This document discusses mitral valve disease, including mitral stenosis and mitral regurgitation. It describes the causes, presentations, treatments for each condition. Rheumatic fever is the most common cause of mitral stenosis. Treatment options include balloon valvuloplasty or surgery depending on severity of stenosis and patient factors. Mitral regurgitation can be acute, such as from papillary muscle rupture, or chronic. The MitraClip procedure is discussed as a less invasive option for treating mitral regurgitation in high surgical risk patients. The COAPT trial demonstrated reduced mortality and heart failure hospitalizations for patients receiving the MitraClip plus medical management compared to medical management alone.

1. Mitral Valve Disease:
Mitral Valve Stenosis/Regurgitation
Moses Mathur MD MSc
November 2018

2. Disclosures
• None

3. Outline
• Mitral stenosis
• Mitral regurgitation
• Questions

6. Mitral Stenosis

7. MS - Etiology
• Rheumatic (90%) - Group
A Strep Pharyngitis
• Non-rheumatic
- Senile, calcific MS
(older patients, MAC,
ESRD)
- IE, SLE,
Endomyocardial
fibrosis, congenital
defects, radiation etc.

8. Rheumatic MS - Progresses
over decades
• Class I: Exercise testing (w/ Doppler/Invasive) measurements of
mitral MG or PASP, if discrepancy between echo findings and Sx

9. Rheumatic MS - staging
• Severe MS: MVA ≤ 1.5 cm2, MG > 10 mmHg, PASP > 30mmHg

11. • Basically:
• Balloon valvuloplasty if severe MS + Sx + favorable anatomy
• Mitral surgery if severe MS + Sx + failed PMBC/not favorable candidates + favorable
candidates for surgery
• Consider mitral surgery, if undergoing other surgery

12. MS - Med Rx
• Class I: Anticoagulation (VKA/Heparin) for
1) MS + Afib
2) MS + prior embolic event
3) MS + LA thrombus
• Class IIa: HR control in MS + Afib
• Class IIb: HR control in MS + NSR (but DOE)

13. Percutaneous Balloon Mitral Commisurotomy (aka “BMV”)
• Goal: Mechanically split the commissures without causing ≥ moderate MR
• Anatomic suitability:
- Wilkins-Abascal score (“Echo score”)
- Commisural calcium
- ≤ Mild MR
- Absence of LAA/LA thrombus

14. • Wilkins-Abascal Score (score 1-4 in each
category, then add up all numbers. Range:
4-16):
- Leaflet mobility
- Leaflet calcium
- Leaflet thickness
- Subvalvular thickness
• Wilkins score < 8 is ideal for successful
PBMC
Abascal et al. Circulation. 1990.
Wilkins < 8
Wilkins > 8

15. Question 1
Which of the following patients is the best candidate for mitral
balloon valvuloplasty?
A. 30 yo F w/ exertional dyspnea, loud opening snap, diastolic
rumble, pre-systolic accentuation, and no systolic murmurs
B. 80 yo M w/ no opening snap, soft diastolic rumble and a CXR
showing heavy mitral annular calcification
C. 45 yo F w/ Atrial fibrillation, a diastolic rumble, and a loud
holosystolic murmur
D. 27 yo F w/ no symptoms. MVA 1.5 cm2 and in sinus rhythm

16. • “Opening snap”: opening of mitral leaflets in diastole.
- Earlier OS means worse MS. (More severe MS = Higher gradient = opens earlier)
- “Loud” OS means pliable leaflets. Soft/Absent OS means leaflet are stiff (calcified)
• “Pre-systolic accentuation”: caused as a result of atrial contraction (P-wave). Absent
in Afib patients.
• “Holosystolic murmur”: think mitral regurgitation

17. Mitral Regurgitation

18. Acute MR
• Common causes:
• Ischemia (pap. m. ischemia/rupture 2-7 days s/p MI)
• IE (leaflet perforation, chord rupture), Spontaneous rupture (Degenerative dz)
• Treatment
• Meds: Vasodilators (as tolerated by BP), IABP
• Cath lab, Urgent/emergent mitral surgery
(RCA)(LAD, LCX)

19. Question 2
A 57 year old male w/ HIV (on HAART), HLD, HTN, was in his usual state of health, until he
walked into the ED with sudden onset SOB noted after dinner/opera with his husband. In the
ED, he became increasingly hypoxic and required STAT intubation. BP was 110/70, HR 150
bpm. EKG was performed (see below). Initial troponin was 4. D-Dimer is positive. ABG showed
pH 7.0, HCO3 18. On P/E, he had diffuse crackles bilaterally, and a brief systolic murmur
(loudest at the apex). CXR showed diffuse pulmonary edema. No widened mediastinum.
What is the next best step?
A. Call a STEMI
B. STAT TEE
C. CT Chest w/
contrast
D. Cardiovert him

20. Acute papillary muscle rupture !
LA
LV
AV
Sev. MR
In hospital mortality ~50%
Needs emergent OR

21. • Primary (Degenerative)
• Diseased valve structure (leaflets,
chords, papillary muscles, annulus)
• MR is the disease
• Etiologies:
• MVP, Barlow’s valve (myxomatous
degeneration), CTD, IE,
Rheumatic, cleft mitral valve,
radiation
Chronic MR
• Secondary (Functional)
• Valve structure usually normal
• MR caused by LV distortion
• Etiologies:
• Ischemic CMP, Non-CMP

22. Stages of chronic secondary MR

23. MR progresses to heart failure

24. Treatment timing

25. • Severe MR vastly under-treated
• Many patients not considered surgical candidates

26. Emergence of percutaneous mitral
valve technologies
• MitraClip: first in class therapy
• Many other Transcatheter Mitral Valve Replacement
(TMVR) therapies in development

27. • 279 pts. Mitraclip vs
Surgery
• ~70% primary MR
• Primary endpoint:
freedom from (death,
surgery for mitral-
valve dysfunction, ≥3
MR) at 12 months.
• Primary safety
endpoint: MACCE at
30d

28. • Surgery was
more
effective than
clip
• Clip was
safer than
surgery

29. • Both sets of
patients felt
similar
symptoms at
12 months

30. EVEREST-II
(5 year data)
• Reduction in
+3/+4 MR and
severe CHF
symptoms
sustained over 5
years

31. • 2013: MitraClip FDA-approved for treatment of
primary MR, in patients considered too high-risk
for surgical repair, with symptoms (NYHA III or IV)

33. What the sub-valvular apparatus actually looks like…
(Favorable anatomy? Check TEE)

34. Echo imaging is key to success in complex structural cases
MV
AV
LAA

35. • 75 yo F w/ chronic AF, multiple sclerosis, chronic dias/sys
HF, Hx of Breast ca (lumpectomy, XRT), severe MR
LV
LA
TEE
RV
RA
Sev. MR

36. 1 Clip 2 Clips 3 Clips

37. LV
LA
Sev. MR
TTE
LV
LA
MR ??
TTE
Baseline POD 1

38. Question 3
A 65 yo woman with history of DM and HTN, presents with leg swelling and
shortness of breath following an extended weekend celebrating Mardi Gras
in New Orleans. Her examination is consistent with heart failure. Her labs
show a CTNI of 0.8 (normal<0.04), BNP of 1500 (normal<100). Her ECG
shows new T wave inversions in the inferior leads. Her TTE shows mod-
severe, central MR, dilated LV and LVEF of 40%. What is the next best step
in her management?
A. Med Rx and send her for cardiac cath
B. Med Rx and refer her to Heart Team for consideration of MitraClip
C. Med Rx and discharge
D. Med Rx and send her for mitral surgery

40. The COAPT Trial
A parallel-controlled, open-label, multicenter trial in ~610
patients with heart failure and moderate-to-severe (3+)
or severe (4+) secondary MR who remained
symptomatic despite maximally-tolerated GDMT
Randomize 1:1*
GDMT alone
N=305
MitraClip + GDMT
N=305
*Stratified by cardiomyopathy etiology (ischemic vs. non-ischemic)
and site

41. Key Inclusion Criteria
1. Ischemic or non-ischemic cardiomyopathy with LVEF 20%-50% and LVESD
≤70 mm
2. Moderate-to-severe (3+) or severe (4+) secondary MR confirmed by an
independent echo core laboratory prior to enrollment (US ASE criteria)
3. NYHA functional class II-IVa (ambulatory) despite a stable maximally-tolerated
GDMT regimen and CRT (if appropriate) per societal guidelines
4. Pt has had at least one HF hospitalization within 12 months and/or a BNP
≥300 pg/ml* or a NT-proBNP ≥1500 pg/ml*
5. Not appropriate for mitral valve surgery by local heart team assessment
6. IC believes secondary MR can be successfully treated by the MitraClip
Adjusted by a 4% reduction in the BNP or NT-proBNP cutoff for every increase of 1
kg/m2 in BMI >20 kg/m2

42. Key Exclusion Criteria
1. ACC/AHA stage D HF, hemodynamic instability or cardiogenic shock
2. Untreated clinically significant CAD requiring revascularization
3. COPD requiring continuous home oxygen or chronic oral steroid use
4. Severe pulmonary hypertension or moderate or severe right ventricular
dysfunction
5. Aortic or tricuspid valve disease requiring surgery or transcatheter intervention
6. Mitral valve orifice area <4.0 cm2 by site-assessed TTE
7. Life expectancy <12 months due to non-cardiac conditions

43. All-cause Mortality
All-causeMortality(%)
0%
20%
40%
60%
80%
100%
Time After Randomization (Months)
0 3 6 9 12 15 18 21 24
46.1%
29.1%
HR [95% CI] =
0.62 [0.46-0.82]
P<0.001
MitraClip + GDMT
GDMT alone
302 286 269 253 236 191 178 161 124
312 294 271 245 219 176 145 121 88
No. at Risk:
MitraClip + GDMT
GDMT alone
NNT (24 mo) =
5.9 [95% CI 3.9, 11.7]

44. MitraClip + GDMT
GDMT alone
All-causeMortalityor
HFHospitalization(%)
0%
20%
40%
60%
80%
100%
Time After Randomization (Months)
0 3 6 9 12 15 18 21 24
67.9%
45.7%
MitraClip + GDMT
GDMT alone
302 264 238 215 194 154 145 126 97
312 244 205 174 153 117 90 75 55
No. at Risk:
HR [95% CI] =
0.57 [0.45-0.71]
P<0.001
NNT (24 mo) =
4.5 [95% CI 3.3, 7.2]
Death or HF Hospitalization

46. Why not just use TAVR
valves for the mitral
position?
Challenges:
• MV is saddle shaped
• MV is bigger
• Sub-valvular apparatus
• Approach (trans-septal,
trans-apical)
• Multiple failure modes
• Anchoring?

47. • Global multicenter registry of
aortic THV in severe MAC
• 116 patients, STS 15 ±11 %
• 94% severe MS (MG 11, MVA
1.3), LVEF 60%, NYHA III-IV
• 30d mortality 25%, 1y
mortality 53.7%
• Majority of pts alive at 30d,
lived to 1 year.

48. • Procedural results:
LVOT obstruction w/ H/D compromise 11.2%
>Moderate PVL 4.9%

49. Mitral VIV (and VIR) results
• 2017: FDA approval for VIV in mitral position with SAPIEN S3 valve
(high risk patients)
JM Paradis et al., JACC November 2015

51. Thanks for your attention !
Questions ?
moses.mathur@virginiamason.org
Answer key: Q1. A, Q2. B, Q3. A