1. 3D Echo and Secondary MR
Also referred to as Functional, Ischemic, Carpentier Type IIIb Dr. Bollen Dr. Shernan

2. Advanced Echo Workshop March 23-27, 2014 SCA Echo Week – Atlanta, GA

3. Stages of Secondary MR Nishimura, RA et al.
2014 AHA/ACC Valvular Heart Disease Guideline

4. Summary of Recommendations for Chronic Severe Secondary MR
Nishimura, RA et al.
2014 AHA/ACC Valvular Heart Disease Guideline

5. 2014 Guideline Comment
The “Mitral Clip” has not been approved in the USA for treatment of secondary MR and symptoms.
Remember that patients with secondary MR have a poor 5 year prognosis regardless of therapy. Patients are treated for symptoms (CABG, MV ring vs replacement). See following 6 slides.
Heart failure cardiologists questioned the superiority of MV clip vs medical therapy in patients with severe MR who are not candidates for surgery.
Thus a clinical trial comparing medical therapy vs Mitral Valve clip is ongoing.

6. W. Bouma et al. European Journal of Cardio-thoracic Surgery 37 (2010)

7. Fig. 6. Several new mechanism-based subvalvular and ventricular surgical techniques for CIMR. (A) Second-order chordal cutting. Inferior MI causes leaflet tethering (including a typical anterior leaflet bend) and loss of coapting surface resulting in CIMR. Second-order (or basal) chordal cutting eliminates the anterior leaflet bend and improves coaptation and CIMR. The primary (or marginal) chordae prevent leaflet prolapse. Reproduced with permission from Messas et al. Copyright 2003, American Heart Association Inc. (B) Papillary muscle approximation by passing a single U-shaped suture reinforced by two patches of autologous pericardium through the bodies of the posterior and anterior papillary muscles. Reproduced with permission from Rama et al. Copyright 2007, the Society of Thoracic Surgeons. (C) Infarct plication to restore papillary muscle position closer to the anterior mitral annulus and to reduce tethering. Reproduced with permission from Liel-Cohen et al. Copyright 2000, American Heart Association Inc. (D) The Coapsys device (Myocor Inc., Maple Grove, MN, USA) was designed to treat mitral annular dilatation and PM displacement. The device consists of epicardial posterior and anterior pads connected by a flexible subvalvular chord. The two pads are located on the epicardial surface of the heart with the load-bearing subvalvular chord passing through the LV. When the device is tightened under echocardiographic guidance, the annular head increases coaptation and the papillary head repositions the PMs. Reproduced with permission from Fuckamachi et al. Copyright 2004, the Society of Thoracic Surgeons. AML: anterior mitral leaflet, Ao: aorta, AP: anterior papillary muscle, CHO: mitral valve chordae, LA: left atrium, LV: left ventricle, MR: mitral regurgitation, PM: papillary muscle, PML: posterior mitral leaflet and PP: posterior papillary muscle.
W. Bouma et al. European Journal of Cardio-thoracic Surgery 37 (2010)

8. Computer generated image (Q-labs, Philips Heathcare,Inc) showing significant apical tethering of posterior and anterior mitral valve leaflets with large tenting volume

9. Fig. 1. The influence of CIMR on survival after myocardial infarction
Fig. 1. The influence of CIMR on survival after myocardial infarction. (A) Survival depending on the presence or absence of CIMR diagnosed after MI.
(B) Survival depending on CIMR severity expressed as the effective regurgitant
orifice area (ERO) diagnosed after MI. Numbers at the bottom indicate patients
at risk for each interval. Reproduced with permission from Grigioni et al.
Copyright 2001, American Heart Association Inc.
W. Bouma et al. European Journal of Cardio-thoracic Surgery 37 (2010)

10. Fig. 4. Survival after surgery for CIMR
Fig. 4. Survival after surgery for CIMR. (A) Propensity-matched survival after CABG alone and after CABG and restrictive mitral valve annuloplasty (MVA) for grade 3+ or 4+ CIMR. After 10 years survival is similar. Modified and reproduced with permission from Mihaljevic et al. Copyright 2007, the American College of Cardiology Foundation.
(B) Survival for propensity-matched quintiles of patients after mitral valve repair (predominately MVA) and mitral valve replacement for CIMR. Quintile I represents the most severely ill patients. Survival is similar after repair or replacement.
(C) Quintiles III through V represent progressively better risk patients, and they derive a survival benefit from mitral valve repair (predominately MVA). Reproduced with permission from Gillinov et al. Copyright 2006, Springer Science and Business Media LLC. Original copyright 2001, the American Association for Thoracic Surgery.
W. Bouma et al. European Journal of Cardio-thoracic Surgery 37 (2010)

11. Fig. 5. Persistence and recurrence of CIMR after restrictive mitral annuloplasty. Postoperative prevalence of CIMR grades 3+ or 4+. Dashed lines are 68% confidence limits of average prevalence. Reproduced with permission from McGee et al. Copyright 2004, the American Association for Thoracic Surgery.
W. Bouma et al. European Journal of Cardio-thoracic Surgery 37 (2010)

12. Echocardiographic predictors of restrictive mitral annuloplasty failure secondary MR have been proposed.
Slides 13 and 14 from W. Bouma et al. European Journal of Cardio-thoracic Surgery 37 (2010) 170—185
Slides 15 and 16 from Silbiger et al. Journal of the American Society of Echocardiography Vol. 24 No. 7

13. Images referencing Table 1, slide 14
W. Bouma et al.
European Journal of Cardio-thoracic Surgery 37 (2010) 170—185

14. Table1. Independent preoperative echocardigraphic predictors of restrictive mitral annuloplasty failure.
W. Bouma et al.
European Journal of Cardio-thoracic Surgery 37 (2010) 170—185

15. Images referencing Table 1, slide 16
Figure 9 Leaflet deformation indices. (A) Parasternal long-axis view. The tenting area is outlined in green. The tenting height (red arrow)extends from the annulus to the coaptation point. (B) Apical four-chamber view demonstrating leaflet angles. The proximal anteriorleaflet angle is formed by the intersection of the annulus (dashed line) and the anterior leaflet bending distance. The distalanterior leaflet angle is formed by the intersection of the annulus and the anterior leaflet tip distance. The posterior leaflet angle isformed by the intersection of the annulus and the posterior leaflet length. The green dot represents the point of leaflet coaptation.LA, Left atrium; LV, left ventricle. Reproduced with permission from Am J Cardiol. 56

16. Table 1. Echocardiographic predictors of persistent and/or recurrent MR
Silbiger et al.
Journal of the American Society of Echocardiography Vol. 24 No. 7

17. Mitral Valve pathology in secondary MR presents in a complex and variable anatomic and dynamic annular/leaflet/chordal/LV presentation.

18. Anatomic 3-dimensional images of mitral annulus and leaflets created to observe actual configuration of annulus and leaflets with surface coloration. Inferior (left) and anterior (right) myocardial infarction. Tenting of mitral leaflets, which were tethered into left ventricle (LV), were seen in both groups of patients with ischemic mitral regurgitation. For patients with anterior infarction, mitral valve leaflets are widely tethered and bulged toward LV, in contrast with patients with inferior infarction showing localized tenting of leaflet with less bulging. L, Lateral; LA, left atrium; M, medial; A, anterior; P, posterior.
Watanbe et al JASE 2006;19:71-75

19. Secondary MR:3D and Coaptation-tenting height and area
3D DICOM images can be sliced with i-slice or other methods to define the mitral leaflet coaptation tenting height and area at different AP slice locations form AL to PM side of the annulus.
Help to define where the annular and leaflet tethering occurs.
This was shown nicely by Saito et al.

20. Saito et al.
JACC: Cardiovascular Imaging Vol. 5, No. 4, 2012

21. Figure 4. MV Apparatus Geometry
MV apparatus geometry in the onset of mitral leaflet closure (left) and the timing of maximum closure of mitral leaflet (right). The 3-dimensional tenting closed leaflet area does not include coapted leaflet area in this study. Abbreviations as in Figure 1.
Saito et al.
JACC: Cardiovascular Imaging Vol. 5, No. 4, 2012

22. Gorman, Cheung et al showed nicely, using 3D echo, the variation of regional mitral annular dysfunction in patients with ischemic mitral regurgitation.
See next two slides.

24. Vergnat et al. Ann Thorac Surg 2011;91:157-64

25. Philips 3DQ Advances
Can be used to help define the segmental wall motion abnormalities influencing leaflet tethering
Regional wall motion varies based upon anterior, inferior lateral or combined ischemia.
Wall motion changes affect motion influencing mitral valve closure causing tethering.

26. Chinitz et al.
JACC: Cardiovascular Imaging Vol. 6, No. 4, 2012

27. Chinitz et al.
JACC: Cardiovascular Imaging Vol. 6, No. 4, 2012

28. Secondary MR: Role of abnormal longitudinal and circumferential LV contraction
Classic LV wall motion assessment has looked at LV radial contraction.
Keep in mind that as the normal LV contracts, the LV muscle contraction causes circumferential and longitudinal shortening influencing normal MV closure
Abnormal LV contraction from ischemia or cardiomyopathy contributes to abnormal motion and flow affecting mitral valve closure.
Next 2 slides give idea of normal LV circumferential and longitudinal contraction (MRI studies)
2D and 3D strain studies of LV contraction are providing new insights into abnormal LV function on MV closure.

29. Codreanu et al.
Journal of Cardiovascular Magnetic Resonance 2010

30. Codreanu et al.
Journal of Cardiovascular Magnetic Resonance 2010

32. Ischemic MR Treat for symptoms (in severe MR) not to increase lifespan
Mycocardial viability, degree of LV dysfunction is key to long term success
Some echocardiographic predictors
Move by some to replace not repair in patient
Mitral clip in future?