Should Functional MR be

Fixed in Heart Failure?

Steven F. Bolling, M.D.

Professor of Cardiac Surgery

University of Michigan

All MR is not the same !

Degenerative MR Functional MR

Functional (2o) MR : Ventricular Problem!

Badhwar, Bolling , chapter in: Advances in Heart Failure, 2004

Traditional view of FMR and CHF

©2011 by BMJ Publishing Group Ltd and British Cardiovascular

Society

MR grade No.

None 9,405

Mild 2,062

Moderate 210

Severe 171

0.0

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Even with GDMT…

FMR survival is not optimal!

Hickey et al: Circulation 78:1-51, 1988

Even with small FMR volumes…

Survival is terrible !

Grigioni et al: Circulation 103:1759, 2001

ERO RVol

“Significant” FMR

ERO > 20 cm2

R Vol > 30 ml

FMR…Not just a “late marker” !

It’s also a CAUSE ! FMR – worsens odds of death

Rossi A et al. Heart 2011;97:1675-1680

r

AHA/ACC Mitral Guidelines - 2014

“Undersized” Mitral Repair

Feasible / Low mortality

“Fixed” MR

Better QOL / less CHF

It works!...it doesn’t work !

Mitral Repair and CHF : benefit ?

What? - No mortality benefit !

FMR bad… no FMR good ?

Why? - No mortality benefit ?

Did not get rid of FMR ! 33 % Recurrent MR : 2004

McGee, Gillinov et al, JTCVS, 2004;128:916-24

Progression of 3 or 4+ MR post-undersized annuloplasty (585)

McGee EC et al. JTCVS 2004;128:916-24 Mihaljevic et al. J Am Coll Cardiol 2007;49:2191-201 Crabtree TD et al. Ann Thorac 2008;85:1537-43 Surg

Residual / recurrent FMR

if we do repair badly

FMR patients do badly !

Freedom from recurrent MR≥3+

...Because the ventricles do badly !

It’s a ventricular problem!

Lots of recurrent FMR = No reverse remodeling

Size of LV

Type of Ring

Large,flexible and/or partial bands

not a durable solution for FMR !

Magne et al. Cardiology 2009;112:244-259

Bothe W, Swanson J, et al., JTCVS 2010

IMR-FMR rings

SMALL, RIGID and COMPLETE Disproportionate AP dimension reduction

Di Salvo et al. JACC 2010;55:271-82

Differential outcome for FMR types

FMR patients do “poorly slowly”

Ischemic FMR does worst !

Different FMR in Ischemia

Badhwar, Bolling , chapter in: Advances in Heart Failure, 2004

Circulation. 2012;125:2639-2648

MORTALITY BENEFIT: CAB/MV repair vs CAB alone with LV dysfunction and moderate - severe MR

STICH TRIAL - iFMR

Randomized Moderate iFMR trial

– JTCVS Fatouch 2009

iFMR - survival

iFMR – exercise MR

Mitral Valve Annuloplasty in Addition to Coronary Artery Bypass Grafting in Moderate Functional

Ischemic Mitral Regurgitation Reverses Left Ventricular Remodelling and Restores Left

Ventricular Geometry: Chan et al , CIRC March 2012

British NHS 2012 : RIME

CABG + MVr for Moderate iFMR Mitral regurg volume - 69% vs 14%

LV end systolic volumes - 24% vs 10%

LV sphericity - 18% vs + 1.7 %

Peak oxygen capacity + 3.0 vs 1.0

Brain natriuretic peptide - 76% vs 59%

All p < 0.01 !

Patients Screened for Moderate Ischemic MR

(n=6,676)

Randomized Patients

(n=301)

Primary Endpoint Analysis

(n=301)

CABG + Valve Repair

Undersized Ring

(n=150)

CABG Alone

(n=151)

Outcomes Measured at 6, 12 and 24 months

CTSN Moderate iMR Trial Design

(excluded

6,375

or 95.5%)

30 Day Mortality:

2.7% (CABG) vs. 1.3% (CABG/MVr),

p =0.68

12 Month Mortality:

7.3% (CABG) vs. 6.7% (CABG/MVr),

p =0.83

Mortality - no “added” price for MVr

MACCE at 12 Months - Same

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60

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80

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er

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CABG Alone CABG + MV Repair

P=NS P=0.03

P=NS

P=NS

P=0.03

Overall SAE Rate (100-pt years) 117.0 (CABG Alone) vs. 137.1 (CABG + Repair)

p=0.15

P=NS

SAEs and Re-hospitalization

Significant MR was 3x worse without a ring

At only

12 months!

1 2

Distribution of Ring Size

1 2

Distribution of Ring Size

Really

Undersize !

Survival benefit - MVR in CHF (Wu)

Before (blue) 29 / After (green) 2000 26

0 500 1000 1500 2000 2500

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Prior to 2000

2000 - 2002

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Medical Group

Survival Functions

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Prior to 2000

2000 -2002

0-censored

1-censored

MVA Group

Survival Functions

medical vs surgical tx

SMALLER, COMPLETE RIGID RINGS

MR is bad !!

LVESI – no change… MR vs. LVESVI Change!

Undersized Rigid Complete Ring

Annuloplasty

Moderate iFMR is bad

What about severe iFMR…?

Al Radi et al, Ann Thorac Surg, 2005;79:1260-7

Valve sparing replacement vs repair

Survival for 4+ severe ischemic FMR

J Thorac Cardiovasc Surg 2013;145:128-39 J Thorac Cardiovasc Surg 2011;142:995-1001

Overall survival

De Bonis M et al. Ann Thorac Surg. 2012;94:44-51

Favor MVR Favor MV

repair Favor MV repair Favor MVR

Short term survival Long term survival

Severe Ischemic Mitral Regurgitation

NEJM 2014, 251 CABG + MV repair vs MV replacement

(3458….447….251 ….7 % )

LVESI (Size/remodeling) same Mortality same CV events same Functional status same

Severe Ischemic Mitral Regurgitation

Different! 32% MV repairs - recurrent MR Sham placebo MVr! Did not get rid of FMR !

NHLBI Trial : Severe iFMR

Mean ring size : 28.4 + 1.9 Did not “downsize”, ~25% > 32!

Not a single “24” used ! Native size never < 28 ?!

Mandatory coaptation length

Severe Ischemic Mitral Regurgitation

Mitral repair operative mortality 1.6%

vs “total valve sparing” MVR 4.2%

Severe Ischemic Mitral Regurgitation

Functional status

MV repair includes 32 % - had “sham nothing” !

Remodeling - LVESI

Kron et al JTCVS 2015 “Good” repair – 46 mm

Replacement – 61 mm

“Bad” repair – 63 mm (40% - basal inferior “aneurysm” )

Mild annular dilatation

Coaptation depth >1 cm

Posterior leaflet angle >45°

post/basal dyskinesia ! Distal anterior leaflet angle >25°

Advanced LV remodelling – LVEDD > 65 mm

– Systolic sphericity index > 0.7

– End systolic interpapillary muscle

distance >20 mm

– LVESV ≥ 145 ml (or ≥ 100 ml/m2)

Predictors of “Bad FMR Repair”

Lancellotti et al. Eur J Echo 2010 EAE recommendations for the

assessment of valvular regurgitation

Dilated Cardiomyopathy : dcFMR

Badhwar, Bolling , chapter in: Advances in Heart Failure, 2004

Michael A. Acker , Mariell Jessup , Steven F. Bolling , Jae Oh , Randall C. Starling ,

Douglas L. Mann , Hani N. Sabbah

Mitral valve repair in heart failure: Five-year follow-up from

the mitral valve replacement stratum of the Acorn

randomized trial

The Journal of Thoracic and Cardiovascular Surgery Volume 142, Issue 3 2011 569 - 574.e1

70% survival @ 5 yrs

76% survival @ 6.5 yrs

MVr …and TVr and AF ablated !

Surgery and dcFMR 2014

MVr treatment for dcFMR

Catheter-Based Mitral Repair – MitralClip

Clip Leaves FMR !

160

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8275

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ml)

CRT : Less than half eligible, less than half “respond”

Improvers: reduction in ≥ 1 grade of MR

van Bommel R J et al. Circulation 2011;124:912-919

Copyright © American Heart Association

Residual FMR is still BAD, but.. !!

MitralClip and CHF / FMR n=78 1 year outcomes

Decreased CHF rehosp by 45%: COAPT/ReShape

Percutaneous Mitral Valves and Rings

FMR 2015

GDMT, CRT, Surgery, Clip

Careful patient selection

ischemic vs. dilated FMR ? Beware the big LV, the bad RV

Fix AF and TR !

Repair - small complete

rigid ring Replacement - selective,

chord-sparing

Find MR

Fix MR

Fix LV !

Mitral Repair and CHF