1. 20090417 Few Patients With Functional MR Are Treated Surgically: Duke Database Results Mitchell W. Krucoff MD FACC, FAHA, FSCAI Professor of Medicine / Cardiology Duke University Medical Center Director, Cardiovascular Devices Unit Duke Clinical Research Institute

2. 20090417 Conflict of Interest Research grants, consulting, advisory: n Abbott Vascular n Cardiac Dimension n Medtronic n St. Jude

3. 20090417 Acknowledgement Zainab Samad, Eric Yow, Linda K Shaw, Hussein R Al-Khalidi, Kristine Arges, John H Toptine, Andrew Wang, James G Jollis, Eric J Velazquez AHA 2011

4. 20090417 Background n While systematic “real world” data exist on patients with MR undergoing surgery (Society of Thoracic Surgery=STS database), there is far less information on the incidence and outcomes of MR patients managed medically. n While valve repair/replacement is accepted therapy for degenerative MR, the value of such interventions in functional MR patients is unknown

5. 20090417 Duke Cardiovascular Database (1995-2012) 126,796 Unique Patients Echo + Cardiac Catheterization N=30,848 Echo only N=74,367 Cardiac Catheterization only N=21,579 Cath within 1 yr N=27,045 Moderate or Severe MR Cath outside 1 yr N=3,803 N=3,920 N= 280 N=5,109 N= 242 9,551 (7.5%) with Moderate or Severe MR

6. 20090417 Treatments Received Medical Therapy % 716853<0.0001 Valve within 1 yr 81742<0.0001 CABG within 1 yr 1314150.4272 Mild MRModerate MRSevere MRP value N817228191136 FMR, %928567<0.0001

7. 20090417 Unadjusted Survival by MR Severity* *censored at surgery

8. 20090417 Survival: Moderate or Severe MR by Treatment – Unadjusted* Survival Probability

9. 20090417 Results Results Echo and Cardiac Catheterization within 1 yr + Moderate or Severe MR N = 3920 Non-High Risk N= 1666 High Risk N= 2254 High Risk Criteria: STS score ≥ 12% Age > 75 + EF <40% Functional MR + EF <40% ≥ 2 prior chest surgeries Prior chest surgery + EF 2.5 mg/dL Age > 75 + prior chest surgery + Cr > 2.5 mg/dL Hepatic cirrhosis Dialysis Chronic lung disease Prior stroke Prior CABG

10. 20090417 Survival: Moderate or Severe MR by Risk Group - Unadjusted*

11. 20090417 Survival: High Risk Moderate or Severe MR by Treatment

12. 20090417 Treatment of Severe FMR: Observations From Longitudinal Data n Valve surgery is rare in all FMR, mild, moderate, severe n Combined high risk and moderate/severe MR outcomes are poor with and without surgery n Longitudinal natural history models of FMR patients may be helpful in percutaneous MV study designs