“Early Surgical” Mitral Regurgitation: View of Cardiologist - Phạm Mạnh Hùng

MR: 
-Slow or reverse remodeling 
-Improve symptoms/functional class 
-Decrease hospitalizations for CHF 
-Increase time to transplant or VAD 
(slow progression to advanced HF) 
-Improve survival 
Medical Therapy 
• Medical treatments proven effective for 
treating the ventricular disease in large 
severity of 
patients 
RCTs also reduce the 
functional MR in some 
• Data directly addressing the effect of 
treatment on MR are less robust- old, 
small series with limited follow up. 
Beta Blocker Therapy Reduces MR 
Lowes et al. AJC 1999; 83:1201-1205 
Beta Blocker Therapy Reduces MR 
Lowes et al. AJC 1999; 83:1201-1205 
Vasodilator Therapy Reduces MR 
Seneviratne. Br Heart J. 1994;72:63-8. 
CRT and MR 
SEVERE MR 
MR reduction in 
responders (n = 25 
of 63 screened). 
EF 23% +/-8 
MILD MR 
Ypenburg C et JACC, 2007; 50:2071-2077 
CRT Reduces FMR Severity 
DiBiase et al, Europace, 2011: 13, 829-838 
Surgical Studies 
For MR 
Primary MR-Surgical Indications 
• Symptoms 
• LV Dysfunction 
• Atrial Fibrillation 
• Pulmonary Hypertension 
• Everybody with severe MR 
surgeon 
and a good 
Surgical Repair for Degenerative MR: 
Leaflet Repair with Annuloplasty 
Surgical Repair for Functional MR: 
Annuloplasty 
J Thorac Cardiovasc Surg 2003;125:1143-1152 
100 
80 
60 
40 
20 
0 
0 1 2 3 4 5 6 7 8 9 10 11 
Mitral Regurgitation 
Survival After Mitral Valve Surgery 
FC I 
 75% 
FC II 
n=840 
FC III 
 66% 
FC IV 52% 
32% 
 p<0.001 
0 2 4 6 8 10 12 14 16 18 20 
Time (years) 
David et al, Circulation 2013;127:1485-1492 
S
u
rv
iv
a
l (
p
e
rc
e
n
t)
Isolated MV Surgery: STS Database 2002-2010 
N = 77,836 cases; 58.4% repair, 41.6% replacement 
Low risk (<4%): 
Intermediate risk (4-<8%): 
High risk (8-<12%): 
Extreme risk (≥12%): 
82% 
10% 
4% 
4% 
25% 
40 Era 1 (2002-2006) 
Era 2 (2007-2010) 
20% 
30 
15% 
20 
10% 2002-2010 
10 5% 
0% 0 
0% 5% 10% 15% 20% 0.00 0.05 0.10 
STS PROM 
0.15 0.20 
Predicted Risk of Mortality 
Overall op mortality 
↓’d from 3.2% to 2.9% (P=0.03), 
and RR of observed vs. expected 
mortality ↓’d from 1.13 (1.06–1.19) 
to 1.02 (0.97–1.08), P=0.02 
2 eras: 2002-2006, 2007-2010 
MV repair rate ↑’d from 54.8% to 61.8% 
(p=0.002); ↑ seen in every risk strata. 
MV repair pts were much lower risk; STS 
<1% in 67% repair vs. 18% replacement. 
Chatterjee S et al. Ann Thorac Surg 2013;96:1587–95 
P
e
rc
e
n
t 
o
f 
P
a
ti
e
n
ts
O
b
s
e
rv
e
d
 M
o
rt
a
li
ty
Isolated MV Surgery: STS database 2002-2010 
N = 77,836 
Proportion 
cases; 58.4% repair, 41.6% replacement 
treated with MV repair vs. replacement 
according 
- 2006 
to predicted risk 
2002 2007 - 2010 
Repair Replacement Repair Replacement 
100% 100% 
80% 80% 
60% 60% 
40% 40% 
70.0 62.4 
20% 20% 
29.6 24.5 22.7 17.8 17.7 12.8 
0% 0% 
Low risk 
(<4%) 
Int risk 
(4-<8%) 
High risk 
(8-<12%) 
Low risk 
(<4%) 
Int risk 
(4-<8%) 
High risk 
(8-<12%) 
Extreme 
risk 
(≥12%) 
Extreme 
risk 
(≥12%) 
Chatterjee S et al. Ann Thorac Surg 2013;96:1587–95 
Surgery in Asymptomatic Severe DMR I 
MIDA registry (6 international centers) between 1980 and 2004: 1,021 asymptomatic pts 
with flail leaflets causing severe MR with LVEF >60% and LVESD <40 mm were treated 
with MV surgery w/i 3 mos (median 14 d; 93% repair; 22% concomitant CABG) vs. med 
Rx (with MV surgery in 59% at median of 1.65 years, 87% repair); 10 yr median FU. 
Outcomes in 324 propensity 
Survival 
matched pairs were compared 
CHF 
50 100 
Early surgery 
HR [95%CI] = 
0.44 [0.26-0.76] 
P=0.003 
80 40 
60% 
60 30 
24% Medical management 
Medical management 53% 
40 20 
HR [95%CI] = 
0.52 [0.35-0.79] 
P=0.002 
20 10 
11% 
Early surgery 
0 0 
0 5 10 
Follow-up (years) 
157 
160 
15 20 0 5 10 
Follow-up (years) 
142 
149 
15 20 
324 
324 
276 
295 
53 
35 
8 
10 
324 
324 
253 
289 
48 
31 
3 
9 
Suri RM et al. JAMA 2013;310:609-16. 
S
u
rv
iv
a
l 
(%
) 
R
is
k
 o
f 
C
H
F
 (
%
) 
CONV 207 199 174 138 108 58 38 CONV 207 199 174 138 108 58 36 CONV 207 199 172 136 108 54 31 
OP 207 203 179 137 94 00 32 OP 207 203 179 137 94 00 32 OP 207 202 170 134 93 00 31 
Surgery in Asymptomatic Severe DMR II 
At 2 S. Korean centers from 1996-2009, 610 asymptomatic pts ≤85 yo with 
severe MR (ERO ≥0.4 cm2) with LVEF >60%, LVESD <40 mm, no Afib or PHTN 
were treated with MV surgery w/i 6 mos (94% repair; 10% concomitant CABG) 
vs. med Rx (with censoring when indications for surgery developed). 
Outcomes in 207 propensity matched pairs were compared (median 8 yr FU). 
50 50 50 
Conservative 
MV surgery 
Conservative 
MV surgery 
Conservative 
MV surgery 
40 40 40 
30 30 30 
HR (95%CI) = 
0.51 (0.24-1.08) 
P=0.08 
HR (95%CI) = 
0.22 (0.08-0.56) 
HR (95%CI) = 
0.11 (0.01-0.84) 
P=0.03 
20 20 20 19% 
P=0.002 15% 
6% 10 10 10 
6% 
1% 
4% 
0 0 0 
0 2 4 6 8 10 12 0 2 4 6 8 10 12 0 2 4 6 8 10 12 
Time after Baseline, years 
No. at risk 
Time after Baseline, years 
No. at risk 
Time after Baseline, years 
No. at risk 
MACE = cardiac death, repeat MV surgery, and HF hospitalization 
Kang DH et al. JACC. 2014;on-line 
A
ll
-c
a
u
s
e
 M
o
rt
a
li
ty
 (
%
) 
C
a
rd
ia
c
 M
o
rt
a
li
ty
 (
%
) 
M
A
C
E
 (
%
) 
No. at risk 
0 1 2 3 4 5 6 7 8 9 10 
Medical treatment 1800 1198 877 633 461 332 
PCI 1295 1038 858 677 486 352 
CABG only 1651 1402 1160 901 673 402 
CABG + MVRR 243 181 144 103 72 48 
Is MV Surgery Beneficial in FMR? 
4,989 pts with CAD and mod/sev ischemic MR at Duke between 1990- 
2009 treated with MED only (1,800; 36%), PCI only (1,295; 26%), CABG 
only (1,651; 33%) and CABG + MV repair or replacement (243; 5%). 
Propensity adjusted multivariable outcomes at median FU 5.4 yrs: 
Median adj 
survival 
5.6 years 
6.8 years 
9.7 years 
8.1 years 
1.0 
0.9 
0.8 
0.7 
0.6 
0.5 
0.4 
0.3 
0.2 
0.1 
0.0 
Medical treatment 
PCI 
CABG only 
CABG + MVRR 
PCI vs Med: Adj HR (95%CI) = 0.83 (0.76 - 0.92), P=0.0002 
CABG vs. Med: Adj HR (95%CI) = 0.56 (0.52 - 0.62), P<0.0001 
CABG+MVRR vs. Med: Adj HR (95%CI) = 0.69 (0.57 - 0.82), P<0.0001 
P for interaction for MR severity = 0.61 
Castleberry AW et al. Circulation 2014:0n-line 
S
u
rv
iv
a
l 
Meta-analysis of Repair vs. Replacement 
for Ischemic MR 
12 non-randomized studies, 2,508 pts, 64% repair, 36% replacement. 
Random effects meta-analysis: 
Repair vs. replacement 
Endpoint (n studies) HR (or OR) [95%CI] P value 
Hospital death (11) 
- Studies after 1988 
Long-term death (11) 
0.56 
0.70 
0.86 
1.05 
[0.38, 
[0.44, 
[0.66, 
[0.92, 
0.85] 
1.12] 
1.13] 
1.19] 
0.006 
0.14 
0.28 
0.46 
<0.0001 
0.16 
(7) 
- Propensity adjusted 
Recurrent MR ≥2+ (5) 
Reoperation (4) 
(4) 
7.51 [3.70, 15.23] 
1.49 [0.91, 2.46] 
Dayan V et al. Ann Thorac Surg 2014;97:758–66 
Current Guidelines 
2014 AHA/ACC Guideline for the 
Management of Patients With 
Valvular Heart Disease 
Developed in Collaboration with the American Association for Thoracic Surgery, 
American Society of Echocardiography, Society for Cardiovascular Angiography and 
Interventions, Society of Cardiovascular Anesthesiologists, and Society of Thoracic 
Surgeons 
© American College of Cardiology Foundation and American Heart Association 
Stages of Progression of VHD 
Stage Definition Description 
A At risk Patients with risk factors for the development of 
VHD 
B Progressive Patients with progressive VHD (mild-to-moderate 
severity and asymptomatic) 
C 
Asymptomatic 
severe 
Asymptomatic patients who have reached the 
criteria for severe VHD 
C1: Asymptomatic patients with severe VHD in 
whom the left or right ventricle remains 
compensated 
C2: Asymptomatic patients who have severe 
VHD, with decompensation of the left or right 
ventricle 
D Symptomatic 
severe 
Patients who have developed symptoms as a result 
of VHD 
 Low Risk (must 
meet ALL criteria 
in this column ) 
Intermediate Risk 
(any 1 criteria in 
this column) 
High Risk 
(any 1 criteria in 
this column) 
Prohibitive Risk 
(any 1 criteria in this 
column) 
STS PROM <4% 
AND 
4% to 8% 
OR 
>8% 
OR 
Predicted risk with surgery 
of death or major morbidity 
(all-cause) >50% at 1 y 
OR 
Frailty None 
AND 
1 index (mild) 
OR 
2 or more indices 
(moderate-to-
severe) 
OR 
Major organ 
system 
compromise not 
to be improved 
postoperatively 
None 
AND 
1 organ system 
OR 
No more than 2 
organ systems 
OR 
3 or more organ systems 
OR 
Procedure-
specific 
impediment 
None Possible procedure-
specific impediment 
Possible procedure-
specific impediment 
Severe procedure-specific 
impediment 
Risk Assessment Combining STS Risk Estimate, Frailty, Major 
Organ System Dysfunction, and Procedure-Specific Impediments 
Stages of Primary Mitral Regurgitation 
Stages of Secondary Mitral Regurgitation (cont.) 
Indications for Surgery for Mitral Regurgitation 
Mitral regurgitation 
Indications for MV repair for 
asymptomatic degenerative MR: 
• 
• 
• 
• 
Chronic severe MR 
Preserved LV function 
Experienced surgical center 
Likelihood of durable repair 
without residual MR > 95% 
class IIa 
• 
• 
Preserved LV function 
Likelihood of durable repair 
and low risk for surgery, and class IIb 
• LA dilatation >60 ml/m2 
-- or -- 
Exercise PAP >60 mmHg 
Mitral regurgitation 
Indications for MV repair for 
asymptomatic degenerative MR: 
• 
• 
• 
• 
Chronic severe MR 
Preserved LV function 
Experienced surgical center 
Likelihood of durable repair 
without residual MR > 95%. 
class IIa 
• Repair better than mitral valve 
replacement ! class I 
• Patients should be referred to 
centers experienced in repair