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“Early Surgical” Mitral

Regurgitation:
View of Cardiologist
A/Prof. Phạm Mạnh Hùng, MD.PhD. FACC.FESC

Director – Cardiac Cath. Lab. VNHI
Secretary General - VNHA


PRIMARY


Pathology >=1
components (leaflets,
chordae tendineae,
papillary muscles,
annulus):




Prolapse
Rheumatic heart disease
IE, connective tissue
disor- ders,, cleft mitral
valve, radiation heart
disease…

SECONDARY


Valve normal, LV
dysfunction:




Ischemic HD
Dilated CM


MR Etiology

Normal

Degenerative MR
(Prolapse)

Degenerative MR
(Flail)

Functional MR
Ischemic vs.
nonischemic


Prognosis of
Untreated MR

Mitral Regurgitation
Natural History of Severe Asymptomatic MR
Asymptomatic with normal LV function
100
Alive, Asymptomatic
without Surgery (%)

Medicare
data
80

Kang

Sarano

*
Rosenhek
Average hospital mortality:
8.8%
*
*

60
40
20

• Low volume centers: 13.0%
Grigioni

• High volume centers: Rosen

6.0%

0 Data from national Medicare database 1994-1999
0
2
4
6
8
10
Time (years)
Bonow, J Am Coll Cardiol 2013;61:693-701

684 hospitals
142,488 AVRs

Rosen et al. Am J Cardiol 1994;74:374-380
Sarano et al. N Engl J Med 2005;352:875-883
Rosenhek et al. Circulation 2006;113:2238-2244
Grigioni et. J Am Coll Cardiol Img 2008;1:133-141
Kang et al. Circulation 2009;119:797-804


Mitral Regurgitation
Natural History of Severe Asymptomatic MR

Alive, Asymptomatic without
Heart Failure or AF (%)

Survival without Heart Failure or Atrial Fibrillation
100

Medicare
data
80

ERO <20 mm2

Average hospital mortality:
mm2
* ERO 20-398.8%
60
40
20

• Low volume centers:
36% 13.0%
ERO ≥40 mm2

• High volume centers: 6.0%

0 Data from national Medicare database 1994-1999
0
2
4
6
8
10
Time (years)

684 hospitals

142,488 AVRs

Sarano et al. N Engl J Med 2005;352:875-883


Management of 3+/4+ MR with HF (CCF)
1,095 pts* with 3+/4+ MR and HF between 2000 and 2008
(74% FMR, 21% DMR). Rx before 10/2011:
DMR pts (n=226): 84% MV surgery, 16% medical Rx
FMR pts (n=814): 36% MV surgery (77% w/CABG), 64% med Rx.
Un-operated pts had lower LVEF (mean 27% vs. 42%, p<0.0001 and higher
STS score (median 5.8 vs. 4.0, p<0.001) compared with operated pts.
100
80

% of Patients

Prognosis
of unoperated
pts with
3+/4+ MR
and HF

Mortality
Surviving pts hospitalized for HF

90

171 of 474 (36%)
un-operated pts

with FMR and good
echos would have
been eligible for
MitraClip based on
published criteria

68
58

60

50
41

50

46
37

40

29
20

20

0
1

2

3

4

5

Years
* Excluded MVA ≤2 cm2, AR ≥2+, aortic peak velocity ≥2.5 m/s, HCM, endocarditis, concomitant AV, Ao or pericardial surgeries, LVAD or OHT.

Goel SS et al. JACC 2014;63,:185–90


Mod/Sev MR after TAVR: CoreValve Registry
In 1,007 pts at multiple Italian sites with severe AS treated with 3rd gen
CoreValve, baseline no/mild, moderate and severe MR (site reported)
was present in 67%, 24% and 9% of pts, respectively.
MR Change at 1 Year According to Baseline Severity
100

Independent predictors
of MR improvement
(HR [95%CI]):

90

35%

Proportion (%)

80

47%

70
60

Improved

50

Unchanged

40

Worsened

62%

30

53%

20
10
0

8%
No/mild

3%

Moderate

Severe

Bedogni F et al. Circulation. 2013;128:2145-53

sPAP ≤55 mm Hg
2.9 [2.7–3.3]; P=0.002
Absence of AF
2.0 [1.9–2.9]; P=0.003
Functional MR etiology
2.6 [1.8-3.1]; P=0.005


Mod/Sev MR after TAVR: CoreValve Registry
In 1,007 pts at multiple Italian sites with severe AS treated with 3rd gen
CoreValve, baseline no/mild, moderate and severe MR (site reported)
was present in 67%, 24% and 9% of pts, respectively.

1-year outcomes according to baseline MR
MR grade
No/mild
(n=670)

Moderate
(n=243)

Severe

(n=94)

P value
trend

Death

15%

20%

0.02

-Cardiac
-Non-cardiac

8%
7%

11%

25%
16%

10%

9%

0.20

NYHA I/II

73%

67%

59%

0.09

HF hosp

8%

13%

18%

0.09

1-year FU

0.01

By multivariable analysis, baseline mod/sev MR was an independent predictor
of overall mortality at 1 year (HR, 2.9; 95% CI, 2.5–3.8; P=0.001). Improvement
in MR severity was not associated with a beneficial effect on survival.
Bedogni F et al. Circulation. 2013;128:2145-53

Mod/Sev MR in TAVR and SAVR: PARTNER A
At baseline mod/sev MR (core lab) was present in
65/331 (19.6%) TAVR pts and 63/299 (21.2%) SAVR pts.

Survival According to Baseline Mod/Sev MR:
TAVR
Moderate/severe MR
No/mild MR

40

Mortality (%)

P interaction
= 0.05
37.0%
32.7%

30
20
10

SAVR

50

HR 1.14 [95% CI; 0.72, 1.78]
Log-rank p=0.58

0

49.1%

Moderate/severe MR
No/mild MR

40

Mortality (%)

50

30

27.9%

20
10

HR 1.96 [95% CI; 1.26, 3.06]
Log-rank p<0.01

0

0

4

8

12

16

20

24

0

4

Months after TAVR

12

16

20

24

175
31

161
26

Months after SAVR

No. at risk
Mod/severe MR 266
None/mild MR 65

8

No. at risk
233
58

216
52

200
50

188
47

178
44

166
40

Mod/severe MR 240
None/mild MR 59

195
45

188
40

Barbanti M et al. Circulation. 2013;128:2776-84

184
37

180
34


Medical Therapy
For MR


Basic Principles of Medical Therapy
Recommendations
Secondary prevention of rheumatic fever is indicated in
patients with rheumatic heart disease, specifically
mitral stenosis
Prophylaxis against infective endocarditis (IE) is
reasonable for the following patients at highest risk for
adverse outcomes from IE prior to dental procedures
that involve manipulation of gingival tissue,
manipulation of the periapical region of teeth, or
perforation of the oral mucosa:
 Patients with prosthetic cardiac valves;
 Patients with previous IE;

 Cardiac transplant recipients with valve regurgitation
due to a structurally abnormal valve; or (continued
on next page)

COR

LOE

I

C

IIa

B


Medical Therapy for
Degenerative MR
• Medical
 Diuretics
 Afterload reduction (ACE)
 Beta blockers for LV dysfunction
 Anticoagulation for atrial fibrillation


Chronic Primary Mitral Regurgitation:
Medical Therapy
Recommendations
Medical therapy for systolic dysfunction is

reasonable in symptomatic patients with chronic
primary MR (stage D) and LVEF less than 60%
in whom surgery is not contemplated
Vasodilator therapy is not indicated for
normotensive asymptomatic patients with
chronic primary MR (stages B and C1) and
normal systolic LV function

COR

LOE

IIa

B

III: No
Benefit

B


Chronic Secondary Mitral Regurgitation:
Medical Therapy
Recommendations
COR LOE
Patients with chronic secondary MR (stages B to D)
and HF with reduced LVEF should receive standard
GDMT therapy for HF, including ACE inhibitors,
I

A
ARBs, beta blockers, and/or aldosterone antagonists
as indicated
Noninvasive imaging (stress nuclear/positron
emission tomography, CMR, or stress
echocardiography), cardiac CT angiography, or
cardiac catheterization, including coronary
I
A
arteriography, is useful to establish etiology of chronic
secondary MR (stages B to D) and/or to assess
myocardial viability, which in turn may influence
management of functional MR


Functional MR and Remodeling
Myocardial Insult

Ventricular Remodeling

Mitral Apparatus
Remodeling

Mitral Valve
Dysfunction

?


Goals of Treatment

• Functional MR:
-Slow or reverse remodeling

-Improve symptoms/functional class
-Decrease hospitalizations for CHF
-Increase time to transplant or VAD
(slow progression to advanced HF)
-Improve survival


Medical Therapy
• Medical treatments proven effective for
treating the ventricular disease in large
RCTs also reduce the severity of
functional MR in some patients
• Data directly addressing the effect of
treatment on MR are less robust- old,
small series with limited follow up.


Beta Blocker Therapy Reduces MR

Lowes et al. AJC 1999; 83:1201-1205


Beta Blocker Therapy Reduces MR

Lowes et al. AJC 1999; 83:1201-1205

Vasodilator Therapy Reduces MR

Seneviratne. Br Heart J. 1994;72:63-8.


CRT and MR
SEVERE MR

MR reduction in
responders (n = 25
of 63 screened).
EF 23% +/-8
MILD MR

Ypenburg C et JACC, 2007; 50:2071-2077


CRT Reduces FMR Severity

DiBiase et al, Europace, 2011: 13, 829-838


Surgical Studies
For MR


Primary MR-Surgical Indications
• Symptoms
• LV Dysfunction

• Atrial Fibrillation
• Pulmonary Hypertension
• Everybody with severe MR and a good
surgeon