mitral regurgitation: the past … the present the …...in patients with secondary mitral...
TRANSCRIPT
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Mitral Regurgitation: The Past … The Present ... The Future
Sean R. Wilson, MD
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Disclosure
None
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Setting the Foundation
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Aortic Valve
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Mitral Valve
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Epidemiology: Mitral RegurgitationPatients with Mitral Valve Regurgitation
– US and EU 2016Mitral Valve Regurgitation – Patient Segmentation
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Indications for Surgery for Mitral Regurgitation
*MV repair is preferred over MV replacement when possible.
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Chronic Secondary Mitral Regurgitation: Medical Therapy
Recommendations COR LOEPatients with chronic secondary MR (stages B to D) and HF with reduced LVEF should receive standard GDMT therapy for HF, including ACE inhibitors, ARBs, beta blockers, and/or aldosterone antagonists as indicated
I A
Noninvasive imaging (stress nuclear/positron emission tomography, CMR, or stress echocardiography), cardiac CT angiography, or cardiac catheterization, including coronary arteriography, is useful to establish etiology of chronic secondary MR (stages B to D) and/or to assess myocardial viability, which in turn may influence management of functional MR
I A
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Two Year Outcomes of Surgical Treatment of Moderate Ischemic MR
Michler RE. NEJM 2016; 374:1932
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Two Year Outcomes of MV Repair Versus Replacement of Severe Ischemic MR
Goldstein D. NEJM 2016 374:344
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Chronic Severe Secondary Mitral Regurgitation: Intervention
Recommendations COR LOEMV surgery is reasonable for patients with chronic severe secondary MR (stages C and D) who are undergoing CABG or AVR
IIa C
New: It is reasonable to choose chordal-sparing MVR over downsized annuloplasty repair if operation is considered for severely symptomatic patients (NYHA class III to IV) with chronic severe ischemic MR (stage D) and persistent symptoms despite GDMT for HF
IIa B-R
MV surgery may be considered for severely symptomatic patients (NYHA class III-IV) with chronic severe secondary MR (stage D) who have persistent symptoms despite optimal GDMT for HF
IIb B
Modified: In patients with chronic, moderate, ischemic MR (stage B) undergoing CABG, the usefulness of mitral valve repair is uncertain
IIb B-R
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Mitral - FR
ObadiaNEJM 2018
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Mitral - FR
ObadiaNEJM 2018
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MITRA-FR: Change in NYHA Class in Surviving Patients
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COAPT Trial Exclusion criteria:
American College of Cardiology/American Heart Association stage D HF, hemodynamic instability, or cardiogenic shock
Untreated clinically significant coronary artery disease requiring revascularization
Chronic obstructive pulmonary disease (COPD) requiring continuous home oxygen or chronic oral steroid use
Severe pulmonary hypertension or moderate or severe right ventricular dysfunction
Aortic or tricuspid valve disease requiring surgery or transcatheter intervention
Mitral valve orifice area <4.0 cm2 by site-assessed transthoracic echocardiography
Life expectancy <12 months due to noncardiac conditions
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COAPT: Characteristics of Patients
Prior myocardial infarction: 51%, prior percutaneous coronary intervention: 46%, prior coronary artery bypass grafting: 40%, COPD: 23%
Society of Thoracic Surgeons Predicted Risk of Mortality score (STS PROM) for replacement: 8.1%, ≥8%: 42%
High surgical risk: 69% Ischemic HF: 61% HF hospitalization within 1 year: 57% Prior CRT: 36% Echo (mean): effective regurgitant orifice area (EROA): 0.41
cm2, LVESD: 53 mm, LV end-diastolic dimension: 62 mm, LVEF: 31.3%
Beta-blockers: 91%, angiotensin-converting enzyme inhibitor/angiotensin-receptor blocker/angiotensin receptor–neprilysin inhibitor: 66%, mineralocorticoid receptor antagonist: 50%
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COAPT Trial
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COAPT Trial
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COAPT Trial
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Functional Mitral Regurgitation Trials
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Functional Mitral Regurgitation TrialsKey Differences Between the 3 RCTs
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Functional MR is One of Many Components of the Heart Failure Syndrome
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Clinical Course/Treatment of Heart Failure in Mitral Regurgitation Patients
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Referral Algorithm for Mitral Regurgitation
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Increasing Complex Environment Various Heart Teams
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Increasing Complex Environment Various Heart Teams
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Increasing Complex Environment Various Heart Teams
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Multidisciplinary Mitral Valve Heart Team
Heart Team meetings to discuss the indications for and timing of intervention together with necessary procedural details.
In collaboration with members of a heart failure service and electrophysiology specialists is needed in patients with secondary mitral regurgitation to ensure that medical therapy (and cardiac resynchronization if indicated) has been optimized before considering surgical or transcatheterintervention
Patients with heart failure and valve disease may be better cared for in a heart failure clinic (rather than a heart valve clinic) if no invasive intervention is planned
European Heart Journal (2017) 38, 2177–2183
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Aortic Percutaneous Valve Marketplace
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Percutaneous Valve Marketplace
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Monthly TAVR Revenue By Brand 2012-2016
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Portfolio and Revenue of Key Transcatheter Companies
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Current Landscape of Percutaneous Mitral Valve Treatment
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Future Issues To Ponder
Health care is transitioning from a volume-based to value-based payment system
Hospitals in general—and high-cost, high-volume procedures in particular—have been a focus for reform, since one-third of US health care spending accrues in such settings
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Future Issues To Ponder
An aging population, concerns about rising drug costs, and the rapid changes to the US health care system serve as the backdrop for this issue
In the foreground, managed care decision-makers, policy experts, clinicians, and others grapple with economic and quality of life questions related to a host of diseases and conditions in an era of limited resources
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All These Options – What Do We Do
We are not yet in a position of trying to determine who is likely to benefit the most Society is not ready for that Basically, if the patient meets the criteria, whether
they just minimally meet those criteria or are the best candidate possible, they are eligible for coverage
The economic realities may ultimately drive us to reconsider how and on whom resources should be allocated This needs to be a societal decision that payers
will then likely support
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Thank You