multi-disciplinary approach to mitral disease …€¦ · multi-disciplinary approach to mitral...
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MULTI-DISCIPLINARY APPROACH TO MITRAL DISEASE
Nikolaos Kakouros, MBBS MRCP PhD MD(Res) FACC FSCAI Director, Structural Heart Disease programProgram Director, Interventional Cardiology SHD FellowshipCo-director, TAVR programAssistant Professor of MedicineUniversity of Massachusetts Medical School
CARDIOLOGIST
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Conflicts of Interest
▪ I do not have any financial arrangements or affiliations with any of the corporate organizations offering financial support or educational grants for this continuing medical education program
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Objectives
▪ Understand catheter based approaches to mitral valve disease
▪ Describe the evaluation and indications for catheter based interventions
▪ Describe the common complications associated with catheter based intervention
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Multi-disciplinary Approach To Mitral Disease
Russell C Brock (1903-1980) leading British chest and heart surgeon
Pioneer of modern open heart surgery
▪ 1947 - Surgical pulmonary valve dilation and infundibular muscle resection in Fallot’s tetralogy to reduce R-L shunt
▪ Exchange professorships with Dr Alfred Blalock at JHH
helped introduce new tech (hypothermia, heart-lung machine) to the nascent field of cardiac surgery
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Russell C Brock (1903-1980)
1948 – One of first four surgeons to operate
on rheumatic mitral stenosis
Finger-fracture Valvuloplasty
(closed commissurotomy)
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RC Brock on Intracardiac Surgery
‘Intracardiac surgery is not for the lone worker. Team work is essential … success is due principally to the loyal and unstinted co-operation of my various colleagues who take part with me in this work both at Guy’s and the Brompton Hospital. To give one example, at Guy’s there is a group of some 15 people actively engaged in the work, and as time passes we find that more and more are drawn into the team.’
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Peacock Club – 70 years ago
▪ Established 4/21/1948 as meeting of “those concerned in the management of congenital disease of the Heart” convened by RC Brock
▪ Thomas Peacock – author of 19C text on cardiac malformations
▪ Core Members: Guy’s cardiologists
Clinical scientists from Medical Research Council
Radiologist
Anesthetists
Surgical assistants
Junior doctors and research fellows
Invited speakers and named visitors
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Peacock Club
▪ Discussions of life threatening risks of the invasive investigations
▪ Shared management planning
▪ Self-critical reviews of operations that often went badly
Hearts of the patients who died were critically examined in the presence of the whole team
▪ Meticulous documentation of treated and untreated cases.
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THE MITRAL VALVE
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MDT approach :MITRAL VALVE DISEASE
STENOSIS REGURGITATION
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MITRAL STENOSIS ETIOLOGY
RHEUMATIC60%, nearly all adult MS
CALCIFIC
•Misc: Congenital (parachute MV), post-inflammatory,
mucopolysaccharidosis, LA myxoma
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The problem
▪ Rheumatic Heart Disease prevalence: Industrialized nations 1/100 000 Worldwide: 12 000 0000 Rh Fever and Rh Heart Disease cases
(Circulation. 2009;119:e211-e219)
0.14/1000 in Japan, 1.86/1000 in China, 0.5/1000 in Korea, 4.54/1000 in India, 1.3/1000 in Bangladesh
▪ Why? Streptococcal GrpA infection → Type II hypersensitivity overpopulation, overcrowding, poverty, poor access to
medical care, limited availability of PCN
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Rheumatic Mitral valve stenosis
• Valve thickening
• Commissural fusion
• Chordal fusion
• Normal Valve area 4-5cm2
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RHEUMATIC MITRAL STENOSIS
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RHEUMATIC MITRAL STENOSIS
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RHEUMATIC MITRAL STENOSIS
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Mitral Stenosis
Severe mitral stenosis: MVA <1.5cm2
Critical mitral stenosis MVA < 1.0 cm2
• Asymptomatic• Present with incapacitating dyspnea
• Pulmonary hypertension
• Hemoptysis
• Right heart failure, peripheral edema, orthopnea
• Atrial fibrillation: 80%
• Systemic thromboembolism: 20%
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MitralCommissurotomy
1902 : Proposed by Brunton
1920s: First successful surgical commissurotomy
1940-1950s: Trans-atrial and transventricularsurgical commissurotomy were accepted clinical procedures. Open commissurotomy preferred in the US
1980s: PTMV emerged
1994: Clinically approved
21st Century: PTMV is the preferred procedure
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• Angelo Thomas Pezzella et al: Ann. Afr. Chir. Thor. Cardiovasc. 2012;7(1)
• International Children’s Heart Fund
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Treatment for Mitral Stenosis
PMBC vs SURGERY
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Balloon vs. Open Surgical
Turi et al, Circulation, 83, 1179-85, 1991
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Mit
ral
Va
lve
Are
a(c
m2)
PMV vs OMC vs CMC
MVA at seven years follow-upPMV OMC CMC
0
0.5
1.5
1
2.5
2
3
Baseline 6 Months
P=0.001
7 Years
P=0.001
P=NS
P=NS
0.9 0.9 0.9
P=NS
2.1 2.2
1.61.8 1.8
1.3
Farhat et al. Circulation 1998
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CONCLUSIONS
• PTMV and OMC have comparable initial results and low
rates of restenosis, and both produce good functional
capacity for at least three years.
• The better hemodynamic results at three years, lower cost,
and elimination of the need for thoracotomy suggest that
PTMV should be considered for all patients with favorable
mitral-valve anatomy.
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Mechanism of PTMV
PTMV relieves mitral stenosis by
splitting fused commissures,
similar to surgical
commissurotomy
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PTMV Technique
Transseptal antegrade approach
Double balloon technique
Inoue balloon technique
Multitrack
Cribie dilator
Retrograde approach
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Double Balloon Technique
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Inoue Balloon
Kanji Inoue performed first PTMV with the eponymous balloon in 1984
FDA approved in 1994
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Inoue Balloon Stages
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Transeptal TEE/ICE
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RHEUMATIC MITRAL STENOSIS post
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RHEUMATIC MITRAL STENOSIS post
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RHEUMATIC MITRAL STENOSIS ASD
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Define success
▪ MVA >2 cm2 or
▪ MV gradient <5 mmHg
▪ Others markers:
50% improvement in valve area
MVA increased to >1 cm2/m2 BSA
STOP when increase in MR by ONE grade (1-4)
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Inoue Balloon Stepwise Technique
Feldman et al. Cath CV Diag 28: 199, 1993
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Min
ute
Inoue vs Double Balloon
Procedural time
0
15
60
45
30
75
90
Procedural time
Inoue Balloon Technique
Double Balloon technique
p<0.05
56
84
1525
Fluoroscopic time
Park SJ et al. Am J Coll 1993
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Ev
ent-
free
surv
iva
l(%
)Event-free Survival
Death, MVR, redoPMV, NYHA≥3
83±5%
76±7%
p=NSInoue BalloonDouble Balloon
100
80
60
40
20
0
4 5 7620 1 3
YearsKang DH, et al J Am Coll Cardiol 2000
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Complications of PTMV
• Mortality
• Systemic embolization
• Severe MR(+4)
• Left to right shunt (>1.5:1)
• Transient heart block and tamponade
• Hemopericardium
0-0.6%
0-4.5%
0.9-3%
<5%
<5%
0.5-5%
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Contraindication of PMV
• Left atrial thrombus
• Apical LV thrombus
• MR>2+
• Bleeding diathesis
• Severe cardiothoracic deformity
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Patient selection is
fundamental in predicting
outcome of PMV
Mitral valve morphology
Echocardiographic Score !!!
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Echo Score
Mitral valve morphology
2 3
Rigidity
Thickening
Calcium
1
mobile valve
thin
no bright echos
4
immobile valve
severe thickening
multiple bright echo
Subvalvular sparse echos multiple thick chordae
apparatus
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Mit
ral
Va
lve
Are
a(c
m2)
MVA according to ES
0
0.5
1.5
1
2
Pre-PMV
P<0.001
1.00.8
2.0
1.6
P<0.001ES ≤ 8 (n=601)
ES > 8 (n=278)
Post-PMV
Palacios Circulation 2002
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80
60
40
20
0
100
86.5%
ES ≤ 8 (n=601)
76.6%
ES > 8 (n=278)Palacios Circulation 2002
P=0.0002
Success according to ES
Post-PMV MVA ≥ 1.5, 50% increase in MVA, MR ≤ 2+
%
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Mit
ral
Va
lve
Are
a(c
m2)
Su
cces
s(%
)
1.5 1.4
0.7
Changes in MVA & Success
0
0.5
3
2.5
2
1.5
1
0%
10%
90%
80%
70%
60%
50%
40%
30%
20%
87%
2.2
1
Pre-PMV
Post-PMV
59%50%
1.6
29%
0.8 0.8
67% 68%
1.8 1.8
0.9 0.9
80%
1.9
0.9
80%
2.1
1
90%
2.2
1
4 5 6 7 8 9 10
Echocardiographic score11 12
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2
1
0
4
3
5
Death MVRTamponade
P<0.006
P=NSP=NS
0.8
4.3
1 1
%
2.2
5.7
2.1
1.3
StrokePalacios Circulation 2002
In-Hospital Events
ES ≤ 8 (n=601)
ES > 8 (n=278)
P=0.0076
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Su
rviv
al
(%)
Survival according to ES
100
80
60
40
20
0
0 20 40 60 80 100 120 140 160 180
Echo Score ≤ 8
Total Group
Echo Score > 8
P<0.001
Time of Follow-up (months)
Palacios Circulation 2002
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Su
rviv
al
(%)
Event-Free Survival
according to ES
100
80
60
40
20
0
0 20 40 60 80 100 120 140 160 180
Death, MVR, redoPMV
P<0.0001
Echo Score ≤ 8
Total Group
Echo Score > 8
Time of Follow-up (months)Palacios Circulation 2002
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Su
rviv
al
(%)
Events according to ES
100
80
60
40
20
0
0 20 40 60 80 100 120 140 160 180
Death, MVR, redoPMV
P<0.0001
Echo Score ≤ 8
Echo Score 9 - 11
Echo Score ≥ 12
Time of Follow-up (months)Palacios Circulation 2002
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Long-Term Events
Independent predictors; Redo MVP, MVR, Death
<0.00001
0.05
0.002
0.03
0.02
<0.00001
<0.00001
P
1.01-1.03
1.00-1.81
1.16-1.92
1.02-1.67
1.09-2.22
2.61-4.72
1.01-1.03
1.02
1.35
1.50
1.31
1.56
3.54
1.02
Age
NYHA IV
Prior commissurotomy
Echo score
Pre-PMV MR ≥ 2+
Post-PMV MR ≥ 3+
Post PMV Pul A pressure
CIORVariables
Palacios Circulation 2002
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CONCLUSIONS
• PTMV is the procedure of choice the
treatment of patients with MS for optimal
candidates from morphologic and clinical points
• Immediate post-PTMV variables in conjunction
with pre-PTMV clinical and mitral morphologic
variables identify most likely to benefit long-term
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Russell C Brock (1903-1980)
1948 – One of first four surgeons to operate on rheumatic mitral stenosis
Finger-fracture Valvuloplasty
(closed commissurotomy)
“the mitral valve was too calcified to permit dilation; immoderate enlargement of the mitral orifice might convert mitral stenosis into severe mitral regurgitation; and patients in whom mitral regurgitation was the chief problem were not candidates for the procedure”
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CALCIFIC MITRAL STENOSIS
✓Not amenable to valvuloplasty
✓ Surgery is high risk
✓Would benefit from specialized mitral valve surgical expertise
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RHEUMATIC MITRAL STENOSIS
2014 AHA/ACC Valve Disease Guidelines
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Mitral Regurgitation
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Normal leaflet
motion
Endocarditis
Dilated annulus
Atrial fibrillation
Restrictive CM
Excess leaflet
motion
Prolapse or flail
leaflet
MVP
Papillary rupture
Trauma
Endocarditis
Leaflet restriction
systole & diastole
Rheumatic
Carcinoid
SLE
Radiation
Drugs
Leaflet restriction
systole only
Ischemic Heart
disease
Dilated CM
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Degenerative MR
Rheumatic changes
Annular dilation
Functional MR
Annular Calcification
Pap muscle dysfxn: fixed or transient
Redundant Leaflets
Elongated or ruptured chords
Endocarditis
Mitral Regurgitation
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Secondary MR
▪ Secondary MR (cf. primary)
▪ Functional MR (cf. degenerative)
▪ Ischemic MR (cf. Non-ischemic)
▪ MR that occurs in the setting of LV dysfunction with normal (or near normal) mitral leaflet and chordal structure
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Degenerative Mitral Regurgitation
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MR Pathophysiology
MR
Increase in LVEDV
Increase in total SV
Maintain
CO
LV dilatation
LV dysfxn CHF
LA dilatation
Atrial fibrillation
Rupture of chordae
Accelerated course
Pulm HTN
RV dysfxn
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MR: classification of severity
MILD MOD SEVERE
Angiographic grade
1 + 2 + 3-4 +
Color Doppler jetarea
< 4 cm2 or < 20% LA
area
>40% LA area,Wall-impinging jet of any
size, swirling in the LA
Doppler vena contracta width
< 0.3 0.3 – 0.69 > 0.7
Regurgitantvolume (ml/beat)
< 30 30 - 59 > 60
Regurgitantfraction (%)
< 30 30 - 49 > 50
Regurgitantorifice area (cm2)
< 0.2 0.2 – 0.39 > 0.4
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Mitral Valve Repair cf Replacement
▪ Preserves the native valve
and, almost always, the subvalvular apparatus
▪ Improved long-term survival
▪ Improved cardiac function
▪ Lower risk of complications (incl. stroke, SBE)
▪ Usually eliminates need for anticoagulants
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Multiple surgical options
Full sternotomy Partial sternotomy
Right thoracotomy Robotic
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All degenerative MR is repairable
▪ Create durable zone of coaptation Leaflet procedures
Mitral Ring Annuloplasty
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All degenerative MR is repairable
▪ Quality of repair Degree of residual MR
▪ Durability of repair Rate of recurrent MR
Rate of reoperation
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Added surgical bonus
▪ Concurrent revascularization
CABG
▪ AF-therapies
e.g. surgical Maze, left atrial appendage closure
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Transcatheter Mitral Valve repair
▪ Mitral valve repair surgery remains optimal
▪ The only FDA-approved TMVr device is MitraClip
▪ Other approaches – leaflet tethering, transcatheter annuloplasty in development
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Transcatheter Mitral Valve Replacement
▪ In development – FDA-approved clinical trials
▪ Deployment of artificial valve across native mitral to fix MR
▪ Trans-apical via left thoracotomy and transeptal
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The MitraClip▪ The only FDA approved percutaneous therapy for Mitral
Regurgitation in the US
▪ Edge-to-edge repair (cf. Alfieri stitch)
Alfieri Ottavio. , De Bonis M. The role of the edge-to-edge repair in the surgical
treatment of mitral regurgitation, J Card Surg 2010, 25(5): 536-541.
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Everest II Trial
Enrolled from 09-2005 to 11-2008, 37 centers US & Canada
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• Primary Safety Endpoint:
• Rate of MAE at 30 d: composite of death, MI, reop for failed MV Surgery, non-elective CV surgery for adverse events, CVA, Ren Failure, deep wound infection, Vent for >48 hrs, GI complications req Surg, new afib, sepsis and transfusion ≥ 2 U blood
• Primary Efficacy Endpoint:
• Freedom from death, surgery for MV Dysfxn & grade 3+ to 4+ MR at 12 mo
Everest II Trial ▪ Grade 3+ to 4+ Chronic
MR
▪ Symptomatic: LVEF >25%, LVESD ≤55 mm
▪ Asymptomatic: LVEF 25-60%, LVESD 40-55 mm, New afib or PulmHypertension
▪ Were candidates for MVRepr or MVRepl
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2:1 randomization
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Conclusions
▪ MitraClip clearly reduces symptoms, although less than MVR in candidates who can have surgery
▪ MitraClip improves quality of life post procedure
▪ MitraClip is non-inferior to surgery in safety
▪ MitraClip 5 year results are durable
▪ MitraClip is reasonable for patients who are at prohibitive risk for surgery
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Future of MitraClip
▪ COAPT: Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation
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Case Presentation
▪ 96-year old woman
▪ Active until July 2016
▪ Developed worsening dyspnea
admitted to the hospital with congestive cardiac failure
Improved after introduction of the diuretics
▪ Severe AS and severe degenerative MR
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Case Presentation
▪ 96-year old woman
▪ Active until July 2016
▪ Developed worsening dyspnea
admitted to the hospital with congestive cardiac failure
Improved after introduction of the diuretics
▪ Severe AS and severe degenerative MR
▪ Underwent TAVR but remained symptomatic with elevated pulmonary pressures
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Results
▪ LVEF normalized
▪ No severe pulmonary hypertension
▪ No severe MR (reduced to mild)
▪ No severe AS
▪ Asymptomatic and independent (98 yrs. old)
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• Patients with mitral valve disease are complex –
• symptoms may be multifactorial,
• require careful diagnostic workup,
• multidisciplinary approach,
• detailed stepwise treatment plan, and
• post procedure surveillance by dedicated teams.
Take home points
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MS
• Transcatheter balloon mitral valvuloplasty is the preferred treatment option for patients with mitral stenosis and favorable anatomy.
MR
• Mitral Valve Repair surgery is the gold standard.
• MitraClip is approved for very high surgical risk patients with MR >3+ and degenerative mitral valve disease if reasonable survival expected.
• 5 year follow-up data show durable result. Landmark analysis shows after 6 months, event free survival improved.
• Ongoing trial for functional mitral regurgitation
Take home points
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ECHO
CARDIO-PCP
InterventionalMS
TEE
PTBMV
Cardiac Surgeon
MV surgery
Unfavorable MS
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ECHO
CARDIO-PCP
Cardiac SurgeonDMRTEE
MitraClip
Interventional
High-risk DMR
MV surgery
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Medical ℞
MDT
ECHO
CARDIO-PCP
Cardiac SurgeonInterventionalMS
PTBMV MV surgery
TEE
Unfavorable MS
DMR
MitraClip
High-risk DMR
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ECHO
CARDIO-PCP
Cardiac SurgeonInterventionalMS DMR
MDT
PTBMV MitraClip Medical ℞ MV surgery
TEE
Unfavorable MS High-risk DMR
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Peacock Club – MDT approach 70 yrs ago
▪ Discussions of life threatening risks of the invasive investigations
▪ Shared management planning
▪ Self-critical reviews of operations that often went badly
Hearts of the patients who died were critically examined in the presence of the whole team
▪ Meticulous documentation of treated and untreated cases.
/interventions
(national registries – STS/ACC TVT)
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MULTI-DISCIPLINARY APPROACH TO MITRAL DISEASE
Nikolaos Kakouros, MBBS MRCP PhD MD(Res) FACC FSCAI Director, Structural Heart Disease programProgram Director, Interventional Cardiology SHD FellowshipCo-director, TAVR programAssistant Professor of MedicineUniversity of Massachusetts Medical School
CARDIOLOGIST
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