Echocardiographic evaluation of the mitral valve.A guide to decision making for
Transcatheter or Surgical Repair / Replacement
M. Chrissoheris
Echo in Mitral RegurgitationShould answer ALL the following:
• Mechanism – Degenerative, Functional, Mixed
• Severity – Moderate to severe, or severe
• Morphology – Clefts, indentations, calcium, thickening?
• Leaflet length
• Mitral valve area (by 2D or preferably 3D planimetry)
• Peak/mean mitral valve gradients
• Left ventricular size and systolic function
• Interatrial septum
• Systolic pulmonary artery pressure
• RV – Size and function
MR: Degenerative / Organic / Primary
Anatomic defect in one or more structures comprising the mitral valve apparatus e.g. prolapse or flail leaflets, endocarditis, rheumatic
MR Functional / Secondary
• MR is associated with severe LV dysfunction – Due to coronary artery disease (ischemic chronic secondary MR) – Idiopathic myocardial disease (nonischemic chronic secondary MR).
• Papillary muscle displacement, leaflet tethering, annular dilation that prevents adequate leaflet coaptation.
MR Functional due to Atrial Dilation
Mitral Regurgitation: Mechanisms
Examples of DMR cases:Large Anterior Flail (A2)
Examples of DMR casesLarge Anterior Flail (A2)
Wide P2 flail
Example of DMR casesPosterior P2 flail
DMR with P3 flail
Examples of FMR cases: Dilated cardiomyopathy
Example of Ischemic FMR
Example of Ischemic FMR (2)
Functional MR due to annular dilatatationDeep indentation between P1-P2
Severely calcified mitral annulus
European Heart Journal (2017) 38, 2739–2791
Zoghbi et al, J Amer Soc Echocardiography 2017;30(4)
Evaluation of Mitral Regurgitation Severity
Change in severe fMR criteria in US guidelines
…the recommended definition of severe secondary MR is now the same as for
primary MR (effective regurgitant orifice ≥0.4 cm22 and regurgitant volume ≥60
mL), with the understanding that effective regurgitant orifice cutoff of >0.2
cm2 is more sensitive and >0.4cm2 is more specific for severe MR.
Circulation. 2017;DOI: 10.1161/CIR.0000000000000503
PISA Method of MR evaluation: Assumes hemispherical PISA, and holosystolic MR
European Heart Journal – Cardiovascular Imaging (2013) 14, 611–644
3D Quantification of Vena Contracta Area
Zoghbi et al, J Amer Soc Echocardiography 2017;30(4)
Mid-late systolic MR compared with holosystolic MR of similar ERO yields smaller volume overload and a more benign outcome with smaller regurgitant volume, less enlargement of LV and LA, fewer hemodynamic consequences, and fewer cardiac events.
Circulation. 2012;125:1643-1651
Circulation. 2017;135:e1159–e1195
Management of Mitral Regurgitation ACC/AHA 2017 update
Pathophysiology and Natural History of Primary MR
• The cutoff criteria of EF<60% and
LVESD>40mm indicate that patient
has reached stage of LV
dysfunction
• Operation should be performed
ideally prior to this stage
J Am Coll Cardiol Img 2018;11:628–43
Global Longitudinal Strain (GLS)For the detection of subclinical LV dysfunction
HYGEIA Hospital Heart Team
Surgical Mitral Valve Repair in Degenerative MR
Surgical expertise and
anatomical complexity
determine probability of
successful repair
J Am Coll Cardiol Img 2018;11:628–43
Probability of Successful Mitral Valve Repair(Based on Echo findings)
European Heart Journal – Cardiovascular Imaging (2013) 14, 611–644
Surgical Mitral Valve Repair / Replacement(for degenerative MR)
J Am Coll Cardiol Img 2018;11:628–43
HYGEIA Hospital Heart Team
Surgeon’s View
HYGEIA Hospital Heart Team
Mitral Valve Quantification:Example of DMR
HYGEIA Hospital Heart Team
HYGEIA Hospital Heart Team
Mitral Valve Quantification:Example of DMR (2)
• Combination of a small LV (LVEDD<45mm), tall posterior leaflet (≥15mm), narrow aorto-mitral angle (<120◦), coaptation to septum distance <25mm and basal septal hypertrophy (≥15mm)
Predicting SAM with 2D TEE
Degenerative MR with P2 Prolapse
MV repair (initial): P2 resection (quadrangular) and annuloplasty with CE Physio II 28mm ring
Systolic Anterior Motion
Systolic anterior motion of the anterior mitral leaflet with LV outflow interference and significant dynamic mitral regurgitation
Redo MV Repair and Final Result
Sliding plasty of the posterior leaflet (to reduce height) and upsizing of annuloplasty ring to a CE Physio II 30 →Resolution of SAM and a satisfactory result
Degenerative / Primary Mitral Regurgitation:
Guidelines for MitraClip
Transcatheter mitral valve repair maybe considered for severelysymptomatic patients (NYHA class III toIV) with chronic severe primary MR(stage D) who have favorable anatomyfor the repair procedure and areasonable life expectancy but whohave a prohibitive surgical risk becauseof severe comorbidities and remainseverely symptomatic despite optimalGDMT for HF (Level of Evidence: B)
Examples of Transcatheter Mitral Valve Repair Techniques
Clin Res Cardiol (2014) 103:85–96
Clin Res Cardiol (2014) 103:85–96
Optimal Anatomy for MitraClip
HYGEIA Hospital Heart Team
Clin Res Cardiol (2014) 103:85–96
Conditionally Suitable Anatomy for MitraClip
Clin Res Cardiol (2014) 103:85–96
Conditionally Suitable Anatomy for MitraClip
Clin Res Cardiol (2014) 103:85–96
Conditionally Suitable Anatomy for MitraClip
Clin Res Cardiol (2014) 103:85–96
Conditionally Suitable Anatomy for MitraClip
Clin Res Cardiol (2014) 103:85–96
Conditionally Suitable Anatomy for MitraClip
Clin Res Cardiol (2014) 103:85–96
Conditionally Suitable Anatomy for MitraClip
Clin Res Cardiol (2014) 103:85–96
Conditionally Suitable Anatomy for MitraClip
PASCAL in a patient with flail P2
Flail P2 Scallop → Severe Eccentric MR
Final result with one PASCAL at the A2-P2 flail
Transcatheter Mitral Valve in Valve
Transcatheter Mitral Valve Replacement for Severe Degenerative MRMedtronic Twelve
Surgical MV repair in Functional MR(Echo characteristics of limited success)
European Heart Journal – Cardiovascular Imaging (2013) 14, 611–644
Functional MR: Markers of Global LV remodelling
Functional MR: Markers of regional LV remodelling
Functional MR: Markers of Mitral Valve Deformation
3D Mitral Valve QuantificationDetailed mapping of valve
J Thorac Dis 2017;9(Suppl 7):S640-S660
Mitral Valve Quantification Example of FMR
HYGEIA Hospital Heart Team
• N=251 patients with severe ischemic MR (ERO ≥40mm2) randomized to repair (restrictive annuloplasty) vs. replacement
• No significant difference in LV reverse remodeling or survival @ 2 yrs
• Significant recurrence of MR in patients treated with repair • Moderate or severe MR in 58.9% at 2 years
post procedure
• Associated with increased cardiovascular hospitalizations
Surgical Repair of Ischemic MR
• Associated with high relapse rates• Mismatch between LV-end systolic diameter
and annuloplasty ring size • Predicts persistent (and / or exacerbated)
leaflet tethering post repair with poor outcome
• Replacement preferable to repair
Circulation. 2016;134:1247–1256
• N=301 patients with moderate ischemic MR (ERO 20-39mm2), all undergoing CABG for multivessel CAD
• Comparison MV repair vs. no treatment • At 2 years significant improvement in LV function,
LVESVi, EF, global and regional wall motion in both groups
• MR ≥3+ in 32.3% CABG only, and 11.2% in repair group
• MR improved just with CABG in 68% of patients• More strokes and s/ventricular arrhythmias in the
repair group
Baseline Characteristics (ii)
HF parametersMitraClip +
GDMT (N=302)
GDMT alone
(N=312)Echo core lab
MitraClip +
GDMT (N=302)
GDMT alone
(N=312)
Etiology of HF MR severity
- Ischemic 60.9% 60.6% - Mod-to-sev (3+) 49.0% 55.3%
- Non-ischemic 39.1% 39.4% - Severe (4+) 51.0% 44.7%
NYHA class EROA, cm2 0.41 ± 0.15 0.40 ± 0.15
- I 0.3% 0% LVESD, cm 5.3 ± 0.9 5.3 ± 0.9
- II 42.7% 35.4% LVEDD, cm 6.2 ± 0.7 6.2 ± 0.8
- III 51.0% 54.0% LVESV, mL 135.5 ± 56.1 134.3 ± 60.3
- IV 6.0% 10.6% LVEDV, mL 194.4 ± 69.2 191.0 ± 72.9
HF hosp w/i 1 year 58.3% 56.1% LVEF, % 31.3 ± 9.1 31.3 ± 9.6
Prior CRT 38.1% 34.9% - 40% 82.2% 82.0%
Prior defibrillator 30.1% 32.4% RVSP, mmHg 44.0 ± 13.4 44.6 ± 14.0
Primary Effectiveness EndpointAll Hospitalizations for HF within 24 months
HR (95% CI] =
0.53 [0.40-0.70]
P<0.001
0 3 21 24
50
100
150
200
250
300
0
MitraClip + GDMT
GDMT alone
160in 92 pts
283in 151 pts
Cum
ula
tive
HF
Hospitaliz
ations
(n)
6 9 12 15 18
Time After Randomization (Months)
MitraClip 302 286 269 253 236 191 178 161 124
GDMT 312 294 271 245 219 176 145 121 88
No. at Risk:
Median [25%, 75%] FU
= 19.1 [11.9, 24.0]mos
MR Severity (Core Lab)MR grade ≤1+ 2+ 3+ 4+ Ptrend ≤2+ P-value
Baseline
MitraClip (n=302) - - 49.0% 51.0%-
--
GDMT (n=311) - - 55.3% 44.7% -
30 days
MitraClip (n=273) 72.9% 19.8% 5.9% 1.5%<0.001
92.7%<0.001
GDMT (n=257) 8.2% 26.1% 37.4% 28.4% 34.2%
6 months
MitraClip (n=240) 66.7% 27.1% 4.6% 1.7%<0.001
93.8%<0.001
GDMT (n=218) 9.2% 28.9% 42.2% 19.7% 38.1%
12 months
MitraClip (n=210) 69.1% 25.7% 4.3% 1.0%<0.001
94.8%<0.001
GDMT (n=175) 11.4% 35.4% 34.3% 18.9% 46.9%
24 months
MitraClip (n=114) 77.2% 21.9% 0% 0.9%<0.001
99.1%<0.001
GDMT (n=76) 15.8% 27.6% 40.8% 15.8% 43.4%
Functional MR: Different definitions of severity between MitraFr and COAPT trials
RESHAPE-HF2N patients, sites 420 patients at up to 40 sites
Control arm GDMT ± CRT
FMR grade EROA ≥20mm2, RVOL ≥30ml, RF≥45% by Corelab
NYHA class II, III or IV-ambulatory
Other inclusion criteria One documented heart failure hospitalization w/in past 12 months OR value of BNP ≥300pg/ml within 90 days (while on optimal therapy)
LVEF 15-45%
Primary efficacy endpoint Composite of recurrent heart failure hospitalizations and cardiovascular death
Primary safety endpoint Composite all cause mortality, stroke, MI, new renal replacement therapy, non-elective cardiac surgery in device group at 30-days
Total follow up 24 months
PIs S Anker, P Ponikowski
Is “moderate” MR acceptable in patients with severe heart failure?
Is “moderate” MR acceptable in patients with severe heart failure?
• 89 year old female, NYHA IV
• Acute anterior MI → 1o PCI
• Ischemic cardiomyopathy
– EF 35%, LVEDD 62mm, LVESD 56mm
• Multiple hospitalizations for acute
pulmonary edema
• “Moderate mitral regurgitation”
• RVOL34ml, RF 45%, EROA 20mm2
PASCAL for severe ischemic FMR
Baseline
Final
Clin Res Cardiol (2014) 103:85–96
Conditionally Suitable Anatomy for MitraClip
Clin Res Cardiol (2014) 103:85–96
Conditionally Suitable Anatomy for MitraClip
CardioValve(Valtech Cardio)
Examples of Transcatheter Mitral Valve Repair Techniques
Transcatheter Mitral Valve Implantation in Patient with severe Functional MR
• 78 year old female, NYHA III
• Severe functional mitral regurgitation
• ERO 47mm2, Rvol 55ml
• LVEDD 62mm, LVESD 51mm, EF33%
• Moderate TR, sPAP 50mmHg
• Fractured pelvis(5/2016), chronic atrial fibrillation,
LBBB, BMI 22kg/m2
• Coronaries, no stenoses
Valve Release under Rapid Ventricular Pacing
Final 3D Color
In Summary…
• Echocardiography and in particular 3-Dimensional has enhanced our understanding of mitral valve pathology and function
• Transcatheter technologies are complementary to traditional surgical techniques for degenerative MR patients with acceptable results in high risk patients
• For functional MR patients transcatheter due to its low invasiveness and high safety profile may become the preferred option for treatment, but severity criteria need to be clarified further to ensure maximal benefit
• Repair or replacement will depend on perceived risk/benefit, randomized data and long term durability concerns