Zoll Firm Lecture Series Mitral regurgitation 2008 Zoll Firm Lecture Series

Valvular regurgitation: P ~ V relationship 2008 Zoll Firm Lecture Series

Normal mitral valve apparatus 2008 Zoll Firm Lecture Series

Zoll Firm Lecture Series 2008 Zoll Firm Lecture Series

Zoll Firm Lecture Series 2008 Zoll Firm Lecture Series

Zoll Firm Lecture Series 2008 Zoll Firm Lecture Series

Zoll Firm Lecture Series 2008 Zoll Firm Lecture Series

Zoll Firm Lecture Series 2008 Zoll Firm Lecture Series

Acute mitral regurgitation Papillary muscle rupture Acute MI Chordal rupture Pre-existing MVP Valve perforation Infectious endocarditis History consistent with ACS 48-72 hours earlier Q waves on ECG Regional WMAs on echo Valve leaflets intact history of MVP younger person no WMA on echo pap muscle intact on echo fevers, systemic symptoms history of predisposition to IE perforated leaflet on echo must rule out involvement of other valves Acute heart failure  cardiogenic shock 2008 Zoll Firm Lecture Series

Papillary muscle rupture 2008 Zoll Firm Lecture Series

Acute mitral regurgitation Must involve cardiac surgery early Intraaortic balloon pump used for immediate afterload reduction Until IABP available Nitroprusside IV Dobutamine IV 2008 Zoll Firm Lecture Series

Chronic mitral regurgitation 2008 Zoll Firm Lecture Series

Chronic (greater than mild) mitral regurgitation Organic (primary) Valve abnormal LV normal at first Secondary Valve normal LV abnormal MVP isolated connective tissue d/o rheumatic congenital endocarditis sequelae anorectic drugs Kawasaki disease Dilated annulus dilated cardiomyopathy old infarction Abnormal valve motion papillary muscle dysfxn hypertrophic myopathy No Sx Atrial arrhythmias PHTN Heart failure (SC)death 2008 Zoll Firm Lecture Series

Zoll Firm Lecture Series Mitral valve prolapse Myxomatous / redundant mitral leaflets Malcoaptation of leaflet tips Most without significant regurgitation Tendency for overdiagnosis (1980’s) 2008 Zoll Firm Lecture Series

Myxomatous mitral valve disease / MVP 2008 Zoll Firm Lecture Series

MR: Selection of patients for surgical therapy 2008 Zoll Firm Lecture Series

Why not necessarily wait until symptoms? Once severe MR is symptomatic, mortality is >20% per year Surgery alleviates symptoms and improves prognosis BUT Surgery does NOT normalize life expectancy in symptomatic patients 2008 Zoll Firm Lecture Series

Severe MR: symptomatic patients Symptoms attributable to severe MR MVR 2008 Zoll Firm Lecture Series

Dilemma in asymptomatic patients Early surgery Alleviation of symptoms Improvement in survival Reduction in disease progression Improvement in surgical methodology Longer-lasting bioprostheses (15-20 years) Intrinsic abnormalities of valve tissue raise questions re: durability of valve repair Medical therapy No operative morbidity Delay 1st operation, potentially avoid need for reoperation Avoid embolic and bleeding complications of prosthetic valves Drugs do not work ** Intrinsic LV dysfunction not always apparent ** 2008 Zoll Firm Lecture Series

Medical management of mitral regurgitation Afterload reduction ”makes sense” physiologically Acute IV vasodilation (nitroprusside)  regurgitant volume ↓ Chronic vasodilation (ACE-I, ARB, hydralazine)  modest change None of the studies demonstrate a reliable benefit in all patients over the long-term 2008 Zoll Firm Lecture Series

Medical management of mitral regurgitation Start afterload reduction (usually ACE-I) in: Anyone with another reason for afterload reduction (cardiomyopathy, HTN) Anyone with a specific indication for a specific drug (e.g., ACE-I) Pt with severe MR who is not a surgical candidate Empiric drug choice in mitral regurgitation CAD, nonischemic myopathy: ACE-I + nitrate MVP with MR – ?avoid pure preload reduction with a decrease in chamber size  beta-blocker + thiazide (careful if diabetic) Rheumatic MR: BB, thiazide, CaChB 2008 Zoll Firm Lecture Series

Severe MR: asymptomatic patients LVEF < 60% LVEDD ≥45 mm Persistent AF Depressed RV function Pulmonary HTN Definite MVR Strongly consider MVR Decreasing RVEF Paroxysmal AF 2008 Zoll Firm Lecture Series

MR: Selection of patients for surgical therapy 2008 Zoll Firm Lecture Series

MR: Selection of patients for surgical therapy Enrique-Sarano et al., NEJM 2005 2008 Zoll Firm Lecture Series

Enriquez-Sarano, et al. Circulation 1995 MVR with CABG Enriquez-Sarano, et al. Circulation 1995 2008 Zoll Firm Lecture Series

Zoll Firm Lecture Series Take home points Consider acute MR in all cases of acute heart failure, especially if patients are young, have no prior cardiac disease, or have endocarditis / ACS Search for chronic MR Use antibiotic prophylaxis if MR is greater than mild (pause to think when you get an echo report back with 2+MR) Look for a reason to start afterload reduction Refer to a cardiologist early on Be aggressive with surgical referrals in young patients with MVP and severe MR 2008 Zoll Firm Lecture Series