Functional MR: When to Intervene Functional MR: When to Intervene? An Interventional Cardiologist’s Perspective. Marvin H. Eng M.D. Structural Heart Disease Fellowship Director Center for Structural Heart Disease

DISCLOSURES No financial disclosures

Functional MR Muscle is the 1° disease

Pathophysiology of CHF Positive Feedback Loop LV dysfunction MR

Prevalence of MR in US Population Functional MR US 319 million ~ 5.1 million IIIa Marchena E. et al. J Card Surg 2011;26:385-392.

Medically Treated Functional MR Prognosis Single center retrospective observational study showing the survival with respect to mortality and heart failure hospitalizations in mostly FMR patients. There was a small population of DMR. About 15% of the patients were observed to have improvements in their MR with medical therapy despite escalation. 2000-2008 Goel S et al. J Am Coll Cardiol 2014;63:185-6.

Survival in Cardiomyopathy Proportional to MR CHF Hospitalization Registry at 4 Italian Centers , excluded AV disease and MI. 1256 patients. KM plots showing mortality and CHF hospitalization for patients with FMR ischemic and non ischemic Survival ICM Survival NICM Rossi A. et al. Heart 2011;97:1675-1680.

Improved Outcomes with (DMR) Intervention Early in Natural History 229 patents with flail leaflets 1980-1989 and the found that survival was worse when NYHA functional class was more advanced. Patients clearly did better with early surgery and with milder symptoms Ling LH et al. Circulation 1997;96:875-883.

Early corrective surgery (DMR) Minimizes heart failure risk Suri RM et al. JAMA 2013;310:609-616.

Advanced Symptoms Portend Poorer Prognosis in Surgery STS Database 1991-2007 % operative mortality STS database 1991-2007 Linked STS and CMS records 77,667 operations, after exclusions 14,604 operations Badhwar V. et al. Ann Thorac Surg 2012;94:1870-9.

Mitral valve surgery

MV Annuloplasty Lack of Efficacy in Functional MR Medical Medical Censoring pts with CAD All comers Surgery Surgery 199-2002 LVEF <= 30% and moderate-severe MR. Pts had mitral annuloplasty N=126 Wu AH et al. J Am Coll Cardiol 2005;45:381-7.

Repair in Functional MR (Ischemic) Prone to Recurrent MR Goldstein D et al. N Engl J Med 2016;374:344-53.

Recurrent MR Portends Worse Long-Term Prognosis 133 patients with recurrent MR Median 3.7 yrs (1.1-7.6) Multivariate analysis for Mortality MR recurrence 1.72 HR (1.24-2.39) p=0.002 Isolated degenerative MR repair N=1218 patients Mayo series 1990-2000 Suri RM et al. J Am Coll Cardiol 2016;67:488-98.

Mitral Valve Replacement in ICM Higher Early Mortality Compared to Repair Acker MA et al. N Engl J Med 2014;370:23-32.

Frailty Impacts mortality and independence Lee DH et al. Circulation 2010;121:973-978.

Percutaneous Treatment FMR

COAPT MR reduction and symptom relief 1+ 2+ N=24 N=36 Stone GW et al. TCT 2016

Meta-Analysis LV remodeling with Mitra-Clip Meta-analysis mitral clip in FMR 9 studies; Follow up 6-12 months (9 months) D’ascenzo F. et al. Am J Cardiol 2015;116:325-331.

Functional MR Clip vs. OMT Survival Hospitalizations 120 patient trial and survival and decreased hospitalizations seen in treated patients. Patients eligible for Clip underwent the procedure and all others were managed with medicines. Giannini C. et al. Am J Cardiol 2016;117:271-277.

FMR Data 1 Yr data across studies OMT OMT

ACCESS-EU FMR Survival Related to Baseline LVEF Schafer U et al. Am J Cardiol 2016;118:873-880.

Post Mitra-Clip NYHA I/II, MR ≤ 2+ do better Kar S TCT 2016

TCVT-Mitral Clip Acute Procedural Complications FMR % Transcatehter Valve Treatment Sentinel Registry or Eurobservation Research Programme. 8 centers 2011-2012. 72% pts with FMR. Pighi M et al. Am J Cardiol (in press)

Summary Functional mitral regurgitation Valve therapy has potential to mitigate progression Historically early treatment of MR improves outcomes Surgical treatment Replacement high early mortality Repair high rates of recurrent MR Percutaneous Mitral clip Lower early morbidity and mortality Appears to have survival benefit Treatment Early in Disease Process is Key Select anatomic candidates with a high chance for success More therapies on the horizon

Mitra-Clip in FMR NICM/ICM Survival Pighi M et al. Am J Cardiol (in press)

Mitra-Clip in FMR NICM/ICM Hospitalization for CHF Pighi M et al. Am J Cardiol (in press)

Mitra-Clip in NICM/ICM Similar Reductions in MR Pighi M et al. Am J Cardiol (in press)

COAPT Roll-in Data N=50 Stone GW et al. TCT 2016

Mitral Clip in FMR Comparison to Surgery Mauri L et al. JACC 2013;62:317-28.

TCVT-European Registry DMR/FMR Survival Nickenig G et al. J Am Coll Cardiol 2014;64:875-84.

TCVT DMR/FMR CHF Hospitalization Nickenig G et al. J Am Coll Cardiol 2014;64:875-84.

Surgical Repair with DCM Cardiomyopathy therapy 54 DCM patients s/p repair for FMR; 2000-2011 De Bonis M et al. Eur J Cardio-Thoracic Surg 2012;42:640-646.

ACCESS-EU MR reduction least with lowest LVEF FMR patients from ACCESS EU; 69.3% FMR Schafer U et al. Am J Cardiol 2016;118:873-880.