the patient with aortic stenosis and mitral regurgitation

The Patient with Aortic Stenosis

and Mitral Regurgitation

Prof. Patrizio LANCELLOTTI , MD, PhD

Heart Valve Clinic, University of Liège, CHU Sart

Tilman, Liège, BELGIUM

Aortic Stenosis + Mitral Regurgitation

?

Etiology of MR in patients with significant

aortic valve disease

LV dysfunction

Functional

Mixed

Intrinsic MV dysfunction

Rheumatic heart disease

Myxomatous degeneration

Chordal/papillary muscle rupture

Calcifications of mitral leaflets or

annulus

Organic

Undetermined…

« Ischemic » MR or not

Mitral regurgitation

LV remodelling Mitral valve deformation

LV pressure LV-LA pressure gradient

Impedes detection of

subclinical myocardial

dysfunction

EF

Low flow low

gradient aortic

stenosisDiagnostic challenge

forward stroke

volume

Atrial fibrillation Functional tolerance

Aortic stenosis

Unger et al. Heart 2010;96:9-14

Pathophysiology

LVOT diameter 2,2 cm

Stroke volume 35 ml (18 ml/m²)

AVA 0.65 cm² (0,34 cm²/m²)

LVOT diameter 2,2 cm

Stroke volume 35 ml (18 ml/m²)

AVA 0.65 cm² (0,34 cm²/m²)

STS database 2005

http://sts.org/documents/pdf/Spring2005STS-ExecutiveSummary.pdf

10% of all cardiac procedures

5% of all AVR

+/-1000/yr

Prevalence

Authors, Year Number of

patients

Exclusion criteria Method of MR assessment Percentage of patients with

preoperative MR

Tunick

Am J Cardiol 1990

44 None Colour flow mapping 61% with ≥ mild MR

Adams

Am J Cardiol 1990

56* None Pulsed wave Doppler mapping 82% with ≥ 1+ MR

Tassan-Mangina

Clin Cardiol 2003

30 Severe AR

Unstable haemodynamic state

Arrhythmia

Colour flow mapping 90% with ≥ mild MR

Moazami

J Card Surg 2004

250 Organic mitral valve disease

Previous sternotomy or mitral

valve surgery

Colour flow mapping 78% with ≥ mild MR

Barreiro

Circulation 2005

408 Need for concomitant bypass

surgery

Age > 70 y

Colour flow mapping 17.2% with ≥ moderate MR

Ruel

Circulation 2006


Patients who did not survive the

operation

2003 American Society of

Echocardiography

recommendations

12.6% with ≥ 2+ MR

Caballero-Borrego

Eur J Cardiothor

Surg 2008


Predominant AR

Predominant coronary artery

disease

Type A aortic dissection

MR secondary to SAM

Colour flow and pulsed wave

Doppler mapping, pulmonary vein

flow

26.5% with non-severe MR

Waisbren

Ann Thor Surg 2008


Combined procedure (CABG)

Endocarditis

Right heart valve procedure

Moderate or severe AR

Vena contracta width 74% with moderate MR

Prevalence of MR in patients undergoing isolated AVR

9 studies

N=2550

Variable

organic MVD (4)

≥moderate AR (3)

CAD/CABG (4)

Qualitative

or

semi-quantitative

≥mild: 60-80%

≥moderate: ±15%

Risk associated with double valve replacement

STS database 2005

http://sts.org/documents/pdf/Spring2005STS-ExecutiveSummary.pdf

Operative mortality and morbidity of interventions according to the underlying valve disease

Iung et al. Eur Heart J 2003; 24:1231

%

Euro Heart Survey

0

2

4

6

8

10

12

Morta

lity

Maj

or ble

edin

g

Tamponnad

e

Embolis

m

Med

iast

initi

s

Aortic stenosis n=512

Multiple valve disease n=185

0

2

4

6

8

10

12

Morta

lity

Maj

or ble

edin

g

Tamponnad

e

Embolis

m

Med

iast

initi

s

Aortic stenosis n=512

Multiple valve disease n=185

Turina, J. et al. Circulation 1999;100:II-48-II-53

Long-term outcome after aortic

+ mitral valve replacement

Independent predictors of late

outcome:

• Age

• LVEF

• Additional tricuspid surgery

• NYHA class

• CAD requiring CABG

Mitral valve repair with AV replacement is

superior to double valve replacement

Gillinov AM, et al. J Thorac Cardiovasc Surg 2003; 125: 1372

Repair: N=295

Replacement: N=518

0

10

20

30

40

50

60

70

80

90

100

2 4 6 8 10 12 14 16

79

72 63

52

46

34

P=0.01

Mean follow-up 6.9±5.9 yrs

%

years

Surv

ival (%

)l

AVR + MV repair

AVR +

MVR

Talwar S, et al Ann Thorac Surg. 2007:84:1219

AVR + MV repair vs AVR + AVR

replacement/ event-free survival

p < 0.001

First author, Year Number of

patients with

MR ≥2

Aetiology of

MR

Prognostic value

Absil, Eur J

Cardiothoracic Surgery

2003

58 Functional No significant prognostic value

Ruel, Circulation 2006 107 Functional No significant effect on mortality

Wan, JTCVS 2009 190 Functional No independent prognostic value

Caballero-Borrego, Eur J

Cardiothoracic Surgery

2008 155 Functional Independent risk factor for

mortality and morbidity

Functional MR

Prognostic impact of MR in patients

undergoing isolated AVR

Age, diabetes, renal failure, LV dysfunction, Atrial fibrillation

Prognostic impact of MR in patients

undergoing isolated AVR

Organic MR

First author, Year Number of

patients with

MR ≥2

Aetiology of

MR

Prognostic value

Barreiro, Circulation

2005

70 Organic (2/3)

Functional

(1/3)

Independent risk factor for long-

term mortality

Takeda, Eur J Cardio

Surg

59 Organic (2/3)

Functional

(1/3)

Independent risk factor for long-

term morbidity

Independent Predictors of Late Mortality as

Determined by Multivariate Statistical Analysis

Barreiro, C. J. et al. Circulation 2005;112:I-443-I-447

First author, Year Aetiology of

MR

Number of patients Timing of the

postoperative echo

examination

Method of MR

assessment

% of patients with

improvement in MR

Tunick 1990 Functional

Organic

N = 27 with ≥ mild MR 58 days CFM 67%

Adams 1990 Organic

Functional

N = 46 with ≥ mild MR 6 months PW Doppler mapping 27%

Harris 1997 Functional N=28 with ≥ mild MR 2.5 months CFM 82%

Brasch 2000 Organic

Functional

N = 16 with ≥ moderate

MR

2.2 months CFM 44%

Christenson 2000 Functional N = 58 with ≥ mild MR 1 week

and

5 months

CFM 46%

and

60%

Tassan-Mangina

2003

Functional in

all except 2

patients

N = 23 with ≥ mild MR 19 days CFM 61%

Moazami 2004 Functional N = 80 with ≥ mild MR > 60 days CFM 45%

Barreiro 2005 Organic

Functional


MR

Early postoperative CFM 82% if functional

35% if organic

Ruel 2006 Functional N = 107 with ≥ 2+ MR 18 months 2003 ASE

recommendations

44-74%

Vanden Eynden 2007 Organic

Functional


MR

1 year CFM and PW Doppler

mapping, PV flow

35%

Caballero-Borrego

2008

Functional N =153 with non-severe

MR

Before hospital

discharge

CFM and PW Doppler

mapping, PV flow

72%

Waisbren 2008 Functional

No CABG

N = 60 ≤ mild MR

N = 167 ≥ moderate MR

Intraoperative Vena contracta width 66% of preop. moderate

MR

Wan 2009 Functional N=159 with ≥ moderate

MR

Discharge 2003 ASE

recommendations

76%

Impact of isolated AVR on MR

13 studies

Functional: 8

Functional + organic: 5

1014 patients

≥mild or

≥moderate MRFrom OR

up to

18 months

65-75%

(27-82%)

Qualitative or ½

quantitative studies

All retrospective studies

except one

Quantitative changes in MR

after isolated AVR

Unger P et al. Am J Cardiol . 2008; 102:1378-82

0

10

20

30

40

50

60

70

80

ERO Reg Vol Reg jet/LA area

P=0.034 vs ERO

P<0.0001 vs ERO

Quantitative changes in MR after AVR

Unger P et al. Am J Cardiol . 2008; 102:1378-82

posto

p r

eduction (

%)

Predictors of MR down-grading after isolated AVRFirst author, Year Aetiology of MR Preoperative predictive factors of MR improvement

Tunick Am J Cardiol 1990 Functional + organic MR severity

Adams Am J Cardiol 1990 Functional + organic None

Harris Am J Cardiol 1997 Functional Low LV fractional area

Large left atrial size

Brasch Am J Cardiol 2000 Functional + organic LV mass

Christenson, Tex Heart Inst J 2000 Functional Presence of coronary artery disease

Tassan-Mangina Clin Cardiol 2003 Functional in all except 2

patients

Peak velocity of tricuspid regurgitant jet

Indexed LV mass

Moazami J Cardiac Surg 2004 Functional History of previous myocardial infarction

Barreiro Circulation 2005 Functional + organic Functional MR

Ruel Circulation 2006 Functional No enlarged left atrium (>5cm), no chronic AF

No low preoperative peak aortic pressure gradient (< 60 mm Hg)

Vanden Eynden Ann Thor Surg 2007 Functional + organic Functional (including ischaemic) MR

Caballero-Borrego Eur J CT Surg 2008 Functional Presence of CAD, absence of diabetes and of PHT

Waisbren Ann Thor Surg 2008 Functional

No CABG

MR severity, trace or mild aortic insufficiency

Left atrial size < 4.5cm

Congestive heart failure

Unger Am J Cardiol 2008 Functional + organic MR severity

Mitral coaptation height

Wan JTCVS 2009 Functional Lesser preop TR, lower MR grade under anesthesia

No cerebrovasc disease

Lower EF

14 studies

Functional: n=8

Organic + funct: n=6

Functional etiology

Low EF, CHF

Lower grade of MR under anesthesia

Less MV deformation

Organic etiology

Enlarged atrium

AFib

Pulmonary HT

Less/no improvement

Improvement

Changes in hemodynamic and echocardiographic data

according to mitral regurgitation etiology

Variables

Functional

MR

(n=20, 48%)

Organic

MR

(n=22, 52%)

P value

LV geometry and function

∆ Indexed LVED volume, ml 12±13 4±7 0.01

∆ Indexed LVES volume, ml 9±12 4±6 NS

∆ Indexed LV mass, g.m-2 9±25 5±26 NS

∆ LV ejection fraction, % -4±11 -5±8 NS

Mitral regurgitation

∆ Effective regurgitant orifice, mm2 5.8±5.2 2.8±4.3 0.04

∆ Regurgitant volume, ml 14.5±7 9.3±8.2 0.03

>1.4 cm²

0.7 cm

9.7 cm²

Preop Predictors of Persistent Functional MR

Matsumura Y et al. Am J Cardiol . 2010; 106: 701-706

-10

-5

0

5

10

15

20

25

-1.5 -1.0 -0.5 0 0.5 1.0 1.5 2.0

Changes in ERO (pre-post), mm2

Postoperative changes in mitral tenting area, cm2

r=0.51

p=0.025

Relationship between postoperative changes in mitral

tenting area and reduction in mitral regurgitation in

patients with functional MR

-10

-5

0

5

10

15

20

25

30

35

-1.5 -1.0 -0.5 0 0.5 1.0 1.5 2.0

Changes in RV (pre-post), ml

r=0.55

p=0.02

Post

op

erati

ve i

mp

rovem

ent

in E

RO

, m

m2

0

2

4

6

8

10

12

No PPM

(n=19, 45%)

PPM

(n=23, 55%)

6.0±4.0

2.6±5.0

p=0.02

Postoperative changes in MR according to the

presence/absence of patient/prosthesis mismatch

Unger P et al. (Abstract) Circulation. 2009;120:S768

PPM: postop indexed AVA < 0.85 cm²/m²

Relationship between aortic projected indexed EOA and

reduction in ERO (preop minus postop value)

A

-10

-5

0

5

10

15

20

r=0.44, p=0.01

Po

sto

per

ati

ve

cha

ng

es i

n E

RO

(p

re-p

ost

), m

m2

Projected indexed EOA, cm2.m-2

r=0.70, p=0.0003

r=0.14, p=NS

Functional MR

Organic MR

0.4 0.6 0.8 1.0 1.2

r=0.44, p=0.01

r=0.14, p=NS

Functional MR

r=0.70, p=0.0003

Organic MR

r=0.44, p=0.01

ACC/AHA 2006 Guidelines for the Management of

Patients With Valvular Heart Disease

« Remarkably few data exist to objectively guide the management of

mixed valve disease…

Hence, each case must be consider individually…

…the committee has developed no specific recommendations. »

2007 ESC Guidelines on the Management of

Valvular Heart Disease

« Data on multiple valve diseases are lacking and do

not allow for evidence-based recommendations.»

When is double-valve surgery indicated?

When is double-valve surgery indicated?

• If MR is severe

• …however,

– There are data on 40 patients with severe MR who

did not undergo surgical mitral valve intervention

• 90% of them had an improvement of at least one grade

• When is MR considered severe?

Ischaemic (functional) MR

≥ 20 mm² (1)

Organic MR

≥ 40 mm² (2)

Threshold of MR severity?

frequent downgrading

after AVR

less frequent downgrading

risk of future reoperation

≥ 30 mm²

1. Lancellotti et al. Circulation 2005

2. Enriquez-Sarano M. et al. N Engl J Med 2005

When is double-valve surgery (not)

indicated?

• Assessment of MR severity (ERO)

• Knowledge of functional or organic aetiology

• Suitability for MV repair

• Operative risk and comorbidities

MR

Symptomatic Aortic Stenosis

ERO ≥ 30 mm²

Operative risk+comorbidities

Isolated AVR

Intermediate

AVR + mitral valve

surgery

(preferably repair)

Low

Percutaneous aortic

valve implantation

High

Yes

High

No

Surgical Risk

Low Intermediate

ERO < 20 mm²

No mitral valve

surgery

Organic MRFunctional MR

ERO 20-29 mm²

+

PASP > 50 mmHg

LAD > 50 mm

Atrial fibrillation

PPM

MV deformation

the patient with aortic stenosis and mitral regurgitation

Documents