should functional mr be fixed in heart failure
TRANSCRIPT
Should Functional MR be
Fixed in Heart Failure?
Steven F. Bolling, M.D.
Professor of Cardiac Surgery
University of Michigan
Functional (2o) MR : Ventricular Problem!
Badhwar, Bolling , chapter in: Advances in Heart Failure, 2004
Traditional view of FMR and CHF
©2011 by BMJ Publishing Group Ltd and British Cardiovascular
Society
MR grade No.
None 9,405
Mild 2,062
Moderate 210
Severe 171
0.0
0.2
0.4
0.6
0.8
1.0
0 1 2 3 4 5
su
rviv
al
Years
Even with GDMT…
FMR survival is not optimal!
Hickey et al: Circulation 78:1-51, 1988
Even with small FMR volumes…
Survival is terrible !
Grigioni et al: Circulation 103:1759, 2001
ERO RVol
FMR…Not just a “late marker” !
It’s also a CAUSE ! FMR – worsens odds of death
Rossi A et al. Heart 2011;97:1675-1680
r
Did not get rid of FMR ! 33 % Recurrent MR : 2004
McGee, Gillinov et al, JTCVS, 2004;128:916-24
Progression of 3 or 4+ MR post-undersized annuloplasty (585)
McGee EC et al. JTCVS 2004;128:916-24 Mihaljevic et al. J Am Coll Cardiol 2007;49:2191-201 Crabtree TD et al. Ann Thorac 2008;85:1537-43 Surg
Residual / recurrent FMR
if we do repair badly
FMR patients do badly !
Freedom from recurrent MR≥3+
...Because the ventricles do badly !
It’s a ventricular problem!
Lots of recurrent FMR = No reverse remodeling
Large,flexible and/or partial bands
not a durable solution for FMR !
Magne et al. Cardiology 2009;112:244-259
Bothe W, Swanson J, et al., JTCVS 2010
IMR-FMR rings
SMALL, RIGID and COMPLETE Disproportionate AP dimension reduction
Circulation. 2012;125:2639-2648
MORTALITY BENEFIT: CAB/MV repair vs CAB alone with LV dysfunction and moderate - severe MR
STICH TRIAL - iFMR
Mitral Valve Annuloplasty in Addition to Coronary Artery Bypass Grafting in Moderate Functional
Ischemic Mitral Regurgitation Reverses Left Ventricular Remodelling and Restores Left
Ventricular Geometry: Chan et al , CIRC March 2012
British NHS 2012 : RIME
CABG + MVr for Moderate iFMR Mitral regurg volume - 69% vs 14%
LV end systolic volumes - 24% vs 10%
LV sphericity - 18% vs + 1.7 %
Peak oxygen capacity + 3.0 vs 1.0
Brain natriuretic peptide - 76% vs 59%
All p < 0.01 !
Patients Screened for Moderate Ischemic MR
(n=6,676)
Randomized Patients
(n=301)
Primary Endpoint Analysis
(n=301)
CABG + Valve Repair
Undersized Ring
(n=150)
CABG Alone
(n=151)
Outcomes Measured at 6, 12 and 24 months
CTSN Moderate iMR Trial Design
(excluded
6,375
or 95.5%)
30 Day Mortality:
2.7% (CABG) vs. 1.3% (CABG/MVr),
p =0.68
12 Month Mortality:
7.3% (CABG) vs. 6.7% (CABG/MVr),
p =0.83
Mortality - no “added” price for MVr
0
10
20
30
40
50
60
70
80
Rat
e p
er
10
0 p
t-yr
s
CABG Alone CABG + MV Repair
P=NS P=0.03
P=NS
P=NS
P=0.03
Overall SAE Rate (100-pt years) 117.0 (CABG Alone) vs. 137.1 (CABG + Repair)
p=0.15
P=NS
SAEs and Re-hospitalization
Survival benefit - MVR in CHF (Wu)
Before (blue) 29 / After (green) 2000 26
0 500 1000 1500 2000 2500
time1
0.0
0.2
0.4
0.6
0.8
1.0
Cu
m S
urv
ival
Set2
Prior to 2000
2000 - 2002
0-censored
1-censored
Medical Group
Survival Functions
0 500 1000 1500 2000 2500
time1
0.0
0.2
0.4
0.6
0.8
1.0
Cu
m S
urv
iva
l
Set2
Prior to 2000
2000 -2002
0-censored
1-censored
MVA Group
Survival Functions
medical vs surgical tx
SMALLER, COMPLETE RIGID RINGS
Al Radi et al, Ann Thorac Surg, 2005;79:1260-7
Valve sparing replacement vs repair
Survival for 4+ severe ischemic FMR
Severe Ischemic Mitral Regurgitation
NEJM 2014, 251 CABG + MV repair vs MV replacement
(3458….447….251 ….7 % )
LVESI (Size/remodeling) same Mortality same CV events same Functional status same
Severe Ischemic Mitral Regurgitation
Different! 32% MV repairs - recurrent MR Sham placebo MVr! Did not get rid of FMR !
NHLBI Trial : Severe iFMR
Mean ring size : 28.4 + 1.9 Did not “downsize”, ~25% > 32!
Not a single “24” used ! Native size never < 28 ?!
Mandatory coaptation length
Severe Ischemic Mitral Regurgitation
Mitral repair operative mortality 1.6%
vs “total valve sparing” MVR 4.2%
Severe Ischemic Mitral Regurgitation
Functional status
MV repair includes 32 % - had “sham nothing” !
Remodeling - LVESI
Kron et al JTCVS 2015 “Good” repair – 46 mm
Replacement – 61 mm
“Bad” repair – 63 mm (40% - basal inferior “aneurysm” )
Mild annular dilatation
Coaptation depth >1 cm
Posterior leaflet angle >45°
post/basal dyskinesia ! Distal anterior leaflet angle >25°
Advanced LV remodelling – LVEDD > 65 mm
– Systolic sphericity index > 0.7
– End systolic interpapillary muscle
distance >20 mm
– LVESV ≥ 145 ml (or ≥ 100 ml/m2)
Predictors of “Bad FMR Repair”
Lancellotti et al. Eur J Echo 2010 EAE recommendations for the
assessment of valvular regurgitation
Michael A. Acker , Mariell Jessup , Steven F. Bolling , Jae Oh , Randall C. Starling ,
Douglas L. Mann , Hani N. Sabbah
Mitral valve repair in heart failure: Five-year follow-up from
the mitral valve replacement stratum of the Acorn
randomized trial
The Journal of Thoracic and Cardiovascular Surgery Volume 142, Issue 3 2011 569 - 574.e1
70% survival @ 5 yrs
Catheter-Based Mitral Repair – MitralClip
Clip Leaves FMR !
160
143
8275
0
40
80
120
160
Vo
lum
e (
ml)
CRT : Less than half eligible, less than half “respond”
Improvers: reduction in ≥ 1 grade of MR
van Bommel R J et al. Circulation 2011;124:912-919
Copyright © American Heart Association
Residual FMR is still BAD, but.. !!
FMR 2015
GDMT, CRT, Surgery, Clip
Careful patient selection
ischemic vs. dilated FMR ? Beware the big LV, the bad RV
Fix AF and TR !
Repair - small complete
rigid ring Replacement - selective,
chord-sparing