Download Functional MR

IM ischémique
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l’IM ischémique!!
Cas clinique mis à disposition par Claire BOULETI
Case Study
• 69-year old man
• Chronic renal failure: creatinine 170 µmol/l
• CV risk factors: smoking 46PY (cessation),
hypertension, dyslipidemia, diabetes mellitus
Medical history
• 1997 acute pulmonary oedema revealing coronary
artery disease with asymptomatic RCA occlusion.
• No symptom until December 2003 :
• 2nd severe pulmonary oedema without triggering
factor. LVEF 40%. Ischaemic MR 2/4. Coronary
arteriography: not modified. Favourable evolution
• Dyspnea NYHA class II-III without hospitalisation until
July 2011
• 3rd pulmonary oedema in July 2011, with fast
improvement under medical treatment
Coronary angiography
TTE
• TTE: Akinesis in the basal inferior segment, LVEF 30%
LVEDD 65mm LVESD 54mm, ERO 60 mm2, RV 66ml
vena contracta 8 mm
• No left ventricular viability
• ECG: Q wave in inferior leads. LBBB (QRS =140ms)
• NYHA class III dyspnea refractory to medical treatment
(B-, ACE-Inhibitors, diuretics)
management of this patient?
• TTE: Akinesis in the basal inferior segment, LVEF 30%
LVEDD 65mm LVESD 54mm, ERO 60 mm2, RV 66ml
vena contracta 8 mm
• No left ventricular viability
• ECG: Q wave in inferior leads. LBBB (QRS =140ms)
• NYHA class III dyspnea refractory to medical treatment
(B-, ACE-Inhibitors, diuretics)
management of this patient?
ESC Guidelines CRT-P/-D
to reduce morbidity and mortality
Class
Patients with NYHA function class III/IV,
LVEF ≤35%,
QRS ≥120 ms,
SR
Optimal medical therapy
Class IV patients should be ambulatory
IA
Medical history
• No clinical improvement
• 4th pulmonary oedema in October without triggering
factor
• TTE : no major changes
LVEF 25% Akinesis of the basal inferior segment,
LVEDD 65mm LVESD 54mm, ERO 60 mm2, RV 66ml
vena contracta 8 mm, sPAP 50 mmHg
• TEE : same findings
Evaluation of functional MR:
Mechanism
Local remodelling ± wall motion abnormalities
 Displacement of papillary muscles
 Traction on mitral leaflets
(tethering)
 Tenting
 Restriction of anterior leaflet opening
(Levine et al. Curr Cardiol Rep 2002;4:125-9)
Incomplete mitral leaflet closure
Evaluation of functional MR:
Mechanism
• Restriction in the leaflet motion (Carpentier type 3)
• Incomplete leaflet closure in systole
is the consequence of changes in geometry
and/or motion of the left ventricle
• Normal structure of leaflets and subvalvular apparatus
• Imbalance between
tethering and
closure force
Evaluation of functional MR:
Mechanism
Tenting
The volume of regurgitation is related to the importance of tenting and
not to LVEF
Tenting area
(Yiu et al. Circulation 2000;102:1400-6)
Evaluation of functional MR:
Quantification
Criteria Mitral Regurgitation
Specific signs of severe
regurgitation
• Vena contracta width  0.7 cm with large central
MR jet (area > 40% of LA) or with a wall
impinging jet of any size, swirling in LA
• Large flow convergence
• Systolic reversal in pulmonary veins
• Prominent flail mitral valve or ruptured papillary
muscle
Supportive signs
• Dense, triangular CW Doppler MR jet
• E-wave dominant mitral inflow (E > 1.2m/s)
• Enlarged LV and LA size (particularly when normal
LV function is present)
Quantitative parameters
Organic MR
Reg. Vol (ml/beat)
 60
RF (%)
 50
ERO (cm²)
 0.40
Functional MR
 30
 0.20
(ESC Guidelines)
Back to Mr G
• 69-year old male, chronic renal failure
• LVEF 25%
• Severe functional MR, with symptoms
refractory to maximal medical treatment and
resynchronisation.
• No viability= no possible revascularisation
Do we have to correct MR?
Rationale for the Correction of
Ischaemic / Functional MR
MR
W
ORSEMR
VOLUMEOVERLOAD
LVDILATION
Options: Medical treatment
Surgery: MVR/valve repair
Mitraclip
The Role of Medical Therapy
Treatments which reduce the degree of
ischaemic MR= treatment of systolic heart failure
• ACE inhibitors, AT1 receptors blockers
• Beta-blockers
• Biventricular pacing
But clinical relevance/pronostic impact on MR remains unclear
Surgery for Functional MR
• Prosthetic valve replacement
Preservation of subvalvular apparatus
• Valve repair
– Undersized annuloplasty
– Restores coaptation but does not correct tethering
– Limitations of intra-operative TEE
→ Risk of residual MR > organic MR
• + CABG
Surgery for Ischaemic MR
Operative Mortality
n=
Operative Mortality (%)
Replacement ± CABG
Grossi (J Thorac Cardiovasc Surg 2001)
Mantovani (J Heart Valve Dis 2004)
Calafiore (Ann Thorac Surg 2004)
71
41
20
20
7.3
10
Repair ± CABG
Grossi (J Thorac Cardiovasc Surg 2001)
Mantovani (J Heart Valve Dis 2004)
Calafiore (Ann Thorac Surg 2004)
Diodato (Ann Thorac Surg 2004)
Glower (J Thorac Cardiovasc Surg 2005)
Fedoruk (Ann Thorac Surg 2007)
Braun (Ann Thorac Surg 2008)
152
61
82
51
141
97
100
10
8.2
3.9
3.9
4.3
8.2
8.0
Ischaemic and Non-Ischaemic MR
Confounding Factors
535 patients operated on for mitral valve repair (1993-2002)
Ischaemic MR
(n=141)
Non-Ischaemic MR
(n=394)
p
69 [61-75]
59 [51-69]
<0.001
Hypertension (%)
39
24
0.001
Diabetes (%)
35
8
<0.001
Renal disease (%)
18
7
<0.001
Lung disease (%)
22
8
<0.001
NYHA IV (%)
72
38
<0.001
40 [30-43]
50 [40-56]
<0.001
Coronary disease (%)
100
18
<0.001
30-day mortality (%)
4.3
1.3
0.04
Age (yrs)
LVEF
(Glower et al. J Thorac Cardiovasc Surg 2005;129:860-8)
Surgery of Ischaemic MR
CABG With or Without Valve Repair
2 groups, ischaemic MR  3/4 :
- 54 had isolated CABG
- 54 had CABG + valve repair
• No significant difference in survival and NYHA class III-IV
• Recurrence of MR after valve repair
(Mihajlevic et al. J Am Coll Cardiol 2007;49:2191-201)
Ischaemic MR
Viability and prognosis
• 54 patients with severe ischaemic MR, mean LVEF 27%
• Viability on PET scan
Viability and survival following coronary bypass and MV Replacement
(Pu et al. Am J Cardiol 2003;92:862-4)
Surgery for Functional MR
vs. Medical Therapy
682 patients with functional MR and severe LV dysfunction
126 had valve repair, 556 were treated medically
Predictors of cardiac event
Hazard Ratio [95% CI]
p
Sodium (1mMol/l increase)
0.93 [0.90-0.96]
<0.0001
Coronary artery disease
1.80 [1.30-2.49]
0.0004
Mean arterial pressure (1 mm increase)
0.98 [0.97-0.99]
0.0006
Blood urea nitrogen (1 mg/dl increase)
1.01 [1.005-1.02]
0.0009
Cancer
2.77 [1.45-5.30]
0.002
Beta-blockers use
0.59 [0.42-0.83]
0.003
Digoxin use
1.66 [1.15-2.39]
0.007
ACE-inhibitor use
0.65 [0.44-0.95]
0.03
Mitral annuloplasty was not a predictor of late cardiac events
(death, ventricular assistance, or transplantation)
(Wu et al. J Am Coll Cardiol 2005;45:381-7)
Impact of Surgery on LV Remodeling
• 87 patients operated for ischaemic MR (2000-2004)
– 86% MR grade 3/4, LVEF 32 ± 10%
– Valve repair (downsized ring) + 86% CABG
– 30-day mortality 8.0%
• 60% of pts had reverse LV remodeling (10% decrease in LV EDD) at
18 months FU
Before
surgery
18 months
p
LV end-diastolic dimension (mm)
64 ± 8
58 ± 10
<0.01
LV end-systolic dimension (mm)
52 ± 8
44± 11
<0.01
Left atrium diameter (mm)
54 ± 6
48 ± 6
<0.01
• Thresholds predicting reverse LV remodeling
– EDD < 65 mm
– ESD < 51 mm
(Braun et al. Eur J Cardiothorac Surg 2005;27:847-53)
Reverse remodeling after surgery
Unsolved questions
• Role of coronary revascularisation?
 Recovery of viable myocardium
• Role of MR correction?
 Removal of volume overload
• Experimental studies suggest that isolated MR
correction does not significantly impact LV
remodeling.
(Guy et al. J Am Coll Cardiol 2004;43:377-83)
(Enomoto et al. J Thorac Cardiovasc Surg 2005;129:504-11)
Benefits of Surgical Correction
of Ischaemic MR
• Decrease
of MR
but risk of late recurrence after repair
(Gelsomino et al. Eur Heart J 2008;29:231-40)
• Left
ventricular reverse remodeling
in 60% of patients, predicted by LV dilatation
(Braun et al. Eur J Cardiothorac Surg 2005;27:847-53)
• Improvement
of symptoms
controversial findings
• No
proven benefit on survival
(Wu et al. J Am Coll Cardiol 2005;45:381-7)
Indications for Surgery in Ischaemic MR
Chronic Ischaemic MR
Class
Patients with severe MR, LV EF > 30% undergoing CABG
IC
Patients with moderate MR undergoing CABG if repair is
feasible
IIaC
Symptomatic patients with severe MR, LV EF < 30% and
option for revascularization
IIaC
Patients with severe MR, LVEF > 30%, no option for
revascularization, refractory to medical therapy, and low
comorbidity
IIbC
(ESC Guidelines)
surgery can be considered only in selected patients with
severe symptoms despite optimal medical therapy
What about the MitraClip System ?
Percutaneous Valve Repair Using
the MitraClip System
Everest-II* Franzen et al.†
HRR (n=78)
(n=26)
Mean age (yrs)
77
70
Functional MR (%)
59
100
NYHA III-IV
90
100
MR ≥ 3/4 (%)
100
100
Mean LVEF (%)
54
22
Implant success (%)
96
92
Implant success and MR ≤2/4 (%)
81
92
(* EuroPCR 2009
† ESC 2009)
Percutaneous Valve Repair Using
the MitraClip System
Franzen et al.
Everest HRR
34
patients
Grade
1+/ 2+with functional MR
Grade 3+/ 4+
At 3 months
87% MR reduction
18%
21%
97%
82%
79%
Baseline
30 days
Symptoms
86 % of patients in NYHA
class I-II
12 months
Mean LVEF 23%  28%
83% symptom improvement
74% NYHA I-II at 12 months
(ESC 2009)
(EuroPCR 2009)
When to propose a Mitraclip in
functional MR?
 The device is safe and the technique is feasible.
 Efficacious in lowering MR
BUT
• No long-term outcome
• Only 1 single randomised study (only 27% of functional MR)
AND
Will the patient benefit from this reduction of MR?
Same problem as for surgical treatment of MR…
but at a lower risk
Back to Mr G
• He benefited from the MitraClip system
• No per-procedural complication
• Favourable evolution (out of hospital at D+3)
Post-procedural TTE
Post-procedural TTE
Post-procedural TTE
Conclusion: evaluation of ischaemic MR
• Functional MR is a totally different disease than organic MR.
• It is frequently associated with severe ischemic heart disease
which carries a poor prognosis in itself, and worsens the
prognosis.
• Quantification of the regurgitation uses specific (lower)
thresholds for ischaemic etiologies
• Need for a complete evaluation of ischaemic MR
– Echocardiography (quantification, mechanism)
–
–
–
–
Viability and ischemia (radionuclide, stress echo)
LV function
Coronary angiography
Functional tolerance (symptoms)
Conclusion: treatment of ischaemic MR
• Operative mortality is higher and long term results are less
satisfying than for organic MR even when using valve repair
• Thus, risks/benefits of surgery remain debated and indications
are far more restrictive than in organic MR:
 if symptoms are refractory to maximal medical therapy
 in case of CABG
• MitraClip system is of potential interest since the risk of the
procedure is low
• Need for long-term outcome and randomized studies