What Degree of MR Deserves Surgical or Transcatheter ...What Degree of MR Deserves Surgical or...

What Degree of MR Deserves

Surgical or Transcatheter Intervention,

and How Should It Be Assessed?

Robert J. Siegel, M.D., FACC

Nov. 14-15, 2017, Beverly Hills

Director, Cardiac Non-Invasive Laboratory

Cedars-Sinai Medical Center, Los Angeles

Professor of Medicine, UCLA & Cedars-Sinai

Robert Siegel, M.D.

As a faculty member for this program, I disclose the following relationships

with industry:

(GRS): Grant/Research Support (C): Consultant (SB): Speaker’s Bureau

(MSH): Major Stock Holder (AB): Advisory Board (E): Employment

(O):Other Financial or Material Support

Name of company: Philips Ultrasound;

Nature of Relationship: Speaker’s Bureau

What Degree of MR Deserves Surgical or Transcatheter Intervention,

and How Should It Be Assessed?

Mechanism of MR – Degenerative v. Functional

• Important for grading MR severity

• Important Management –

Surgical, Catheter Intervention, or Medical

Functional v. Degenerative MR FMR:

Structurally normal MV but LV dysfunction

and dilation leads to MR

DMR:

A diseased MV causes severe MR

which leads to LV dysfunction

Severe Functional MR JACC 2015 MVARC & ACC/AHA*

Qualitative

MV Morphology Leaflet tenting, restriction, ↓coaption

Color jet Large, aliasing, deep into LA

Flow convergence zone Large

CW signal Dense; Holosystolic; Low velocity

Semiquantitative

Vena contracta (mm) ≥7mm

Pulm vein flow reversal Present +

Mitral Inflow E –wave dominant

Quantitative*

EROA (cm2) (PISA) ≥0.4* (0.4 specific, 0.2 more sensitive)

Regurgitant Vol (ml) (PISA) ≥30

LV dysfunction / LV dilation (as present not helpful in grading) Patients with any secondary MR have a worse prognosis –

MV repair may improve symptoms but not yet shown to ↑ survival

FMR very dependent on SBP and LV volume

2009 → went for a Mitraclip

55 y.o. woman

Functional MR

LVEF 27%

↑↑ LVESD 53mm

DOE: NYHA Class III

on ACE-I / Beta-blockers

F/U Echo in 2017-

8 yrs post MitraClip

Asymptomatic – very active

Minimal MR

LVEF pre Mitraclip- 27%

LVEF 8 yrs postclip- 57%

LV size normalized

Severe Functional Mitral Regurgitation

Surgery : If LVEF <55%- Post-op LV dysfunction 38%, no survival benefit, ↑↑failure MV repair failure(CAD) Matsumura 2004, Acker 2014

MitraClip: Several studies show good results

↓ MR, ↑ Cardiac output, ↓filling pr, ↑NYHA Class

• Procedural mortality ≈ 0%; no data on ↑ing survival

• Post-clip LV dysfunction/low C.O rare (> 60,000 pts)

• ↑ 6MWT, ↓BNP & ↑QOL

• ↓ LV size, ↑LVEF D’Ascenzo 2015 , Pighi 2016,Scotti 2017, Van De Heyning 2016

Schimdt 2017,Plegers 2013;Auricchio 2011; Franzen 2011, Siegel, Biner, Kar 2011;2012 Mendirichaga 2016

COAPT TRIAL: Clinical Evaluation of the Safety and Effectiveness of the MitraClip® System

for the Treatment of Functional Mitral Regurgitation in Symptomatic Heart Failure Subjects

Severe Degenerative MR – JACC MVARC 2015 ≈ ACC/AHA 2014

Color jet Significant penetration; holosystolic

Flow convergence zone Large; holosystolic MR

CW signal Dense; holosystolic MR

Semiquantitative

Vena contracta (mm) ≥7mm

Pulm vein flow reversal Present +

Mitral inflow E –wave dominant > 1.2 - 1.5cm/s

TVI mitral/TVI aortic >1.4

Quantitative:

Regurgitant vol (ml) (PISA) ≥60

EROA (cm2) (PISA) ≥0.4

LA / LV size* Enlarged

Qualitative

MV Morphology Flail, pap rupt, retraction, perforation

Severe MR very unlikely if LV and LA size are normal

Beware of “color flowitis”

MR Quantification

• “PISA strongly recommended but inherent

limitations”(MVARC) (reproducibility poor Biner/Siegel JACC 2010)

• Each echo parameter has limitations & lack of

precision→ use integrated approach

• Quantitation better than qualitative assessment

but may lead to false sense of accuracy

• NO ECHO GOLD STANDARD for MR severity

How does echo integrated approach compare

with a reference standard - MRI?

r=12mm

Uretsky et al. JACC 2015

• If severe MR on echo - only 22% severe on MRI

• In 34% severe MR on echo – MR was mild by MRI

-MRI - Severe MR strongly correlated with

post-op LV remodeling (r = 0.85; p < 0.0001)

-Echo - No correlation with post-op LV remodeling

& “Severe MR” (r = 0.32; p = 0.1) “Integrated approach”

Only 36% concordance!

ROC analysis area under curve - LV EDD was predictive for concordance - MR severity by TTE & MRI

LV EDD cut-off of 5.5 cm:

Very good sensitivity & specificity for TTE & MRI concordance

Must integrate LV size into MR assessment!

Chronic severe volume overload → LV dilation

If still uncertain of MR severity consider getting an MRI

Rafique & Siegel JACC 2015

AUC 0.86 (95% CI 0.75-0.98

p <0.001)

Y.M. 76y, asymptomatic M. Echo 05/10/06 – flail posterior MV leaflet

Prior guidelines equated flail mitral leaflet & severe MR

But still need an integrated approach – this not severe

MV inflow: E/A Reversal; Normal LV size, PASP 11 yrs later Normal LV size, EF, PASP,Exercise Capacity

Degenerative MR

A diseased MV with severe MR

→ Has adverse consequences

→ LV volume overload

→ LA dilation & increased LAP

When to intervene:

• Progressive LV Dilation → ≥ 40mm LVID (s)

• Decline in LVEF towards ≤ 60%

• Increase in PASP to ≥ 50 mmHg

• Symptoms – even “mild” symptoms (DOE)

Stress Echo in MR to Assess:

• Symptomatic status

• Functional capacity

• Heart rate recovery

• Contractile reserve

• Exercise induced pulmonary hypertension

• Worsening of MR

All have been shown to be prognostic and facilitate

timing surgery

What Degree of MR Deserves Surgical

or Transcatheter Intervention • Know your patient

Are they symptomatic, are they going to be compliant

with regular f/u echos and visits

• Know your surgeon

What is their repair rate? What are their morbidity

and mortality rates?

• Know your practice and yourself

Are you able to follow your patients?

Can you do step care? Do your patients “fly-in”?

Thank you

Adjunctive testing

• Serial Echo Doppler studies

• TEE if MR jet is eccentric

• BNP

• Strain

• MRI

• Stress echo

Management of patients with MR is based

not only on MR severity but on -

Consequences:

• - Clinical findings

• - LV function

• - LV size

• - PA pressure

Thanks!

William Osler

• DMR & FMR are different entities

• Guidelines- “Integrate findings” but no data on how to

weight a parameter

• Using integrated method in DMR, to diagnose chronic

severe MR, LV needs to be dilated

Optimal assessment of MR requires incorporating

symptoms, LV size & function- to assess impact of MR

volume overload on the LV and on the patient

Take home

messages

Caveats to Be Considered in Echo

Doppler evalautaion of MR

• 60% LA (severe) DCM Large central jets may be

present in patients with DCM and only mild MR

• Late systolic MR (MVP) ERO >0.4 cm2

Overestimation of the severity of MR by PISA with

late systolic jets

• Cannot have severe chronic MR with normal LV size

Is 3D Echo the Answer for MR Grading?

• Direct 3D planimetry of MV ROA

• 3D VC

• 3D PISA

These 3D methods reported to be more

accurate than 2D

However ….

TTE

*

Importance of “MR

severity”-

is the effect of MR on

patient & heart.

Chronic Severe MR

Results in LV dilation

(volume overload)

Grading of MR Severity

3D Echo is New

• Limited temporal/spatial resolution

• EROA variation during systole

• Artifacts

• Technical difficulties

• No gold standard for 3D MR validation

• To date - no validated guidelines or reference

standards on 3D quantification

POTENTIAL LIMITATIONS

MitraClip vs

Optimal Medical Therapy

(OMT) for FMR Giannini, AJC 2016 ( N=120) Overall survival

Survival free from CVD

Survival free from

rehospitalization

Months f/u

Months f/u

Months f/u

CLIP

OMT

LVEF 34%; NYHA Class 3-4;

60 vs 60 age matched

MC vs OMT(BiV) (f/u 515 days)

MitraClip vs OMT > overall survival (p=0.007)

> CV survival (p=0.002)

Survival 1 & 3 yrs MC 90% 61 %

OMT 64% 35 %

Functional v. Degenerative MR

FMR:

Structurally normal MV but

LV dysfunction leads to MR

DMR:

A diseased MV where severe

MR leads to LV dysfunction

FMR: LV Dysfxn

MV leaflets normal

but motion restricted

from

• Annular dilation • Tethering (apical / posterior displacement

of papillary muscles)

15% CHF pts have

significant FMR*

3D MV from LA from LV

13 mo f/u- post clip NYHA I

LVEDD normalized

Pre: 62 mm - Post: 49 mm

LVESD normalized

Pre: 52 mm - Post: 39 mm

LVEF improved

Pre: 27% - post: 45%

F/U Echo in 2017-

8 yrs post MitraClip

Asymptomatic – very active

MR- trivial

CFD- trivial

PW:

E/A

Reversal

Pulm V

S Dom

Multiparameter MR Severity Assessment

CFD CW PW- MV Inflow PW- PV flow

Vena Contracta 9 mm

PISA - EROA

12 mm

>40% Holosystolic* E≥120cm/s Blunted/reversed

≥ 7mm EROA ≥ 0.4cm2

Beware of “color flowitis”

• Normal PASP: 28 mmHg

• Severe = multiple parameters

• MV inflow: E/A Reversal

• CW Doppler: Not holosystolic signal – low intensity

Echo 05/10/2006

Flail posterior leaflet

but MR is not severe

Because:

• LV size normal LVEDD: 5.0 cm; LVESD: 3.1 cm

• Spectral Doppler very helpful

MV inflow:

E/A Reversal

11 yrs later Exercise Stress Echo:

LV size, LVEF still normal LVEDD: 5.0 cm; LVESD: 3.1 cm

PASP: 32-34 mmHg

Excellent functional capacity

MR not severe in spite of

flail MV leaflet