Managing Mitral Regurgitation: Repair, Replace, or Clip? Michael Howe, MD Traverse Heart & Vascular

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1 Managing Mitral Regurgitation: Repair, Replace, or Clip? Michael Howe, MD Traverse Heart & Vascular

2 Mitral Regurgitation Anatomy Mechanisms of MR Presentation Evaluation Management Repair Replace Clip

3 Mitral Valve Anatomy Otto, NEJM 2001

4 Mechanisms of MR Primary MR Mitral annular disorders Mitral leaflet disorders Chordae tendinae dysfunction Papillary muscle dysfunction Secondary MR Valve is often normal LV dysfunction

5 Mechanisms of MR (ischemic) ASE Comprehensive Echocardiography 2016

6 Presentation Related to severity and rate of progression Gradual limitation of daily activities Exertional dyspnea / fatigue Decreased cardiac output Left ventricular failure Pulmonary hypertension Atrial fibrillation

7 Presentation AHA/ACC 2014 Valvular Heart Disease Guidelines

8 Evaluation Related to severity and rate of progression Exam: holosystolic murmur at the apex EKG: left atrial enlargement, possible RVH CXR: cardiomegaly Echo: essential Etiology and severity Start with TTE / consider TEE later

9 Severity of MR Trace, mild, moderate, severe Amount of back-flow (regurgitant volume) Mild MR Severe MR

10 Follow-up Mild MR: TTE every 3-5 years Unless symptoms change Moderate MR: TTE every 1-2 years. Severe MR: TTE every 6-12 months Dilating LV = more frequently.

11 When should we be involved? Symptomatic. Moderate or greater? Clinically unclear. Comfort.

12 Medical management of MR Primary MR: Surgery Secondary MR: Guideline-directed treatment for heart failure ACEi/ARB, beta blocker, aldosterone antagonist Resynchronization therapy Surgery

13 Surgical management of MR Once symptoms have occurred, the patient should be considered for mitral valve operation. Once the MR is severe, the patient should be considered for mitral valve operation.

14 Surgical Management of MR What about asymptomatic severe MR? Watchful waiting Early surgery

15 ACC/AHA Guidelines 2014: Primary MR MV surgery is recommended for symptomatic patients with chronic severe primary MR and LVEF >30% MV surgery is recommended for asymptomatic patients with chronic severe primary MR and LV dysfunction (LVEF 30 60% and/or LVESD >40mm) MV surgery is indicated in patients with chronic severe primary MR undergoing cardiac surgery for other reasons MV surgery is reasonable in asymptomatic patients with chronic severe primary MR with preserved LV function in whom the likelihood of success is >95% and mortality <1% MV surgery is reasonable in asymptomatic patients with chronic severe primary MR with preserved LV function with new AF or resting pulmonary HTN (PASP >50) MV surgery may be considered in symptomatic patients with chronic severe primary MR and LVEF <30% Transcatheter MV repair may be considered for severely symptomatic patients (NYHA III/IV) who have reasonable life expectancy but prohibitive surgical risk I I I IIa IIa IIb IIb B B B B B B B

16 ACC/AHA Guidelines 2014: Secondary MR MV surgery is reasonable for patients with chronic severe secondary MR who are undergoing CABG or AVR IIa C MV surgery may be considered for severely symptomatic patients (NYHA III/IV) with chronic severe secondary MR MV repair may be considered for patients with chronic moderate secondary MR who are undergoing other cardiac surgery IIb IIb B C

17 Surgery: Mitral Repair The preferred option. Benefits: Preserves functional components of native valve Avoids use of prosthetic valve, associated complications Repair vs replacement depends on anatomic cause of MR

18 Drake, NEJM 2014

19 Surgery: Mitral Repair Easiest to repair: Ruptured cord to posterior leaflet Pure mitral annular dilation Small perforation Hardest to repair: Ruptured cord to both leaflets Severe prolapse of both leaflets Extensive annular calcification (UC Irvine)

20 Surgery: Mitral Repair Predictors of Unsuccessful Repair: Severe annular calcium Extensive disease ( 3 segments) Annular dilation >50mm Scarcity of tissue in the leaflets

21 Surgery: Mitral Replacement Mechanical vs bioprosthetic? Bioprosthetic if pt cannot take warfarin Bioprosthetic if age >65 Mechanical if age <65 with longstanding atrial fibrillation Bioprosthetic if <65 in NSR after detailed discussion of anticoagulation vs need for redo (St Jude, Medtronic)

22 Transcatheter Repair (MitraClip) Cobalt/chromium clip that binds mitral leaflets Approved for pts with severe primary MR Indications: Severe symptomatic HF despite medical treatment Chronic severe primary MR Favorable anatomy Reasonable life expectancy Prohibitive surgical risk (Abbott)

23 Transcatheter Repair (MitraClip) Cobalt/chromium clip that binds mitral leaflets Approved for pts with severe primary MR Contraindications: Intolerance of anticoagulation / antiplatelet therapy Active endocarditis Rheumatic valve disease Intracardiac thrombus (Abbott)

24 Transcatheter Repair (MitraClip) NEJM 2011

25 Transcatheter Repair (MitraClip)

26 Summary Follow patient s symptoms. Follow the patient s echo. Multiple treatment options. Earlier is probably better.

Mitral Valve Repair Mitral Valve Repair versus Replacement: A successfully repaired heart valve is expected to have a better outcome than replacing a damaged heart valve with a man-made valve. The life

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