evidence-based management of mitral regurgitation?

Robert O. Bonow, MD, MS

No Relationships to Disclose

Northwestern University Feinberg School of Medicine

Bluhm Cardiovascular Institute

Northwestern Memorial Hospital

Editor-in-Chief, JAMA Cardiology

Evidence-Based Management

of Mitral Regurgitation?

www.acc.org

www.americanheart.org

Mitral regurgitation

Primary mitral regurgitation

Secondary mitral regurgitation

• Symptomatic patients class I


Indications for mitral valve surgery

for primary MR?

• Symptomatic patients

• Asymptomatic patients

• LV systolic dysfunction

class I

class I



for primary MR?

LVEF <60%




class I

class I



for primary MR?

LVEF <60%

LVSD >40mm




• Pulmonary hypertension

class I

class I

class IIa



for primary MR?

PASP >50 mmHg at rest





• Atrial fibrillation

class I

class I

class IIa

class IIa



for primary MR?





• Atrial fibrillation

• Normal LV function,

repair feasible? ?

class I

class I

class IIa

class IIa



for primary MR?

Asymptomatic severe primary MR:

• 66% come to surgery in 5 years because

of symptoms, LV dysfunction, pulmonary

hypertension or AF

• Long-term postoperative survival is worse

if surgery is performed after patients

become symptomatic

Indications for mitral valve repair

for asymptomatic primary MR:


class IIa

• Chronic severe MR

• Preserved LV function

• Experienced surgical center

• Likelihood of durable repairwithout residual MR > 95%


class IIa

class I

Indications for mitral valve repair

for asymptomatic primary MR:

!• Repair better than mitral valvereplacement

• Patients should be referred tocenters experienced in repair


• Preserved LV function

• Experienced surgical center

• Likelihood of durable repairwithout residual MR > 95%.

• STS Database 2011-2016

• Isolated primary MV surgery

• 87,214 patients

Annual Case Volume

Degenerative Mitral Disease

Cases Centers

0 106

1-6 763

6-25 213

26-50 28

50-100 11

>100 4

Repair rate 66.7%

Repair rate 90.0%


class IIb

Indications for transcatheter MV

repair for severe primary MR:


• Severely symptomatic

• Prohibited surgical risk

• Reasonable life expectancy


Primary MR: primary valve disease

Secondary MR: primary myocardial disease




• Post MI,

• Heart failure

• Dilated cardiomyopathy




• Diagnostic dilemmas

• Therapeutic dilemmas

Deja et al. Circulation 2012

p<0.001

0

200

400

600

800

1 2 3 4 5 6 7 8

Ischemic Cardiomyopathy80

0

Time (years)

0

60

40

20Mort

alit

y (

perc

ent)

1 2 3 4 5 6

55%

47%

30%

Deja et al. Circulation 2012;125:2639-2648

No MR

Mild MR

Mod-Severe MR

p<0.001

Deja et al. Circulation 2012

p<0.001

0

200

400

600

800

1 2 3 4 5 6 7 8

Ischemic Cardiomyopathy80

0

Time (years)

0

60

40

20Mort

alit

y (

perc

ent)

1 2 3 4 5 6

Deja et al. Circulation 2012;125:2639-2648

No MR

Mild MR

Mod-Severe MR

EF 25%

ESVI 90 mL/m2

EF 27%

ESVI 80 mL/m2

EF 30%

ESVI 73 mL/m2

p<0.001

Functional MR: a marker of a sicker LV

Does it contribute to a sicker LV?


can be repaired.

But should it be repaired?


can be repaired.

But should it be repaired?

0

20

40

60

80

100

1 2 3 4 5 6 7 8

100

80

Su

rviv

al (p

erc

en

t)

60

40

20

0

p=NS

n=419

Medical

Surgical

5000 1000 1500 2000

Wu et al. J Am Coll Cardiol 2005;45:381-387

Time (days)


Guideline-directed medical

therapy for heart failure,

including CRT

class I

Indications for mitral valve surgery:


Guideline-directed medical


including CRT


• Patients with severe MR undergoing CABG or AVR

class I

class IIa



• Patients with severe MR undergoing CABG or AVR

class IIb• Severe MR, persistent

symptoms despite optimal medical therapy, including CRT

class IGuideline-directed medical


including CRT

class IIa

Baseline Optimized Medical Therapy

and Biventricular Pacing

Obadia et al. N Engl J Med 2018;379:2297-2306

MITRA-FR Trial

COAPT Trial

Stone et al. N Engl J Med 2018;379:2307-2318

COAPT Trial

67.9%

45.7%

Control group

Device group

Stone et al. N Engl J Med 2018;379:2307-2318

Rationalizing the Different Outcomes

Between MITRA-FR and COAPT Trials

• Patients in COAPT had more severe MR

• Patients in MITRA-FR had more severe LV dysfunction

• Medical therapy was more aggressively optimized

before randomization in COAPT

• COAPT operators more experienced; lower rates of

residual MR at 12 months

Rationalizing the Different Outcomes

Between MITRA-FR and COAPT Trials

• Patients in COAPT had more severe MR

• Patients in MITRA-FR had more severe LV dysfunction

LVEF LVEDV RV EROA

MITRA-FR 33% 252 ml 45 ml 0.31 cm2

COAPT 31% 192 ml 60 ml 0.41 cm2

Grayburn et al. JACC Cardiovasc Imaging 2019;12:353-362

Prevalence of MR in Patients with LV Dysfunction

Prevalence

N MR

Yiu et al Circulation 2000 128 63%

Grigioni et al Circulation 2001 303 64%

Koelling et al Am Heart J 2002 1436 49%

Trichon et al Am J Cardiol 2003 2057 56%

Robbins et al Am J Cardiol 2003 221 59%

Cleland et al N Engl J Med 2004 605 50%

Grayburn et al J Am Coll Cardiol 2005 336 77%

Bursi et al Circulation 2005 303 50%

Acker et al J Thorac CV Surg 2006 300 66%

Di Mauro et al Ann Thorac Surg 2006 239 75%

Rossi et al Heart 2011 1300 74%

Deja et al Circulation 2012 599 63%

Onishi et al Circ Heart Fail 2013 277 48%

Patients with moderate to severe MR*

*

*

*




Secondary MR: primary atrial fibrillation

Lancet 2006;368:1005-1011

0

1

2

3

4

5

6

1 2 3

Nkomo et al, Lancet 2006;368:1005-1011

6.0

4.4

4

6

0

Olmstead County (n=16,501)

<45 45-54 55-64 65-74 ≥75

Age

ARIC, CHS, CARDIA (n=11,911)

28,412 subjects

5

3

1

2

Perc

ent

Moderate-Severe Mitral Valve Disease

www.acc.org

Primary care provider

Clinical Cardiologist

Imaging subspecialist

Imaging subspecialist

Heart valve team

• Clinical valve expert

• Imaging subspecialist

• Mitral valve surgeon

• Interventional cardiologist

• Anesthesiologist

• Nurse care team

• Social services

Clinical Cardiologist

Primary care provider

IDENTIFY

DEFINE

ASSESS

TREAT

FOLLOW

UP

O’Gara et al, J Am Coll Cardiol 2017;70:2421-2449

evidence-based management of mitral regurgitation?

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