancellotti P et al. Eur J Echocardiogr 2010;11:307-332)

The debate around patients with asymptomatic severe mitral regurgitation There are no randomized trials comparing strategies of early versus later surgical intervention for mitral regurgitation caused by degenerative mitral valve disease; recommendations therefore are based on data from longitudinal observational studies

Event-Free Survival in Asymptomatic Patients With Severe Degenerative Mitral Regurgitation and Preserved Ventricular Function Copyright 2011 American College of Cardiology Foundation. Restrictions may apply.

Long-term survival in asymptomatic patients with severe degenerative mitral regurgitation: a propensity score-based comparison between an early surgical strategy and a conservative treatment approach Montant P et al, J Thorac Cardiovasc Surg 2009 192 patients survival at 10 years was significantly better in patients undergoing early surgery for severe mitral regurgitation (86% vs. 50%, p < 0.00001)

Survival implication of left ventricular end-systolic diameter in mitral regurgitation due to flail leaflets: a long-term follow-up multicenter study Tribouilloy C et al, J Am Coll Cardiol 2009 10-year risk-adjusted cardiac death-free survival was higher with an LVESD <40 mm versus one of 40 mm or more (73 ± 5% vs. 63 ± 10%, p = 0.001)

Ισχαιμική MR Διάταση δακτυλίου Μετατόπιση των δύο θηλοειδών μυών (κορυφή και οπίσθιο-κάτω τοίχωμα) Διάταση (tethering) και ατελή σύγκλειση των γλωχίνων Τμηματική δυσλειτουργία του τοιχώματος της LV

Mechanisms of Ischemic Mitral Regurgitation Papillary muscle traction Bulging Increased tethering Decreased closing force MR Annular dilatation

the ventricle, rather than the valve, should be our prime focus in targeting ischemic mitral regurgitation Pre-operative assessment of patients with moderate ischemic mitral valve regurgitation probably should include more detailed study of ventricular viability and papillary muscle function

Pathophysiology of Secondary MR Normal leaflets Global (and regional) LV dysfunction Type III restricted motion Incomplete mitral leaflet closure : - apical displacement of PM - increased tethering distance - increased tenting area - bending of mid anterior leaflet (seagull sign) - diastolic restriction of anterior leaflet opening

Rationale for the Correction of Secondary MR Which is the chicken, which is the egg?

Ischemic vs Non-Ischemic MR 535 patients operated using annuloplasty (1993-2002) Ischemic MR (n=141) Non ischemic MR (n=394) p Age (years) Hypertension (%) 69 [61-75] 39 59 [51-69] 24 <0.001 0.001 Diabetes (%) 35 8 <0.001 Renal insufficiency (%) 18 7 <0.001 COPD(%) 22 8 <0.001 NYHA IV (%) 72 38 <0.001 LV EF 40 [30-43] 50 [40-56] <0.001 Coronaropathy (%) 100 18 <0.001 Mortality at 30 D (%) 4.3 1.3 0.04 (Glower. J Thorac Cardiovasc Surg 2005;129:860-8)

Large exercise-induced increase in ischaemic mitral regurgitation. ERO 22 mm2 ERO 38 mm2 Piérard L A, Carabello B A Eur Heart J 2010;31:2996-3005 Published on behalf of the European Society of Cardiology. All rights reserved. The Author 2010. For permissions please email: journals.permissions@oup.com

Ischaemic MR is severe if ERO >20 mm2 and Regurgitant Volume>30 ml

Outcomes of surgery for MR

Mortality of Mitral Surgery in Europe EACTS (2010) UK (2004-2008) Germany (2009) Valve Repair (%) 2.1 (n= 3231) 2 (n=3283) 2 (n=3335) Valve replacement (%) 4.3 (n=6838) 6.1 (n=3614) 7.8 (n=1855) Repair / Replac.+ CABG (%) 6.8/11.4 (n= 2515/1612) 8.3/11.1 (n=2021/1337) 6.5/14.5 (n=1785/837) EACTS report 2010. Dendrite Clinical Systems Ed, Henley-on-Thames, UK. Bridgewater B 2009 Dendrite Clinical Systems Ltd, Henley-on-Thames. Gummert JF, J Thorac Cardiovasc Surg 2010;58:379-386.

Valve Repair is the Treatment of Choice (Enriquez-Sarano. Circulation 1995:1022-8)

Mitral Valve Repair Valve repair, when feasible, is the optimal surgical treatment in patients with severe MR (ESC Guidelines Eur Heart J 2007;28:230-268) Considering the beneficial effect of MV repair on survival and LV function, cardiologists are strongly encouraged to refer patients who are candidates for MV repair to surgical centers experienced in performing MV repair (ACC/AHA Guidelines J Am Coll Cardiol 2006;48:598-675)

PATIENTS IN WHOM REPAIR IS UNLIKELY TO BE SUCCESFUL Complex multiple jets No annular dilatation Large tenting area Coaptation depth > 1.5 cm. Alfieri

PATIENTS UNLIKELY TO SURVIVE THE OPERATION Right heart failure No or little contractile reserve Significant comorbidities Alfieri

MV Repair in pts with LV Dysfunction and Mod/severe MR Undergoing CABG: STICH Of 1,212 pts with CAD and LVEF <35% enrolled in STICH, 220 pts (18%) had site reported moderate (181) or severe (39) MR. 116 were rand to med Rx and 104 to CABG (91 of whom underwent surgery, with MV repair in 49). Mortality in the Med Rx arm according to MR grade 1.0 0.9 0.8 0.7 0.6 0.5 0.4 Mortality 0.3 0.2 0.1 Patients at Risk: Moderate/Severe 116 Mild 261 None/Trace 222 Mild MR vs. none/trace: HR (95%CI) = 1.54 (1.14 2.07) Mod/sev MR vs. none/trace: HR (95%CI) = 2.01 (1.42 2.85) 0.0 0.0 0.5 1.0 Moderate or Severe MR Mild MR None or Trace MR 95 238 197 1.5 2.0 2.5 85 242 188 3.0 3.5 4.0 Years 75 185 173 Deja MA et al. Circulation 2012;on-line 50 131 129 52% 45% 29% 4.5 5.0 5.5 6.0 22 57 73 5 30 44

MV Repair in pts with LV Dysfunction and Mod/severe MR Undergoing CABG: STICH Of 1,212 pts with CAD and LVEF <35% enrolled in STICH, 220 pts (18%) had site reported moderate (181) or severe (39) MR. 116 were rand to med Rx and 104 to CABG (91 of whom underwent surgery, with MV repair in 49). Mortality with Med Rx vs CABG in pts with mod/sev MR 1.0 0.9 0.8 0.7 0.6 0.5 Mortality 0.4 Patients at Risk: 0.3 0.2 0.1 0.0 MED 115 CABG 104 MED (N=116, 58 deaths) CABG (N=104, 50 deaths) CABG vs Med Rx: HR (95%CI) = 0.92 (0.63 1.35) 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 Years 95 82 85 71 75 67 Deja MA et al. Circulation 2012;on-line 50 52 52% 48% 4.5 5.0 5.5 6.0 22 24 5 15

Post repair case 1

Post repair case 2

Functional MR Dilated Cardiomyopathy Disease of the left ventricle NOT of the mitral valve MR caused by apical lateral distraction of the papillary muscles tethering the leaflets Annular dilitation is secondary and occurs greatest in the septallateral (anterior-posterior) dimension Surgical repair based on over correction of the annular dilitation

Surgical Options Correction of FMR Annuloplasty Valve Replacement Chord cutting Chordal shortening

Impact of CRT in pts with MR

CRT in pts with HF and Severe FMR 98 pts with 3-4+ FMR: mean age 71 yrs, mean NYHA 3.2, mean log EuroScore 26, mean LVEF 23%; matched echos in 85 Outcomes in MR responders vs non-responders (median FU median 32 months [range 6.0 to 116 months]): 100% 80% 60% Survival 40% 97% 88% 92% 67% MR responders (n=42) MR non-responders (n=43) Patients at risk 20% 0% MR responders 42 MR non-responders 43 p<0.001 0 12 24 36 48 60 Follow-up (months) 37 38 28 24 24 14 18 9 13 8 van Bommel RJ et al. Circulation 2011;124:912-9

MitraClip studies

MitraClip: Worldwide Experience As of 5/25/12 Study EVEREST I (Feasibility) EVEREST II (Pivotal) EVEREST II (High Risk Registry) EVEREST II (Pivotal) REALISM (Continued Access) Compassionate/Emergency Use ACCESS Europe Phase I ACCESS Europe Phase II Commercial Use Total Population Feasibility pts Pre-randomized pts Non-randomized pts Randomized pts Non-randomized pts Non-randomized pts Non-randomized pts Non-randomized pts Commercial pts N* 55 60 78 184 699 42 566 152 3,675 5,511 Source: Abbott Vascular

MitraClip Commercial Implant Experience As of 5/25/12 Patients:1 4,393 Treating Centers: 157 Implant Rate:1 96% Acute MR reduction:1,2 98% Etiology Functional MR Degenerative MR Mixed 1. First-time procedures only 2. Successful implants only 67% 25% 8% 25% Etiology 8% Mixed DMR FMR 67% Source: Abbott Vascular

Utility of Real-time 3DE to Guide MitraClip Structured analysis of MitraClip procedure in 28 pts treated for 3-4+ MR 2D TEE showing acceptable clip position in ML direction (intercommissural view) and AP direction (LVOT view) 3D TEE in zoom mode from LA showing clip is too medial 3D TEE showing optimal clip position in AP and ML direction Altiok E et al. Clin Res Cardiol 2011;100:675 681

The Classic Struggle Between Catheter-Based Therapy and Surgery Less Invasive and Safer vs. Less Effective

The Balance - FMR Surgical Intervention Long Term Outcome Known No Survival Benefit Demonstrated Better Efficacy Less MR FC and LV Remodeling Improved MitraClip Less Invasive with Lower Morbidity More Rapid Return to Function Favorable Remodeling FC and QOL Improved Surgical options preserved

Στένωση μιτροειδούς

Συμπερασματικά για την αορτική και μιτροειδική βαλβιδοπάθεια Bελτίωση στο μέλλον αναμένεται με: Καλύτερη εφαρμογή κατεθευντήριων οδηγιών Εξειδικευμένα χειρουργικά κέντρα επανακατασκευής (repair) βαλβίδων μεγαλύτερης διάρκειας Νέες μελέτες με καλύτερες αποδείξεις