echocardiographic evaluation of the mitral valve. a guide ... · primary mr (effective regurgitant...

Echocardiographic evaluation of the mitral valve.A guide to decision making for

Transcatheter or Surgical Repair / Replacement

M. Chrissoheris

Echo in Mitral RegurgitationShould answer ALL the following:

• Mechanism – Degenerative, Functional, Mixed

• Severity – Moderate to severe, or severe

• Morphology – Clefts, indentations, calcium, thickening?

• Leaflet length

• Mitral valve area (by 2D or preferably 3D planimetry)

• Peak/mean mitral valve gradients

• Left ventricular size and systolic function

• Interatrial septum

• Systolic pulmonary artery pressure

• RV – Size and function

MR: Degenerative / Organic / Primary

Anatomic defect in one or more structures comprising the mitral valve apparatus e.g. prolapse or flail leaflets, endocarditis, rheumatic

MR Functional / Secondary

• MR is associated with severe LV dysfunction – Due to coronary artery disease (ischemic chronic secondary MR) – Idiopathic myocardial disease (nonischemic chronic secondary MR).

• Papillary muscle displacement, leaflet tethering, annular dilation that prevents adequate leaflet coaptation.

MR Functional due to Atrial Dilation

Mitral Regurgitation: Mechanisms

Examples of DMR cases:Large Anterior Flail (A2)

Examples of DMR casesLarge Anterior Flail (A2)

Wide P2 flail

Example of DMR casesPosterior P2 flail

DMR with P3 flail

Examples of FMR cases: Dilated cardiomyopathy

Example of Ischemic FMR

Example of Ischemic FMR (2)

Functional MR due to annular dilatatationDeep indentation between P1-P2

Severely calcified mitral annulus

European Heart Journal (2017) 38, 2739–2791

Zoghbi et al, J Amer Soc Echocardiography 2017;30(4)

Evaluation of Mitral Regurgitation Severity

Change in severe fMR criteria in US guidelines

…the recommended definition of severe secondary MR is now the same as for

primary MR (effective regurgitant orifice ≥0.4 cm22 and regurgitant volume ≥60

mL), with the understanding that effective regurgitant orifice cutoff of >0.2

cm2 is more sensitive and >0.4cm2 is more specific for severe MR.

Circulation. 2017;DOI: 10.1161/CIR.0000000000000503

PISA Method of MR evaluation: Assumes hemispherical PISA, and holosystolic MR

European Heart Journal – Cardiovascular Imaging (2013) 14, 611–644

3D Quantification of Vena Contracta Area

Zoghbi et al, J Amer Soc Echocardiography 2017;30(4)

Mid-late systolic MR compared with holosystolic MR of similar ERO yields smaller volume overload and a more benign outcome with smaller regurgitant volume, less enlargement of LV and LA, fewer hemodynamic consequences, and fewer cardiac events.

Circulation. 2012;125:1643-1651

Circulation. 2017;135:e1159–e1195

Management of Mitral Regurgitation ACC/AHA 2017 update

Pathophysiology and Natural History of Primary MR

• The cutoff criteria of EF<60% and

LVESD>40mm indicate that patient

has reached stage of LV

dysfunction

• Operation should be performed

ideally prior to this stage

J Am Coll Cardiol Img 2018;11:628–43

Global Longitudinal Strain (GLS)For the detection of subclinical LV dysfunction

HYGEIA Hospital Heart Team

Surgical Mitral Valve Repair in Degenerative MR

Surgical expertise and

anatomical complexity

determine probability of

successful repair

J Am Coll Cardiol Img 2018;11:628–43

Probability of Successful Mitral Valve Repair(Based on Echo findings)

European Heart Journal – Cardiovascular Imaging (2013) 14, 611–644

Surgical Mitral Valve Repair / Replacement(for degenerative MR)

J Am Coll Cardiol Img 2018;11:628–43

HYGEIA Hospital Heart Team

Surgeon’s View

HYGEIA Hospital Heart Team

Mitral Valve Quantification:Example of DMR

HYGEIA Hospital Heart Team

HYGEIA Hospital Heart Team

Mitral Valve Quantification:Example of DMR (2)

• Combination of a small LV (LVEDD<45mm), tall posterior leaflet (≥15mm), narrow aorto-mitral angle (<120◦), coaptation to septum distance <25mm and basal septal hypertrophy (≥15mm)

Predicting SAM with 2D TEE

Degenerative MR with P2 Prolapse

MV repair (initial): P2 resection (quadrangular) and annuloplasty with CE Physio II 28mm ring

Systolic Anterior Motion

Systolic anterior motion of the anterior mitral leaflet with LV outflow interference and significant dynamic mitral regurgitation

Redo MV Repair and Final Result

Sliding plasty of the posterior leaflet (to reduce height) and upsizing of annuloplasty ring to a CE Physio II 30 →Resolution of SAM and a satisfactory result

Degenerative / Primary Mitral Regurgitation:

Guidelines for MitraClip

Transcatheter mitral valve repair maybe considered for severelysymptomatic patients (NYHA class III toIV) with chronic severe primary MR(stage D) who have favorable anatomyfor the repair procedure and areasonable life expectancy but whohave a prohibitive surgical risk becauseof severe comorbidities and remainseverely symptomatic despite optimalGDMT for HF (Level of Evidence: B)

Examples of Transcatheter Mitral Valve Repair Techniques

Clin Res Cardiol (2014) 103:85–96

Clin Res Cardiol (2014) 103:85–96

Optimal Anatomy for MitraClip

HYGEIA Hospital Heart Team

Clin Res Cardiol (2014) 103:85–96

Conditionally Suitable Anatomy for MitraClip

Clin Res Cardiol (2014) 103:85–96

Conditionally Suitable Anatomy for MitraClip

Clin Res Cardiol (2014) 103:85–96

Conditionally Suitable Anatomy for MitraClip

Clin Res Cardiol (2014) 103:85–96

Conditionally Suitable Anatomy for MitraClip

Clin Res Cardiol (2014) 103:85–96

Conditionally Suitable Anatomy for MitraClip

Clin Res Cardiol (2014) 103:85–96

Conditionally Suitable Anatomy for MitraClip

Clin Res Cardiol (2014) 103:85–96

Conditionally Suitable Anatomy for MitraClip

PASCAL in a patient with flail P2

Flail P2 Scallop → Severe Eccentric MR

Final result with one PASCAL at the A2-P2 flail

Transcatheter Mitral Valve in Valve

Transcatheter Mitral Valve Replacement for Severe Degenerative MRMedtronic Twelve

Surgical MV repair in Functional MR(Echo characteristics of limited success)

European Heart Journal – Cardiovascular Imaging (2013) 14, 611–644

Functional MR: Markers of Global LV remodelling

Functional MR: Markers of regional LV remodelling

Functional MR: Markers of Mitral Valve Deformation

3D Mitral Valve QuantificationDetailed mapping of valve

J Thorac Dis 2017;9(Suppl 7):S640-S660

Mitral Valve Quantification Example of FMR

HYGEIA Hospital Heart Team

• N=251 patients with severe ischemic MR (ERO ≥40mm2) randomized to repair (restrictive annuloplasty) vs. replacement

• No significant difference in LV reverse remodeling or survival @ 2 yrs

• Significant recurrence of MR in patients treated with repair • Moderate or severe MR in 58.9% at 2 years

post procedure

• Associated with increased cardiovascular hospitalizations

Surgical Repair of Ischemic MR

• Associated with high relapse rates• Mismatch between LV-end systolic diameter

and annuloplasty ring size • Predicts persistent (and / or exacerbated)

leaflet tethering post repair with poor outcome

• Replacement preferable to repair

Circulation. 2016;134:1247–1256

• N=301 patients with moderate ischemic MR (ERO 20-39mm2), all undergoing CABG for multivessel CAD

• Comparison MV repair vs. no treatment • At 2 years significant improvement in LV function,

LVESVi, EF, global and regional wall motion in both groups

• MR ≥3+ in 32.3% CABG only, and 11.2% in repair group

• MR improved just with CABG in 68% of patients• More strokes and s/ventricular arrhythmias in the

repair group

Baseline Characteristics (ii)

HF parametersMitraClip +

GDMT (N=302)

GDMT alone

(N=312)Echo core lab

MitraClip +

GDMT (N=302)

GDMT alone

(N=312)

Etiology of HF MR severity

- Ischemic 60.9% 60.6% - Mod-to-sev (3+) 49.0% 55.3%

- Non-ischemic 39.1% 39.4% - Severe (4+) 51.0% 44.7%

NYHA class EROA, cm2 0.41 ± 0.15 0.40 ± 0.15

- I 0.3% 0% LVESD, cm 5.3 ± 0.9 5.3 ± 0.9

- II 42.7% 35.4% LVEDD, cm 6.2 ± 0.7 6.2 ± 0.8

- III 51.0% 54.0% LVESV, mL 135.5 ± 56.1 134.3 ± 60.3

- IV 6.0% 10.6% LVEDV, mL 194.4 ± 69.2 191.0 ± 72.9

HF hosp w/i 1 year 58.3% 56.1% LVEF, % 31.3 ± 9.1 31.3 ± 9.6

Prior CRT 38.1% 34.9% - 40% 82.2% 82.0%

Prior defibrillator 30.1% 32.4% RVSP, mmHg 44.0 ± 13.4 44.6 ± 14.0

Primary Effectiveness EndpointAll Hospitalizations for HF within 24 months

HR (95% CI] =

0.53 [0.40-0.70]

P<0.001

0 3 21 24

50

100

150

200

250

300

0

MitraClip + GDMT

GDMT alone

160in 92 pts

283in 151 pts

Cum

ula

tive

HF

Hospitaliz

ations

(n)

6 9 12 15 18

Time After Randomization (Months)

MitraClip 302 286 269 253 236 191 178 161 124

GDMT 312 294 271 245 219 176 145 121 88

No. at Risk:

Median [25%, 75%] FU

= 19.1 [11.9, 24.0]mos

MR Severity (Core Lab)MR grade ≤1+ 2+ 3+ 4+ Ptrend ≤2+ P-value

Baseline

MitraClip (n=302) - - 49.0% 51.0%-

--

GDMT (n=311) - - 55.3% 44.7% -

30 days

MitraClip (n=273) 72.9% 19.8% 5.9% 1.5%<0.001

92.7%<0.001

GDMT (n=257) 8.2% 26.1% 37.4% 28.4% 34.2%

6 months

MitraClip (n=240) 66.7% 27.1% 4.6% 1.7%<0.001

93.8%<0.001

GDMT (n=218) 9.2% 28.9% 42.2% 19.7% 38.1%

12 months

MitraClip (n=210) 69.1% 25.7% 4.3% 1.0%<0.001

94.8%<0.001

GDMT (n=175) 11.4% 35.4% 34.3% 18.9% 46.9%

24 months

MitraClip (n=114) 77.2% 21.9% 0% 0.9%<0.001

99.1%<0.001

GDMT (n=76) 15.8% 27.6% 40.8% 15.8% 43.4%

Functional MR: Different definitions of severity between MitraFr and COAPT trials

RESHAPE-HF2N patients, sites 420 patients at up to 40 sites

Control arm GDMT ± CRT

FMR grade EROA ≥20mm2, RVOL ≥30ml, RF≥45% by Corelab

NYHA class II, III or IV-ambulatory

Other inclusion criteria One documented heart failure hospitalization w/in past 12 months OR value of BNP ≥300pg/ml within 90 days (while on optimal therapy)

LVEF 15-45%

Primary efficacy endpoint Composite of recurrent heart failure hospitalizations and cardiovascular death

Primary safety endpoint Composite all cause mortality, stroke, MI, new renal replacement therapy, non-elective cardiac surgery in device group at 30-days

Total follow up 24 months

PIs S Anker, P Ponikowski

Is “moderate” MR acceptable in patients with severe heart failure?

Is “moderate” MR acceptable in patients with severe heart failure?

• 89 year old female, NYHA IV

• Acute anterior MI → 1o PCI

• Ischemic cardiomyopathy

– EF 35%, LVEDD 62mm, LVESD 56mm

• Multiple hospitalizations for acute

pulmonary edema

• “Moderate mitral regurgitation”

• RVOL34ml, RF 45%, EROA 20mm2

PASCAL for severe ischemic FMR

Baseline

Final

Clin Res Cardiol (2014) 103:85–96

Conditionally Suitable Anatomy for MitraClip

Clin Res Cardiol (2014) 103:85–96

Conditionally Suitable Anatomy for MitraClip

CardioValve(Valtech Cardio)

Examples of Transcatheter Mitral Valve Repair Techniques

Transcatheter Mitral Valve Implantation in Patient with severe Functional MR

• 78 year old female, NYHA III

• Severe functional mitral regurgitation

• ERO 47mm2, Rvol 55ml

• LVEDD 62mm, LVESD 51mm, EF33%

• Moderate TR, sPAP 50mmHg

• Fractured pelvis(5/2016), chronic atrial fibrillation,

LBBB, BMI 22kg/m2

• Coronaries, no stenoses

Valve Release under Rapid Ventricular Pacing

Final 3D Color

In Summary…

• Echocardiography and in particular 3-Dimensional has enhanced our understanding of mitral valve pathology and function

• Transcatheter technologies are complementary to traditional surgical techniques for degenerative MR patients with acceptable results in high risk patients

• For functional MR patients transcatheter due to its low invasiveness and high safety profile may become the preferred option for treatment, but severity criteria need to be clarified further to ensure maximal benefit

• Repair or replacement will depend on perceived risk/benefit, randomized data and long term durability concerns