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Minneapolis Heart Institute Foundation® Cardiovascular Grand Rounds Title: The intersection of heart failure and structural cardiology
Speaker(s): Peter Eckman, MD, FACC, FHFSA Section Head, Advanced Heart Failure, Minneapolis Heart Institute® at Abbott Northwestern Hospital Paul Sorajja, MD Director, Center for Valve and Structural Heart Disease Minneapolis Heart Institute® at Abbott Northwestern Hospital
Date: December 17, 2018 Time: 7:00 – 8:00 AM
Location: ANW Education Building, Watson Room OBJECTIVES At the completion of this activity, the participants should be able to: 1. Describe the incidence of heart failure and valve disease. 2. Describe contemporary structural heart treatments that are pertinent for heart failure patients. 3. Identify patients that might be candidates for structural heart failure treatments.
ACCREDITATION Physician - Allina Health is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Allina Health designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Nurse - This activity has been designed to meet the Minnesota Board of Nursing continuing education requirements for 1.0 hours of credit. However, the nurse is responsible for determining whether this activity meets the requirements for acceptable continuing education. DISCLOSURE POLICY & STATEMENTS Allina Health, Learning & Development intends to provide balance, independence, objectivity and scientific rigor in all of its sponsored educational activities. All speakers and planning committee members participating in sponsored activities and their spouse/partner are required to disclose to the activity audience any real or apparent conflict(s) of interest related to the content of this conference. The ACCME defines a commercial interest as “any entity” producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. The ACCME does not consider providers of clinical service directly to patients to be commercial interests - unless the provider of clinical service is owned, or controlled by, an ACCME-defined commercial interest. Moderator(s)/Speaker(s) Dr. Peter Eckman has disclosed the following relationships: Honoraria (self): Abbott Vascular, Medtronic. Dr. Paul Sorajja has disclosed the following relationships: Abbott Vascular: research, consulting, speaking; Boston Scientific: research, consulting, speaking; Edwards Lifesciences: research, consulting speaking; Admedus: consulting; Medtronic: research, consulting, speaking.
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Planning Committee Dr. Alex Campbell, Jake Cohen, Jane Fox, Dr. Mario Gössl, Dr. Kevin Harris, Dr. Kasia Hryniewicz, Rebecca Lindberg, Amy McMeans, Dr. Michael Miedema, Dr. JoEllyn Moore, Pamela Morley, Dr. Scott Sharkey, and Jolene Bell Makowesky have disclosed that they DO NOT have any real or apparent conflicts with any commercial interest as it relates to the planning of this activity/course. Dr. David Hurrell has disclosed the following relationship –Boston Scientific: Chair, Clinical Events Committee.
NON-ENDORSEMENT OF COMMERCIAL PRODUCTS AND/OR SERVICES We would like to thank the following company for exhibiting at our activity.
Actelion Pharmaceutical Companies of Johnson & Johnson
Pfizer, Inc.
Accreditation of this educational activity by Allina Health does not imply endorsement by Allina Learning & Development of any commercial products displayed in conjunction with an activity. A reminder for Allina employees and staff, the Allina Policy on Ethical Relationship with Industry prohibits taking back to your place of work, any items received at this activity with branded and or product information from our exhibitors. PLEASE SAVE YOUR SERIES FLIER When you request a transcript this serves as your personal tracking of activities attended. Most professional healthcare licensing/certification boards will not accept a Learning Management System (LMS) transcript as proof of credit; there are too many LMS’s across the country and their validity/reliability are always in question. If audited by a licensing board or submitting for license renewal or certification renewal, boards will ask you not the entity providing the education for specific information on each activity you are using for credit. You will need to demonstrate that you attended the activity with a copy of your certificate/evidence of attendance, a brochure/flier and/or the conference handout. Each attendee at an activity is responsible for determining whether an activity meets their requirements for acceptable continuing education and should only claim those credits that he/she actually spent in the activity. Maintaining these details are the responsibility of the individual.
PLEASE SAVE A COPY OF THIS FLIER AS YOUR CERTIFICATE OF ATTENDANCE.
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Allina Health - Learning & Development - 2925 Chicago Ave - MR 10701 - Minneapolis MN 55407
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MHIF CV Grand Rounds – Dec. 17, 2018
Integrating Heart Failure and Structural Cardiology
Peter Eckman, MD, FACC, FHFSA
Section Head – Advanced Heart Failure
Minneapolis Heart Institute
Disclosure InformationPeter Eckman, MD
Disclosure InformationPeter Eckman, MD
I have the following financial relationships to disclose:
Consultant for: Abbott, Medtronic
Advisory Board: Abbott, Medtronic
I WILL be discussing off‐label and investigational use.
All $$$ donated to Minneapolis Heart Institute Foundation
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MHIF CV Grand Rounds – Dec. 17, 2018
77 year old man with exertional dyspnea
• Prior CAB, Parox AF (flutter ablation ‘13), HFpEF
• Sleeps a lot, can only walk 10‐20 feet (>1 mile 6 months ago)
• Aortic stenosis – moderate vs severe?
• PFTs reassuring, OSA on CPAP (religiously)
• BP 132/60, HR 51
• Meds: Amlodipine 5, HCTZ 25, Losartan 100, Metoprolol 50 bid, ASA/Warfarin/Rosuvastatin
• Labs: Na 140, BUN 28, Cr 1.2, Hgb 12.8
77 year old man with exertional dyspnea
• Echo: LVEF 45‐50%, grade 3 diastolic filling, elevated E/e;
• RV size normal, mild dysfunction• Ao AVA 0.82, mean gradient 12, peak 2.2 m/s, DI 0.21
• Angiography: patent grafts• AoV moderate stenosis• RHC:
– Baseline SBP 160 and PCWP 17– Arm exercise: SBP to 180 and PCWP to 27
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MHIF CV Grand Rounds – Dec. 17, 2018
HFpEF Management Framework
• Consider uncommon etiologies (constriction, restrictive disease, amyloid, etc)
• Phenotype (exercise‐induced, PH, volume overload)• Address pertinent comorbidities
– CAD– Atrial fibrillation– Sleep disordered breathing– Anemia– Deconditioning/obesity
• Congestion management, including CardioMEMS, consider spironolactone
• Role of nitrates (NEAT‐HFpEF found worse exercise)• Consider clinical trials
Adamson PB et al, Circ Heart Failure 2014.
CardioMEMS in HFrEF/HFpEF
HFpEF
Low EF
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MHIF CV Grand Rounds – Dec. 17, 2018
HFpEF
• Hallmark is effort intolerance
• Profound/brisk increase in LA pressure during exercise
• Lutembacher syndrome (1916)
– Combination of mitral stenosis and secundum ASD
– Originally described 1750 byJohann Friedrich Meckel, Sr.
Kaye D et al, J Card Fail 2014.
Actual
Simulated
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MHIF CV Grand Rounds – Dec. 17, 2018
Rest Exercise
Kaye D et al, J Card Fail 2014.
HF Cardiologist on Valves
• Very common in HF patients (LV/RV/BiV)
• Outcomes with surgery in low LVEF poor
• Not infrequent to see patient who had MVsurgery ~6‐12 months ago who now needs aVAD/Transplant
• Meds will often make it better– Decongest, vasodilate, treat HF
• Spend more time on:– BB, ACEI/ARB/ARNI, AA, ICD, CRT, etc
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MHIF CV Grand Rounds – Dec. 17, 2018
Medical Management of TR
• Preload
– Can be hard to optimize volume status – what isgoal? How to measure with pulsatile JVP?
• Afterload
– Pulmonary vasodilators expensive and off‐label
• Contractility
– Digoxin?
• Consider addressing anatomy/mechanical
Outcomes of Isolated TR
• 353 patients with isolated TR
• Age 70, 33% male, EF 63%, all with RVSP <50, noother valve disease >mild, no pacer/ICD wires
• Severe by ERO ≥ 40 mm2
• Difficult to study due to confounders, PH,left‐sided disease
• Independent or surrogate?
• Hard to assess, define severe TR
• Limited indications for isolated surgery, timing??
Topilsky Y et al JACC: Cardiovasc Imag 2014
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MHIF CV Grand Rounds – Dec. 17, 2018
Survival by EROA in TR
Topilsky Y et al JACC: Cardiovasc Imag 2014
No difference if AF/SRNo difference if symptoms/not
TR associated with increase mortality independent of RVP and RV failure
• Systematic review of 70 studies with 32,601 patients
• Mean follow‐up 3.2±2.1 years
• Mod/sev associated with mortality risk 1.95 [1.75‐2.17]
All Cause Mortality
Wang N et al Eur Heart J 2018.
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MHIF CV Grand Rounds – Dec. 17, 2018
Wang N et al Eur Heart J 2018.
TR in HFrEF – Long Term Outcomes• 3,943 patients
• All with LVEF <35%
• Age 69±14, 74% male
• Median follow‐up:– 8.1 years
• Excluded:– AS/AI > Moderate
– Mitral stenosis
– Valve replaced
Kazum SS et al Am J Med 2018.
Severity %Median
Survival (y)
Non‐signif 70% 4.9
Moderate 24% 2.3
Severe 6% 1.6
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MHIF CV Grand Rounds – Dec. 17, 2018
Timing of surgical referral for ITVR
• All ITVS in France 2013‐2014 (84 repair 157 replacements)
• 61±16 years old, 53% women, 10% CAD, 26% CHF, 20% endocarditis, 10% renal failure
• In‐hospital mortality 10%
• Major complications 19% (death, dialysis, MV with ECMO)
• Hospitalization 26±40 days
• Do transcatheter options change timing?
Dreyfus J et al Am J Cardiol 2018.
The 2 times to fix the tricuspid valve
Too early
Too late
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MHIF CV Grand Rounds – Dec. 17, 2018
Pagnesi M et al Int J Cardiol 2017.
Cardiac Death All‐cause mortality
Address TR with Left‐sided surgery?Meta‐analysis: 15 studies, 2840 patients
Outcome of MR
• 2000‐2010: 1,294 with mod/sev MR
• Median age 77, 42% with LVEF <50%
• Mean EROA (available in n=822) 0.25 cm2
• 51% CV death with RR 2.23 [2.06‐2.41]
• 64% with HF at 5 years
• Surgery in 15% (75% repairs) but only 5% of those with LVEF <50%
• Only ~25% with class I surgical indications had surgery
Dziadzko V et al Lancet 2018.
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MHIF CV Grand Rounds – Dec. 17, 2018
Survival after isolated mod/sev MR
LVEF <50%
LVEF ≥50%
Dziadzko V et al Lancet 2018.
All Patients
Management/Outcomes of mod/sevFMR with severe HFrEF
• Mod/Severe FMR and severe HFrEF(EF ≤30% or LVESD >55 mm)
• 1,441 patients, median follow‐up 4.7 years• Median age 64, 39% women• Therapy:
– Medical therapy 75%– PCI 8%– CAB 6%– CAB/MV 7%– MV surgery alone 4%– Repair 143/151
Samad Z et al Eur Heart J 2015
ACC/AHA Guidelines
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MHIF CV Grand Rounds – Dec. 17, 2018
Samad Z et al Eur Heart J 2015
Does medical therapy alter FMR?
• Extent of FMR at baseline and 50 months in 163 consecutive HFrEF patients– 31% with severe MR at baseline, 38% of those improved to nonsevere
– 18% nonsevere developed severe despite GDMT
• Sustained severe FMR or worsening FMR had OR 2.5 [CI 1.5‐4.3] for major AE’s
• LBBB and diabetes predictive of deterioration of MR
Nasser R et al JACC: HF 2017
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MHIF CV Grand Rounds – Dec. 17, 2018
Evolution of MR in HFrEF
• 249 patients with HFrEF
• 19% had progression of MR
• Progression predicted mortality
– Uni: HR 2.33 [1.34‐4.08], p=0.003
–Multi: HR 2.48 [1.40‐4.39], p=0 .002
• Regression of MR was NOT associated with benefit
Bartko PE et al Eur Heart J: Cardiovasc Imag 2018.
Valsartan/sacubitril and FMR
• 118 HF with FMR randomized to valsartan/sacubitril vs valsartan
• Primary endpoint at 12 months change in EROA
• EROA ‐0.058±0.095 vs ‐0.018±0.105 cm2
p=0.032
• Regurg Vol: ‐7.3 [‐12.6 to ‐1.9]p=0.009
Kang DH et al Circulation 2018
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MHIF CV Grand Rounds – Dec. 17, 2018
• ATTEND registry – 4842 patients with ADHF
• Association of FMR and all‐cause mortality and HF readmission, stratified by HFpEF/HFrEF
Kajimoto K et al Eur J Heart Fail 2016
HFpEF Low EF
Remodeling after MitraClip
Attizzani GF et al JACC: Cardiovasc Int 2015.
LVEF LVEDV
LA Vol LVESV
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MHIF CV Grand Rounds – Dec. 17, 2018
One year remodeling (FMR and HFrEF)
• 41 patients• Rx w/ MitraClip• Median age: 77• LVEF 33±3%• CI 2.0±0.2• LVESD 50±2• Mean PA 37±3.1
Pleger SV et al Eur J HF 2013.
LVEF ≤ 30%
LVEFLA Vol LVESD
Do transcatheter therapies impact neurohormones?
• 21 patients with mR undergoing MitrClip
• Noradrenaline level – no change
• Sympathetic nerve activity – MSNA burst frequency from 130±78/min to 74±21/min
Öztürk C et al, JACC Cardiovasc Interv 2016.
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MHIF CV Grand Rounds – Dec. 17, 2018
What about bivalvular FR?• 1021 consecutive HFrEF patients
– Median 62y, 80% male– 41% NYHA III and 17% NYHA IV– 34% CRT
• 32% had moderate/severe BVFR– 45% FMR, 35% FTR (in general)
• Severe BVFR with more symptoms, adverse remodeling, and NH activation
• Severe BVFR associated with excess mortality, independent of clinical and echo parameters, GDMT, and NH activation
• BVFR conveys deleterious impact of global regurgitation load on failing heart
Bartko PE et al, Eur Heart J 2018.
Bartko PE et al, Eur Heart J 2018.
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MHIF CV Grand Rounds – Dec. 17, 2018
Bartko PE et al, Eur Heart J 2018.
Thank [email protected]
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MHIF CV Grand Rounds – Dec. 17, 2018
The Intersection of Heart Failure and
Structural Heart Disease
The Intersection of Heart Failure and
Structural Heart Disease
Paul Sorajja, MDRoger L. and Lynn C. Headrick Family ChairValve Science Center Minneapolis Heart Institute Foundation Abbott Northwestern Hospital
Paul Sorajja, MDRoger L. and Lynn C. Headrick Family ChairValve Science Center Minneapolis Heart Institute Foundation Abbott Northwestern Hospital
MHIF Grand RoundsMHIF Grand Rounds
DisclosuresDisclosures
• Consulting or Advisory Board: Abbott Structural,
Admedus, Boston Scientific, Edwards Lifesciences,
Medtronic, Gore
• Research: Abbott Structural, Boston Scientific,
Edwards Lifesciences, Medtronic
• Speaking: Abbott Structural, Boston Scientific, Edwards
Lifesciences, Medtronic
• National P.I.: Tendyne in MAC, Alt-FLOW, TRILUMINATE
II Pivotal
• Consulting or Advisory Board: Abbott Structural,
Admedus, Boston Scientific, Edwards Lifesciences,
Medtronic, Gore
• Research: Abbott Structural, Boston Scientific,
Edwards Lifesciences, Medtronic
• Speaking: Abbott Structural, Boston Scientific, Edwards
Lifesciences, Medtronic
• National P.I.: Tendyne in MAC, Alt-FLOW, TRILUMINATE
II Pivotal
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MHIF CV Grand Rounds – Dec. 17, 2018
Key PointsKey Points
• SHD therapy improves symptoms and saves
lives even in late HF stages
• SHD therapy improves symptoms and saves
lives even in late HF stages
• Heart failure and SHD beget each other• Heart failure and SHD beget each other
• MHI and MHIF is leading the way for innovative
trials in these patients, and we need your help!
• MHI and MHIF is leading the way for innovative
trials in these patients, and we need your help!
Heart Failure and Structural Heart DiseaseHeart Failure and Structural Heart Disease
Heart FailureHeart Failure
Valvular Heart Disease
Valvular Heart Disease
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MHIF CV Grand Rounds – Dec. 17, 2018
Structural Heart Disease
Structural Heart Disease
Heart FailureHeart
Failure
A Different ParadigmA Different Paradigm
Aortic Stenosis PathophysiologyAortic Stenosis PathophysiologyA One-way HighwayA One-way Highway
Pressure hypertrophy
Pressure hypertrophy
AVR, curative?
AVR, curative?
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MHIF CV Grand Rounds – Dec. 17, 2018
Aortic Stenosis and Heart FailureAortic Stenosis and Heart FailureAny Myocardial Disease is AdverseAny Myocardial Disease is Adverse
Baron SJ et al. J Am Coll Cardiol 2016;67:2349-68Baron SJ et al. J Am Coll Cardiol 2016;67:2349-68
11,292 TAVR
patients in TVT
11,292 TAVR
patients in TVT
Aortic Stenosis and Heart FailureAortic Stenosis and Heart Failure
Van Gils et al., J Am Coll Cardiol 2017;69:2383-92Dweck et al., J Am Coll Cardiol 2011Van Gils et al., J Am Coll Cardiol 2017;69:2383-92Dweck et al., J Am Coll Cardiol 2011
4 year death = 36%4 year death = 36%
TAVR Unload StudyTAVR Unload Study
600 patients Moderate ASLVEF <50%
TAVR vs. GDMT
600 patients Moderate ASLVEF <50%
TAVR vs. GDMT
LVEF <50% and Moderate ASLVEF <50% and Moderate AS
Poor SurvivalPoor Survival
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MHIF CV Grand Rounds – Dec. 17, 2018
Aortic Stenosis and Heart FailureAortic Stenosis and Heart FailureMore Than Just EFMore Than Just EF
Cavalcante JL, JACC Cardio Intv 2016;9:399-405Cavalcante JL, JACC Cardio Intv 2016;9:399-405
Aortic StenosisAortic Stenosis
Replacement FibrosisReplacement Fibrosis AmyloidosisAmyloidosisInterstitial FibrosisInterstitial Fibrosis
PerfusionPerfusionVentricular FunctionVentricular Function
Classical Dogma of PathophysiologyClassical Dogma of Pathophysiology
Mitral RegurgitationMitral Regurgitation
“EF drops and patients can do worse.”“EF drops and patients can do worse.”
PreloadPreload AfterloadAfterload
Str
oke
Vo
lum
eS
tro
ke V
olu
me
MVRMVR MVRMVR
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MHIF CV Grand Rounds – Dec. 17, 2018
Modern Experiences with TMVRModern Experiences with TMVRSevere LV dysfunction, no MRSevere LV dysfunction, no MR
EF = 30%EF = 30% EF = 20%EF = 20%
Transcatheter MVRTranscatheter MVR
Sorajja P, et al. J Am Coll Cardiol [In press]Sorajja P, et al. J Am Coll Cardiol [In press]
17.2% 22.7% 27.1%34.6%34.0%
60.9%62.7% 60.0%
51.9%61.9%
18.4%13.3% 12.9% 11.5%
4.1% 3.4% 1.3% 1.9%
0%
20%
40%
60%
80%
100%
Baseline 1 mo 3 mo 6 mo 12 mo
Class I Class II Class III Class IV
N=97 N=87 N=75 N=70 N=52
First 100 Tendyne PatientsFirst 100 Tendyne Patients
No procedural deaths
30-day O/E = 0.76
87% NYHA I/II at 1-yr
KCCQ = +22 pts
No procedural deaths
30-day O/E = 0.76
87% NYHA I/II at 1-yr
KCCQ = +22 pts
Now in SUMMIT, U.S. pivotal trial
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MHIF CV Grand Rounds – Dec. 17, 2018
Sorajja P et al. JACC Intv 2017
Severe Mitral Annular CalcificationSevere Mitral Annular CalcificationTendyne Early Feasibility StudyTendyne Early Feasibility Study
Nat’l Principal Investigators: Paul Sorajja, MD, Vinod Thourani, MDNat’l Principal Investigators: Paul Sorajja, MD, Vinod Thourani, MD
Enrolling Now!Enrolling Now!
79 year-old man on GDMT79 year-old man on GDMTSevere secondary MR, EF = 30%Severe secondary MR, EF = 30%
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MHIF CV Grand Rounds – Dec. 17, 2018
Left atrial
pressure
Left atrial
pressure
Stone GW, et al. N Engl J Med 2018Stone GW, et al. N Engl J Med 2018
NNT = 3NNT = 3 NNT = 6NNT = 6
One of the lowest NNTs to save a life, everOne of the lowest NNTs to save a life, ever
MitraClip vs. GDMT for Secondary MRMitraClip vs. GDMT for Secondary MR
Cardiovascular Outcomes Assessment of
MitraClip Percutaneous Therapy (COAPT)
Cardiovascular Outcomes Assessment of
MitraClip Percutaneous Therapy (COAPT)
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MHIF CV Grand Rounds – Dec. 17, 2018
The COAPT TrialThe COAPT TrialMR and HF beget each otherMR and HF beget each other
180
185
190
195
200
205
210
215
Baseline 12 months
GDMT
MitraClipL
VE
DV
(m
l)L
VE
DV
(m
l)
194 ±76194 ±76
196±69196±69
211±94211±94
192±77192±77
P<0.001P<0.001
8 cm8 cm 6.5 cm6.5 cm
35 year-old Woman, NYHA III35 year-old Woman, NYHA III
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MHIF CV Grand Rounds – Dec. 17, 2018
Percutaneous Ventricular TherapyPercutaneous Ventricular Therapy
AccuCinchAccuCinch
“Thank you for saving my life..”
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MHIF CV Grand Rounds – Dec. 17, 2018
ACCUCINCH Trials at MHIFACCUCINCH Trials at MHIF
Percutaneous Ventricular TherapyPercutaneous Ventricular Therapy
AccuCinch EFS• LV dysfunction with moderate or severe MR
CorCinch – HFrEF• NYHA III with LVEDD >55 mm, EF 20 to 40%
CorCinch - PMVI• Secondary MR with prior failed surgery or MC
AccuCinch EFS• LV dysfunction with moderate or severe MR
CorCinch – HFrEF• NYHA III with LVEDD >55 mm, EF 20 to 40%
CorCinch - PMVI• Secondary MR with prior failed surgery or MC
82 year-old Woman with TR82 year-old Woman with TR
10-year survival, 14%10-year survival, 14%
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MHIF CV Grand Rounds – Dec. 17, 2018
A Natural History Construct for TRA Natural History Construct for TR
ModerateModerateSevereSevere
Su
rviv
al a
nd
Sx
Su
rviv
al a
nd
Sx
YearsYears
Very steep both ways
Very steep both ways
Years of indolenceYears of indolence
RV failure, a late phenomenon
RV failure, a late phenomenon
MassiveMassive
TorrentialTorrential
Impairment already
Impairment already
Proprietary and confidential — do not distribute
TRILUMINATE EFS KCCQ at 30 days (n=60)
TRILUMINATE EFS KCCQ at 30 days (n=60)
23
55.7 54.7 56.175.1 64.7 73.6
20
30
40
50
60
70
80
90
100
3 (Severe) 4 (Massive) 5 (Torrential)Baseline TR Severity
Baseline 30 Day
50% with still severe TR
BUTKCCQ still 15 points better
50% with still severe TR
BUTKCCQ still 15 points better
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MHIF CV Grand Rounds – Dec. 17, 2018
TRILUMINATE II U.S. Pivotal Study for TR
TRILUMINATE II U.S. Pivotal Study for TR
National Principal InvestigatorsPaul Sorajja, MD and David Adams, MD
Tri-Clip vs. Medical TherapyLaunch Q2 2019
National Principal InvestigatorsPaul Sorajja, MD and David Adams, MD
Tri-Clip vs. Medical TherapyLaunch Q2 2019
Unexplained Dyspnea EvaluationUnexplained Dyspnea Evaluation
PCWP = 39PCWP = 39
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MHIF CV Grand Rounds – Dec. 17, 2018
Atrial Shunting for Heart FailureAtrial Shunting for Heart Failure
CorviaCorvia V WaveV Wave
8 mm diameter8 mm diameter 5 mm valve5 mm valve
Both ↓ exercise PCWPBoth ↓ exercise PCWP
Atrial Shunting for Heart FailureAtrial Shunting for Heart Failure
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MHIF CV Grand Rounds – Dec. 17, 2018
Alt-FLOW Early Feasibility StudyAlt-FLOW Early Feasibility Study
• Ambulatory HFpFEF or HFrEF
• PCWP >15 at rest or >25 at exer.
• Stable GDMT >4 weeks
• No significant valve disease
• Ambulatory HFpFEF or HFrEF
• PCWP >15 at rest or >25 at exer.
• Stable GDMT >4 weeks
• No significant valve disease
Multicenter Study of ROOT DeviceNational Principal Investigator: Paul Sorajja, MD
Multicenter Study of ROOT DeviceNational Principal Investigator: Paul Sorajja, MD
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MHIF CV Grand Rounds – Dec. 17, 2018
Key PointsKey Points
• SHD therapy improves symptoms and saves
lives even in late HF stages
• SHD therapy improves symptoms and saves
lives even in late HF stages
• Heart failure and SHD beget each other• Heart failure and SHD beget each other
• MHI and MHIF is leading the way for innovative
trials in these patients, and we need your help!
• MHI and MHIF is leading the way for innovative
trials in these patients, and we need your help!
Heart Failure and Structural Heart DiseaseHeart Failure and Structural Heart Disease
Thank you!
Tel: 507-513-1357
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MHIF CV Grand Rounds – Dec. 17, 2018
MitraClip Trials for Secondary MRMitraClip Trials for Secondary MR
73739595
7070
3131 3333
7272
31314141
135135101101
Age (yr)Age (yr)
EF (%)EF (%)
LVEDVI (ml/m2)LVEDVI (ml/m2)
ERO (cm2)ERO (cm2)
Implanted (%)Implanted (%)
Stone GW, et al. N Engl J Med 2018; Obadia JF et al. N Engl J Med 2018Stone GW, et al. N Engl J Med 2018; Obadia JF et al. N Engl J Med 2018
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Aortic Stenosis and Heart FailureAortic Stenosis and Heart FailureParadoxical LFLGSASParadoxical LFLGSAS
Better with AVR, but remain at risk
Better with AVR, but remain at risk
“Normal” EFLVH, small LV
Low SVHTN
“Normal” EFLVH, small LV
Low SVHTN
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