what degree of mr deserves surgical or transcatheter ...what degree of mr deserves surgical or...
TRANSCRIPT
What Degree of MR Deserves
Surgical or Transcatheter Intervention,
and How Should It Be Assessed?
Robert J. Siegel, M.D., FACC
Nov. 14-15, 2017, Beverly Hills
Director, Cardiac Non-Invasive Laboratory
Cedars-Sinai Medical Center, Los Angeles
Professor of Medicine, UCLA & Cedars-Sinai
Robert Siegel, M.D.
As a faculty member for this program, I disclose the following relationships
with industry:
(GRS): Grant/Research Support (C): Consultant (SB): Speaker’s Bureau
(MSH): Major Stock Holder (AB): Advisory Board (E): Employment
(O):Other Financial or Material Support
Name of company: Philips Ultrasound;
Nature of Relationship: Speaker’s Bureau
What Degree of MR Deserves Surgical or Transcatheter Intervention,
and How Should It Be Assessed?
Mechanism of MR – Degenerative v. Functional
• Important for grading MR severity
• Important Management –
Surgical, Catheter Intervention, or Medical
Functional v. Degenerative MR FMR:
Structurally normal MV but LV dysfunction
and dilation leads to MR
DMR:
A diseased MV causes severe MR
which leads to LV dysfunction
Severe Functional MR JACC 2015 MVARC & ACC/AHA*
Qualitative
MV Morphology Leaflet tenting, restriction, ↓coaption
Color jet Large, aliasing, deep into LA
Flow convergence zone Large
CW signal Dense; Holosystolic; Low velocity
Semiquantitative
Vena contracta (mm) ≥7mm
Pulm vein flow reversal Present +
Mitral Inflow E –wave dominant
Quantitative*
EROA (cm2) (PISA) ≥0.4* (0.4 specific, 0.2 more sensitive)
Regurgitant Vol (ml) (PISA) ≥30
LV dysfunction / LV dilation (as present not helpful in grading) Patients with any secondary MR have a worse prognosis –
MV repair may improve symptoms but not yet shown to ↑ survival
FMR very dependent on SBP and LV volume
2009 → went for a Mitraclip
55 y.o. woman
Functional MR
LVEF 27%
↑↑ LVESD 53mm
DOE: NYHA Class III
on ACE-I / Beta-blockers
F/U Echo in 2017-
8 yrs post MitraClip
Asymptomatic – very active
Minimal MR
LVEF pre Mitraclip- 27%
LVEF 8 yrs postclip- 57%
LV size normalized
Severe Functional Mitral Regurgitation
Surgery : If LVEF <55%- Post-op LV dysfunction 38%, no survival benefit, ↑↑failure MV repair failure(CAD) Matsumura 2004, Acker 2014
MitraClip: Several studies show good results
↓ MR, ↑ Cardiac output, ↓filling pr, ↑NYHA Class
• Procedural mortality ≈ 0%; no data on ↑ing survival
• Post-clip LV dysfunction/low C.O rare (> 60,000 pts)
• ↑ 6MWT, ↓BNP & ↑QOL
• ↓ LV size, ↑LVEF D’Ascenzo 2015 , Pighi 2016,Scotti 2017, Van De Heyning 2016
Schimdt 2017,Plegers 2013;Auricchio 2011; Franzen 2011, Siegel, Biner, Kar 2011;2012 Mendirichaga 2016
COAPT TRIAL: Clinical Evaluation of the Safety and Effectiveness of the MitraClip® System
for the Treatment of Functional Mitral Regurgitation in Symptomatic Heart Failure Subjects
Severe Degenerative MR – JACC MVARC 2015 ≈ ACC/AHA 2014
Color jet Significant penetration; holosystolic
Flow convergence zone Large; holosystolic MR
CW signal Dense; holosystolic MR
Semiquantitative
Vena contracta (mm) ≥7mm
Pulm vein flow reversal Present +
Mitral inflow E –wave dominant > 1.2 - 1.5cm/s
TVI mitral/TVI aortic >1.4
Quantitative:
Regurgitant vol (ml) (PISA) ≥60
EROA (cm2) (PISA) ≥0.4
LA / LV size* Enlarged
Qualitative
MV Morphology Flail, pap rupt, retraction, perforation
Severe MR very unlikely if LV and LA size are normal
Beware of “color flowitis”
MR Quantification
• “PISA strongly recommended but inherent
limitations”(MVARC) (reproducibility poor Biner/Siegel JACC 2010)
• Each echo parameter has limitations & lack of
precision→ use integrated approach
• Quantitation better than qualitative assessment
but may lead to false sense of accuracy
• NO ECHO GOLD STANDARD for MR severity
How does echo integrated approach compare
with a reference standard - MRI?
r=12mm
Uretsky et al. JACC 2015
• If severe MR on echo - only 22% severe on MRI
• In 34% severe MR on echo – MR was mild by MRI
-MRI - Severe MR strongly correlated with
post-op LV remodeling (r = 0.85; p < 0.0001)
-Echo - No correlation with post-op LV remodeling
& “Severe MR” (r = 0.32; p = 0.1) “Integrated approach”
Only 36% concordance!
ROC analysis area under curve - LV EDD was predictive for concordance - MR severity by TTE & MRI
LV EDD cut-off of 5.5 cm:
Very good sensitivity & specificity for TTE & MRI concordance
Must integrate LV size into MR assessment!
Chronic severe volume overload → LV dilation
If still uncertain of MR severity consider getting an MRI
Rafique & Siegel JACC 2015
AUC 0.86 (95% CI 0.75-0.98
p <0.001)
Y.M. 76y, asymptomatic M. Echo 05/10/06 – flail posterior MV leaflet
Prior guidelines equated flail mitral leaflet & severe MR
But still need an integrated approach – this not severe
MV inflow: E/A Reversal; Normal LV size, PASP 11 yrs later Normal LV size, EF, PASP,Exercise Capacity
Degenerative MR
A diseased MV with severe MR
→ Has adverse consequences
→ LV volume overload
→ LA dilation & increased LAP
When to intervene:
• Progressive LV Dilation → ≥ 40mm LVID (s)
• Decline in LVEF towards ≤ 60%
• Increase in PASP to ≥ 50 mmHg
• Symptoms – even “mild” symptoms (DOE)
Stress Echo in MR to Assess:
• Symptomatic status
• Functional capacity
• Heart rate recovery
• Contractile reserve
• Exercise induced pulmonary hypertension
• Worsening of MR
All have been shown to be prognostic and facilitate
timing surgery
What Degree of MR Deserves Surgical
or Transcatheter Intervention • Know your patient
Are they symptomatic, are they going to be compliant
with regular f/u echos and visits
• Know your surgeon
What is their repair rate? What are their morbidity
and mortality rates?
• Know your practice and yourself
Are you able to follow your patients?
Can you do step care? Do your patients “fly-in”?
Thank you
Adjunctive testing
• Serial Echo Doppler studies
• TEE if MR jet is eccentric
• BNP
• Strain
• MRI
• Stress echo
Management of patients with MR is based
not only on MR severity but on -
Consequences:
• - Clinical findings
• - LV function
• - LV size
• - PA pressure
Thanks!
William Osler
• DMR & FMR are different entities
• Guidelines- “Integrate findings” but no data on how to
weight a parameter
• Using integrated method in DMR, to diagnose chronic
severe MR, LV needs to be dilated
Optimal assessment of MR requires incorporating
symptoms, LV size & function- to assess impact of MR
volume overload on the LV and on the patient
Take home
messages
Caveats to Be Considered in Echo
Doppler evalautaion of MR
• 60% LA (severe) DCM Large central jets may be
present in patients with DCM and only mild MR
• Late systolic MR (MVP) ERO >0.4 cm2
Overestimation of the severity of MR by PISA with
late systolic jets
• Cannot have severe chronic MR with normal LV size
Is 3D Echo the Answer for MR Grading?
• Direct 3D planimetry of MV ROA
• 3D VC
• 3D PISA
These 3D methods reported to be more
accurate than 2D
However ….
TTE
*
Importance of “MR
severity”-
is the effect of MR on
patient & heart.
Chronic Severe MR
Results in LV dilation
(volume overload)
Grading of MR Severity
3D Echo is New
• Limited temporal/spatial resolution
• EROA variation during systole
• Artifacts
• Technical difficulties
• No gold standard for 3D MR validation
• To date - no validated guidelines or reference
standards on 3D quantification
POTENTIAL LIMITATIONS
MitraClip vs
Optimal Medical Therapy
(OMT) for FMR Giannini, AJC 2016 ( N=120) Overall survival
Survival free from CVD
Survival free from
rehospitalization
Months f/u
Months f/u
Months f/u
CLIP
OMT
LVEF 34%; NYHA Class 3-4;
60 vs 60 age matched
MC vs OMT(BiV) (f/u 515 days)
MitraClip vs OMT > overall survival (p=0.007)
> CV survival (p=0.002)
Survival 1 & 3 yrs MC 90% 61 %
OMT 64% 35 %
Functional v. Degenerative MR
FMR:
Structurally normal MV but
LV dysfunction leads to MR
DMR:
A diseased MV where severe
MR leads to LV dysfunction
FMR: LV Dysfxn
MV leaflets normal
but motion restricted
from
• Annular dilation • Tethering (apical / posterior displacement
of papillary muscles)
15% CHF pts have
significant FMR*
3D MV from LA from LV
13 mo f/u- post clip NYHA I
LVEDD normalized
Pre: 62 mm - Post: 49 mm
LVESD normalized
Pre: 52 mm - Post: 39 mm
LVEF improved
Pre: 27% - post: 45%
F/U Echo in 2017-
8 yrs post MitraClip
Asymptomatic – very active
MR- trivial
CFD- trivial
PW:
E/A
Reversal
Pulm V
S Dom
Multiparameter MR Severity Assessment
CFD CW PW- MV Inflow PW- PV flow
Vena Contracta 9 mm
PISA - EROA
12 mm
>40% Holosystolic* E≥120cm/s Blunted/reversed
≥ 7mm EROA ≥ 0.4cm2
Beware of “color flowitis”
• Normal PASP: 28 mmHg
• Severe = multiple parameters
• MV inflow: E/A Reversal
• CW Doppler: Not holosystolic signal – low intensity
Echo 05/10/2006
Flail posterior leaflet
but MR is not severe
Because:
• LV size normal LVEDD: 5.0 cm; LVESD: 3.1 cm
• Spectral Doppler very helpful
MV inflow:
E/A Reversal
11 yrs later Exercise Stress Echo:
LV size, LVEF still normal LVEDD: 5.0 cm; LVESD: 3.1 cm
PASP: 32-34 mmHg
Excellent functional capacity
MR not severe in spite of
flail MV leaflet