20090417 few patients with functional mr are treated surgically: duke database results mitchell w....

20090417

Few Patients With Functional MR Are Treated Surgically:Duke Database Results

Mitchell W. Krucoff MD

FACC, FAHA, FSCAIProfessor of Medicine / Cardiology

Duke University Medical CenterDirector, Cardiovascular Devices Unit

Duke Clinical Research Institute

20090417

Conflict of Interest

Research grants, consulting, advisory: Abbott Vascular Cardiac Dimension Medtronic St. Jude

20090417

Acknowledgement

Zainab Samad, Eric Yow, Linda K Shaw, Hussein R Al-Khalidi, Kristine Arges, John H

Toptine, Andrew Wang, James G Jollis, Eric J Velazquez

AHA 2011

20090417

Background

While systematic “real world” data exist on patients with MR undergoing surgery (Society of Thoracic Surgery=STS database), there is far less information on the incidence and outcomes of MR patients managed medically.

While valve repair/replacement is accepted therapy for degenerative MR, the value of such interventions in functional MR patients is unknown

20090417

Duke Cardiovascular Database (1995-2012)

126,796 Unique Patients Echo + Cardiac CatheterizationN=30,848

Echo onlyN=74,367

Cardiac Catheterization onlyN=21,579

Cath within 1 yr N=27,045

Moderate or Severe MR

Cath outside 1 yrN=3,803

N=3,920

N= 280

N=5,109

N= 242

9,551 (7.5%) with Moderate or Severe MR

20090417

Treatments Received

Medical Therapy %

71 68 53 <0.0001

Valve within 1 yr

8 17 42 <0.0001

CABG within 1 yr

13 14 15 0.4272

Mild MR Moderate MR Severe MR P value

N 8172 2819 1136

FMR, % 92 85 67 <0.0001

20090417

Unadjusted Survival by MR Severity*

*censored at surgery

0 2 4 6 8 10 12 14 160

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

None/Trivial MR

Mild MR

Moderate

Severe MR

Years

Su

rviv

al P

rob

abil

ity

p<.0.0001

20090417

Survival: Moderate or Severe MR by Treatment – Unadjusted*

0 2 4 6 8 10 12 140

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Medical

Isolated CABG

Isolated Valve

CABG + Valve

Years

p<0.0001

Sur

viva

l Pro

babi

lity

20090417

Results

Echo and Cardiac Catheterization within 1 yr

+ Moderate or Severe MR N = 3920

Non-High RiskN= 1666

High RiskN= 2254

High Risk Criteria:• STS score ≥ 12%• Age > 75 + EF <40%• Functional MR + EF

<40%• ≥ 2 prior chest surgeries• Prior chest surgery + EF

<35% + Cr > 2.5 mg/dL• Age > 75 + prior chest

surgery + Cr > 2.5 mg/dL• Hepatic cirrhosis• Dialysis• Chronic lung disease• Prior stroke• Prior CABG

20090417

Survival: Moderate or Severe MR by Risk Group- Unadjusted*

0 2 4 6 8 10 12 140

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Not High Risk

High Risk

Years

Su

rviv

al P

rob

abili

ty

p<0.0001

20090417

Survival: High Risk Moderate or Severe MR by Treatment

0 2 4 6 8 10 12 140

0.2

0.4

0.6

0.8

1

Medical

Isolated Valve

CABG +/- Valve

YearsSu

rviv

al P

rob

ab

il-it

y p=.0299

20090417

Treatment of Severe FMR:Observations From Longitudinal Data

Valve surgery is rare in all FMR, mild, moderate, severe

Combined high risk and moderate/severe MR outcomes are poor with and without surgery

Longitudinal natural history models of FMR patients may be helpful in percutaneous MV study designs