Secondary Mitral Regurgitation

Secondary Mitral Regurgitation

Vera H. Rigolin, MD, FASEVice-President, American Society of Echocardiography

Professor of MedicineNorthwestern University

Bluhm Cardiovascular InstituteMedical Director, Echocardiography Laboratory

Northwestern Memorial HospitalChicago, IL USA

Case 1• 78 yr old male with a history of an ischemic

cardiomyopathy• s/p PCI RCA• Admitted to the hospital 3 times in the past 4

months for heart failure exacerbations• s/p upgrade of ICD to CRT-D with residual

dyspnea • h/o prior CVA, COPD, Afib• STS Score=10.9%• Cath: Occluded distal LCX, 90% lesion in

PDA, patent RCA stents

Cardiac Meds

• Amiodarone 200 mg daily• Nebivolol 20 mg daily• Furosemide 80- mg daily• Isosorbide mononitrate 60 mg daily• Spironolactone 25 mg daily• Warfarin 5 mg daily• Pravastatin 40 mg daily

Physical Exam

• BP: 120/68, HR=70• JVP=8-10 cm• Lungs: Clear• Cor: Inferolat displaced PMI; RRR; 2/6 systolic

murmur at apex• Abd: Soft, NT. No HSM or ascites• Ext: No edema

Transthoracic Echo

MV Annulus=4.9 cmCoapt depth=1.4 cm

LVEDV=193 mlLVESV=130 mlEF=33%

EROA = 0.24 cm2 RV=47 ml

VC=0.8 cm

E=92 cm/sec

Organic MR

Nishimura, RA et al.2014 AHA/ACC Valvular Heart Disease Guideline

Functional MR

Nishimura, RA et al.2014 AHA/ACC Valvular Heart Disease Guideline

• What can we offer this patient?Medical therapy?Surgery?Mitra Clip?

COAPT TRIAL

• A clinical trial designed to study the safety and effectiveness of the MitraClip® device in heart failure patients who have functional mitral regurgitation (MR) and are not appropriate for mitral value surgery.

• Patients randomly assigned to a Device Group or Control Group

Followup

• Addition of lisinopril 10 mg daily• PCI of PDA• 5 months later: c/o fatigue, SOB improved

Echo 5 months later

LVEDV=184 mlLVESV=109 mlEF=40%

Case 2• 67 yr old male with h/oMi (PDA) 1 yr prior• MI complicated by cardiogenic shock and MR• Improved with medical therapy• Recently admitted multiple times with

decompensated heart failure• h/o Afib• CKD (GFR=40)• Meds:

– Bumetanide 1 mg BID– Lisinopril 10 mg daily– Warfarin 5 mg daily– Metoprolol 100 mg daily– Atrovastatin 20 mg daily– ASA 81 mg daily

Physical Exam

• BP=110/82, HR=78• JVP<10 cm• Lungs: Decreased BS right base• Cor: Irreg irreg rhythm, 2/6 systolic murmur at

apex• Abd: No HSM or ascites• Ext: 1+ edema

Transthoracic Echo

MV Annulus = 4.2 cmCoapt depth= 0.9 cm

E=84 cm/sec

EROA=0.24 cm2RV=33 ml

VC=0.6 cm

What Can We Offer This Patient?

Followup

• Patient underwent mitral and tricuspid valve repair and MAZE procedure

• Is doing well 1 year post op

Case 3

• 83 yr old male with longstanding ischemic heart disease

• Ischemic cardiomyopathy• h/o PCI LCX, RCA• Carotid artery stenosis• CKD – Stage IV (GFR=30)• HTN• DM

• Hospitalized numerous times with heart failure symptoms

• On maximal tolerated meds– Spironolactone 25 mg daily– Isosorbide dinitrate 40 mg TID– Carvedilol 6.25 mg BID– Furosemide 40 mg daily– Clopidogrel 75 mg daily– Atrovastatin 40 mg daily– ASA 81 mg daily

• Frailty: Incontinence, grip strength=20 (frail), 15 ft walk time=8.3 sec(frail)

• STS score=20%

Physical Exam

• BP=134/70, HR=62• Neck: JVP to jaw• Lungs: Difficult to hear due to tachypnea• Cor: RRR, 3/6 holosystolic murmur at apex• Abd: No HSM or ascites• Ext: 1+ edema

MV Annulus=4.8 cmCoaptationdepth=1.2 cm

LVEDV=201 mlLVESV=134 mlEF=33%

Radius=0.8 cm

VC=0.6 cm

EROA=0.23 cm2RV= 47 ml

E=90 cm/s

What Can We Offer This Patient?

TEE During Mitra-Clip

Post Mitra Clip

Post Mitra Clip

Follow up Echo 11 Months Later

LVEDV= 217 mlLVESV=171 mlEF=28%

Follow up

• Dyspnea improved but still in class IV HF• Second mitra clip procedure unsuccessful• Pt died of progressive heart failure one year

after first MitraClip

Thank You