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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
