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Mitral RegurgitationMitral RegurgitationBrett Carlson, MDEssentia Health Heart and Vascular Conference May 18, 2012

Mitral Regurgitation (MR)

• ObjectivesDefinition– Definition

• Most common valvular heart disease• Systolic Flow Reversal LV->LA• Severe organic MR associated with excess mortality

– Anatomic Review• Etiologies of Mitral Regurgiation (MR)g g g ( )

– Clinical and Echo Findings (Chronic MR)– Role of Cardiac Cath Lab– Surgical Indications & Treatment Options

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Mitral Valve Anatomy

Kuwahara, et al. Circulation 2006;114;I-529-I-534

Mitral Valve Anatomy

Jouan, et al. Eur J Cardiothorac Surg 2004;26:1112-1117

Fig 1. Site of ischemic mitral valve prolapse (n=44). The posteromedialcommissure was involved in the majority of cases. The A3 portion of the anterior leaflet was prolapsed in one-third of the cases.

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Etiology of Mitral Regurgitation

• EtiologyDegenerative– Degenerative

– Functional – Inflammatory – SBE – Congenital

N l t

Figure 1: Carpentier’s functional classification. Type I, normal leaflet motion; Type II, increased leaflet motion (leaflet prolapse); Type IIIa restricted

• Nomenclature– Babel Syndrome– Carpentier class

Carpentier A. Cardiac valve surgery--the "French correction". J Thorac Cardiovasc Surg, 1983 September;86(3):323-37.

( p p ); ypleaflet motion during diastole and systole; Type IIIbrestricted leaflet motion predominantly during systole.*

Primary Mitral Regurgitation

• Primary (organic)I t i i l l b lit– Intrinsic valvular abnormality

• Leaflet Tissue, Chordae, Annulus– Degenerative

– Flail

– Ischemic

Barlow JB, Pocock WA. The significance of late systolic murmurs and mid-late systolic clicks. Md State Med J 1963 February;12:76-7

Figure 2: Degenerative mitral valve disease. A, Barlow’s disease; B, fibroelastic deficiency.*

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Ischemic Mitral Regurgitation

Photograph courtesy of Dr. Edward Woods, Geisinger Medical Center, Danville, PA

Functional Mitral Regurgitation

• Functional (secondary) – Structurally normal mitral valve

• Annular enlargement secondary to left ventricular dilatation

• Papillary muscle displacement due to LV remodeling

– Cardiomyopathyy p y

– Ischemic

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Function Mitral Regurgitation

Cohn, et al. Cardiac Surgery in the Adult, 3rd Edition.

Cohn, et al. Cardiac Surgery in the Adult, 3rd Edition.

Indications for Mitral Valve Operationin Patients with Functional MR

Class IIb

ACC/AHA 2006 Guidelines

ACC/AHA 2006 Guidelines

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Severity of Mitral Regurgitation

• Transthoracic Echo– Severity

• Mild, Moderate, Severe

– Etiology

– Valve Reparability

• Transesophageal Echo (TEE)Transesophageal Echo (TEE)

Clinical Findings

• SymptomsDyspnea Edema Fatigue Palpitations– Dyspnea, Edema, Fatigue, Palpitations

• Physical Exam– Diminished S1

• Failure of leaflet coaptation

– Wide split S2, Prominent P2• Decreased LV ejection time, Pulmonary HTNDecreased LV ejection time, Pulmonary HTN

– S3 Gallup• LV Failure

– MVP Click

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Severity of Mitral Regurgitation

ASE guideline J Am Soc Echocardiogr 2003;16:777-802

Severe Eccentric Mitral Regurgitation

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Mitral Valve PISA

Survival in Asymptomatic MR Pts (Medical Management)

42% Mortality at 5 years!

Enriquez-Sarano M et al. N Engl J Med 2005; 352(9): 875-83

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Asymptomatic Mitral Valve Prolapse

Enriquez-Sarano M, et al. Circulation 2002, 106: 1355-1361

Long-Term Survival with Medical Treatmentin Patients with MR Due to Flail Leaflet

Ling LH, NEJM 1996;335:1417-23

Ling LH, NEJM 1996;335:1417-23

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Enriquez-Sarano M et al. Circulation 2010, 121:804-812

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Post-op Death or Severe CHF According to Pre-op LV Systolic Dimension (LVDs)

Wisenbaugh T et al. Circulation 89,1994

Survival by Preoperative Rhythm

Lim E et al. Circulation 2001, 104:I-59-I-63

Lim E et al. Circulation 2001, 104:I-59-I-63

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Indications for Treatment

ACC/AHA 2006 Guidelines

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Treatment Options

• Confounding Data/Symptoms– Stress EchoSt ess c o– Cath Lab

• Verification of Severity and RV pressures• Coronary Anatomy

• Mitral Valve Repair• Mitral Valve Replacement

• Mechanical, Bioprosthetic, Mitral Clip

• Medical Management• Primum Non Nocere• Late Presentation• Poor Surgical Candidate

Overall Survival of Patients with AsymptomaticSevere Degenerative MR Managed According to a

Watchful Waiting Strategy

Criteria for surgery

1 LVESD≥451. LVESD≥45mm

2. LVESDI ≥26mm/m2

3. FS<32%

4. EF<60%

5. SPAP>50mmHg

6 Recurrent AF6. Recurrent AF

Follow-up every 12M-6M 3M (shortened if the data has changed)

Rosenhek, R. et al. Circulation 2006;113:2238-2244

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Enriquez-Sarano M , Sundt T M Circulation 2010;121:804-812

Early Surgery for MR

• Flail Leaflet90% of pts ith se ere MR d e to flail leaflet– 90% of pts with severe MR due to flail leaflet die or have surgery within 10 years.

• Operative mortality – 1% (<75 y.o.)

• Valve repair– Survival similar to the expected survival.– Can be performed on more than 90% of pts

with degenerative MR.

Ling LH, NEJM 1996;335:1417-23

Ling LH, NEJM 1996;335:1417-23

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CarpentierCarpentier Techniques (MV Repair)

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Freedom from Reoperation and Recurrent MR

David TE, JTCVS 2005; 130(5):1242-9

David TE, JTCVS 2005; 130(5):1242-9

Selection of Mitral Valve Prosthesis

Class I

Class IIa

ACC/AHA 2006 GuidelinesACC/AHA 2006 Guidelines

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Mitral Valve Replacement

Preservation of annular-i l i bapical connection by

chordae tendinae

Townsend: Sabiston Textbook of Surgery 18th Edition

Prosthetic Mitral Valves

• Bioprosthetic– No anticoagulation required– No anticoagulation required– Degradation

• Mechanical Valves– Low rate of structural failure– Anticoagulation requirement– Complications:

Paravalvular leakEndocarditisStrut fracture (i.e. Bjork-Shiley)Obstruction (pannus, thrombus)

Zoghbi, et al. Journal of the American Society of EchocardiographyVolume 22 Number 9, pp.978-9.

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Treatment Options

• Mitral Valve Repair– Better outcomes vs MVR

• Mitral Valve Replacement (MVR)– Age-dependent

• Not a Surgical Candidate?Mitral Clip– Mitral Clip

– Medical Management

MitraClip Criteria

• Sufficient leaflet tissue for mechanical coaptation

• Non-rheumatic/endocarditic valve morphology

• Protocol exclusions:

Flail gap >10mm

Flail width >15mm

LVIDs > 55mmLVIDs > 55mm

Coaptation depth >11mm

Coaptation length < 2mm

Grayburn et al, Am J Cardiol, Volume 108, Issue 6, Pages 882-887

mm

>15mm

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MitraClip

3-D Transesophageal Echo Guidance

Grayburn et al, Am J Cardiol, Volume 108, Issue 6, Pages 882-887

Grayburn et al, Am J Cardiol, Volume 108, Issue 6, Pages 882-887

3D TEE is essentialPercutaneous valve repair has advantagesOption for patients who are not ideal for surgeryActually increased surgical volume

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Summary

• Clinical Pearls– Early Operation for Severe MR

• Asymptomatic and EF <60% or LV dilation

• Asymptomatic and Afib, PHTN

• Symptomatic

• Flail Leaflet

– Correlation of clinical, echo, cath lab

– Repair > MVR > Medical Mgmt• Mitral Clip

Questions??

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References• Kuwahara, et al. Circulation 2006;114;I-529-I-534• Jouan, et al. Eur J Cardiothorac Surg 2004;26:1112-1117• Carpentier A. Cardiac valve surgery--the "French correction". J Thorac Cardiovasc Surg, 1983

September;86(3):323-37• Barlow JB, Pocock WA. The significance of late systolic murmurs and mid-late systolic clicks. Md , g y y

State Med J 1963 February;12:76-7• Photograph courtesy of Dr. Edward Woods, Geisinger Medical Center, Danville, PA• Cohn, et al. Cardiac Surgery in the Adult, 3rd Edition• ASE guideline J Am Soc Echocardiogr 2003;16:777-802• Enriquez-Sarano M et al. N Engl J Med 2005; 352(9): 875-83• Enriquez-Sarano M et al. Circulation 2010, 121:804-812• Enriquez-Sarano M et al. Circulation 2010, 121:804-812• Wisenbaugh T et al. Circulation 89,1994• Ling LH, NEJM 1996;335:1417-23• Lim E et al. Circulation 2001, 104:I-59-I-63• Rosenhek, R. et al. Circulation 2006;113:2238-2244Rosenhek, R. et al. Circulation 2006;113:2238 2244• Enriquez-Sarano M , Sundt T M Circulation 2010;121:804• Ling LH, NEJM 1996;335:1417-23• David TE, JTCVS 2005; 130(5):1242-9• ACC/AHA 2006 Guidelines• Townsend: Sabiston Textbook of Surgery 18th Edition• Volume 22 Number 9, pp.978-9.• Zoghbi, et al. Journal of the American Society of Echocardiography• Grayburn et al, Am J Cardiol, Volume 108, Issue 6, Pages 882-887• www.uptodate.com/contents/etiology-clinical-features-and-evaluation-of-chronic-mitral-

regurgitation

www.uptodate.com/contents/etiology-clinical-features-and-evaluation-of-chronic-mitral-regurgitation