Download as PDF, PPTX
More Related Content
The road ahead.
- 1. The conundrum ofmitral regurgitation in heart failure Piotr Ponikowski, MD, PhD, FESC Medical University, Centre for Heart Disease Clinical Military Hospital Wroclaw, Poland The road ahead
- 2. Disclosure Consultancy fees andspeaker’s honoraria from: ABBOTT VASCULAR
- 3. Primary vs functionalMR: key question for the current management n Primary MR MR→LV volume overload→remodeling with subsequent consequences „correction of primary MR in a timely fashion reverses these consequences” n Functional MR – damaged LV causes MR „primarily a ventricular problem it is less obvious that correcting the MR by itself will be curative or even beneficial” Carabello BA, JACC 2008;52:319-26 • Secondary MR „because MR is only 1 component of the disease (severe LV dysfunction, CAD or idiopathic myocardial disease are the others), restoration of mitral valve competence is not by itself curative; 2014 AHA/ACC Valvular Heart Disease Guideline
- 4. Primary vs functionalMR: key question for the current management Marwick TH, Zoghbi WA, Narula J. JACC CV Imaging 2014 Potential confounders in the causal pathway linking FMR and adverse events
- 5. MR in HeartFailure Management options: how / when to intervene ? • Optimal medical therapy • CRT • Surgery MV surgery Surgical treatment of LV • Percutaneous techniques
- 6. Functional Mitral Regurgitation– management options Acute effect of CRT on FMR in HF patients (EF<30%) with LBBB Breithardt OA et al. JACC 2003;41,765-770 …increase in TMP mediated by a rise in maximal rate of LV systolic pressure rise due to more coordinated LV contraction, may facilitate effective MV closure…
- 7. Functional Mitral Regurgitation– management options Impact of CRT on the severity of FMR Di Biase L et al. Europace 2011;13, 829–838 The distribution of MR in CRT population
- 8. Functional Mitral Regurgitation– management options CRT in Patients with Moderate-Severe FMR van Bommel et al. Circulation 2011;124:912-9 100 200 300 BL F-UP BL F-UP LVEDV (mL) LVESV (mL) BL F-UP BL F-UP LVEDV (mL) LVESV (mL) MR improvers MR non-improvers
- 9. MR in HeartFailure Management options: how / when to intervene ? • Optimal medical therapy • CRT • Surgery MV surgery Surgical treatment of LV • Percutaneous techniques
- 10. ESC Guidelines onthe Management of VHD 2012 Indications for mitral valve surgery in chronic secondary MR
- 11. Euro Heart Survey: whysurgery is denied in clinical practice ? Mirabel et al., Eur Heart J 2007;28:1358-65
- 12. Cardiac surgeon Cardiologist Anaesthetists Other specialists: geriatrician, GP,etc Imaging specialist (ECHO, CT, MRI) Decision-making in VHD patient HEART TEAM ‘heart team’ approach is particularly advisable in the management of high-risk patients and is also important for other subsets, such as asymptomatic patients, where the evaluation of valve repairability is a key component in decision-making… ESC Guidelines on the Management of VHD 2012
- 13. MR in HeartFailure Management options: how / when to intervene ? • Optimal medical therapy • CRT • Surgery MV surgery Surgical treatment of LV • Percutaneous techniques
- 14. Percutaneous Mitral ValveRepair MitraClip® System
- 15. WHY to recommend„new procedure” for HF patient ? Therapy footprint Economic impact Patient Durability Procedural success Safety profile Survival & QoL
- 16. MitraClip therapy “The mostestablished PMVR therapy” n More than 20000 patients treated worldwide n Used in more than 420 centers and 35 countries n More than 560 clinical papers published to date* n Included in: – 2012 ESC/HFA/EACTS Guidelines² – 2014 ACC/AHA Guidelines3 – 2012/2013 German Guidelines4,5 – 2014 Italian Guidelines6 • H. Hermann & F. Maisano – Transcatheter therapy of Mitral Regurgitation – Circulation 2014; 130:1712-1722 • ESC/EACTS 2012 Guidelines on the management of valvular heart disease. Eur Heart J (2012) 33, 2451–2496. • Nishimura RA, et al. - 2014 ACC/AHA valve guidelines: earlier intervention for chronic mitral regurgitation - Heart June 2014 Vol 100 No 12 • Boekstegers P. et.al. Percutaneous interventional mitral regurgitation treatment using the Mitra-Clip system Clin. Res. Cardiol. 2013 • Nickenig G. et al. - Consensus of the German Cardiac Society and the German Society for Thoracic and Cardiovascular Surgery on treatment of mitral valve insufficiency - Kardiologe 2013 · 7:76–90 • Maisano et al. - Transcatheter treatment of chronic mitral regurgitation with the MitraClip system: an Italian consensus statement - J Cardiovasc Med 2014, 15:173–188 Therapy footprint
- 17. EVEREST II: 279patients with moderately severe or severe (grade 3+ or 4+) MR randomized in a 2:1 ratio to percutaneous repair or conventional surgery LVEF – 60%, functional MR – 27% 12 months Surgery better Percutaneous repair better Feldman T et al., N Engl J Med 2011 MitraClip therapy “The most established PMVR therapy” Therapy footprint
- 18. MitraClip therapy Safety profile •T. Feldman, et al., The New England journal of medicine 364, 1395 (2011)/ 2. P. L. Whitlow, et al., Journal of the American College of Cardiology 59, 130 (2012)/ 3. F. Maisano, et al., Journal of the American College of Cardiology 62, 1052 (2013)/ 4. S. Kar, Presented at TCT, 2013, San Francisco, CA (2013)/ 5. W. Schillinger, et al., EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology 9, 84 (2013)/4. C. Grasso, et al., The American journal of cardiology 111, 1482 (2013) Safety profile • Low Major Adverse Events (MAEs) • Low post-procedural mortality Low Major Adverse Events (MAEs) Low post-procedural mortality S MC
- 19. MitraClip as therapeuticoption for MR first (and strong) evidence EVEREST II: 4-year results Sustained clinical benefits comparable to those after surgery Improvement in MR durable through 4 years Mauri et al., JACC 2013 Survival & QoL
- 20. MitraClip as therapeuticoption for MR first (and strong) evidence EVEREST II: 4-year results Mauri et al., JACC 2013 Differences in rates of the efficacy endpoints: freedom from death, MV surgery and from +3/+4 MR Survival & QoL
- 21. MitraClip as therapeuticoption for MR Real World Experience ACCESS-EU: 567 pts with significant MR who underwent MitraClip therapy at 14 European sites; 69% functional MR, 85% NYHA III-IV, 53% LVEF <40% Implant rate – 99.6%; mortality: 30-day – 3.4%,1-year – 81.8% Maisano F et al., JACC 2013;62:1052–61 Severity of MR at baseline and during follow-up Changes in 6MWT in patients with MitraClip Survival & QoL
- 22. MitraClip as therapeuticoption for MR Real World Experience TCVT – ESC : 628 consecutive pts with significant MR who underwent MitraClip therapy at 25 European sites; 72% functional MR: 88% NYHA III-IV, 42% LVEF <30%, EuroScore - 22 Nickenig G al., JACC 2014;64:875–84 Survival & QoL Composite of death and HF rehospitalisation
- 23. MitraClip as therapeuticoption for MR Real World Experience 139 consecutive pts with MitraClip therapy vs 53 treated surgically vs 59 treated conservatively MitraClip: EuroScore: 24±16% NYHA II-III: 77%; LVEF: 37±15% FMR: 77% Swaans et al., JACC Interv 2014;7:875-81 Conclusion: high-surgical-risk patients treated with TMVR displayed survival benefit vs those treated conservatively. Survival & QoL
- 24. Grades A &B At risk of MR → Progressive MR •Primary myocardial disease with LV dilation and systolic dysfunction •Symptoms due to CAD/HF •OMT/devices/revascularization Grade C Asymptomatic severe MR •Abnormal valve hemodynamics – ERO, RF •Symptoms due to CAD/HF •OMT/devices/revascularization Grade D Symptomatic severe MR •Abnormal valve hemodynamics – ERO, RF •Symptoms due to MR, persist even after OMT/devices/revascularizationModified from 2014 AHA/ACC Valvular Heart Disease Guideline strategy: 1.Treat HF optimally 2.MR - watch and see strategy: 1.Treat HF optimally 2.MR – consider intervention Ready to challenge this paradigm ? Is there enough evidence ? FMR in Heart Failure how / when / WHY to intervene ?