1. High-Risk/End-stage Patient With Functional MR: Should We Treat with Anything? Steven R. DeBeer, MD Cardiothoracic Surgery Fellow Emory University AATS April 2015

2. Disclosures None

3. Case Presentation 66 yo F who walks using a cane and is in mod distress w/ ambulation from waiting room to exam room who presents for evaluation of her MR: – CAD MI x5 (last 10/2013) PTCA x1 CABG x3 (1996) and CABG x2 (2000) – BLE + BIMA harvested NYHA IV / CCS III – Acute on chronic CHF (systolic & diastolic) – h/o Afib, now w/ NSR s/p endocardial ablation ‘00 – COPD Home O2 dependent 40 pack year hx (quit ’13) – OSA – Pulm HTN – DM – HTN – STS PROM (MV replacement) = 22% – STS PROM (MV repair) = 16%

4. Preoperative Assessment Pulmonary Function Testeing FVC: – Post BD=1.23 (50%) FEV1: – Post BD=0.78 (42%) DLCO: – 8.4 (45%) Current Medical Management Beta-blocker ASA Statin ARB Aldosterone antagonist Loop diuretic Inhaled steroid/beta-agonist Insulin

5. TEE EF=20% – Severe global hypokinesis – Akinetic apex Mod-severe MR – Central secondary to restricted P2 scallop mobility – Coaptation length <2mm Grade 3 descending and 4 distal arch atheromatous change Mod-severe TR Mod pulm HTN

6. Cath LM: – Luminal irregularities LAD: – Occluded mid distal to LIMA-LAD anastomosis LCx: – Occluded mid RCA: – Occluded proximally, w/ distal collateral filling from LAD – Dominant Mod pulmonary HTN – PVR=3.49 W units – Mean PAP=36 No viable targets for bypass and/or PCI

7. Cardiac MRI Mod-severe MR – Dilated annulus – Poor leaflet coaptation Tethering of posterior leaflet LV – Severely dilated with reduced systolic EF (21%) – Multiple akinetic segments – Predominantly viable segment of myocardium except apex in LAD distribution – LCx distribution MI w/ nonviable myocardium RV – Mildly reduced systolic function – Mod sized reversible defect in RCA distribution

8. Tx? After GDMT, I would do: – Redo-sternotomy MVR – Thoracotomy MVR – MitraClip – TMVR – Transplant evaluation – Cont GDMT only

9. Thank you. Steven R. DeBeer, MD sdebeer@emory.edu