Functional mitral regurgitation: The role of echocardiography in taking therapeutic decisions Ilias K Karabinos Euroclinic Athens
DECLARATION OF INTEREST Nothing to declare
Mitral Regurgitation:classification
FMR Pathophysiology: the balance between tethering and closing
Phenotypes of FMR: Asymmetric Model an inferoposterior myocardial infarction outpouching of the LV myocardium displacement of the posteromedial PM increase tethering forces on the leaflets. less LV closing force decreased basal clockwise rotation force Less mitral annulus contraction dysynchrony Pseudoprolapse and a posteriorly directed eccentric MR
Phenotypes of FMR: Symmetric Model global LV dilatation spherical remodelling enlarged mitral annulus displacement both PMs posteriorly, laterally, apically tethering of both mitral leaflets less LV closing force decreased basal clockwise rotation force Less mitral annulus contraction dysynchrony Apical displacent of the mitral leaflets and a central MR
Functional Mitral Regurgitation
Functional Mitral Regurgitation
Why FMR is an important clinical issue?
Frequency of MR in heart failure pts 90% of pts with NYHA III-IV, 50% mod/sev
Prognostic Value of FMR in HF pts Rossi et al. Heart 2011;97:1675-1680
Prognostic Value of FMR in HF pts Bursi, Eur J Heart Fail 2010, 12:382-8
The role of echocardiography: we have to know the problem Is MR severe?
In functional ischaemic MR, an EROA 20 mm2 or an RVol 30 ml identifies a subset of patients at an increased risk of cardiovascular events.
Pitfalls in the quantitative echo assessment of FMR Non circular orifices in FMR: overestimation/undrestimation vena contracta
Pitfalls in the quantitative echo assessment of FMR Variation of the PISA during systole in FMR In early and late systole, closing forces are relatively low and so the ERO and PISA relatively large In midsystole, coincident with peak regurgitant velocity closing forces are maximal and so the ERO and PISA smaller.
The role of echocardiography: we have to know the problem MR consequences?
When MR is more than mild MR, providing the LV diameters, volumes, and ejection fraction as well as the LA dimensions (preferably LA volume) and the pulmonary arterial systolic pressure in the final echocardiographic report is mandatory. The quantitative assessment of myocardial function (systolic myocardial velocities, strain, strain rate) is reasonable, particularly in asymptomatic patients with severe primary MR and borderline values in terms of LV ejection fraction (60 65%) or LV end-systolic diameter (close to 40 mmor 22 mm/m2)
The role of echocardiography: we have to know the problem FMR of ischemic or DCM origin?
FMR of ischemic and DCM origin: echo differences Papadopoulou et al Hellenic J Cardiol 2009; 50: 37-44
The role of echocardiography: road map to intervention Recognizing pathophysiology?
The coaptation triangle and the mitral valve geometry
Mitral regurgitation with distorted mitral valve geometry: trapeze (IIIB) Absence of the standard triangle of coaptation,transformed into a trapeze
The role of echocardiography: questions to be answered What to measure?
Echo assessment of FMR: Global left ventricular remodelling LV Volumes Dimensions of LV Sphericity Index
Echo assessment of FMR: Local left ventricular remodelling Apical displacement of the posteromedial papillary muscle Second order cords Interpapillary muscle distance
Echo assessment of FMR: Mitral valve deformation systolic tenting area posterolateral angle coaptation distance
Echo assessment of FMR: Closing Forces LV dyssynchrony Reduced Contractility: LV dp/dt
The role of stress echocardiography: a novel approach of FMR Additional Diagnostic, Prognostic, Pathophysiologic informations?
Stress induced changes in FMR
Clinical relevance of exercise-induced changes in FMR: the role of stress echo Exercise can unmask the severity of a seemingly mild MR Exercise-induced changes in FMR correlate with exercise capacity Exercise-induced changes in FMR contribute explaining the origin of exercise limitation Acute increase in FMR may cause nonischemic acute pulmonary edema The relationship between contractile reserve during exercise and MR may have relevant therapeutical implications
Stress echo and functional mitral regurgitation Long-term outcome of patients with heart failure and dynamic functional mitral regurgitation. Lancellotti P, et al. Eur Heart J 2005;26:1528 32
Exercise Stress Echo and FMR
The role of echocardiography: intervening but not surgically Encouraging CRT?
LBBB and FMR: reduction with CRT Van Bommel et al Circulation 2011
The role of echocardiography: guiding surgical intervention When and what surgical technique?
When CABG and EF>30% When CABG and EF<30% but with Viability Without revascularization
How are Patients with Isolated FMR Treated?
Surgical approach of FMR: where do we stand? Surgery (either Repair or Replacement) can reduce FMR acutely Some patients get clear improvement in HF symptoms after surgery No mortality benefit has been shown to result from surgery (either Repair or Replacement)
MV Repair vs Replacement No differences regarding death, MACE, readmissions, functional status in 12 months fu Acker et al. NEJM 2014
MV repair: 28,6% moderate, 4,2% severe vs MVR:2,3% moderate in 12 months fu
Acker et al N Engl J Med 2014;370:23-32 Successful repair outplays the best MVR
Repair or Replacement in FMR?
Limitations of surgery Which operation to perform? Increased morbidity and mortality in high risk pts High recurrence rates of MR after MV repair
The role of echocardiography in selecting pts for Mitral Clip-EVEREST II Inclusion Criteria Moderate to severe MR 3/4 Symptomatic >25% EF LVESD 55mm Asymptomatic with one or more of the following LVEF 25-60% LVESD 40mm New onset atrial fibrillation Pulmonary hypertension Exclusion Criteria MV anatomical exclusions Mitral valve area <4.0cm2 Leaflet flail width ( 15mm) and gap ( 10mm) Leaflet tethering/coaptati on depth (>11mm) and length (<2mm)
Ηχωκαρδιογραφία:λήψη αποφάσεων στη σοβαρή λειτουργική ανεπάρκεια μιτροειδούς Διάγνωση και εκτίμηση της βαρύτητας της ανεπάρκειας της βαλβίδος. Ανάδειξη στοιχείων παρουσίας στεφανιαίας νόσου. Δυναμική ηχωκαρδιογραφία με δοβουταμίνη ή άσκηση, για κατάδειξη μυοκαρδιακής βιωσιμότητας. Κατάδειξη ή αποκλεισμός συνυπάρχουσας παθολογίας των γλωχίνων και των τενοντίων χορδών. Μελέτη της γεωμετρίας της αριστερής κοιλίας ως και των θηλοειδών μυών, ειδικά με την 3D ηχωκαρδιογραφία. Διοισοφάγειος ηχωκαρδιογραφία διεγχειρητικά ΠΟΤΕ; ΧΕΙΡΟΥΡΓΙΚΗ ΠΑΡΕΜΒΑΣΗ TI; ΕΠΙΔΙΟΡΘΩΣΗ ή ΑΝΤΙΚΑΤΑΣΤΑΣΗ ΕΠΙΤΥΧΙΑ ΕΠΕΜΒΑΣΗΣ
Πότε αποφασίζεται χειρουργική θεραπεία στη λειτουργική ανεπάρκεια μιτροειδούς Σε σοβαρού ή μετρίου βαθμού ανεπάρκεια, ΜΟΝΟ στα πλαίσια χειρουργικής επαναιμάτωσης εφόσον το κλάσμα εξώθησης είναι >30%, ή ακόμη και σε ΚΕ<30% εφόσον όμως υπάρχει μυοκαρδιακή βιωσιμότητα. Μεμονωμένη χειρουργική θεραπεία δεν ενδείκνυται. Σε σοβαρή ανεπάρκεια με ΚΕ>30% και συμπτώματα παρά την μέγιστη αγωγή συμπεριλαμβανομένης ΚΑΙ CRT μπορεί να εξετασθεί η χειρουργική θεραπεία.
Ηχώ Δείκτες που προβλέπουν υποτροπή της λειτουργικής ανεπάρκειας μετά από πλαστική επιδιόρθωση Τελοδιαστολική Διάμετρος ΑΚ>65χιλ Γωνία οπίσθιας γλωχίνας με το μιτροειδικό δακτύλιο>45ο Γωνία άπω τμήματος της πρόσθιας γλωχίνας με το μιτροειδικό δακτύλιο>45ο Επιφάνεια μεταξύ των γλωχίνων και του επιπέδου του μιτροειδικού δακτυλίου (tenting area) >2,5 cm2 Απόσταση σημείου σύγκλεισης των γλωχίνων από το επίπεδο του μιτροειδικού δακτυλίου (coaptation distance) >10χιλ Απόσταση μεταξύ των δύο θηλοειδών μυών (short axis) στην τελοσυστολή >20χιλ Δείκτης σφαιρικότητας στην τελοσυστολή >0,7.