american heart association chicago 18 11-2014
TRANSCRIPT
Carlo Fino MDCarlo Fino MDCardiovascular Department
Azienda Ospedaliera Papa Giovanni XXIIIBergamo, Italy
Mechanical versus Biological Prostheses for Chronic Ischaemic Mitral Regurgitation: A Long-Term Hemodynamic and Functional Capacity
Comparison
Background
• Chronic ischemic mitral regurgitation is a common complication in patients with coronary artery disease
• The outcome is poor
• The treatment is still debated
Lamas et al Circulation 1997 Magne et a Circulation 2009Lorusso et al JTCVS 2013
COR: Class of Recommendation LOE: level of Evidence
Summary of Recommendations for Chronic Severe Ischemic MR
AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease, JACC 2014
…Replacement provided a more durable correction of mitral regurgitation, but there was no significant between-group difference in clinical outcomes…
Acker M.A et al
Complete chordal-sparing mitral valve replacement
Pibarot P et al, Heart 2006
•6-MWT is a practical, simple, inexpensive test, which does not require any exercise equipment.
•It has been proposed both as a functional status indicator and as an outcome measure in various categories of patients (i.e postcardiac surgery)
•Coupled with exercise stress echocardiography, is able to accurately assess global cardiovascular function, specifically in patients with LV dysfunction
Demers et al, Am Heart J 2001 Picano et al, Heart 2013 Rostagno et al, Intern Emerg Med 2008
Cardiovascular Assessment
Aim of the Study
Long-term global cardiovascular performance
assessed by ESE and 6-MWT, in patients with
ischaemic mitral regurgitation referred to valve
replacement with Bio prostheses, compared to
replacement with Mech prostheses.
.
Preoperative Data
M: mechanical prostheses; B: biological prostheses; BSA: body surface area; VC: vena contracta; 6-MWT: six-minute walking test
Operative Data
M: mechanical prostheses, B: biological prostheses; CPB: cardio pulmonary by-pass; ACC: aortic cross clamp; CABG: coronary artery by-pass grafting; IABP: intraortic ballon pump
*P values refer to differences among Mech and Bio groups
Resting and Exercise Follow-up Echocardiographic data 32±13 months
M: mechanical prostheses, B: biological prostheses; CO: cardiac output; CI: cardiac index; MPG: mitral peak gradient; MMG: mitral mean gradient; SPAP: systolic pulmonary arterial pressure
*p<0.05 (Rest vs. Exercise); † p<0.05 (M vs. B)
Change in 6-MWD
MechBioBio Mech
Absolute difference (mt)
Relative change (%)
P<0.0001P<0.0001
32±13 months
20 30 40 50 60 70 80-250
-200
-150
-100
-50
0
50
100
150
200
250P
ost
-op
ch
an
ges
in 6
MW
T d
ista
nc
e
r=-0.70p<0.0001
Biological Mechanical
Exercise SPAP, mmHg
Postoperative change 6-MWT distance
Independent Determinants of 6-MWD
IEOA: indexed effective orifice area; SPAP:systolic pulmonary arterial pressure; 6-MWD: six-minute walking distance
Limitations
Retrospective study
The prosthesis choice for individual patients may have been subjected to selection bias
Limited informations regarding preoperative myocardial viability in the two groups
No comparison group with newer ring and subvalvular procedures
CONCLUSIONS
Our findings suggest that use of mechanical prosthesis in patients with severe ischemic MR is not inferior to bioprostheses.
In the long term, patients with mechanical prostheses seem to show a better cardiovascular performance compared to patients with biological prostheses
These observations warrant future bigger confirmatory studies with a longer follow-up
There’s plenty of room at the bottom Richard Feynman
1918-1988
Thank you very much