The Conundrum of Mitral Regurgitation

in Heart Failure

Multimodality ImagingMultimodality ImagingPhilippe Pibarot, DVM, PhD, Philippe Pibarot, DVM, PhD, FACC, FASE, FESCFACC, FASE, FESCCanada Canada Research Chair in Valvular Heart Research Chair in Valvular Heart DiseaseDisease

UniversitéUniversitéLAVALLAVAL

InstitutInstitut UniversitaireUniversitaire de Cardiologie de Cardiologie et de Pneumologie de Québec / et de Pneumologie de Québec / Québec Heart & Lung InstituteQuébec Heart & Lung Institute

Disclosure related to this Disclosure related to this presentation: presentation: NoneNone

Etiology of Chronic Mitral regurgitation

Primary MRMyxomatous (MVP)

Secondary MRIschemic CM Dilated CM

Disease of the Valve(Abnormal MV Leaflets)

Disease of the Left Ventricle(MV Leaflets are normal but tethered)

Management of MR in HF

TreatmentMedicalMedical

CRTCRTPCI / CABGPCI / CABG

SurgicalSurgical MVA/MVRMVA/MVRPercutaneousPercutaneous MitralClipMitralClip / Annuloplasty / Annuloplasty

TETHERING FORCE CLOSING

FORCE

Multimodality Imaging:1- MR severity at rest and exercise (echo, stress echo)

2- LV function: EF/dyssynchrony/viability/ischemia (stress echo, CMR, PET)

3- LV remodeling and MV deformation (echo, 3D echo, CT, CMR)

Clinical: HF symptoms, episodes of decompensation

Indications for Indications for MV Surgery MV Surgery in in Chronic Chronic Secondary MRSecondary MR

Vahanian et al. ESC/EACTS 2012 Guidelines

Multimodality Imaging – Step 1

Assessing of MR Severity at rest and during exercise

- To stratify risk

- To determine indication for MV intervention

Assessing MR Severity

NOT VALID

Lancellotti et al, Eur J Echo 2010

QualitativeMitral valve morphologyColour flow MR jetFlow convergence zoneCW signal of MR jet

Semi-quantitativeVC width (mm)Pulmonary vein flowMitral inflowTVI mit/TVI Ao

QuantitativeEROA (mm²)R Vol (ml)

RepercussionsLV/LA/sPAP/TA

ERO =MR VPeak

RV = ERO × MR VTI

VC width

Quantitation of MR SeverityQuantitation of MR Severity

2πr2 × Valiasing

Vena Contracta PISA Method

Imaging of ischemic MRQuantitation of MR SeverityQuantitation of MR Severity

Volumetric Method

Quantitation of MR Severity

Severe Primary MR

ERO ≥ 40 mm2

RV ≥ 60 mL

“Severe” Secondary MR

ERO ≥ 20 mm2

RV ≥ 30 mL

Enriquez-Sarano et al. NEJM, 2005 Grigioni et al Circulation 2001, 103; 1759

VC 6.1 mm

RV 41 mlEROA 22 mm2

Man of 52 y old , History of inferior MI, PCMK NYHA III, Episodes of acute dyspnea

Grigioni et al Circulation 2001, 103; 1759

Lancellotti et al Circulation 2003, 108:1713

Severity of Secondary MR and Outcome

103 fatigue58 dyspnea

Dynamic MR on Exercise : Relationship with Symptoms and Outcomes

Lancellotti et al Circulation 2003; Eur Heart J 2005Piérard et Lancellotti NEJM, 2006

Lancellotti et al, 2012

Dynamic PHT and Outcomes in HF with Secondary MR

AUC: 0.7 for 61 mmHg

- 161 HF pts with ischemic LV dysdunction

- SPAP > 61 mmHg at exercise: 38% of patients

- Predictors of outcome: rest EROA, ΔERO, ΔSPAP

AUC 0.73

REST EXERCISE

VC 7.3 mmVC 6.1 mm

RV 41 mlEROA 22 mm2

CASE

RV 81 mlEROA 38 mm2

TTPG = 77 mmHgTTPG = 36 mmHg

Secondary MR is a disease of the left ventricle!

So look at MR Severity and …. at the left ventricle

Multimodality Imaging – Step 2

Assessing LV function/ synchrony / viability/ ischemia

- To stratify risk

- To determine indication for CRT

- To determine indication and options for revascularization

• LV function: LVEF, contractile reserveEcho, Stress echocardiography

• LV dyssynchronyEcho, Stress echocardiography

• Viability/ischemiaStress echocardiography, SPECT/PET, or CMR

• Coronary artery stenosis Cardiac CT angiography or coronary angiography

Assessing LV Function/ Synchrony / Viability/ Ischemia

Indication for CRT a/o revascularization

CASE • QRS > 130 ms with LBBB QRS morphology• LVEF <30%• Coronary Angio: no significant stenosis--> Indication of CRT (Class I)

Lancellotti et al, Am J Cardiol 2004, 94

R Vol 41 ml

R Vol 81 ml R Vol 41 ml

R Vol 23 mlDiff 18 ml

Diff 44 ml

REST OFF REST ON

EXER OFF EXER ON

Verhaert et al Circulation: Cardiovascular Imaging.2012; 5: 21-26

Outcome of Patients not Responding to CRT

CASE: 1 Year later

Back in severe heart failure

Secondary MR in HFExtent of Myocardial Necrosis/Viable Myocardium

Postero-Lateral Scar

Bleeker GB et al. Circulation 2006

Postero-Lateral Scar

Lancellotti et al Eur J Echo 2009

Bleeker GB et al. Circulation 2006

Global LV Contractile ReserveRest examination

LV EF = 36%

Low dose dobutamine

LV EF = 45%

Secondary MR in HFExtent of Myocardial Necrosis/Viable Myocardium

Penicka et al Circulation 2009MR ↓ in 47% of patients

MR ↓MR ↓MR ~

MR ~12 month-Fup

DSE Biphasic response

CASEWoman of 61 y old who was in NYHA I Patient’s history

• RF: Smoker, Non-insulin dependent diabetes, HPT• COPD

Clinical features• Acute pulmonary edema

CORONARY ANGIOGRAPHY

EuroSCORE, STS, and Ambler score

- provide relatively good discrimination- a gross estimation of risk category- cannot be used to estimate the exact operative mortality in

an individual patient because of unsatisfactory calibration

Lancellotti et al Heart 2008

Cas présentation NB: Non inidcation for revascOther case with option?RESTREST

EXERCISEEXERCISE

No contractile reserveNo evidence of inducible ischemia

Multimodality Imaging – Step 3

Assessing LV remodeling & MV deformation

- To predict risk of persistent / recurrent MR following MV annuloplasty

- To determine best option for MV intervention

MV Repair vs. Replacement in Severe IMR

0

5

10

15

20≥ Moderate MR at 1 Year

18%18%

44%% 0

10

20

30

40≥ Moderate MR at 1 Year

33%33%

2%2%

Magne et al. Circulation 2009 Acker et al NEJM 2013

MVRp MVR MVRp MVR

CABG Alone vs. CABG + MV Repair in Moderate IMR

0

10

20

30

40≥ Moderate MR at 1 Year

31%31%

11%11%

Smith et al. NEJM 2014

CABGAlone

CABG+MVRp

Incidence of postoperative ≥ Moderate MR after MV Annuloplasty

Magne et al. Cardiology 2007

LV Remodeling and MV Deformation Global LV Global LV

RemodelingRemodelingLocal LV Local LV

RemodelingRemodeling MV DeformationMV Deformation

Predicting Risk of MV Annuloplasty Failure:Severity of MV DeformationSeverity of MV Deformation

Pérard et al. European Heart Journal ; 2010: 31, 2996–3005

Global LV remodellingEDD ≥ 65 mm, ESD ≥ 51 mm (ESV ≥ 140 mL)

Local LV remodellingInterpapillary muscle distance ≥ 20 mm

Posterior papillary-fibrosa distance ≥ 40 mmLateral wall motion abnormality

Mitral valve deformationCoaptation distance ≥1 cm

Tenting area ≥ 2.5 cm2

Posterior leaflet angle ≥45○

Complex jets

Echo Features of LV Remodeling and MV Deformation To Predict Persistent/Recurrent

MR for MV Repair

Lancellotti et al. EHJ; 2010:11,307–332EACVI Recommendations

FUTURE PERSPECTIVES

Secondary MR is not ONLY a disease of the left ventricle!

It is ALSO a maladaptation of the MV leaflets

So look at the MV leaflet size

Beaudoin et al., SCCT 2012

Anterior leaflet

Posterior leaflet

F

A B

DC

Measuring the surface of MV leaflets by CT or 3D Echo

Beaudoin et al. JACC 2013

Beaudoin et al. JACC 2013

Total MV Leaflet Area vs. LV End-Diatsolic Volume

• Patients with secondary MR have inadequate leaflet compensation, as expressed by decreased ratios of leaflet area / annulus area

• Imaging will play a key role to understand why some patients have adequate vs inadequate valve adaptation

• Medications targeting the TGF-beta pathway may help to reduce the leaflet/annulus size mismatch and thus secondary MR in HF

Total MV Leaflet Area vs. LV End-Diatsolic Volume

SEVERE MR (ERO ≥20 mm2)

LV EDD ≥65 mmSevere Mitral Valve

Deformation

CABG+MVS

MVA+Adjuvant TechniqueMitral Valve Replacement

Optimization of HF Therapy including

CRT if indicated (I)

Myocardial Viability / IschemiaIndication / Options for revascularization

Heart TransplantMitraclip?

MVS (IIb) /Mitraclip

Moderately Depressed LVEF (>30%)

Severely Depressed LVEF (<30%)

No Yes NoYes(IIa)(I) Optimization of HF

Therapy including CRT if indicated (I)

No Improvement

No Improvement

MODERATE MR (ERO <20 mm2)

LV EDD ≥65 mmSevere Mitral Valve Deformation

CABG+MVS (IIa)

MVA + Adjuvant TechniqueMitral Valve Replacement

Manage as severe MR

Indication for CABG

Dynamic Increase in MR / SPAP

NoYesOptimization of HF Therapy including

CRT if indicated (I)

MR and SPAP stable

Exercise Stress Echo