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Insuficiencia Mitral Funcional: tratamiento quirurgico o endovascular?
Functional MR : Percutaneous or Surgical treatment ?
Patrice Guérin Interventional cardiology unit
L’institut du Thorax University hospital Nantes
FRANCE
Disclosure Statement of Financial Interest
I currently have, or have had over the last two years, an affiliation or financial interests or interests of any
order with a company or I receive compensation or fees or research grants with a commercial company :
Grant/Research Support: Abbott Vascular, Boston scientific, Biotronic
Consulting Fees/Honoraria: Abbott Vascular, AstraZeneca, Lilly, Actelion
Major Stock Shareholder/Equity: Company Three
Royalty Income: Company Four
Ownership/Founder: Company Five
Intellectual Property Rights: Company Six
Other Financial Benefit: Company Seven
• EVEREST II
Feldman et al. , NEJM 2011; 364:1395-406
.
The ESC guidelines: indications for FMR percutaneous treatment
Volkmar Falk et al. European Heart Journal (2017) 38, 2739–2791
Indications for surgery in Secondary MR
The ESC guidelines classify indications for FMR surgery in 3 groups
Volkmar Falk et al. European Heart Journal (2017) 38, 2739–2791
1. RO closure by an increase in coaptation lenght and coaptation area (A2 P2) responsible for MR reduction
2. Restriction of the antero posterior diameter (limit the AP expension of mitral annulus)
• Ibtihal Al Amri et al. EuroIntervention 2016;11:1554-1561
What will be the place of surgery for FMR treatment ?
Follow-up Death
HF hospitalization
Composite of death and HF hospitalization
MR severity
NYHA class
15 %
26 %
35 %
Nickenig et al.
JACC 2014;
64:875-84
2011–2012
Pilot European
Sentinel Registry
(FMR 72.0%)
Fabrizio D’Ascenzio et al. , Am J Cardiol 2015; 116:325-331
FMR :
Median follow-up
of 9 months (6 to 12)
What will be the place of surgery for FMR treatment ?
What will be the place of surgery for FMR treatment ?
Gaemperli et al. Circulation. 2013;127:1018-1027
Frantisek Bednar et al. BioMed Research International 2016
The EVEREST II High Risk Registry (STS>12)
Whitelow et al. JACC 2012; 59: 130-39
May be efficient to limit the rate of rehospitalization
Swaans et al. , JACC intervention 2014; 7:875-81
Survival of Transcatheter
Mitral Valve
Repair Compared With
Surgical
and Conservative
Treatment in
High-Surgical-Risk
Patients
EuroSCORE:
Mitraclip (23.9±16.1%)
Surgery (14.2±8.9%)
Conservative
(18.7±13.2%)
p < 0.0001)
What will be the place of surgery for FMR treatment ?
The survival of Mitraclip group seems to join that of the surgical group while their
euroscore is significantly higher
• Nickenig et al. J A C C CardioVascular Interv 2016, 19.
No effect on mitral annulus ? But it is not an annuloplasty
Keep in mind that Mitraclip therapy is not the only one percutaneous treatment for FMR
What will be the place of surgery for FMR treatment ?
• Nickenig et al. J A C C CardioVascular Interv 2 0 1 6, 19.
• A-P diameter of the FMR mitral orifice was greatly decreased at 6 months (stable).
• Patients with grade 3 or 4 mitral regurgitation was significantly reduced (from 77% to 11%)
• NYHA ssociat functional class, 6-minute walk test, and Minnesota QOL were also improved
What will be the place of surgery for FMR treatment ?
Indications for surgery in Secondary MR
The ESC guidelines classify indications for FMR surgery in 3 groups
Volkmar Falk et al. European Heart Journal (2017) 38, 2739–2791
Franzen O. et al., Eur J Heart Failure (2011) 13, 569–576
Registries and non randomized studies
What will be the place of surgery for FMR treatment ?
Franzen O. et al., Eur J Heart Failure (2011) 13, 569–576
What will be the place of surgery for FMR treatment ?
Franzen O. et al., Eur J Heart Failure
(2011) 13, 569–576
Functional class III or IV
Mean logistic EuroSCORE 34%
6-month follow-up
What will be the place of surgery for FMR treatment ?
MitraClip therapy in patients with end-stage systolic heart failure
Franzen O. et al., Eur J Heart Failure (2011) 13, 569–576
NYHA III or IV
Mean logistic EuroSCORE 34%
What will be the place of surgery for FMR treatment ?
Franzen O. et al., Eur J Heart Failure (2011) 13, 569–576
What will be the place of surgery for FMR treatment ?
Independant factors of MAE : TR and RV function
Neuss M. et al., Eur J Heart Failure (2013) 15, 786–576795
Boerlage-vanDijk. et al., Int J of Cardiology 2015;238-243
Indications for surgery in Secondary MR
The ESC guidelines classify indications for FMR surgery in 3 groups
Volkmar Falk et al. European Heart Journal (2017) 38, 2739–2791
Indications for surgery in Secondary MR
The ESC guidelines classify indications for FMR surgery in 3 groups
Volkmar Falk et al. European Heart Journal (2017) 38, 2739–2791
What will be the place of surgery for FMR treatment ?
ESC Guidelines 2014
What will be the place of surgery for FMR treatment ?
• H. Takagi et al. International Journal of Cardiology 228 (2017) 289–294
Metanalysis : A review of comparative studies of MitraClip versus surgical repair for MR
What will be the place of surgery for FMR treatment ?
• H. Takagi et al. International Journal of Cardiology 228 (2017) 289–294
Metanalysis : A review of comparative studies of MitraClip versus surgical repair for MR
What will be the place of surgery for FMR treatment ?
• H. Takagi et al. International Journal of Cardiology 228 (2017) 289–294
Metanalysis : A review of comparative studies of MitraClip versus surgical repair for MR
What will be the place of surgery for FMR treatment ?
• H. Takagi et al. International Journal of Cardiology 228 (2017) 289–294
Mc Gee et al. J Thorac Cardiovasc Surg 2004;128: 916-24.
30%
Metanalysis : A review of comparative studies of MitraClip versus surgical repair for MR
What will be the place of surgery for FMR treatment ?
• H. Takagi et al. International Journal of Cardiology 228 (2017) 289–294
Metanalysis : A review of comparative studies of MitraClip versus surgical repair for MR
What will be the place of surgery for FMR treatment ?
• H. Takagi et al. International Journal of Cardiology 228 (2017) 289–294
The arithmetic mean of late-survival rates was 91.5% and 92.7% at 1 year and 79.2% and
84.0% at 3 years in theMitraClip and surgical repair group, respectively
Metanalysis : A review of comparative studies of MitraClip versus surgical repair for MR
What will be the place of surgery for FMR treatment ?
• Benjamin Wan et al. Ann Cardiothorac Surg. 2013 Nov; 2(6): 683–692
A meta-analysis of MitraClip system versus surgery for treatment of
severe mitral regurgitation
What will be the place of surgery for FMR treatment ?
• Benjamin Wan et al. Ann Cardiothorac Surg. 2013 Nov; 2(6): 683–692
A meta-analysis of MitraClip system versus surgery for treatment of
severe mitral regurgitation
What will be the place of surgery for FMR treatment ?
• Benjamin Wan et al. Ann Cardiothorac Surg. 2013 Nov; 2(6): 683–692
A meta-analysis of MitraClip system versus surgery for treatment of
severe mitral regurgitation
Mortality at 12 months (7.4% vs. 7.3%; P=0.66)
What will be the place of surgery for FMR treatment ?
• Too early to answer
• We have to wait results from MitraFr, COAPT, Reshape
• Long term results of Mitraclip therapy
• Association of Mitraclip and percutaneous annuloplasty
• Depending on these datas, indication of surgery for FMR will be limited to patients – Requiring CABGs because of PCI impossibility – Requiring tricuspid annuloplasty because of TR ?
No more sternotomy for mitral valve surgery in FMR ?
Thank you for your attention
Nantes Mendoza
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