cardiology grand rounds - minneapolis heart institute ... · presentation: mitral disease speakers:...
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C A R D I O L O G Y G R A N D R O U N D S Presentation: Mitral Disease
Speakers: Robert S. Farivar, MD, PhD Chief, Cardiothoracic Surgery, Abbott Northwestern Hospital Chairman, Allina Cardiothoracic; Minneapolis Heart Institute® at Abbott Northwestern Hospital
Paul Sorajja, MD Director of the Center for Valve and Structural Heart Disease Minneapolis Heart Institute ® at Abbott Northwestern Hospital
Date: Monday, April 20, 2015, 7:00 – 8:00 AM Location: ANW Education Building, Watson Room
OBJECTIVES At the completion of this activity, the participants should be able to:
1. Recognize various quality metrics for mitral disease 2. Identify various minimally invasive incisions. 3. Identify what cases may be appropriate for referral for mitraclip.
ACCREDITATION Physicians: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Allina Health and Minneapolis Heart Institute Foundation. Allina Health is accredited by the ACCME to provide continuing medical education for physicians.
Allina Health designates this live activity for a maximum of 1.0 AMA PRA Category 1 CreditTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Nurses: This activity has been designed to meet the Minnesota Board of Nursing continuing education requirements for 1.2 hours of credit. However, the nurse is responsible for determining whether this activity meets the requirements for acceptable continuing education.
Others: Individuals representing other professional disciplines may submit course materials to their respective professional associations for 1.0 hours of continuing education credit.
DISCLOSURE STATEMENTS Speaker(s): Dr. Farivar declares the following relationship; Consultant: Edwards LifeSciences, LLC. Dr. Sorrajja declares the following relationships; Consultant & Speaker Bureau: Abbott Vascular; Consultant: Medtronic; Consultant: Lake Region Medical.
Planning Committee: Dr. Michael Miedema, and Eva Zewdie have declared that they do not have any conflicts of interest associated with the planning of this activity. Dr. Robert Schwartz declared the following relationships - stockholder: Cardiomind, Interface Biologics, Aritech, DSI/Transoma, InstyMeds, Intervalve, Medtronic, Osprey Medical, Stout Medical, Tricardia LLC, CoAptus Inc, Augustine Biomedical; scientific advisory board: Abbott Laboratories, Boston Scientific, MEDRAD Inc, Thomas, McNerney & Partners, Cardiomind, Interface Biologics; options: BackBeat Medical, BioHeart, CHF Solutions; speakers bureau: Vital Images; consultant: Edwards LifeSciences.
1
Mitral RegurgitationMitral Regurgitation
Paul Sorajja, MDDirector, Center for Valve and Structural Heart DiseaseMinneapolis Heart Institute at Abbott Northwestern Hospital
Paul Sorajja, MDDirector, Center for Valve and Structural Heart DiseaseMinneapolis Heart Institute at Abbott Northwestern Hospital
Robert S. Farivar, MD PhDChairman, Cardiac SurgeryMinneapolis Heart Institute at Abbott Northwestern HospitalChair, Allina Health Cardiac Surgical Services
Robert S. Farivar, MD PhDChairman, Cardiac SurgeryMinneapolis Heart Institute at Abbott Northwestern HospitalChair, Allina Health Cardiac Surgical Services
62 year-old man, asymptomatic62 year-old man, asymptomatic
a) Observe
b) Mitral valve replacement
c) Mitral valve repair
d) Transcatheter MitraClip
a) Observe
b) Mitral valve replacement
c) Mitral valve repair
d) Transcatheter MitraClip
2
Key PointsKey Points
• Highly prevalent disease that is under-treatedExcess mortality from treatment delays
• Success of mini-MV repair is >90% with risk of <1% and minimal LOS
• MitraClip indicated for high-risk patients Success >90% in selected patients
3
Prevalence of Mitral RegurgitationPrevalence of Mitral RegurgitationAge-dependentAge-dependent
Nkomo et al. Lancet, 2006; 368: 1005-11.
6% for ≥65 year olds
14
12
10
8
6
4
2
0
Pre
vale
nce
(%
)
Aortic valve disease
Age (years)
<45 45-54 55-64 65-74 >75
Mitral valve disease
All valve disease
3
Classification of MRClassification of MR
Sorajja, Paul, MD; Abbott Northwestern Hospital
Primary
“The Valve”
Secondary
“The Ventricle”
Usually myxomatous Ischemic or not
Key Prognostic DeterminantsKey Prognostic Determinants
Severity
Left Ventricular Function
Symptoms
4
6
Asymptomatic Primary MRAsymptomatic Primary MRSeverity and SurvivalSeverity and Survival
Enriquez-Sarano M et al. NEJM 2005;352:875-83Enriquez-Sarano M et al. NEJM 2005;352:875-83
Worse Survival
100
90
80
70
60
50
0
100
90
80
70
60
50
0
Su
rviv
al (
%)
Su
rviv
al (
%)
YearsYears
0 1 2 3 4 50 1 2 3 4 5
P<0.01P<0.01
ERO <20mm2 (91 ±3%)ERO <20mm2 (91 ±3%)
ERO 40mm2 (58 ±9%)ERO 40mm2 (58 ±9%)
ERO 20-39mm2
(66 ±6%)ERO 20-39mm2
(66 ±6%)
Worse Survival
100
90
80
70
60
50
0
Su
rviv
al (
%)
Years
0 1 2 3 4 5
P<0.01
ERO <20mm2 (91 ±3%)
ERO 40mm2 (58 ±9%)
ERO 20-39mm2
(66 ±6%)
More CV Events
70
60
50
40
30
20
10
0
70
60
50
40
30
20
10
0
Rat
e o
f C
ard
iac
Eve
nts
%R
ate
of
Car
dia
c E
ven
ts %
YearsYears
0 1 2 3 4 50 1 2 3 4 5
P<0.01P<0.01
ERO <20mm2 (15 ±4%)ERO <20mm2 (15 ±4%)
ERO 20-39mm2
(40 ±7%)ERO 20-39mm2
(40 ±7%)
ERO 40mm2 (62 ±8%)ERO 40mm2 (62 ±8%)
More CV Events
70
60
50
40
30
20
10
0
Rat
e o
f C
ard
iac
Eve
nts
%Years
0 1 2 3 4 5
P<0.01
ERO <20mm2 (15 ±4%)
ERO 20-39mm2
(40 ±7%)
ERO 40mm2 (62 ±8%)
EF and Surgical OutcomeEF and Surgical Outcome
100
80
60
40
20
0
Su
rviv
al %
Years
0 1 2 3 4 5 6 7 8 9 10
EF 60%
EF 50-60%
EF <50%
P=0.0001
72 ±4%
53 ±9%
EF <60% is Abnormal in MR
32 ±12%
Enriquez-Sarano M, et al., Circulation 1994;90:830-837
5
LV Function in MRLV Function in MR
Preload
Myocardial performance
Afterload
EF usually drops after surgery
MVR
MVR
9
Symptoms and SurgerySymptoms and SurgeryOutcome with Primary MROutcome with Primary MR
100
80
60
40
20
0
Su
rviv
al %
Years
0 1 2 3 4 5 6 7 8 9 10
NYHA I-II
NYHA III-IV
P<0.0001
90 ±276 ±5
73 ±3
48 ±4
Tribouilly CM et al., Circulation 1999;99:400-5
6
10
Flail Mitral LeafletFlail Mitral LeafletNatural HistoryNatural History
Ling L, et al. N Engl J Med 1996; 335:1417-1423Ling L, et al. N Engl J Med 1996; 335:1417-1423
100
80
60
40
20
0
100
80
60
40
20
0
Su
rviv
al %
Su
rviv
al %
Years After DiagnosisYears After Diagnosis
0 1 2 3 4 5 6 7 8 9 100 1 2 3 4 5 6 7 8 9 10
P<0.001P<0.001
Class I or IIClass I or II
Class III or IVClass III or IV
Mortality4% per yearMortality4% per year
34% per year34% per year
11
• Papillary muscle displacement
Trichon BH, et al. Am J Cardiol 2003;91:538-43
A Ventricular ProblemA Ventricular Problem
Regional or Global Dysfunction
• Annular flattening
• Leaflet tethering
Secondary Mitral Regurgitation
7
12
MR and Heart FailureMR and Heart FailurePrevalence in CHFPrevalence in CHF
Moderate or severe MR present in
40%
4 million people with heart failure and MR in U.S.
Patel JB, et al. J Card Fail 2004;10:285-291; Go AS, et al. Circulation 2013;127:e6.
0
10
20
30
40
50
60
70
%
None
Moderate
Mod-Severe
Severe
Advanced Heart Failure
13
Secondary Mitral RegurgitationSecondary Mitral RegurgitationA Harbinger of Poor OutcomeA Harbinger of Poor Outcome
Two-fold Increase Risk of DeathGrigioni F, et al. Circulation 2001;103:1759-64; Basket JF, et al. Can J Cardiol 2007;23:797-800
1.0
0.8
0.6
0.4
0.2
0.0
Su
rviv
al (
%)
Years
0 1 2 3 4 5
P<0.001
50
40
30
20
10
0
Dea
th o
r h
eart
fai
lure
h
osp
ital
izat
ion
%
Follow-up time (days)
0 365 730 1095
P=0.0006
MI w/o MR
MI with MR61 ±6
38 ±5
MitralRegurgitation
No Mitral Regurgitation
Post-MI SOLVD (EF >35%)
8
What about therapy?
Mitral RegurgitationMitral Regurgitation
General Principles of TherapyGeneral Principles of Therapy
Primary
Surgery for symptoms or LV
dysfunction
Secondary
Try to repair
Medical therapy first
No medical option
Consider CRT
Surgery only in highly selected patients with HFConsider
prophylactic repair
9
16
Timing of Surgical InterventionTiming of Surgical InterventionACC/AHA Guidelines – Primary MRACC/AHA Guidelines – Primary MR
Consider surgery whenSymptomsor
LV dysfunction (EF<60%, ESD≥40 mm)
Try to repair in a experienced center
Nishimura R, et al., J Am Coll Cardiol 2014;63:2438-88
17
Early Surgery Is BetterEarly Surgery Is BetterPatients without Class I IndicationsPatients without Class I Indications
100
80
60
40
20
0
Su
rviv
al %
Follow-up, y
0 5 10 15 20
Suri R et al., JAMA 2013;310:609-16
Early surgery
Medical management
Log-rank P<.001
10
Based on Patient RiskBased on Patient Risk
Surgery MitraClip
What Therapy for Primary MR?What Therapy for Primary MR?
Not High High
Mitral Valve SurgeryMinneapolis Heart Institute
Abbott Northwestern Hospital
Mitral Valve SurgeryMinneapolis Heart Institute
Abbott Northwestern Hospital
Mitral RegurgitationMitral Regurgitation
11
Nishimura RA, et al. JACC 2014
• Multidisciplinary
• Guideline adherence
• All therapy options
• Quality improvement
• Public reporting
2014 Valve Guidelines2014 Valve GuidelinesValve Center of ExcellenceValve Center of Excellence
Carpentier Principles of MVP(How we do mitral repair)
Carpentier Principles of MVP(How we do mitral repair)
• 1. Smooth Coaptation surface
• 2. Reduced height of posterior leaflet
• 3. Annuloplasty reinforcement
• 1. Smooth Coaptation surface
• 2. Reduced height of posterior leaflet
• 3. Annuloplasty reinforcement
12
Why we do mini mitral repairWhy we do mini mitral repair
Mini Mitral IncisionsMini Mitral Incisions
Paramedian
Lower hemi
Mini thoracotomy
Full sternotomy (small incision)
13
Lower hemisternotomy mitralLower hemisternotomy mitral
Lower hemisternotomy mitralLower hemisternotomy mitral
14
Port access mitralPort access mitral
Port Access VideoPort Access Video
15
Port Access PicturesPort Access Pictures
SINGLE SURGEON EXPERIENCESINGLE SURGEON EXPERIENCE
16
Mitral Valve Cases performed by Dr Farivar over initial 10 months
41
Mitral Valve Cases performed by Dr Farivar over initial 10 months
41
DemographicsDemographics
• Average age• Average XC• Average CPB• Male:Female
• Average age• Average XC• Average CPB• Male:Female
• 64 yo• 66 min• 92 min• 22:19
• 64 yo• 66 min• 92 min• 22:19
17
Deaths = 0 (zero)Deaths = 0 (zero)
Permanent Strokes = 0 (zero)Permanent Strokes = 0 (zero)
18
MI/Reop for Bleed/Infections = 1 reop bleed (2.6%)
MI/Reop for Bleed/Infections = 1 reop bleed (2.6%)
Mitral Valve Repair (Intention to Treat)
27/28 (96% intention to treat)
Mitral Valve Repair (Intention to Treat)
27/28 (96% intention to treat)
19
Mitral Valve Replacement =13
(mechanical 4)(tissue 7)
Mitral Valve Replacement =13
(mechanical 4)(tissue 7)
Mean Diastolic Gradient (repairs) on pre-discharge echo
4 mm Hg
Mean Diastolic Gradient (repairs) on pre-discharge echo
4 mm Hg
20
Concomitant CasesConcomitant Cases
• Double valves (5/41) = 12%Aortic 1/41 (2.4%)Tricuspid 4/41 (9.8%)
• Ascending aortic replacement 2/41 (4.9%)
• Left atrial appendage ligation 8/41 (19.5%)
• PFO closure 3/41 (7%)• CABG 3/41 (7%)
• Double valves (5/41) = 12%Aortic 1/41 (2.4%)Tricuspid 4/41 (9.8%)
• Ascending aortic replacement 2/41 (4.9%)
• Left atrial appendage ligation 8/41 (19.5%)
• PFO closure 3/41 (7%)• CABG 3/41 (7%)
MinisMinis
• For single valve cases 13/24 are minimally invasive (54%) [over half minis]
Port are over half (8/13) Lead up time for ports, since team needed to be trained
• For single valve cases 13/24 are minimally invasive (54%) [over half minis]
Port are over half (8/13) Lead up time for ports, since team needed to be trained
21
Complexity/ComorbidityComplexity/Comorbidity
• Extreme Kyphoscoliosis 2/39 (5%)• Reoperations 4/39 (10%)• Re-repair failed repairs 2+ (5%)• IABP (low EF) 3/39 (8%)• Barlowe (bileaflet)/anterior leaflet prolapse 8/30
(27%), functional 3/39 (8%), posterior 22/30 (73%)• HIV/HepC/renal insufficiency/stoma 5/39 (13%)• Combined HOCM patients 2/39 (5%)• Endocarditis 2/39 (5%)• > 75 yo 10/39 (26%)
• Extreme Kyphoscoliosis 2/39 (5%)• Reoperations 4/39 (10%)• Re-repair failed repairs 2+ (5%)• IABP (low EF) 3/39 (8%)• Barlowe (bileaflet)/anterior leaflet prolapse 8/30
(27%), functional 3/39 (8%), posterior 22/30 (73%)• HIV/HepC/renal insufficiency/stoma 5/39 (13%)• Combined HOCM patients 2/39 (5%)• Endocarditis 2/39 (5%)• > 75 yo 10/39 (26%)
LOSLOS
•Overall LOS = 7d (all comers)
•Lower Hemi = 6d•Port Access = 5d
•Overall LOS = 7d (all comers)
•Lower Hemi = 6d•Port Access = 5d
22
AP PA
Complexity: Extreme Kyphoscoliosis Mitral Repai
AP PA
Complexity: Extreme Kyphoscoliosis Mitral Repai
23
24
Results: Mitral Regurg on Postop
Echo
Results: Mitral Regurg on Postop
Echo
0
5
10
15
20
25
None 1+ 2+ 3 or 4+
Number pts
Number pts
25
Financials at ANWFinancials at ANW
Mitral Repair
Mitral Replacement
26
Summary Data InsightsSummary Data Insights
•Selection of cases is appropriate
• Intraop decision making and clinical support is good
•Postoperative Care is appropriate
•Financial aspects extremely favorable
•Selection of cases is appropriate
• Intraop decision making and clinical support is good
•Postoperative Care is appropriate
•Financial aspects extremely favorable
Goals/Vision/FutureGoals/Vision/Future
• Reference CenterELS
• Mini growth• Help for other surgical
programs in system• Gets us the latest equipment
& Trials(Advantages of a reference center)
• Reference CenterELS
• Mini growth• Help for other surgical
programs in system• Gets us the latest equipment
& Trials(Advantages of a reference center)
27
Catheter-based Therapy for Mitral Regurgitation
Catheter-based Therapy for Mitral Regurgitation
Mitral RegurgitationMitral Regurgitation
MitraClip® SystemMitraClip® System
28
Suitable Anatomy?Suitable Anatomy?Clip openClip open Closed to 60Closed to 60
SpaceThick
leaflets, no Ca+2
helpful
SpaceThick
leaflets, no Ca+2
helpful
4 mm long≥2 mm tip coaptation
4 mm long≥2 mm tip coaptation
Grasping viewGrasping view
M vs LM vs L
Bi-com (60) and LVOT (150)Bi-com (60) and LVOT (150)EchocardiographyEchocardiography
150150
6060
Tells You Where and How Many ClipsTells You Where and How Many Clips
29
Clip Like Alfieri StitchLess risk of chord entrapment
Surgery MitraClip
MitraClip CaseMitraClip Case
30
Post-Superior TransseptalPost-Superior Transseptal
Avoiding ASDAvoiding ASD
3.5 - 4.0 cm
3.5 - 4.0 cm
Loosen
Torque
ML
31
32
Commissures Can Be DoneCommissures Can Be Done
MAC is not an contraindicationMAC is not an contraindication
33
An Important TidbitAn Important Tidbit
August 2014August 2014 October 2014October 2014
PCIPCI
Remember how dynamic MR is
LAP = 13 with SBP at 150 mmHg
77 year-old man77 year-old man
34
Outcomes of the Initial Experience
with Commercial Transcatheter Mitral
Valve Repair in the U.S.
Outcomes of the Initial Experience
with Commercial Transcatheter Mitral
Valve Repair in the U.S.
ACC 2015 LBCT
Paul Sorajja, MD, Saibal Kar, MD, Amanda Stebbins, Sreekanth
Vemulapalli, MD, D. Scott Lim, MD, Vinod Thourani, MD,
Michael Mack, MD, David R. Holmes, Jr., MD,
Wesley A. Pedersen, MD, and Gorav Ailawadi, MD
A report from the STS/ACC TVT RegistryA report from the STS/ACC TVT Registry
Study Population564 Patients
Study Population564 Patients
• Median age (% men)…………………..…..
• NYHA III/IV……………………………….……….
• HF hospitalization prior yr…………….……....
• Atrial fibrillation………………………….……...
• Prior CVA………………………………….………
• Diabetes………………………………….……….
• Prior CABG……………………………….………
• Prior MI…………………………………………...
• Creatinine ≥2 g/dl……………………………….
• O2-dependency………………………….………
• Median STS-PROM MV repair..............…
• Median STS-PROM MV replacement.….
83 yrs (56%)
83.9%
51.8%
62.6%
8.7%
25.0%
32.4%
24.6%
16.7%
14.7%
7.9% (4.7, 12.2)
10.0% (6.3, 14.5)
35
0%
20%
40%
60%
80%
100%
Baseline Post-implant
Grade 4
Grade 3
Grade 2
Grade 1
Mitral Regurgitation
Change in Mitral RegurgitationChange in Mitral RegurgitationClip implantation occurred in 94%
93% MR ≤2
63.7% MR≤1
p<0.001
Clinical OutcomesClinical Outcomes
• In-hospital mortality…
• Procedure success….
• Complications............
• Length-of-stay............
• Home discharge.........
2.3%
91.8%
7.8%
3 d (1,6 d)
81.9%
36
U.S. vs. Other RegistriesU.S. vs. Other Registries
• STS/ACC TVT (US)...…….
• SENTINEL (EU)….………..
• ACCESS (EU)….……...….
• TRAMI (DE)………..………
• MitraSwiss (CH)................
• France (FR)……................
• GRASP (IT)……..….…….…
• Netherlands (NL)…………
• MARS (Asia)………………
93%
95%
91%
95%
85%
88%
100%
93%
94%
MR ≤2DMR In-hospital
death
2.3%
2.9%
2.9%
4.0%
3.3%
4.2%
Age (yrs)
83
74
74
75
77
73
72
73
71
86%
28%
23%
29%
38%
23%
24%
18%
46%• EVEREST I………………..
• EVEREST II RCT…...….…
• EVEREST II HRS……......
71
67
76
74%
77%
86%
0.9%
1.1%
2.6%
79%
51%
30%
A New Mitral TherapyA New Mitral Therapy
TendyneTendyne
37
April 8, 2015April 8, 2015
38
Key PointsKey Points
• Highly prevalent disease that is under-treatedExcess mortality from treatment delays
• Success of mini-MV repair is >90% with risk of <1% and minimal scars and LOS
• MitraClip indicated for high-risk patients Success >90% in selected patients