Mitralinsuffizienz: Bedeutung oft verkannt und unterbehandelt (?)

Transcription

1 What is wanted is not the wish to believe, but the will to find out which is the exact opposite (Bertrand Russel, ) Mitralinsuffizienz: Bedeutung oft verkannt und unterbehandelt (?) Pascal A. Berdat HerzGefässZentrum Klinik Im Park Zürich 14. Zürcher Herz.Kurs 4.September 2014

2 Content! Importance of organic MR " Natural history! Importance of functional MR " In acute myocardial infarction " Chronic MR! MR undertreated? " Evidence " Actual Guidelines

3 Organic MR: Mortality and Morbidity in MVP syndrome Das Bild kann nicht angezeigt werden. Dieser Computer verfügt möglicherweise über zu wenig Arbeitsspeicher, um das Bild zu öffnen, oder das Bild ist beschädigt. Starten Sie den Computer neu, und öffnen Sie dann erneut die Datei. Wenn weiterhin das rote x angezeigt wird, müssen Sie das Bild möglicherweise löschen und dann erneut einfügen. Avierinos JF et al. Circulation 2002;106:

4 Importance of organic MR TABLE 2. OUTCOME AT 5 AND 10 YEARS WITH MEDICAL TREATMENT OF MITRAL REGURGITATION DUE TO FLAIL LEAFLET.* EVENT OVERALL POPULATION 10-YEAR RATE ACCORDING TO NYHA CLASS LINEAR- NO. OF EVENTS 5-YEAR RATE 10-YEAR RATE IZED YEARLY RATE CLASS I CLASS II P VALUE percent Death from any cause Death from cardiac cause Congestive heart failure Chronic atrial fibrillation Thromboembolism Hemorrhage Endocarditis Mitral-valve surgery Mitral-valve surgery or death Outcome in subgroups of patients Death NYHA class III or IV NYHA class I or II Ejection fraction 60% Ejection fraction 60% Congestive heart failure Left atrial diameter 30 mm/m 2 Left atrial diameter 30 mm/m 2 Ling et al., NEJM 1996;335: *Plus minus values are means SE. NYHA denotes New York Heart Association.

5 Clinical outcome of medical treatment in severe MR 100 Event rate [%] Surgery or death Surgery CHF Time [year after diagnosis] Ling et al. NEJM 1996;335:

6 Progression of organic MR in asymptomatic patients Enriquez-Sarano et al. JACC 1999;34:

7 Mortality of organic MR in asymptomatic patients 100 Overall survival [%] Expected ERO < 20 mm² ERO mm² ERO 40 mm² p< ± ±6 58±9 p=ns p=0.04 p=0.03 Time [year] Enriquez-Sarano et al. NEJM 2005;352:875-83

8 Organic MR: Natural history according to symptoms 100 Overall survival [%] ±11 p= ±7 NYHA Class I -II NYHA Class III- IV Expected Time [year] Ling et al., New Engl J Med 1996;335:

9 Natural history of organic MR: LV dysfunction % within 8.6±5.4 y 2.7% per year [2] Overall survival [%] Expected EF 60% EF<60% p< ±4 42±12 Time [year] 1. Ling et al., New Engl J Med 1996;335: Suri RM et al. Eur J Cardiothorac Surg 2011;40:

10 Organic MR: Atrial fibrillation 5% per year! Grigioni et al. JACC 2002;40:84-92

11 Organic MR: Impact of atrial fibrillation on survival 100 Adjusted survival [%] Persistent SR AF during F-U Time [year] adjusted for age, gender, LVEF, symptoms Grigioni et al. JACC 2002;40:84-92

12 Organic MR: Impact of PHT on survival Figure 2. Magne et al. Circulation 2010;122:33-41

13 Organic MR: Impact of PHT on survival 100 Symptom-free survival [%] Resting PHT No resting PHT p= Time [month] Magne et al. Circulation 2010;122:33-41

14 Organic MR: Impact of PHT on survival 100 Symptom-free survival [%] Exercise PHT No Exercise PHT p< Time [year] Magne et al. Circulation 2010;122:33-41

15 Importance of functional MR: IMR in acute myocardial infarction 50-57% in AMI (<30d, mean 3±4.5d) ; 25-30% moderate [1,2] Figure 2. Overall survival according to degree of MR in 773 patients who underwent echocardiography within 30 days after MI (solid line indicates no MR, dotted line mild MR, and dashed line moderate or severe MR). Number of patients at risk of Bursi F. et al. Circulation 2005;111: Hillis GS et al. Am H J 2005;50: Figure 1. Survival free of heart failure according to degree of MR in 773 patients who underwent echocardiography within 30 days after MI (solid line indicates no MR, dotted line mild MR, and dashed line moderate or severe MR). Number of patients at

16 Chronic IMR is bad IMR is associated with excess mortality independently of baseline characteristics and LV dysfunction. Grigioni F et al. Circulation 2001;103: Hillis GS et al. Am Heart J 2005;150: Koelling TM et al. Am Heart J 2002;144:524-9 Lancellotti P et al. EHJ 2005;26:

17 Leaving IMR is not good Even mild IMR identified by intraop TEE, predicts worse outcomes after CABG. Revascularization alone did not eliminate negative long-term effects of mild IMR. CABG patients with uncorrected mild or moderate IMR are at increased risk for death and heart failure hospitalization; consideration for surgical repair or more aggressive medical management and follow-up is warranted. Paparella et al. Ann Thorac Surg 2003;76: Schroder et al. Circ 2005;112:293-8

18 IMR not resolved with revasc Although many pts have some improvement in their MR, a significant proportion (41%) were left with moderate to severe (3+ to 4+) MR [2] 1. Lam BK et al. ATS 2005;79: Aklog L et al. Circ 2001;104[suppl I]:I68-75.

19 MI unterbehandelt?! Schwierig abschätzbar: " Prävalenz:! Mitral prolapse syndrome 5-10% der Bevölkerung [1,2]! 50-57% bei akutem Myokardinfarkt (<30d, mean 3±4.5d) ; davon 25-30% mind. mittelschwer [3,4]! Zweithäufigstes Klappenproblem in Europa [5]: 1-2%; Häufigstes Klappenproblem in den USA (>75j >10%) [6]! Eingriffe in der CH: " MKR/ -E:? Keine Statistik " Mitraclip:?! Aktuelle Guidelines eher konservativ! Gegenüberstehend: Tiefe M&M bei MKR, schonendere Verfahren, MitraClip 1. Savage DD et al. Am H J 1983;106: Hillis GS et al. Am H J 2005;50: Markiewicz W et al. Circ 1976;53: Klein A et al. J Am Soc Echo 1990;3: Bursi F et al. Circulation 2005;111: Nkomo VT et al. Lancet 2006;368:

20 Over- & underuse of intervention Fig. 1 Comparison between the indications retained for intervention in asymptomatic patients with severe single-valve disease and the recommendations from Working Group on Valvular Heart Disease of the European Society of Cardiology. 11 Over-use of intervention refers to patients who underwent interventions without having an indication according to the guidelines. Under-use of intervention refers to patients who had no intervention but for whom there was an indication according to the guidelines. AS: aortic stenosis; AR: Aortic regurgitation; MR: mitral regurgitation Iung B. et al. Eur Heart J 2003;24:

21 Vahanian A. et al. Eur Heart J 2012;33: No Symptoms Table 12 Indications for surgery in severe primary mitral regurgitation LVEF 60% or LVESD 45 mm Yes LVEF >30% Mitral valve repair should be the preferred technique when it is expected to be durable. Surgery is indicated in symptomatic patients with LVEF >30% and LVESD <55 mm. Class a Level b Ref C I C I B 127, 128 Yes No Surgery is indicated in asymptomatic patients with LV dysfunction (LVESD 45 mm and/or LVEF 60%). I C No New onset of AF or SPAP >50mmHg Yes Yes Refractory to medical therapy No Surgery should be considered in asymptomatic patients with preserved LV function and new onset of atrial fibrillation or pulmonary hypertension (systolic pulmonary pressure at rest >50 mmhg). Surgery should be considered in asymptomatic patients with preserved LV function, high likelihood of durable repair, low surgical risk and flail leaflet and LVESD 40 mm. IIa IIa C C No High likelihood of durable repair, low surgical risk, and presence of risk factors a Yes Yes Durable valve repair is likely and low comorbidity No Surgery should be considered in patients with severe LV dysfunction (LVEF <30% and/ or LVESD >55 mm) refractory to medical therapy with high likelihood of durable repair and low comorbidity. Surgery may be considered in patients with severe LV dysfunction (LVEF <30% and/ or LVESD >55 mm) refractory to medical therapy with low likelihood of durable repair and low comorbidity. IIa IIb C C No Follow-up Yes Surgery (repair whenever possible) Extended HF treatment b Medical therapy Surgery may be considered in asymptomatic patients with preserved LV function, high likelihood of durable repair, low surgical risk, and: left atrial dilatation (volume index 60 ml/m² BSA) and sinus rhythm, or pulmonary hypertension on exercise (SPAP 60 mmhg at exercise). IIb C

22 Impact of baseline Symptoms on post-op Survival 100 Survival from diagnosis [%] Expected NYHA I - II NYHA III - IV p< ± 5 48 ± Independant of age, Time [year] LV-function, CAD Tribouilloy et al. Circulation 1999;99:400-5

23 Impact of baseline Symptoms on post-op Survival Independant of age, LV-function, CAD Tribouilloy et al. Circulation 1999;99:400-5

24 Impact of baseline EF on post-op Survival 100 Survival from diagnosis [%] EF > 60% 60 > EF > 50% EF < 50% 72 ± 4 53 ± 9 p< ± Time [year] Enriquez-Sarano et al. Circulation 1994;90:830-7

25 Cardiac Dimensions after Early vs. Late Mitral Surgery Kang et al. Circ 2009;119:

26 Impact of baseline Cardiac Rhythm on post-op Survival 100 Sinus Rhythm 80 78±8 Survival [%] AFib 57±6 20 p<0.001; HR Time [year] Eguchi et al. Eur Heart J 2005;26:

27 Chronic MR Class I indications of mitral surgery are associated with dire outcome consequences!

28 Survival in asymptomatic severe MR Montant P. et al. JTCVS 2009;138:

29 Survival in asymptomatic severe MR & AF, PHT Patients with AF or PHT or both ontant P et al. JTCVS 2009;138:

30 Survival in asymptomatic severe MR: The Mr International DAtabase registry MIDA Survival [%] Log rank p < Medical Early surgery Time [year] Suri RM et al. JAMA 2013;310:609-16

31 Heart failure in asymptomatic severe MR: the MIDA registry 50 Medical Early surgery Heart failure [%] Log rank p < Time [year] Suri RM et al. JAMA 2013;310:609-16

32 Survival in asymptomatic severe MR: the MIDA registry Suri RM et al. JAMA 2013;310:609-16

33 Results of contemporary Mitral Surgery in organic MR! Early Mortality <0.5% [1,2,3]! Rate of repair >90%! Excellent durable Results: no/mild MR 92%, preserved LVEF in [4]! Excellent QoL [4,5]...both short- and longterm risks of mitral valve repair appear minimal, allowing to propose this procedure to low-risk patients with no or minimal symptoms. [6] 1. David et al. JTCVS 2003;125: v Leeuwen et al. Interact Cardiovasc Thorac Surg 2013;16: Smolens et al. Ann Thorac Surg 2001;72: Ay et al. AnnThorac Cardiovasc Surg 2013;19: Kang et al. Circ 2009;119: Montant P et al. JTCVS 2009;138:

34 Clinical decision making algorithm proposed J.L.Vanoverschelde MR murmur Doppler echocardiography ERO > 40 mm²? Doubt No Follow-up Yes TEE, MRI Lesions repairable? No or doubt NYHA II, EF < 60%, ESD > 40 mm? Yes Yes No Repair Surgery Follow-up

35 IMR: Effect of added MVR? - 99 patients - Grade 2-3+ IMR, EF <30% - Group I: CABG / MV surgery - Group II: Isolated CABG Surgical correction of grade 2-3+ MR provides better survival and improves LV function. Open MVR for MR in the setting of ischemic CMP and low EF appear to improve ventricular function, mid-term symptoms and survival. Prifti et al. J Heart Valv Dis 2001;10: Chen et al. Circ 1998;98:II124-7 Vitali et al. Am J Cardiol 2003;91(Suppl):88F-94F Performance of MVR with CABG was not associated with improved survival vs. CABG alone. Whereas MVR can be added safely to CABG in this high-risk group without increasing mortality, its impact on late survival and functional class may be limited. Trichon et al. Circ 2003;108:II Diodato et la. ATS 2004;78:794-9

36 IMR: No added risk of surgery! Mortality rates %, many center 4-6% [1-9]! Determined more by " LV function " Comorbidity " Age " NYHA class " Wall motion abnormalities " Complex regurgitant jet " Absence of angina [2] 1. Kim et al. ATS 2005:79: Trichon et al. Circ 2003;108:II Adams et al. J Heart Valv Dis 2002;11:S Braun et al. EJCTS 2005;27: Diodato et al. ATS 2004;78: Gillinov et al. ATS 2005;80: Shah et al. ATS 2005;80: Glower et al. JTCVS 2005;129: Calafiore et al. ATS 2001;71:

37 IMR: Residual & recurrent MR after CABG+MV Surgery 302 pts ( ), 55% degenerative MR, 45% IMR RECURRENT MR in 12% [2]: 150 pts with idiopathic/ ischemic CMP, EF 16%, NYHA class 4, mortality 6%...presence of residual grade II or greater MV regurgitation was an independant risk factor for death and congestive heart failure. Dahlberg PS et al. Ann Thorac Surg 2003;76: Bolling SF et al. J Heart Valve Dis 2002;11(Suppl I):S26-31.

38 IMR: Reverse Remodeling? [1] UNPREDICTABLE REVERSE REMODELING [2]: 51 pts with ischemic CMP, EF 31±8%, NYHA class 3.4±0.8, ring size 28±2, mortality 5.6% 33% early remodeling 40% late remodeling 27% no remodeling 1. Braun J et al. EJCTS 2005;27: Bax JJ et al. Circ 2004;110(Suppl II):II103-6.

39 IMR: Restrictive Annuloplasty: Physio Ring P=0.002 P=0.012 Braun et al. Ann Thorac Surg 2008;85:430-7

40 IMR: Guidelines 2012 LV Dysfunktion EF >30% Indikation ACB Ja Nein Klinische Evaluation + Echokardiographie Medikamentöse Herzinsuffizienztherapie ± ICD, ± CRT nach Leitlinien Ja Mittel-hochgradige MI Nein Ja Nachweis myokardiale Viabilität LV Dysfunktion EF < 30% Indikation ACB Nein Table 13 Indications for mitral valve surgery in chronic secondary mitral regurgitation Surgery is indicated in patients with severe MR c undergoing CABG, and LVEF >30%. Class a Level b Surgery should be considered in patients with moderate MR undergoing CABG. d IIa C Surgery should be considered in symptomatic patients with severe MR, LVEF <30%, option for revascularization, and evidence of viability. Surgery may be considered in patients with severe MR, LVEF >30%, who remain symptomatic despite optimal medical management (including CRT if indicated) and have low comorbidity, when revascularization is not indicated. I IIa IIb C C C Niedriges Operationsrisiko Hohes Operationsrisiko Herzteam Operation anatomische Eignung Nein Konservativ Transplantation MitraClip Nickenig G et al. Der Kardiologie 2013;7: Vahanian A. et al. Eur Heart J 2012;33:

41 Summary! Organic and functional MR induce significant Morbidity and Mortality! In light of low perioperative M&M, excellent long-term results, and impaired outcome with class 1 indications current guidelines may seem rather conservative! Underuse of mitral valve interventions is probable both in organic and functional MR