13. FMR bad… no FMR good ?
Why? - No mortality benefit ?
14. Did not get rid of FMR !
33 % Recurrent MR : 2004
McGee, Gillinov et al, JTCVS, 2004;128:916-24
Progression of 3 or 4+ MR post-undersized annuloplasty (585)
15. McGee EC et al. JTCVS 2004;128:916-24
Mihaljevic et al. J Am Coll Cardiol 2007;49:2191-201
Crabtree TD et al. Ann Thorac 2008;85:1537-43 Surg
Residual / recurrent FMR
if we do repair badly
FMR patients do badly !
16. Freedom from recurrent MR≥3+
...Because the ventricles do badly !
It’s a ventricular problem!
Lots of recurrent FMR = No reverse remodeling
27. Mitral Valve Annuloplasty in Addition to Coronary Artery Bypass Grafting in Moderate Functional
Ischemic Mitral Regurgitation Reverses Left Ventricular Remodelling and Restores Left
Ventricular Geometry: Chan et al , CIRC March 2012
British NHS 2012 : RIME
CABG + MVr for Moderate iFMR
Mitral regurg volume - 69% vs 14%
LV end systolic volumes - 24% vs 10%
LV sphericity - 18% vs + 1.7 %
Peak oxygen capacity + 3.0 vs 1.0
Brain natriuretic peptide - 76% vs 59%
All p < 0.01 !
28.
29. Patients Screened for Moderate Ischemic MR
(n=6,676)
Randomized Patients
(n=301)
Primary Endpoint Analysis
(n=301)
CABG + Valve Repair
Undersized Ring
(n=150)
CABG Alone
(n=151)
Outcomes Measured at 6, 12 and 24 months
CTSN Moderate iMR Trial Design
(excluded
6,375
or 95.5%)
30. 30 Day Mortality:
2.7% (CABG) vs. 1.3% (CABG/MVr),
p =0.68
12 Month Mortality:
7.3% (CABG) vs. 6.7% (CABG/MVr),
p =0.83
Mortality - no “added” price for MVr
42. Favor MVR Favor MV
repair
Favor MV repair Favor MVR
Short term survival Long term survival
43. Severe Ischemic Mitral Regurgitation
NEJM 2014, 251 CABG + MV repair vs MV replacement
(3458….447….251 ….7 % )
LVESI (Size/remodeling) same
Mortality same
CV events same
Functional status same
44. Severe Ischemic Mitral Regurgitation
Different!
32% MV repairs - recurrent MR
Sham placebo MVr!
Did not get rid of FMR !
45. NHLBI Trial : Severe iFMR
Mean ring size : 28.4 + 1.9
Did not “downsize”, ~25% > 32!
Not a single “24” used !
Native size never < 28 ?!
Mandatory coaptation length
46. Severe Ischemic Mitral Regurgitation
Mitral repair operative mortality 1.6%
vs “total valve sparing” MVR 4.2%
47. Severe Ischemic Mitral Regurgitation
Functional status
MV repair includes 32 % - had “sham nothing” !
48. Remodeling - LVESI
Kron et al JTCVS 2015
“Good” repair – 46 mm
Replacement – 61 mm
“Bad” repair – 63 mm
(40% - basal inferior “aneurysm” )
49. Mild annular dilatation
Coaptation depth >1 cm
Posterior leaflet angle >45°
post/basal dyskinesia !
Distal anterior leaflet angle >25°
Advanced LV remodelling
– LVEDD > 65 mm
– Systolic sphericity index > 0.7
– End systolic interpapillary muscle
distance >20 mm
– LVESV ≥ 145 ml (or ≥ 100 ml/m2)
Predictors of “Bad FMR Repair”
Lancellotti et al. Eur J Echo 2010 EAE recommendations for the
assessment of valvular regurgitation
51. Michael A. Acker , Mariell Jessup , Steven F. Bolling , Jae Oh , Randall C. Starling ,
Douglas L. Mann , Hani N. Sabbah
Mitral valve repair in heart failure: Five-year follow-up from
the mitral valve replacement stratum of the Acorn
randomized trial
The Journal of Thoracic and Cardiovascular Surgery Volume 142, Issue 3 2011 569 - 574.e1
70% survival @ 5 yrs
52. 76% survival @ 6.5 yrs
MVr …and TVr and AF ablated !
Surgery and dcFMR 2014
58. FMR 2015
GDMT, CRT, Surgery, Clip
Careful patient selection
ischemic vs. dilated FMR ?
Beware the big LV, the bad RV
Fix AF and TR !
Repair - small complete
rigid ring
Replacement - selective,
chord-sparing
