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IM ischmique Tout ce que vous avez toujours voulu savoir sur lIM ischmique!! Cas clinique mis disposition par Claire BOULETI Slide 2 Case Study 69-year old man Chronic renal failure: creatinine 170 mol/l CV risk factors: smoking 46PY (cessation), hypertension, dyslipidemia, diabetes mellitus Slide 3 Medical history 1997 acute pulmonary oedema revealing coronary artery disease with asymptomatic RCA occlusion. No symptom until December 2003 : 2 nd severe pulmonary oedema without triggering factor. LVEF 40%. Ischaemic MR 2/4. Coronary arteriography: not modified. Favourable evolution Dyspnea NYHA class II-III without hospitalisation until July 2011 3rd pulmonary oedema in July 2011, with fast improvement under medical treatment Slide 4 Coronary angiography Slide 5 TTE Slide 6 Slide 7 TTE: Akinesis in the basal inferior segment, LVEF 30% LVEDD 65mm LVESD 54mm, ERO 60 mm 2, RV 66ml vena contracta 8 mm No left ventricular viability ECG: Q wave in inferior leads. LBBB (QRS =140ms) NYHA class III dyspnea refractory to medical treatment (B-, ACE-Inhibitors, diuretics) management of this patient? Slide 8 TTE: Akinesis in the basal inferior segment, LVEF 30% LVEDD 65mm LVESD 54mm, ERO 60 mm 2, RV 66ml vena contracta 8 mm No left ventricular viability ECG: Q wave in inferior leads. LBBB (QRS =140ms) NYHA class III dyspnea refractory to medical treatment (B-, ACE-Inhibitors, diuretics) management of this patient? Slide 9 Class Patients with NYHA function class III/IV, LVEF 35%, QRS 120 ms, SR Optimal medical therapy Class IV patients should be ambulatory IA ESC Guidelines CRT-P/-D to reduce morbidity and mortality Slide 10 No clinical improvement 4 th pulmonary oedema in October without triggering factor TTE : no major changes LVEF 25% Akinesis of the basal inferior segment, LVEDD 65mm LVESD 54mm, ERO 60 mm 2, RV 66ml vena contracta 8 mm, sPAP 50 mmHg TEE : same findings Medical history Slide 11 Slide 12 Slide 13 Evaluation of functional MR: Mechanism Local remodelling wall motion abnormalities Displacement of papillary muscles Traction on mitral leaflets (tethering) Tenting Restriction of anterior leaflet opening Incomplete mitral leaflet closure (Levine et al. Curr Cardiol Rep 2002;4:125-9) Slide 14 Restriction in the leaflet motion (Carpentier type 3) Incomplete leaflet closure in systole is the consequence of changes in geometry and/or motion of the left ventricle Normal structure of leaflets and subvalvular apparatus Imbalance between tethering and closure force Evaluation of functional MR: Mechanism Slide 15 Tenting The volume of regurgitation is related to the importance of tenting and not to LVEF Tenting area (Yiu et al. Circulation 2000;102:1400-6) Evaluation of functional MR: Mechanism Slide 16 Criteria Mitral Regurgitation Specific signs of severe regurgitation Vena contracta width 0.7 cm with large central MR jet (area > 40% of LA) or with a wall impinging jet of any size, swirling in LA Large flow convergence Systolic reversal in pulmonary veins Prominent flail mitral valve or ruptured papillary muscle Supportive signsDense, triangular CW Doppler MR jet E-wave dominant mitral inflow (E > 1.2m/s) Enlarged LV and LA size (particularly when normal LV function is present) Quantitative parameters Organic MR Functional MR Reg. Vol (ml/beat) 60 30 RF (%) 50 ERO (cm) 0.40 0.20 Evaluation of functional MR: Quantification (ESC Guidelines) Slide 17 Back to Mr G 69-year old male, chronic renal failure LVEF 25% Severe functional MR, with symptoms refractory to maximal medical treatment and resynchronisation. No viability= no possible revascularisation Do we have to correct MR? Slide 18 Rationale for the Correction of Ischaemic / Functional MR Options: Medical treatment Surgery: MVR/valve repair Mitraclip Slide 19 The Role of Medical Therapy Treatments which reduce the degree of ischaemic MR= treatment of systolic heart failure ACE inhibitors, AT1 receptors blockers Beta-blockers Biventricular pacing But clinical relevance/pronostic impact on MR remains unclear Slide 20 Surgery for Functional MR Prosthetic valve replacement Preservation of subvalvular apparatus Valve repair Undersized annuloplasty Restores coaptation but does not correct tethering Limitations of intra-operative TEE Risk of residual MR > organic MR + CABG Slide 21 Surgery for Ischaemic MR Operative Mortality Slide 22 535 patients operated on for mitral valve repair (1993-2002) Ischaemic and Non-Ischaemic MR Confounding Factors ( Glower et al. J Thorac Cardiovasc Surg 2005;129:860-8) Slide 23 Surgery of Ischaemic MR CABG With or Without Valve Repair 2 groups, ischaemic MR 3/4 : - 54 had isolated CABG - 54 had CABG + valve repair No significant difference in survival and NYHA class III-IV Recurrence of MR after valve repair (Mihajlevic et al. J Am Coll Cardiol 2007;49:2191-201) Slide 24 54 patients with severe ischaemic MR, mean LVEF 27% Viability on PET scan Ischaemic MR Viability and prognosis Viability and survival following coronary bypass and MV Replacement (Pu et al. Am J Cardiol 2003;92:862-4) Slide 25 682 patients with functional MR and severe LV dysfunction 126 had valve repair, 556 were treated medically Surgery for Functional MR vs. Medical Therapy (Wu et al. J Am Coll Cardiol 2005;45:381-7) Mitral annuloplasty was not a predictor of late cardiac events (death, ventricular assistance, or transplantation) Slide 26 Impact of Surgery on LV Remodeling 87 patients operated for ischaemic MR (2000-2004) 86% MR grade 3/4, LVEF 32 10% Valve repair (downsized ring) + 86% CABG 30-day mortality 8.0% 60% of pts had reverse LV remodeling ( 10% decrease in LV EDD) at 18 months FU Thresholds predicting reverse LV remodeling EDD < 65 mm ESD < 51 mm (Braun et al. Eur J Cardiothorac Surg 2005;27:847-53) Slide 27 Role of coronary revascularisation? Recovery of viable myocardium Role of MR correction? Removal of volume overload Experimental studies suggest that isolated MR correction does not significantly impact LV remodeling. (Guy et al. J Am Coll Cardiol 2004;43:377-83) (Enomoto et al. J Thorac Cardiovasc Surg 2005;129:504-11) Reverse remodeling after surgery Unsolved questions Slide 28 Benefits of Surgical Correction of Ischaemic MR Decrease of MR but risk of late recurrence after repair (Gelsomino et al. Eur Heart J 2008;29:231-40) Left ventricular reverse remodeling in 60% of patients, predicted by LV dilatation (Braun et al. Eur J Cardiothorac Surg 2005;27:847-53) Improvement of symptoms controversial findings No proven benefit on survival (Wu et al. J Am Coll Cardiol 2005;45:381-7) Slide 29 Indications for Surgery in Ischaemic MR Chronic Ischaemic MR Class Patients with severe MR, LV EF > 30% undergoing CABGIC Patients with moderate MR undergoing CABG if repair is feasible IIaC Symptomatic patients with severe MR, LV EF < 30% and option for revascularization IIaC Patients with severe MR, LVEF > 30%, no option for revascularization, refractory to medical therapy, and low comorbidity IIbC surgery can be considered only in selected patients with severe symptoms despite optimal medical therapy (ESC Guidelines) Slide 30 What about the MitraClip System ? Slide 31 Percutaneous Valve Repair Using the MitraClip System Everest-II * HRR (n=78) Franzen et al. (n=26) Mean age (yrs)7770 Functional MR (%)59100 NYHA III-IV90100 MR 3/4 (%)100 Mean LVEF (%)5422 Implant success (%)9692 Implant success and MR 2/4 (%)8192 (* EuroPCR 2009 ESC 2009) Slide 32 Everest HRR 34 patients with functional MR 83% symptom improvement 74% NYHA I-II at 12 months (EuroPCR 2009) Percutaneous Valve Repair Using the MitraClip System Grade 3+/ 4+ Grade 1+/ 2+ 97% 18%21% 82%79% Franzen et al. At 3 months 87% MR reduction Symptoms 86 % of patients in NYHA class I-II Mean LVEF 23% 28% (ESC 2009) Baseline 30 days 12 months Slide 33 When to propose a Mitraclip in functional MR? The device is safe and the technique is feasible. Efficacious in lowering MR BUT No long-term outcome Only 1 single randomised study (only 27% of functional MR) AND Will the patient benefit from this reduction of MR? Same problem as for surgical treatment of MR but at a lower risk Slide 34 Back to Mr G He benefited from the MitraClip system No per-procedural complication Favourable evolution (out of hospital at D+3) Slide 35 Post-procedural TTE Slide 36 Slide 37 Slide 38 Conclusion: evaluation of ischaemic MR Functional MR is a totally different disease than organic MR. It is frequently associated with severe ischemic heart disease which carries a poor prognosis in itself, and worsens the prognosis. Quantification of the regurgitation uses specific (lower) thresholds for ischaemic etiologies Need for a complete evaluation of ischaemic MR Echocardiography (quantification, mechanism) Viability and ischemia (radionuclide, stress echo) LV function Coronary angiography Functional tolerance (symptoms) Slide 39 Thus, risks/benefits of surgery remain debated and indications are far more restrictive than in organic MR: if symptoms are refractory to maximal medical therapy in case of CABG MitraClip system is of potential interest since the risk of the procedure is low Need for long-term outcome and randomized studies Operative mortality is higher and long term results are less satisfying than for organic MR even when using valve repair Conclusion: treatment of ischaemic MR