1. 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

2. DISCLOSURES
No financial disclosures

3. Functional MR Muscle is the 1° disease

4. Pathophysiology of CHF Positive Feedback Loop
LV dysfunction MR

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

6. 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
Goel S et al. J Am Coll Cardiol 2014;63:185-6.

7. Survival in Cardiomyopathy Proportional to MR
CHF Hospitalization
Registry at 4 Italian Centers , excluded AV disease and MI 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:

8. Improved Outcomes with (DMR) Intervention Early in Natural History
229 patents with flail leaflets 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:

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

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

11. Mitral valve surgery

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

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

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

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

17. Frailty Impacts mortality and independence
Lee DH et al. Circulation 2010;121:

18. Percutaneous Treatment FMR

19. COAPT MR reduction and symptom relief1+ 2+
N=24
N=36
Stone GW et al. TCT 2016

20. 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:

21. 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:

22. FMR Data 1 Yr data across studies
OMT
OMT

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

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

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

26. 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

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

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

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

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

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

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

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

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

36. 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: