Insuficiencia Mitral Funcional: tratamiento · Insuficiencia Mitral Funcional: tratamiento quirúrgico o endovascular? Functional MR : Percutaneous or Surgical treatment ? Patrice

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


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)



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)


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


• 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





Franzen O. et al., Eur J Heart Failure (2011) 13, 569–576

Registries and non randomized studies




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


MitraClip therapy in patients with end-stage systolic heart failure


NYHA III or IV

Mean logistic EuroSCORE 34%




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








ESC Guidelines 2014


• 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









Mc Gee et al. J Thorac Cardiovasc Surg 2004;128: 916-24.

30%







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



• 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)


• 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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Insuficiencia Mitral Funcional: tratamiento · Insuficiencia Mitral Funcional: tratamiento quirúrgico o endovascular? Functional MR : Percutaneous or Surgical treatment ? Patrice