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

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

3. Lancet 2006;368:

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

5. Moderate-Severe Mitral Valve Disease
CARDIA, ARIC,
CHS 10
Population-Based Studies
9.5%
11,911 subjects in
CARDIA, ARIC, CHS
Lancet 2006;368: 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:

6. 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:

7. 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:

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

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

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

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

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

16. 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

17. ? 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 ?

18. 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
684 hospitals
142,488 AVRs 2 4 6 8 10
Time (years)
Rosen et al. Am J Cardiol 1994;74:

19. * 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
684 hospitals
142,488 AVRs 2 4 6 8 10
Time (years)
Sarano et al. N Engl J Med 2005;352:
Rosen et al. Am J Cardiol 1994;74:

20. * 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
684 hospitals
142,488 AVRs 2 4 6 8 10
Time (years)
Sarano et al. N Engl J Med 2005;352:
Rosen et al. Am J Cardiol 1994;74:
Rosenhek et al. Circulation 2006;113:

21. * * 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
684 hospitals
142,488 AVRs 2 4 6 8 10
Time (years)
Sarano et al. N Engl J Med 2005;352:
Rosen et al. Am J Cardiol 1994;74:
Rosenhek et al. Circulation 2006;113:
Grigioni et. J Am Coll Cardiol Img 2008;1:

22. * * * 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
684 hospitals
142,488 AVRs 2 4 6 8 10
Time (years)
Kang et al. Circulation 2009;119:
Sarano et al. N Engl J Med 2005;352:
Rosen et al. Am J Cardiol 1994;74:
Rosenhek et al. Circulation 2006;113:
Grigioni et. J Am Coll Cardiol Img 2008;1:

23. * 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
684 hospitals
142,488 AVRs 2 4 6 8 10
Time (years)
Sarano et al. N Engl J Med 2005;352:

24. * 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 mm2
Alive, Asymptomatic without Heart Failure or AF (%) 40
ERO ≥40 mm2 20
Data from national Medicare database
684 hospitals
142,488 AVRs 2 4 6 8 10
Time (years)
Sarano et al. N Engl J Med 2005;352:

25. * 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 mm2
Alive, Asymptomatic without Heart Failure or AF (%)
36% 40
ERO ≥40 mm2 20
Data from national Medicare database
684 hospitals
142,488 AVRs 2 4 6 8 10
Time (years)
Sarano et al. N Engl J Med 2005;352:

26. Surgery for Acquired Cardiovascular Disease
J Thorac Cardiovasc Surg 2003;125:

27. 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: 40 20
p<0.001 2 4 6 8 10 12 14
Time (years)
David et al, J Thorac Cardiovasc Surg 2003;126:

28. 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: 40 20
p<0.001 2 4 6 8 10 12 14
Time (years)
David et al, J Thorac Cardiovasc Surg 2003;126:

29. 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

30. 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

31. ! 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

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

35. 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:

36. 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:

37. Functional mitral regurgitation
can be repaired.

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

39. 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

40. 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

41. 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