primary vs secondary mitral regurgitation: tailoring
TRANSCRIPT
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Robert O. Bonow, MD, MS
Northwestern University Feinberg School of Medicine
Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
Editor-in-Chief, JAMA Cardiology
No Relationships to Disclose
Primary vs Secondary Mitral Regurgitation:
Tailoring Treatment to the Patient and Setting
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Stages of Valvular Heart Disease
Stage Definition
A Risk of valve disease
B Mild - moderate asymptomatic disease
C Severe valve disease but asymptomatic
C1: Normal LV function
C2: Depressed LV function
D Severe, symptomatic valve disease
RHD, MVP, HF, post MI
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Mitral regurgitation
Primary MR: primary valve disease
Secondary MR: primary myocardial disease
Degenerative
Functional
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Mitral regurgitation
Primary MR: primary valve disease
Secondary MR: primary myocardial disease
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Mitral regurgitation
Indications for mitral valve surgery
for degenerative MR?
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Mitral regurgitation
Indications for mitral valve surgery
for degenerative MR?
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Mitral regurgitation
Indications for mitral valve surgery
for degenerative MR?
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• Symptomatic patients class I
Indications for mitral valve surgery
for degenerative MR?
Mitral regurgitation
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• Symptomatic patients
• Asymptomatic patients
• LV systolic dysfunction
class I
class I
Indications for mitral valve surgery
for degenerative MR?
Mitral regurgitation
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Mitral regurgitation
• Symptomatic patients
• Asymptomatic patients
• LV systolic dysfunction
class I
class I
Indications for mitral valve surgery
for degenerative MR?
LVEF <60%
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Mitral regurgitation
• Symptomatic patients
• Asymptomatic patients
• LV systolic dysfunction
class I
class I
Indications for mitral valve surgery
for degenerative MR?
LVEF <60%
LVSD >40mm
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Mitral regurgitation
• Symptomatic patients
• Asymptomatic patients
• LV systolic dysfunction
• Pulmonary hypertension
class I
class I
class IIa
Indications for mitral valve surgery
for degenerative MR?
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Mitral regurgitation
• Symptomatic patients
• Asymptomatic patients
• LV systolic dysfunction
• Pulmonary hypertension
class I
class I
class IIa
Indications for mitral valve surgery
for degenerative MR?
PASP >50 mmHg at rest
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Mitral regurgitation
• Symptomatic patients
• Asymptomatic patients
• LV systolic dysfunction
• Pulmonary hypertension
• Atrial fibrillation
class I
class I
class IIa
class IIa
Indications for mitral valve surgery
for degenerative MR?
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Mitral regurgitation
• Symptomatic patients
• Asymptomatic patients
• LV systolic dysfunction
• Pulmonary hypertension
• Atrial fibrillation
• Normal LV function, repairfeasible?
?
class I
class I
class IIa
class IIa
Indications for mitral valve surgery
for degenerative MR?
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Mitral regurgitation
• Symptomatic patients
• Asymptomatic patients
• LV systolic dysfunction
• Pulmonary hypertension
• Atrial fibrillation
• Normal LV function, repairfeasible?
class I
class I
class IIa
class IIa
Indications for mitral valve surgery
for degenerative MR?
MV repair to improve survival?
?
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Mitral regurgitation
• Symptomatic patients
• Asymptomatic patients
• LV systolic dysfunction
• Pulmonary hypertension
• Atrial fibrillation
• Normal LV function, repairfeasible?
class I
class I
class IIa
class IIa
Indications for mitral valve surgery
for degenerative MR?
MV repair to improve survival?
What is the natural history?
?
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Mitral regurgitation
• Symptomatic patients
• Asymptomatic patients
• LV systolic dysfunction
• Pulmonary hypertension
• Atrial fibrillation
• Normal LV function, repairfeasible?
class I
class I
class IIa
class IIa
Indications for mitral valve surgery
for degenerative MR?
66% come to surgery in 5 years because of symptoms,
LV dysfunction, pulmonary hypertension or AF
Asymptomatic severe primary MR:
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Mitral regurgitation
• Symptomatic patients
• Asymptomatic patients
• LV systolic dysfunction
• Pulmonary hypertension
• Atrial fibrillation
• Normal LV function, repairfeasible?
class I
class I
class IIa
class IIa
Indications for mitral valve surgery
for degenerative MR?
Severe primary MR:
Long-term postoperative survival is worse if surgery
is performed after patients become symptomatic
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J Thorac Cardiovasc Surg 2003;125:1143-1152
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10 11
Mitral RegurgitationSurvival After Mitral Valve Surgery
40
20
0
Surv
ival (p
erc
ent)
2 4 6 8 10 2012
Time (years)
David et al, Circulation 2013;127:1485-1492
FC I
32%
75%
n=840
p<0.001
0 14 16 18
52%
66%60
80
100
FC IV
FC III
FC II
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Indications for MV repair for
asymptomatic primary MR:
Mitral regurgitation
class IIa
• Chronic severe MR
• Preserved LV function
• Experienced surgical center
• Likelihood of durable repairwithout residual MR > 95%
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Mitral regurgitation
class IIa
class IIb
• Chronic severe MR
• Preserved LV function
• Experienced surgical center
• Likelihood of durable repairwithout residual MR > 95%
• Preserved LV function
• Likelihood of durable repair and low risk for surgery, and
• LA dilatation >60 ml/m2 -- or --
Exercise PAP >60 mmHg
Indications for MV repair for
asymptomatic primary MR:
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Mitral regurgitation
class IIa
class I
Indications for MV repair for
asymptomatic primary MR:
• Repair better than mitral valvereplacement
• Patients should be referred tocenters experienced in repair
• Chronic severe MR
• Preserved LV function
• Experienced surgical center
• Likelihood of durable repairwithout residual MR > 95%.
!
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INTERVENTIONAL CARDIOLOGY AND SURGERY
Mitral repair best practice: proposed standards
B Bridgewater, T Hooper, C Munsch, S Hunter, U von Oppell, S Livesty, B Keogh,F Wells, M Patrick, J Kneeshaw, J Chambers, N Masani, S Ray
Heart 2006;92:939-944
• Surgical training
• Intraoperative echocardiography
• Volume thresholds
• Audit
• Cardiology and imaging
Surgeon: >25/yr
Hospital: >50/yr
Operative mortality <1%
5 year reoperation <5%
Rigorous
criteria
19 criteria for best practice:
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Centers of Excellence in Mitral Valve Repair
Criteria:
• MV surgery volume requirement (center and surgeon)
• Expert periprocedural imaging capabilities
• Access to transcatheter technology
• Transparency regarding outcomes including: repair rates,
mortality rates, stroke rates, repair durability
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Mitral regurgitation
class IIb
Indications for transcatheter MV
repair for severe degenerative MR:
• Chronic severe MR
• Severely symptomatic
• Prohibited surgical risk
• Reasonable life expectancy
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Mitral regurgitation
Primary MR: primary valve disease
Secondary MR: primary myocardial disease
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Mitral regurgitation
Primary MR: primary valve disease
Secondary MR: primary myocardial disease
•Diagnostic dilemmas
• Therapeutic dilemmas
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Imprecision in grading severity of secondary MR
What is “severe”
secondary MR?
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Secondary mitral regurgitation:
…a marker of a sicker LV
- or -
…a contributor to a sicker LV?
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Secondary mitral regurgitation:
…a marker of a sicker LV
- or -
…a therapeutic target?
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Functional mitral regurgitation
can be repaired.
But should it be repaired?
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Functional mitral regurgitation
can be repaired.
But should it be repaired?
… or replaced?
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Secondary mitral regurgitation
Guideline-directed medical
therapy for heart failure,
including CRT
class I
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Secondary mitral regurgitation
Guideline-directed medical
therapy for heart failure,
including CRT
Indications for mitral valve surgery:
• Patients with severe MR undergoing CABG or AVR
class IIa
class I
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Secondary mitral regurgitation
Guideline-directed medical
therapy for heart failure,
including CRT
Indications for mitral valve surgery:
• Patients with severe MR undergoing CABG or AVR
class IIa
class IIb• Severe MR, persistent
symptoms despite optimal medical therapy, including CRT
class I
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Indications for mitral valve surgery:
• Severe MR, persistent symptoms despite optimal medical therapy, including CRT
class IIb
• Patients with severe MR undergoing CABG or AVR
class IIa
Secondary mitral regurgitation
class I
• Patients with moderate MR undergoing CABG or AVR
class IIb
Guideline-directed medical
therapy for heart failure,
including CRT
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Baseline Optimized Medical Therapy
and Biventricular Pacing
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class IIb
Indications for transcatheter MV
repair for severe secondary MR:
Secondary mitral regurgitation
• Severe secondary MR
• Severely symptomatic
• Prohibited or high surgical risk
• Reasonable life expectancy
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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*
*
*
*
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Average hospital mortality: 8.8%
• Low volume centers: 13.0%
• High volume centers: 6.0%
Data from national Medicare database 1994-1999
684 hospitals
142,488 AVRs
Medicare data
0
2
4
6
8
10
12
14
16
86 87 88 90Age Group (years)
16
0
Pre
vale
nce (
perc
ent)
20-34
10
8
45-54 55-64 65-7935-44 ≥80
4
Men
Women
6
2
14
12
Prevalence of Heart Failure
United States
Source: NHANES, CDC, and American Heart Association
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Average hospital mortality: 8.8%
• Low volume centers: 13.0%
• High volume centers: 6.0%
Data from national Medicare database 1994-1999
684 hospitals
142,488 AVRs
Medicare data
0
2
4
6
8
10
12
86 87 88 90Age Group (years)
12
0
Perc
enta
ge w
ith A
F
50-59
Prevalence of Atrial FibrillationThe ATRIA Study
10
8
Go et al, JAMA 2001;285:2370-2375
65-69 75-79 80-8460-64 70-74 ≥85
4
Men
Women
6
2
n=17,974
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Average hospital mortality: 8.8%
• Low volume centers: 13.0%
• High volume centers: 6.0%
Data from national Medicare database 1994-1999
684 hospitals
142,488 AVRs
Medicare data
0
1
2
3
4
5
6
7
8
9
10
87 88 90Age Group (years)
10
0
Perc
ent
with V
alv
e D
isease
<45
Prevalence of Mitral Valve Disease
8
Nkomo et al, Lancet 2006;368:1005-1011
55-6445-54 65-74 ≥75
4
Olmstead County (n=16,501)
6
2
28,412 subjects 6.4
2.9
9.6
7.3CARDIA, ARIC, CHS (n=11,911)