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Mitral Regurgitation in the HF Patient

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Andrew Wang, MD
Duke University Medical Center

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Mitral Regurgitation in the HF Patient

  1. 1. Mitral Regurgitation in the Heart Failure Patient Andrew Wang, MD Professor of Medicine
  2. 2. All Rights Reserved, Duke Medicine 2008 Disclosure • Research: COAPT Site PI (Abbott Vascular)
  3. 3. All Rights Reserved, Duke Medicine 2008 Case • 84 yo M with chronic NICM, LVEF 30%, AF, pulmonary HTN, s/p CRT-D • Admitted 2 months ago for pulmonary edema • NYHA 3 dyspnea • STS 12% for mitral valve replacement • Meds: – Carvedilol 6.25 mg twice daily – Lisinopril 5 mg twice daily – Furosemide 40 mg daily – Warfarin
  4. 4. All Rights Reserved, Duke Medicine 2008
  5. 5. All Rights Reserved, Duke Medicine 2008 What do you recommend? a) MitraClip repair (commercial use) b) Enrollment in RCT of MitraClip for functional MR c) Titration of HF medications over next few months d) Refer back to CT surgery for MV repair e) Refer for LVAD
  6. 6. All Rights Reserved, Duke Medicine 2008 Anatomic Causes of Mitral Regurgitation Source: American Heart Association.  Leaflets  Annulus  Chordae  Papillary muscle  LV wall
  7. 7. All Rights Reserved, Duke Medicine 2008 MR Etiologies MR SECONDARY (functional) PRIMARY (degenerative) Ischemic FMR Non- ischemic FMR
  8. 8. All Rights Reserved, Duke Medicine 2008 Ischemic MR: Restricted Leaflet Mobility JACC, 2010;55:271-82.
  9. 9. All Rights Reserved, Duke Medicine 2008 Prevalence of Secondary MR in HF • N=211 pts with HF • LVEF <30% • 59% >mild MR • 22% severe MR • N=1095 with severe MR and HF • FMR 74% vs. DMR 21% • 64% FMR treated medically Goel SS, JACC 2014:185-86.Robbins JD, AJC 2003:360-62.  1/5 PATIENTS WITH HF HAVE SEVERE MR  SEVERE MR MORE COMMONLY DUE TO SECONDARY MR THAN PRIMARY
  10. 10. All Rights Reserved, Duke Medicine 2008 Severe Secondary MR Criteria • ERO ≥0.20 cm2 • Regurgitant volume ≥30 mL • Regurgitant fraction ≥50% J Am Coll Cardiol 2014;63:e57–185.
  11. 11. All Rights Reserved, Duke Medicine 2008 Quantification of Secondary MR Echo Measurement Limitation in Secondary MR Effect on Grading MR Severity Color Doppler jet area Central jet through slit- like orifice Overestimate Vena contracta width Elliptical or slit-like orifice Underestimate Effective regurgitant orifice area (EROA) by PISA Assumption that ERO is round Underestimate EROA by 3D Technical Overestimate Grayburn P. Circ 2012;126: 2005-2017.
  12. 12. All Rights Reserved, Duke Medicine 2008 Functional MR Severity is Associated with Higher Mortality Pellizzon, JACC 2004:1368-74. Trichon, AJC , 2003;91:538-43.
  13. 13. All Rights Reserved, Duke Medicine 2008 FMR and Medical Therapy • Patients with chronic secondary MR (stages B to D) and HF with reduced LVEF should receive standard GDMT therapy for HF, including ACE inhibitors, ARBs, beta blockers, and/or aldosterone antagonists as indicated (I, A) • Cardiac resynchronization therapy with biventricular pacing is recommended for symptomatic patients with chronic severe secondary MR (stages B to D) who meet the indications for device therapy (I, A) J Am Coll Cardiol 2014;63:e57–185.
  14. 14. All Rights Reserved, Duke Medicine 2008 CRT Can Reduce FMR Circ 2011;124:912-919. AND REDUCED MR IS ASSOCIATED WITH LOWER MORTALITY
  15. 15. All Rights Reserved, Duke Medicine 2008 JACC 2005;45:381-7. No Mortality Benefit for Surgical Treatment of FMR vs. Medical Therapy
  16. 16. All Rights Reserved, Duke Medicine 2008 Other Benefits of Surgery for Functional MR? • Single center, retrospective, uncontrolled studies • Acceptable operative mortality <5% • Improved LV dimensions • Improved NYHA J. Am. Coll. Cardiol. 2010;55;271-282
  17. 17. All Rights Reserved, Duke Medicine 2008 Moderate Ischemic MR Trial NEJM 2014;371:2178-88. Death, stroke, MV surgery, HF admission or worsening
  18. 18. All Rights Reserved, Duke Medicine 2008 Duke Experience with FMR • 1995-2010 • LVEF ≤30% • N= 1441 • Moderate (70%) or severe (30%) FMR Samad, EHJ, 2015.
  19. 19. All Rights Reserved, Duke Medicine 2008 Indications for Surgery in Severe FMR • Patients undergoing other cardiac surgery (IIa) • Severely symptomatic patients (NYHA class III to IV) who have persistent symptoms despite optimal GDMT for HF (IIb) J Am Coll Cardiol 2014;63:e57–185.
  20. 20. All Rights Reserved, Duke Medicine 2008 Mitra-Clip Percutaneous Edge-to-Edge Repair
  21. 21. All Rights Reserved, Duke Medicine 2008 MitraClip for Primary MR • Transcatheter mitral valve repair may be considered for severely symptomatic patients (NYHA class III to IV) with chronic severe primary MR (stage D) who have favorable anatomy for the repair procedure and a reasonable life expectancy but who have a prohibitive surgical risk because of severe comorbidities and remain severely symptomatic despite optimal GDMT for HF (IIb) J Am Coll Cardiol 2014;63:e57–185.
  22. 22. All Rights Reserved, Duke Medicine 2008 Date of download: 11/10/2014 Copyright © The American College of Cardiology. All rights reserved. From: 4-Year Results of a Randomized Controlled Trial of Percutaneous Repair Versus Surgery for Mitral Regurgitation J Am Coll Cardiol. 2013;62(4):317-328. doi:10.1016/j.jacc.2013.04.030
  23. 23. All Rights Reserved, Duke Medicine 2008 Observational Studies of MitraClip Repair for Secondary MR • Improved NYHA, LVESV, fewer hospitalizations JACC 2014;64:2688-700.
  24. 24. COAPT TRIAL OVERVIEW NPL 03976 Rev B CAUTION: Investigational device. Limited by Federal (U.S.) law to investigational use only. ~420 patients enrolled at up to 75 US sites Randomize 1:1 Clinical and TTE follow-up: 1, 6, 12, 18, 24, 36, 48, 60 months Control group Standard of care N=210 High risk for mitral valve surgery Specific valve anatomic criteria MitraClip N=210 Significant FMR (≥3+ by core lab) Trial design Protocol conditionally approved by FDA July 26, 2012
  25. 25. COAPT TRIAL OVERVIEW NPL 03976 Rev B CAUTION: Investigational device. Limited by Federal (U.S.) law to investigational use only. Primary Endpoints • Primary Effectiveness (min 1-year FU all pts) – Recurrent heart failure hospitalizations • Superiority hypothesis (Andersen-Gill) • Primary Safety (1 year) – Composite of all-cause death, stroke, worsening kidney function, or LVAD or cardiac transplant • Non-inferiority hypothesis Protocol conditionally approved by FDA July 26, 2012
  26. 26. All Rights Reserved, Duke Medicine 2008 Summary • Secondary MR is common in patients with HF due to restricted leaflet mobility and coaptation. • Quantification of severity has challenges and smaller orifice area may still be associated with worse prognosis. • Medical therapy and CRT are evidence based treatments to improve patient outcome first line! • Effect of MV repair on survival needs additional trials.
  27. 27. All Rights Reserved, Duke Medicine 2008 HFSA Mitral Regurgitation Resource • http://www.hfsa.org/hfsa-wp/wp/mitral-regurgitation- resource-page

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