Mitral Regurgitation: Epidemiology, Pathophysiology and When to Repair

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Presentation transcript:

Mitral Regurgitation: Epidemiology, Pathophysiology and When to Repair Robert O. Bonow, M.D.

Mitral Regurgitation: Epidemiology, Pathophysiology and When to Repair Robert O. Bonow, M.D. Consultant Edwards Life Sciences

Lancet 2006;368:1005-1011

Moderate-Severe Mitral Valve Disease CARDIA, ARIC, CHS 10 Population-Based Studies 9.5% 11,911 subjects in CARDIA, ARIC, CHS Lancet 2006;368:1005-1011 8 6 Percent 4 2 <45 45-54 55-64 65-74 ≥75 Age Nkomo et al Lancet 2006;368:1005-1011

Moderate-Severe Mitral Valve Disease CARDIA, ARIC, CHS 10 Population-Based Studies 9.5% 11,911 subjects in CARDIA, ARIC, CHS Lancet 2006;368:1005-1011 8 Olmstead Cty. Olmstead County 7.3% 6 16,501 subjects Percent 4 2 <45 45-54 55-64 65-74 ≥75 Age Nkomo et al Lancet 2006;368:1005-1011

The Mitral Apparatus from Otto N Engl J Med 2001:345:740-746 Anterior annulus Anterior leaflet Anteromedial commissure Posterolateral commissure Posterior leaflet Posterior annulus Chordae tendineae Anterolateral papillary muscle Posteromedial papillary muscle Left ventricular free wall from Otto N Engl J Med 2001:345:740-746

Functional Mitral Regurgitation The Mitral Apparatus Anterior annulus Anterior leaflet Anteromedial commissure Posterolateral commissure Posterior leaflet Posterior annulus Chordae tendineae Anterolateral papillary muscle Posteromedial papillary muscle Left ventricular free wall Functional Mitral Regurgitation from Otto N Engl J Med 2001:345:740-746

Carpentier’s Functional Classification Type I Type II Type IIIa Type IIIb Carpentier. J Thorac Cardiovasc Surg 1983;86:323-337

Mitral regurgitation Indications for mitral valve surgery: • Symptomatic patients class I

Mitral regurgitation Indications for mitral valve surgery: • Symptomatic patients • Asymptomatic patients class I class I LV systolic dysfunction

Mitral regurgitation Indications for mitral valve surgery: • Symptomatic patients • Asymptomatic patients class I class I LV systolic dysfunction LVEF <60% LVSD >40 mm

Mitral regurgitation Indications for mitral valve surgery: • Symptomatic patients • Asymptomatic patients class I class I LV systolic dysfunction Pulmonary hypertension class IIa

Mitral regurgitation Indications for mitral valve surgery: • Symptomatic patients • Asymptomatic patients class I class I LV systolic dysfunction Pulmonary hypertension Atrial Fibrillation class IIa class IIa

? Mitral regurgitation Indications for mitral valve surgery: • Symptomatic patients • Asymptomatic patients class I class I LV systolic dysfunction Pulmonary hypertension Atrial Fibrillation Normal LV function, repair feasible? class IIa class IIa ?

Mitral Regurgitation Natural History of Severe Asymptomatic MR Asymptomatic with normal LV function 100 Medicare data Average hospital mortality: 8.8% • Low volume centers: 13.0% • High volume centers: 6.0% 80 60 Alive, Asymptomatic without Surgery (%) 40 Rosen 20 Data from national Medicare database 1994-1999 684 hospitals 142,488 AVRs 2 4 6 8 10 Time (years) Rosen et al. Am J Cardiol 1994;74:374-380

* Mitral Regurgitation Natural History of Severe Asymptomatic MR Asymptomatic with normal LV function 100 Medicare data Average hospital mortality: 8.8% • Low volume centers: 13.0% • High volume centers: 6.0% Sarano 80 * 60 Alive, Asymptomatic without Surgery (%) 40 Rosen 20 Data from national Medicare database 1994-1999 684 hospitals 142,488 AVRs 2 4 6 8 10 Time (years) Sarano et al. N Engl J Med 2005;352:875-883 Rosen et al. Am J Cardiol 1994;74:374-380

* Mitral Regurgitation Natural History of Severe Asymptomatic MR Asymptomatic with normal LV function 100 Medicare data Average hospital mortality: 8.8% • Low volume centers: 13.0% • High volume centers: 6.0% Sarano 80 * Rosenhek 60 Alive, Asymptomatic without Surgery (%) 40 Rosen 20 Data from national Medicare database 1994-1999 684 hospitals 142,488 AVRs 2 4 6 8 10 Time (years) Sarano et al. N Engl J Med 2005;352:875-883 Rosen et al. Am J Cardiol 1994;74:374-380 Rosenhek et al. Circulation 2006;113:2238-2244

* * Mitral Regurgitation Natural History of Severe Asymptomatic MR Asymptomatic with normal LV function 100 Medicare data Average hospital mortality: 8.8% • Low volume centers: 13.0% • High volume centers: 6.0% Sarano 80 * Rosenhek 60 * Alive, Asymptomatic without Surgery (%) 40 Grigioni Rosen 20 Data from national Medicare database 1994-1999 684 hospitals 142,488 AVRs 2 4 6 8 10 Time (years) Sarano et al. N Engl J Med 2005;352:875-883 Rosen et al. Am J Cardiol 1994;74:374-380 Rosenhek et al. Circulation 2006;113:2238-2244 Grigioni et. J Am Coll Cardiol Img 2008;1:133-141

* * * Mitral Regurgitation Natural History of Severe Asymptomatic MR Asymptomatic with normal LV function 100 Kang Medicare data Average hospital mortality: 8.8% • Low volume centers: 13.0% • High volume centers: 6.0% Sarano 80 * * Rosenhek 60 * Alive, Asymptomatic without Surgery (%) 40 Grigioni Rosen 20 Data from national Medicare database 1994-1999 684 hospitals 142,488 AVRs 2 4 6 8 10 Time (years) Kang et al. Circulation 2009;119:797-804 Sarano et al. N Engl J Med 2005;352:875-883 Rosen et al. Am J Cardiol 1994;74:374-380 Rosenhek et al. Circulation 2006;113:2238-2244 Grigioni et. J Am Coll Cardiol Img 2008;1:133-141

* Mitral Regurgitation Natural History of Severe Asymptomatic MR Asymptomatic with normal LV function 100 Medicare data Average hospital mortality: 8.8% • Low volume centers: 13.0% • High volume centers: 6.0% Sarano 80 * 60 Alive, Asymptomatic without Surgery (%) 40 20 Data from national Medicare database 1994-1999 684 hospitals 142,488 AVRs 2 4 6 8 10 Time (years) Sarano et al. N Engl J Med 2005;352:875-883

* Mitral Regurgitation Natural History of Severe Asymptomatic MR Survival without Heart Failure or Atrial Fibrillation 100 Medicare data Average hospital mortality: 8.8% • Low volume centers: 13.0% • High volume centers: 6.0% ERO <20 mm2 80 * 60 ERO 20-39 mm2 Alive, Asymptomatic without Heart Failure or AF (%) 40 ERO ≥40 mm2 20 Data from national Medicare database 1994-1999 684 hospitals 142,488 AVRs 2 4 6 8 10 Time (years) Sarano et al. N Engl J Med 2005;352:875-883

* Mitral Regurgitation Natural History of Severe Asymptomatic MR Survival without Heart Failure or Atrial Fibrillation 100 Medicare data Average hospital mortality: 8.8% • Low volume centers: 13.0% • High volume centers: 6.0% ERO <20 mm2 80 * 60 ERO 20-39 mm2 Alive, Asymptomatic without Heart Failure or AF (%) 36% 40 ERO ≥40 mm2 20 Data from national Medicare database 1994-1999 684 hospitals 142,488 AVRs 2 4 6 8 10 Time (years) Sarano et al. N Engl J Med 2005;352:875-883

Surgery for Acquired Cardiovascular Disease J Thorac Cardiovasc Surg 2003;125:1143-1152

Mitral Regurgitation Survival After Mitral Valve Surgery Surgery for Acquired Cardiovascular Disease Mitral Regurgitation Survival After Mitral Valve Surgery 100 Expected 80 n=488 60 64% Survival (percent) J Thorac Cardiovasc Surg 2003;125:1143-1152 40 20 p<0.001 2 4 6 8 10 12 14 Time (years) David et al, J Thorac Cardiovasc Surg 2003;126:1143-1152

Mitral Regurgitation Survival After Mitral Valve Surgery Surgery for Acquired Cardiovascular Disease Mitral Regurgitation Survival After Mitral Valve Surgery 100 FC I-II 81% 80 n=488 FC III-IV 60 Survival (percent) 58% J Thorac Cardiovasc Surg 2003;125:1143-1152 40 20 p<0.001 2 4 6 8 10 12 14 Time (years) David et al, J Thorac Cardiovasc Surg 2003;126:1143-1152

Mitral regurgitation Indications for mitral valve repair in asymptomatic MR: Chronic severe MR Preserved LV function Experienced surgical center Likelihood of successful repair without residual MR > 90%. class IIa

Mitral regurgitation Indications for mitral valve repair in asymptomatic MR: Chronic severe MR Preserved LV function Experienced surgical center Likelihood of successful repair without residual MR > 90%. class IIa Preserved LV function Likelihood of durable repair Low risk for surgery class IIb

! Mitral regurgitation Indications for mitral valve repair in asymptomatic MR: Chronic severe MR Preserved LV function Experienced surgical center Likelihood of successful repair without residual MR > 90%. class IIa Repair better than mitral valve replacement Patients should be referred to centers experienced in repair ! class I

Ischemic Mitral Regurgitation Restricted leaflet closure Mitral regurgitation Tethering of posterior leaflet Levine, N Engl J Med 2004;351:1681-1684

Survival After MI 100 80 60 61% Survival (percent) 47% 40 29% 20 MI without MR 60 61% ERO 1-19 Survival (percent) 47% 40 ERO ≥20 29% 20 p<0.001 1 2 3 4 5 Time (years) Grigioni et al. Circulation 2001;103:1759-1764

Development of Heart Failure 100 80 p<0.001 68% 60 ERO ≥20 Heart Failure (percent) 46% 40 ERO 1-19 MI without MR 18% 20 1 2 3 4 5 Time (years) Grigioni et al. Circulation 2001;103:1759-1764

Functional mitral regurgitation can be repaired.

Functional mitral regurgitation can be repaired. But should it be repaired?

Gardner and O’Gara. J Thorac Cardiovasc Surg 2010;139:830 National Heart Lung and Blood Institute People Science Health CARDIOTHORACIC SURGICAL TRIALS Gardner and O’Gara. J Thorac Cardiovasc Surg 2010;139:830

Moderate ischemic MR protocol (MMR) • CABG vs CABG plus MV repair National Heart Lung and Blood Institute People Science Health CARDIOTHORACIC SURGICAL TRIALS Moderate ischemic MR protocol (MMR) • CABG vs CABG plus MV repair Gardner and O’Gara. J Thorac Cardiovasc Surg 2010;139:830

Moderate ischemic MR protocol (MMR) • CABG vs CABG plus MV repair National Heart Lung and Blood Institute People Science Health CARDIOTHORACIC SURGICAL TRIALS Moderate ischemic MR protocol (MMR) • CABG vs CABG plus MV repair Severe chronic ischemic MR protocol (SMR) • MV repair vs MV replacement Gardner and O’Gara. J Thorac Cardiovasc Surg 2010;139:830