Post on 03-Aug-2020
MULTI-DISCIPLINARY APPROACH TO MITRAL DISEASE
Nikolaos Kakouros, MBBS MRCP PhD MD(Res) FACC FSCAI Director, Structural Heart Disease programProgram Director, Interventional Cardiology SHD FellowshipCo-director, TAVR programAssistant Professor of MedicineUniversity of Massachusetts Medical School
CARDIOLOGIST
Conflicts of Interest
▪ I do not have any financial arrangements or affiliations with any of the corporate organizations offering financial support or educational grants for this continuing medical education program
Objectives
▪ Understand catheter based approaches to mitral valve disease
▪ Describe the evaluation and indications for catheter based interventions
▪ Describe the common complications associated with catheter based intervention
Multi-disciplinary Approach To Mitral Disease
Russell C Brock (1903-1980) leading British chest and heart surgeon
Pioneer of modern open heart surgery
▪ 1947 - Surgical pulmonary valve dilation and infundibular muscle resection in Fallot’s tetralogy to reduce R-L shunt
▪ Exchange professorships with Dr Alfred Blalock at JHH
helped introduce new tech (hypothermia, heart-lung machine) to the nascent field of cardiac surgery
Russell C Brock (1903-1980)
1948 – One of first four surgeons to operate
on rheumatic mitral stenosis
Finger-fracture Valvuloplasty
(closed commissurotomy)
RC Brock on Intracardiac Surgery
‘Intracardiac surgery is not for the lone worker. Team work is essential … success is due principally to the loyal and unstinted co-operation of my various colleagues who take part with me in this work both at Guy’s and the Brompton Hospital. To give one example, at Guy’s there is a group of some 15 people actively engaged in the work, and as time passes we find that more and more are drawn into the team.’
Peacock Club – 70 years ago
▪ Established 4/21/1948 as meeting of “those concerned in the management of congenital disease of the Heart” convened by RC Brock
▪ Thomas Peacock – author of 19C text on cardiac malformations
▪ Core Members: Guy’s cardiologists
Clinical scientists from Medical Research Council
Radiologist
Anesthetists
Surgical assistants
Junior doctors and research fellows
Invited speakers and named visitors
Peacock Club
▪ Discussions of life threatening risks of the invasive investigations
▪ Shared management planning
▪ Self-critical reviews of operations that often went badly
Hearts of the patients who died were critically examined in the presence of the whole team
▪ Meticulous documentation of treated and untreated cases.
THE MITRAL VALVE
MDT approach :MITRAL VALVE DISEASE
STENOSIS REGURGITATION
MITRAL STENOSIS ETIOLOGY
RHEUMATIC60%, nearly all adult MS
CALCIFIC
•Misc: Congenital (parachute MV), post-inflammatory,
mucopolysaccharidosis, LA myxoma
The problem
▪ Rheumatic Heart Disease prevalence: Industrialized nations 1/100 000 Worldwide: 12 000 0000 Rh Fever and Rh Heart Disease cases
(Circulation. 2009;119:e211-e219)
0.14/1000 in Japan, 1.86/1000 in China, 0.5/1000 in Korea, 4.54/1000 in India, 1.3/1000 in Bangladesh
▪ Why? Streptococcal GrpA infection → Type II hypersensitivity overpopulation, overcrowding, poverty, poor access to
medical care, limited availability of PCN
Rheumatic Mitral valve stenosis
• Valve thickening
• Commissural fusion
• Chordal fusion
• Normal Valve area 4-5cm2
RHEUMATIC MITRAL STENOSIS
RHEUMATIC MITRAL STENOSIS
RHEUMATIC MITRAL STENOSIS
Mitral Stenosis
Severe mitral stenosis: MVA <1.5cm2
Critical mitral stenosis MVA < 1.0 cm2
• Asymptomatic• Present with incapacitating dyspnea
• Pulmonary hypertension
• Hemoptysis
• Right heart failure, peripheral edema, orthopnea
• Atrial fibrillation: 80%
• Systemic thromboembolism: 20%
MitralCommissurotomy
1902 : Proposed by Brunton
1920s: First successful surgical commissurotomy
1940-1950s: Trans-atrial and transventricularsurgical commissurotomy were accepted clinical procedures. Open commissurotomy preferred in the US
1980s: PTMV emerged
1994: Clinically approved
21st Century: PTMV is the preferred procedure
• Angelo Thomas Pezzella et al: Ann. Afr. Chir. Thor. Cardiovasc. 2012;7(1)
• International Children’s Heart Fund
Treatment for Mitral Stenosis
PMBC vs SURGERY
Balloon vs. Open Surgical
Turi et al, Circulation, 83, 1179-85, 1991
Mit
ral
Va
lve
Are
a(c
m2)
PMV vs OMC vs CMC
MVA at seven years follow-upPMV OMC CMC
0
0.5
1.5
1
2.5
2
3
Baseline 6 Months
P=0.001
7 Years
P=0.001
P=NS
P=NS
0.9 0.9 0.9
P=NS
2.1 2.2
1.61.8 1.8
1.3
Farhat et al. Circulation 1998
CONCLUSIONS
• PTMV and OMC have comparable initial results and low
rates of restenosis, and both produce good functional
capacity for at least three years.
• The better hemodynamic results at three years, lower cost,
and elimination of the need for thoracotomy suggest that
PTMV should be considered for all patients with favorable
mitral-valve anatomy.
Mechanism of PTMV
PTMV relieves mitral stenosis by
splitting fused commissures,
similar to surgical
commissurotomy
PTMV Technique
Transseptal antegrade approach
Double balloon technique
Inoue balloon technique
Multitrack
Cribie dilator
Retrograde approach
Double Balloon Technique
Inoue Balloon
Kanji Inoue performed first PTMV with the eponymous balloon in 1984
FDA approved in 1994
Inoue Balloon Stages
Transeptal TEE/ICE
RHEUMATIC MITRAL STENOSIS post
RHEUMATIC MITRAL STENOSIS post
RHEUMATIC MITRAL STENOSIS ASD
Define success
▪ MVA >2 cm2 or
▪ MV gradient <5 mmHg
▪ Others markers:
50% improvement in valve area
MVA increased to >1 cm2/m2 BSA
STOP when increase in MR by ONE grade (1-4)
Inoue Balloon Stepwise Technique
Feldman et al. Cath CV Diag 28: 199, 1993
Min
ute
Inoue vs Double Balloon
Procedural time
0
15
60
45
30
75
90
Procedural time
Inoue Balloon Technique
Double Balloon technique
p<0.05
56
84
1525
Fluoroscopic time
Park SJ et al. Am J Coll 1993
Ev
ent-
free
surv
iva
l(%
)Event-free Survival
Death, MVR, redoPMV, NYHA≥3
83±5%
76±7%
p=NSInoue BalloonDouble Balloon
100
80
60
40
20
0
4 5 7620 1 3
YearsKang DH, et al J Am Coll Cardiol 2000
Complications of PTMV
• Mortality
• Systemic embolization
• Severe MR(+4)
• Left to right shunt (>1.5:1)
• Transient heart block and tamponade
• Hemopericardium
0-0.6%
0-4.5%
0.9-3%
<5%
<5%
0.5-5%
Contraindication of PMV
• Left atrial thrombus
• Apical LV thrombus
• MR>2+
• Bleeding diathesis
• Severe cardiothoracic deformity
Patient selection is
fundamental in predicting
outcome of PMV
Mitral valve morphology
Echocardiographic Score !!!
Echo Score
Mitral valve morphology
2 3
Rigidity
Thickening
Calcium
1
mobile valve
thin
no bright echos
4
immobile valve
severe thickening
multiple bright echo
Subvalvular sparse echos multiple thick chordae
apparatus
Mit
ral
Va
lve
Are
a(c
m2)
MVA according to ES
0
0.5
1.5
1
2
Pre-PMV
P<0.001
1.00.8
2.0
1.6
P<0.001ES ≤ 8 (n=601)
ES > 8 (n=278)
Post-PMV
Palacios Circulation 2002
80
60
40
20
0
100
86.5%
ES ≤ 8 (n=601)
76.6%
ES > 8 (n=278)Palacios Circulation 2002
P=0.0002
Success according to ES
Post-PMV MVA ≥ 1.5, 50% increase in MVA, MR ≤ 2+
%
Mit
ral
Va
lve
Are
a(c
m2)
Su
cces
s(%
)
1.5 1.4
0.7
Changes in MVA & Success
0
0.5
3
2.5
2
1.5
1
0%
10%
90%
80%
70%
60%
50%
40%
30%
20%
87%
2.2
1
Pre-PMV
Post-PMV
59%50%
1.6
29%
0.8 0.8
67% 68%
1.8 1.8
0.9 0.9
80%
1.9
0.9
80%
2.1
1
90%
2.2
1
4 5 6 7 8 9 10
Echocardiographic score11 12
2
1
0
4
3
5
Death MVRTamponade
P<0.006
P=NSP=NS
0.8
4.3
1 1
%
2.2
5.7
2.1
1.3
StrokePalacios Circulation 2002
In-Hospital Events
ES ≤ 8 (n=601)
ES > 8 (n=278)
P=0.0076
Su
rviv
al
(%)
Survival according to ES
100
80
60
40
20
0
0 20 40 60 80 100 120 140 160 180
Echo Score ≤ 8
Total Group
Echo Score > 8
P<0.001
Time of Follow-up (months)
Palacios Circulation 2002
Su
rviv
al
(%)
Event-Free Survival
according to ES
100
80
60
40
20
0
0 20 40 60 80 100 120 140 160 180
Death, MVR, redoPMV
P<0.0001
Echo Score ≤ 8
Total Group
Echo Score > 8
Time of Follow-up (months)Palacios Circulation 2002
Su
rviv
al
(%)
Events according to ES
100
80
60
40
20
0
0 20 40 60 80 100 120 140 160 180
Death, MVR, redoPMV
P<0.0001
Echo Score ≤ 8
Echo Score 9 - 11
Echo Score ≥ 12
Time of Follow-up (months)Palacios Circulation 2002
Long-Term Events
Independent predictors; Redo MVP, MVR, Death
<0.00001
0.05
0.002
0.03
0.02
<0.00001
<0.00001
P
1.01-1.03
1.00-1.81
1.16-1.92
1.02-1.67
1.09-2.22
2.61-4.72
1.01-1.03
1.02
1.35
1.50
1.31
1.56
3.54
1.02
Age
NYHA IV
Prior commissurotomy
Echo score
Pre-PMV MR ≥ 2+
Post-PMV MR ≥ 3+
Post PMV Pul A pressure
CIORVariables
Palacios Circulation 2002
CONCLUSIONS
• PTMV is the procedure of choice the
treatment of patients with MS for optimal
candidates from morphologic and clinical points
• Immediate post-PTMV variables in conjunction
with pre-PTMV clinical and mitral morphologic
variables identify most likely to benefit long-term
Russell C Brock (1903-1980)
1948 – One of first four surgeons to operate on rheumatic mitral stenosis
Finger-fracture Valvuloplasty
(closed commissurotomy)
“the mitral valve was too calcified to permit dilation; immoderate enlargement of the mitral orifice might convert mitral stenosis into severe mitral regurgitation; and patients in whom mitral regurgitation was the chief problem were not candidates for the procedure”
CALCIFIC MITRAL STENOSIS
✓Not amenable to valvuloplasty
✓ Surgery is high risk
✓Would benefit from specialized mitral valve surgical expertise
RHEUMATIC MITRAL STENOSIS
2014 AHA/ACC Valve Disease Guidelines
Mitral Regurgitation
Normal leaflet
motion
Endocarditis
Dilated annulus
Atrial fibrillation
Restrictive CM
Excess leaflet
motion
Prolapse or flail
leaflet
MVP
Papillary rupture
Trauma
Endocarditis
Leaflet restriction
systole & diastole
Rheumatic
Carcinoid
SLE
Radiation
Drugs
Leaflet restriction
systole only
Ischemic Heart
disease
Dilated CM
Degenerative MR
Rheumatic changes
Annular dilation
Functional MR
Annular Calcification
Pap muscle dysfxn: fixed or transient
Redundant Leaflets
Elongated or ruptured chords
Endocarditis
Mitral Regurgitation
Secondary MR
▪ Secondary MR (cf. primary)
▪ Functional MR (cf. degenerative)
▪ Ischemic MR (cf. Non-ischemic)
▪ MR that occurs in the setting of LV dysfunction with normal (or near normal) mitral leaflet and chordal structure
Degenerative Mitral Regurgitation
MR Pathophysiology
MR
Increase in LVEDV
Increase in total SV
Maintain
CO
LV dilatation
LV dysfxn CHF
LA dilatation
Atrial fibrillation
Rupture of chordae
Accelerated course
Pulm HTN
RV dysfxn
MR: classification of severity
MILD MOD SEVERE
Angiographic grade
1 + 2 + 3-4 +
Color Doppler jetarea
< 4 cm2 or < 20% LA
area
>40% LA area,Wall-impinging jet of any
size, swirling in the LA
Doppler vena contracta width
< 0.3 0.3 – 0.69 > 0.7
Regurgitantvolume (ml/beat)
< 30 30 - 59 > 60
Regurgitantfraction (%)
< 30 30 - 49 > 50
Regurgitantorifice area (cm2)
< 0.2 0.2 – 0.39 > 0.4
Mitral Valve Repair cf Replacement
▪ Preserves the native valve
and, almost always, the subvalvular apparatus
▪ Improved long-term survival
▪ Improved cardiac function
▪ Lower risk of complications (incl. stroke, SBE)
▪ Usually eliminates need for anticoagulants
Multiple surgical options
Full sternotomy Partial sternotomy
Right thoracotomy Robotic
All degenerative MR is repairable
▪ Create durable zone of coaptation Leaflet procedures
Mitral Ring Annuloplasty
All degenerative MR is repairable
▪ Quality of repair Degree of residual MR
▪ Durability of repair Rate of recurrent MR
Rate of reoperation
Added surgical bonus
▪ Concurrent revascularization
CABG
▪ AF-therapies
e.g. surgical Maze, left atrial appendage closure
Transcatheter Mitral Valve repair
▪ Mitral valve repair surgery remains optimal
▪ The only FDA-approved TMVr device is MitraClip
▪ Other approaches – leaflet tethering, transcatheter annuloplasty in development
Transcatheter Mitral Valve Replacement
▪ In development – FDA-approved clinical trials
▪ Deployment of artificial valve across native mitral to fix MR
▪ Trans-apical via left thoracotomy and transeptal
The MitraClip▪ The only FDA approved percutaneous therapy for Mitral
Regurgitation in the US
▪ Edge-to-edge repair (cf. Alfieri stitch)
Alfieri Ottavio. , De Bonis M. The role of the edge-to-edge repair in the surgical
treatment of mitral regurgitation, J Card Surg 2010, 25(5): 536-541.
Everest II Trial
Enrolled from 09-2005 to 11-2008, 37 centers US & Canada
• Primary Safety Endpoint:
• Rate of MAE at 30 d: composite of death, MI, reop for failed MV Surgery, non-elective CV surgery for adverse events, CVA, Ren Failure, deep wound infection, Vent for >48 hrs, GI complications req Surg, new afib, sepsis and transfusion ≥ 2 U blood
• Primary Efficacy Endpoint:
• Freedom from death, surgery for MV Dysfxn & grade 3+ to 4+ MR at 12 mo
Everest II Trial ▪ Grade 3+ to 4+ Chronic
MR
▪ Symptomatic: LVEF >25%, LVESD ≤55 mm
▪ Asymptomatic: LVEF 25-60%, LVESD 40-55 mm, New afib or PulmHypertension
▪ Were candidates for MVRepr or MVRepl
2:1 randomization
Conclusions
▪ MitraClip clearly reduces symptoms, although less than MVR in candidates who can have surgery
▪ MitraClip improves quality of life post procedure
▪ MitraClip is non-inferior to surgery in safety
▪ MitraClip 5 year results are durable
▪ MitraClip is reasonable for patients who are at prohibitive risk for surgery
Future of MitraClip
▪ COAPT: Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation
Case Presentation
▪ 96-year old woman
▪ Active until July 2016
▪ Developed worsening dyspnea
admitted to the hospital with congestive cardiac failure
Improved after introduction of the diuretics
▪ Severe AS and severe degenerative MR
Case Presentation
▪ 96-year old woman
▪ Active until July 2016
▪ Developed worsening dyspnea
admitted to the hospital with congestive cardiac failure
Improved after introduction of the diuretics
▪ Severe AS and severe degenerative MR
▪ Underwent TAVR but remained symptomatic with elevated pulmonary pressures
Results
▪ LVEF normalized
▪ No severe pulmonary hypertension
▪ No severe MR (reduced to mild)
▪ No severe AS
▪ Asymptomatic and independent (98 yrs. old)
• Patients with mitral valve disease are complex –
• symptoms may be multifactorial,
• require careful diagnostic workup,
• multidisciplinary approach,
• detailed stepwise treatment plan, and
• post procedure surveillance by dedicated teams.
Take home points
MS
• Transcatheter balloon mitral valvuloplasty is the preferred treatment option for patients with mitral stenosis and favorable anatomy.
MR
• Mitral Valve Repair surgery is the gold standard.
• MitraClip is approved for very high surgical risk patients with MR >3+ and degenerative mitral valve disease if reasonable survival expected.
• 5 year follow-up data show durable result. Landmark analysis shows after 6 months, event free survival improved.
• Ongoing trial for functional mitral regurgitation
Take home points
ECHO
CARDIO-PCP
InterventionalMS
TEE
PTBMV
Cardiac Surgeon
MV surgery
Unfavorable MS
ECHO
CARDIO-PCP
Cardiac SurgeonDMRTEE
MitraClip
Interventional
High-risk DMR
MV surgery
Medical ℞
MDT
ECHO
CARDIO-PCP
Cardiac SurgeonInterventionalMS
PTBMV MV surgery
TEE
Unfavorable MS
DMR
MitraClip
High-risk DMR
ECHO
CARDIO-PCP
Cardiac SurgeonInterventionalMS DMR
MDT
PTBMV MitraClip Medical ℞ MV surgery
TEE
Unfavorable MS High-risk DMR
Peacock Club – MDT approach 70 yrs ago
▪ Discussions of life threatening risks of the invasive investigations
▪ Shared management planning
▪ Self-critical reviews of operations that often went badly
Hearts of the patients who died were critically examined in the presence of the whole team
▪ Meticulous documentation of treated and untreated cases.
/interventions
(national registries – STS/ACC TVT)
MULTI-DISCIPLINARY APPROACH TO MITRAL DISEASE
Nikolaos Kakouros, MBBS MRCP PhD MD(Res) FACC FSCAI Director, Structural Heart Disease programProgram Director, Interventional Cardiology SHD FellowshipCo-director, TAVR programAssistant Professor of MedicineUniversity of Massachusetts Medical School
CARDIOLOGIST