Primary vs Secondary Mitral Regurgitation: Tailoring ...

Robert O. Bonow, MD, MS

Northwestern University Feinberg School of Medicine

Bluhm Cardiovascular Institute

Northwestern Memorial Hospital

Editor-in-Chief, JAMA Cardiology

No Relationships to Disclose

Primary vs Secondary Mitral Regurgitation:

Tailoring Treatment to the Patient and Setting

Stages of Valvular Heart Disease

Stage Definition

A Risk of valve disease

B Mild - moderate asymptomatic disease

C Severe valve disease but asymptomatic

C1: Normal LV function

C2: Depressed LV function

D Severe, symptomatic valve disease

RHD, MVP, HF, post MI

Mitral regurgitation

Primary MR: primary valve disease

Secondary MR: primary myocardial disease

Degenerative

Functional





Indications for mitral valve surgery

for degenerative MR?







• Symptomatic patients class I




• Symptomatic patients

• Asymptomatic patients

• LV systolic dysfunction

class I

class I








class I

class I



LVEF <60%





class I

class I



LVEF <60%

LVSD >40mm





• Pulmonary hypertension

class I

class I

class IIa








class I

class I

class IIa



PASP >50 mmHg at rest






• Atrial fibrillation

class I

class I

class IIa

class IIa









• Normal LV function, repairfeasible?

?

class I

class I

class IIa

class IIa










class I

class I

class IIa

class IIa



MV repair to improve survival?

?








class I

class I

class IIa

class IIa



MV repair to improve survival?

What is the natural history?

?








class I

class I

class IIa

class IIa



66% come to surgery in 5 years because of symptoms,

LV dysfunction, pulmonary hypertension or AF

Asymptomatic severe primary MR:








class I

class I

class IIa

class IIa



Severe primary MR:

Long-term postoperative survival is worse if surgery

is performed after patients become symptomatic

J Thorac Cardiovasc Surg 2003;125:1143-1152

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10 11

Mitral RegurgitationSurvival After Mitral Valve Surgery

40

20

0

Surv

ival (p

erc

ent)

2 4 6 8 10 2012

Time (years)

David et al, Circulation 2013;127:1485-1492

FC I

32%

75%

n=840

p<0.001

0 14 16 18

52%

66%60

80

100

FC IV

FC III

FC II

Indications for MV repair for

asymptomatic primary MR:


class IIa

• Chronic severe MR

• Preserved LV function

• Experienced surgical center

• Likelihood of durable repairwithout residual MR > 95%


class IIa

class IIb




• Likelihood of durable repairwithout residual MR > 95%


• Likelihood of durable repair and low risk for surgery, and

• LA dilatation >60 ml/m2 -- or --

Exercise PAP >60 mmHg




class IIa

class I



• Repair better than mitral valvereplacement

• Patients should be referred tocenters experienced in repair




• Likelihood of durable repairwithout residual MR > 95%.

!

INTERVENTIONAL CARDIOLOGY AND SURGERY

Mitral repair best practice: proposed standards

B Bridgewater, T Hooper, C Munsch, S Hunter, U von Oppell, S Livesty, B Keogh,F Wells, M Patrick, J Kneeshaw, J Chambers, N Masani, S Ray

Heart 2006;92:939-944

• Surgical training

• Intraoperative echocardiography

• Volume thresholds

• Audit

• Cardiology and imaging

Surgeon: >25/yr

Hospital: >50/yr

Operative mortality <1%

5 year reoperation <5%

Rigorous

criteria

19 criteria for best practice:

Centers of Excellence in Mitral Valve Repair

Criteria:

• MV surgery volume requirement (center and surgeon)

• Expert periprocedural imaging capabilities

• Access to transcatheter technology

• Transparency regarding outcomes including: repair rates,

mortality rates, stroke rates, repair durability


class IIb

Indications for transcatheter MV

repair for severe degenerative MR:


• Severely symptomatic

• Prohibited surgical risk

• Reasonable life expectancy







•Diagnostic dilemmas

• Therapeutic dilemmas

Imprecision in grading severity of secondary MR

What is “severe”

secondary MR?

Secondary mitral regurgitation:

…a marker of a sicker LV

- or -

…a contributor to a sicker LV?

Secondary mitral regurgitation:

…a marker of a sicker LV

- or -

…a therapeutic target?

Functional mitral regurgitation

can be repaired.

But should it be repaired?

Functional mitral regurgitation

can be repaired.

But should it be repaired?

… or replaced?

Secondary mitral regurgitation

Guideline-directed medical

therapy for heart failure,

including CRT

class I




including CRT

Indications for mitral valve surgery:

• Patients with severe MR undergoing CABG or AVR

class IIa

class I




including CRT



class IIa

class IIb• Severe MR, persistent

symptoms despite optimal medical therapy, including CRT

class I


• Severe MR, persistent symptoms despite optimal medical therapy, including CRT

class IIb


class IIa


class I

• Patients with moderate MR undergoing CABG or AVR

class IIb



including CRT

Baseline Optimized Medical Therapy

and Biventricular Pacing

class IIb

Indications for transcatheter MV

repair for severe secondary MR:


• Severe secondary MR

• Severely symptomatic

• Prohibited or high surgical risk

• Reasonable life expectancy

Prevalence of MR in Patients with LV Dysfunction

Prevalence

N MR

Yiu et al Circulation 2000 128 63%

Grigioni et al Circulation 2001 303 64%

Koelling et al Am Heart J 2002 1436 49%

Trichon et al Am J Cardiol 2003 2057 56%

Robbins et al Am J Cardiol 2003 221 59%

Cleland et al N Engl J Med 2004 605 50%

Grayburn et al J Am Coll Cardiol 2005 336 77%

Bursi et al Circulation 2005 303 50%

Acker et al J Thorac CV Surg 2006 300 66%

Di Mauro et al Ann Thorac Surg 2006 239 75%

Rossi et al Heart 2011 1300 74%

Deja et al Circulation 2012 599 63%

Onishi et al Circ Heart Fail 2013 277 48%

Patients with moderate to severe MR*

*

*

*

Average hospital mortality: 8.8%

• Low volume centers: 13.0%

• High volume centers: 6.0%

Data from national Medicare database 1994-1999

684 hospitals

142,488 AVRs

Medicare data

0

2

4

6

8

10

12

14

16

86 87 88 90Age Group (years)

16

0

Pre

vale

nce (

perc

ent)

20-34

10

8

45-54 55-64 65-7935-44 ≥80

4

Men

Women

6

2

14

12

Prevalence of Heart Failure

United States

Source: NHANES, CDC, and American Heart Association





684 hospitals

142,488 AVRs

Medicare data

0

2

4

6

8

10

12

86 87 88 90Age Group (years)

12

0

Perc

enta

ge w

ith A

F

50-59

Prevalence of Atrial FibrillationThe ATRIA Study

10

8

Go et al, JAMA 2001;285:2370-2375

65-69 75-79 80-8460-64 70-74 ≥85

4

Men

Women

6

2

n=17,974





684 hospitals

142,488 AVRs

Medicare data

0

1

2

3

4

5

6

7

8

9

10

87 88 90Age Group (years)

10

0

Perc

ent

with V

alv

e D

isease

<45

Prevalence of Mitral Valve Disease

8

Nkomo et al, Lancet 2006;368:1005-1011

55-6445-54 65-74 ≥75

4

Olmstead County (n=16,501)

6

2

28,412 subjects 6.4

2.9

9.6

7.3CARDIA, ARIC, CHS (n=11,911)

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Primary vs Secondary Mitral Regurgitation: Tailoring ...

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