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Multimodality imaging.
- 1. The Conundrum of Mitral Regurgitation in Heart Failure Multimodality ImagingMultimodality Imaging Philippe Pibarot, DVM, PhD,Philippe Pibarot, DVM, PhD, FACC, FASE, FESCFACC, FASE, FESC CanadaCanada Research Chair in Valvular HeartResearch Chair in Valvular Heart DiseaseDisease UniversitéUniversité LAVALLAVAL InstitutInstitut UniversitaireUniversitaire de Cardiologiede Cardiologie et de Pneumologie de Québec /et de Pneumologie de Québec / Québec Heart & Lung InstituteQuébec Heart & Lung Institute
- 2. Disclosure related to thisDisclosure related to this presentation:presentation: NoneNone
- 3. Etiology of Chronic Mitral regurgitation Primary MR Myxomatous (MVP) Secondary MR Ischemic CM Dilated CM Disease of the Valve (Abnormal MV Leaflets) Disease of the Left Ventricle (MV Leaflets are normal but tethered)
- 4. Management of MR in HF Treatment MedicalMedical CRTCRT PCI / CABGPCI / CABG SurgicalSurgical MVA/MVRMVA/MVR PercutaneousPercutaneous MitralClipMitralClip / Annuloplasty/ Annuloplasty TETHERING FORCE CLOSING FORCE Multimodality Imaging: 1- MR severity at rest and exercise (echo, stress echo) 2- LV function: EF/dyssynchrony/viability/ischemia (stress echo, CMR, PET) 3- LV remodeling and MV deformation (echo, 3D echo, CT, CMR) Clinical: HF symptoms, episodes of decompensation
- 5. Indications forIndications for MV SurgeryMV Surgery inin ChronicChronic Secondary MRSecondary MR Vahanian et al. ESC/EACTS 2012 Guideline
- 6. Multimodality Imaging – Step 1 Assessing of MR Severity at rest and during exercise - To stratify risk - To determine indication for MV intervention
- 7. Assessing MR Severity NOT VALID Lancellotti et al, Eur J Echo 2010 Qualitative Mitral valve morphology Colour flow MR jet Flow convergence zone CW signal of MR jet Semi-quantitative VC width (mm) Pulmonary vein flow Mitral inflow TVI mit/TVI Ao Quantitative EROA (mm²) R Vol (ml) Repercussions LV/LA/sPAP/TA
- 8. ERO = MR VPeak RV = ERO × MR VTI VC width Quantitation of MR SeverityQuantitation of MR Severity 2πr2 × Valiasing Vena Contracta PISA Method
- 9. Imaging of ischemic MR Quantitation of MR SeverityQuantitation of MR Severity Volumetric Method
- 11. Quantitation of MR Severity Severe Primary MR ERO ≥ 40 mm2 RV ≥ 60 mL “Severe” Secondary MR ERO ≥ 20 mm2 RV ≥ 30 mL Enriquez-Sarano et al. NEJM, 2005 Grigioni et al Circulation 2001, 103; 1759
- 12. VC 6.1 mm RV 41 ml EROA 22 mm2 Man of 52 y old , History of inferior MI, PCMK NYHA III, Episodes of acute dyspnea Grigioni et al Circulation 2001, 103; 1759 Lancellotti et al Circulation 2003, 108:1713 Severity of Secondary MR and Outcome
- 13. 103 fatigue 58 dyspnea Dynamic MR on Exercise : Relationship with Symptoms and Outcomes Lancellotti et al Circulation 2003; Eur Heart J 2005Piérard et Lancellotti NEJM, 2006
- 14. Lancellotti et al, 2012 Dynamic PHT and Outcomes in HF with Secondary MR AUC: 0.7 for 61 mmHg - 161 HF pts with ischemic LV dysdunction - SPAP > 61 mmHg at exercise: 38% of patients - Predictors of outcome: rest EROA, ΔERO, ΔSPAP AUC 0.73
- 16. REST EXERCISE VC 7.3 mmVC 6.1 mm RV 41 ml EROA 22 mm2 CASE RV 81 ml EROA 38 mm2 TTPG = 77 mmHgTTPG = 36 mmHg
- 17. Secondary MR is a disease of the left ventricle! So look at MR Severity and …. at the left ventricle
- 18. Multimodality Imaging – Step 2 Assessing LV function/ synchrony / viability/ ischemia - To stratify risk - To determine indication for CRT - To determine indication and options for revascularization
- 19. • LV function: LVEF, contractile reserve Echo, Stress echocardiography • LV dyssynchrony Echo, Stress echocardiography • Viability/ischemia Stress echocardiography, SPECT/PET, or CMR • Coronary artery stenosis Cardiac CT angiography or coronary angiography Assessing LV Function/ Synchrony / Viability/ Ischemia Indication for CRT a/o revascularization
- 20. CASE • QRS > 130 ms with LBBB QRS morphology • LVEF <30% • Coronary Angio: no significant stenosis --> Indication of CRT (Class I) Lancellotti et al, Am J Cardiol 2004, 94 R Vol 41 ml R Vol 81 ml R Vol 41 ml R Vol 23 ml Diff 18 ml Diff 44 ml REST OFF REST ON EXER OFF EXER ON
- 21. Verhaert et al Circulation: Cardiovascular Imaging.2012; 5: 21-26 Outcome of Patients not Responding to CRT
- 22. CASE: 1 Year later Back in severe heart failure
- 23. Secondary MR in HF Extent of Myocardial Necrosis/Viable Myocardium Postero-Lateral Scar Bleeker GB et al. Circulation 2006
- 24. Postero-Lateral Scar Lancellotti et al Eur J Echo 2009 Bleeker GB et al. Circulation 2006 Global LV Contractile Reserve Rest examination LV EF = 36% Low dose dobutamine LV EF = 45% Secondary MR in HF Extent of Myocardial Necrosis/Viable Myocardium
- 25. Penicka et al Circulation 2009MR ↓ in 47% of patients MR ↓ MR ↓MR ~ MR ~ 12 month-Fup
- 26. DSE Biphasic response
- 27. CASE Woman of 61 y old who was in NYHA I Patient’s history • RF: Smoker, Non-insulin dependent diabetes, HPT • COPD Clinical features • Acute pulmonary edema
- 29. EuroSCORE, STS, and Ambler score - provide relatively good discrimination - a gross estimation of risk category - cannot be used to estimate the exact operative mortality in an individual patient because of unsatisfactory calibration Lancellotti et al Heart 2008
- 30. Cas présentation NB: Non inidcation for reva Other case with option?RESTREST EXERCISEEXERCISE No contractile reserve No evidence of inducible ischemia
- 31. Multimodality Imaging – Step 3 Assessing LV remodeling & MV deformation - To predict risk of persistent / recurrent MR following MV annuloplasty - To determine best option for MV intervention
- 32. MV Repair vs. Replacement in Severe IMR 0 5 10 15 20 ≥ Moderate MR at 1 Year 18%18% 44%% 0 10 20 30 40 ≥ Moderate MR at 1 Year 33%33% 2%2% Magne et al. Circulation 2009 Acker et al NEJM 2013 MVRp MVR MVRp MVR
- 33. CABG Alone vs. CABG + MV Repair in Moderate IMR 0 10 20 30 40 ≥ Moderate MR at 1 Year 31%31% 11%11% Smith et al. NEJM 2014 CABG Alone CABG+ MVRp
- 34. Incidence of postoperative ≥ Moderate MR after MV Annuloplasty Magne et al. Cardiology 2007
- 35. LV Remodeling and MV Deformation Global LVGlobal LV RemodelingRemodeling Local LVLocal LV RemodelingRemodeling MV DeformationMV Deformation
- 36. Predicting Risk of MV Annuloplasty Failure: Severity of MV DeformationSeverity of MV Deformation Pérard et al. European Heart Journal ; 2010: 31, 2996–3005
- 37. Global LV remodelling EDD ≥ 65 mm, ESD ≥ 51 mm (ESV ≥ 140 mL) Local LV remodelling Interpapillary muscle distance ≥ 20 mm Posterior papillary-fibrosa distance ≥ 40 mm Lateral wall motion abnormality Mitral valve deformation Coaptation distance ≥1 cm Tenting area ≥ 2.5 cm2 Posterior leaflet angle ≥45○ Complex jets Echo Features of LV Remodeling and MV Deformation To Predict Persistent/Recurrent MR for MV Repair Lancellotti et al. EHJ; 2010:11,307–332 EACVI Recommendations
- 38. FUTURE PERSPECTIVES Secondary MR is not ONLY a disease of the left ventricle! It is ALSO a maladaptation of the MV leaflets So look at the MV leaflet size
- 39. Beaudoin et al., SCCT 2012 Anterior leaflet Posterior leaflet F A B DC Measuring the surface of MV leaflets by CT or 3D Echo
- 40. Beaudoin et al. JACC 2013
- 41. Beaudoin et al. JACC 2013 Total MV Leaflet Area vs. LV End-Diatsolic Volume
- 42. • Patients with secondary MR have inadequate leaflet compensation, as expressed by decreased ratios of leaflet area / annulus area • Imaging will play a key role to understand why some patients have adequate vs inadequate valve adaptation • Medications targeting the TGF-beta pathway may help to reduce the leaflet/annulus size mismatch and thus secondary MR in HF Total MV Leaflet Area vs. LV End-Diatsolic Volume
- 43. SEVERE MR (ERO ≥20 mm2) LV EDD ≥65 mm Severe Mitral Valve Deformation CABG+MVS MVA+Adjuvant Technique Mitral Valve Replacement Optimization of HF Therapy including CRT if indicated (I) Myocardial Viability / Ischemia Indication / Options for revascularization Heart Transplant Mitraclip? MVS (IIb) / Mitraclip Moderately Depressed LVEF (>30%) Severely Depressed LVEF (<30%) No Yes NoYes (IIa)(I) Optimization of HF Therapy including CRT if indicated (I) No Improvement No Improvement
- 44. MODERATE MR (ERO <20 mm2) LV EDD ≥65 mm Severe Mitral Valve Deformation CABG+MVS (IIa) MVA + Adjuvant Technique Mitral Valve Replacement Manage as severe MR Indication for CABG Dynamic Increase in MR / SPAP NoYes Optimization of HF Therapy including CRT if indicated (I) MR and SPAP stable Exercise Stress Echo