Hở van hai lá do thiếu máu cơ tim có gì mới năm 2014

Ischemic Mitral Regurgitation:
What we can do in 2014
Peter M. Pollak MD

©2011 MFMER | 3138928-1


Disclosure
Relevant Financial Relationship(s)
• None
Off Label Usage
• None

©2012 MFMER | 3208595-2


What we can do in 2014…
Understand
IMR Better
Medical
Therapy
Percutaneous
Therapies
Surgical
Therapy

• Clinical Significance
• Pathophysiology & Mechanism
• ACE Inhibitors
• Beta Blockers
• Cardiac Resynchronization Therapy

• MitraClip
• Valve Repair vs. Replacement
• CABG/Revascularization
©2011 MFMER | 3138928-3


MR decreases survival after diagnosis

Copyright © American Heart Association, Inc. All rights reserved.
Grigioni F et al. Circulation. 2001;103:1759-1764


Worse Ischemic MR
Worse Long-Term
Survival
100

No MR

80

%

61±6

60

ERO<20 mm2

40

ERO 20

20

47±8

mm2

29±9

P<0.001

0
0

1

2

3

4

5

Years
Grigioni et al Circulation 2001

Ischemic MR

The old Paradigm:
Chronic Ischemic MR is due to
annular dilatation, and

should be corrected by
annuloplasty


Comparison Ischemic MR-Atrial Fibrillation
Annular diameter

Regurgitant fraction

4
3.5

30

3

25

2.5

20

2

15

1.5

10

1

5

0.5

0

0
Functional MR

A Fib

Otsuji JACC 2002


Ischemic MR

The New Paradigm:

There is more to
Ischemic MR than just
annular dilatation

Forces on mitral leaflets in systole.

Levine R A , and Schwammenthal E Circulation. 2005;112:745-758


Patch placement and balloon inflation over
infarct region improves MR

Levine R A , and Schwammenthal E Circulation. 2005;112:745-758


Medical Therapy is Important
Beta Blocker effect on
survival in patients with
severe MR

Varadarjan AJC 2008

Effect of Enalapril 10mg
on LVSV in Patients with
severe MR

Tischler AJC 1998
©2011 MFMER | 3138928-11


Medical Therapy Effect from Heart
Failure Reference Trials

McDonagh ESC 2014

©2011 MFMER | 3138928-12


CRT improves Ischemic MR

• Temporary effect during CRT
• MR returns when CRT off
Van Bomel CIRC 2011

©2011 MFMER | 3138928-13


Response to CRT correlates with survival

Van Bomel CIRC 2011

©2011 MFMER | 3138928-14


MitraClip Device

©2011 MFMER | 3138928-15


MitraClip is successful in treating MR

©2011 MFMER | 3138928-16

MitraClip survival similar to surgery

©2011 MFMER | 3138928-17


Ischemic MR : Survival after Surgery
Recent Improvements
100
80

1990’s
1980’s

60

525

40
366

444

20
P = 0.05

254

0
0

2

4

6

Years

8

10


©2011 MFMER | 3138928-19


Surgical Repair vs. Replacement
• 251 patients with Severe Ischemic MR
ERO >0.4cm2
12 month follow-up
• Prospectively randomized to:
• (1) Mitral Valve Repair with ring annuloplasty
• (2) Chordal-sparing Replacement
• 75% had concomitant CABG
• Results: no difference in death or composite endpoint
• Higher recurrence of MR with repair (32% vs. 2%)
©2011 MFMER | 3138928-20

Acker MA et al. N Engl J Med 2014;370:23-32


Summary
• Ischemic MR is a myocardial problem
• Worsens prognosis with increasing severity

• Treat the myocardium
• Revascularization – particularly if dynamic
• OMT – ACE-I, Beta-Blockers
• Relieve Dyssynchrony  CRT
• MitraClip is a percutaneous option for some
patients
• Surgical valve repair or replacement during CABG
helpful for severe MR
• Valve replacement is more durable with similar
outcomes

©2011 MFMER | 3138928-22


Thank you!


©2011 MFMER | 3138928-23