Update on ischemic mitral regurgitation - Phạm Mạnh Hùng

Update on 
Ischemic Mitral Regurgitation: 
A/Prof. Phạm Mạnh Hùng, MD.PhD. FACC.FESC 
Director – Cardiac Cath. Lab. VNHI 
Secretary General - VNHA 
MR Etiology 
Degenerative MR 
(Prolapse) 
Functional MR 
Ischemic vs. 
nonischemic 
Degenerative MR 
(Flail) 
Normal 
Ischemic MR Pathology 
Cardiol Clin 31 (2013) 231–236 
Secondary (Functional) MR: The disease is the LV! 
Asgar, Mack, Stone. 2015;65:1231–48 
 Idiopathic 
 dilated 
cardiomyopathy 
 Ischemic 
cardiomyopathy 
Ischemic MR Outcomes 
Eur Heart J 2005;26: 1528–1532. 
 In facteven with small 
amounts of iFMR - it’s poor ! 
Options to Treat Seconday MR 
 GDMT 
 Resynchronization 
 (when LVEF impaired and LBB or QRS width 150-180ms) 
Court. M. Mack TCT 2015 
su
rv
iv
a
l 
MR grade 
None 
Mild 
Moderate 
Severe 
 No. 
9,405 
2,062 
 210 
 171 
0.4 
0.2 
0.0 
1.0 
0.8 
0.6 
0 1 2 3 4 5 
Years 
 Even with GD medical therapy 
FMR survival is not optimal! 
Hickey et al: Circulation 78:1-51, 1988 
The Treatment of MR is Much More 
 Complicated than for AS 
Secondary MR (FMR) 
COR LOE Pts with chronic secondary MR (stages B 
to D) and HF with reduced LVEF should 
receive standard GDMT therapy for HF, 
including ACE inhibitors, ARBs, beta 
blockers, and/or aldosterone antagonists 
as indicated 
Cardiac resynchronization therapy with 
biventricular pacing is recommended for 
symptomatic pts with chronic severe 
secondary MR (stages B to D) who meet 
Class I Indications 
the indications for device therapy 
Class IIb Indication 
MV surgery may be considered for severely 
symptomatic pts (NYHA class III/IV) with 
chronic severe secondary MR (stage D) 
 Nishimura RA et al. J Am Coll Cardiol 2014;63:e57–185 
In pts NOT undergoing 
 other cardiac surgery 
CRT Reduces FMR Severity 
DiBiase et al, Europace, 2011: 13, 829-838 
 CRT < half eligible, < half “respond” 
Improvers: reduction in ≥ 1 grade of FMR 
 van Bommel R J et al. Circulation 2011;124:912-919 
Residual FMR is BAD, but they do OK ? 
Copyright © American Heart Association 
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
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374;20 nejm.org May 19, 2016 
Two-Year Outcomes of Surgical Treatment of 
Severe Ischemic Mitral Regurgitation 
1. OUS commercial experience 
 MitraClip Therapy 
Global Use through April 30th, 2016 
Centers 
Patients 
Functional MR1 
 724 
>30,000 
 64% 
MR1,2 Degenerative 
Mixed* 
Implant rate3 
22% 
14% 
97% 
 2. Etiology not inclusive of U.S. cases as of 04/14/2014 
 3. First-time procedures only. Includes commercial pts, ACCESS I and II 
Data source: Abbott Vascular 
EVEREST II: Primary EP at 1 and 5 Years 
 - DMR (73%) vs. FMR (27%) - 
 (Freedom from Death, MV Surgery, or 3+ or 4+ MR): ITT 
Feldman T et al. NEJM 2011;364:1395-406 
 Feldman T et al. JACC 2015;66:2844–54 
Etiology MitraClip Surgery 
P value for 
Interaction 
Difference between MitraClip 
and Surgery (%) 
0.02 
0.02 
 26/48 (54.2%) 12/24 (50.0%) 
74/133 (55.6%) 53/65 (81.5%) 
 17/42 (40.5%) 4/14 (28.6 %) 
51/112 (45.5%) 32/42 (76.2%) 
50 0 
Surgery better MitraClip better 
-50 
1 year 
Functional 
Degenerative 
5 years 
Functional 
Degenerative 
S
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F
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 f
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 H
F
 R
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o
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p
 ,
 %
O
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 S
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 %
Giannini C et al. Am J Cardiol 2016;117:271-7 
 Comparison of MitraClip to Conservative Therapy 
 in FMR: A Matched Registry Analysis 
 60 high-risk MitraClip pts with 3+-4+ FMR were propensity matched to 
 60 conservatively treated pts with 3+-4+ FMR from a single center in Italy 
Mean age 75 yrs; mean LVEF 34% (52% ICM); median FU 515 days 
71.2% 
51.7% 
71.5% 
48.2% 
 HR [95%CI] = 
2.31 [1.30 to 4.09] 
 P=0.007 
 HR [95%CI] = 
1.86 [1.05 to 3.29] 
 P=0.04 
MitraClip 
OMT 
MitraClip 
OMT 
Follow-up in months No. at risk: 
MitraClip 
OMT 
0 6 
0.0 
12 
60 
60 
43 
35 
18 
21 
24 
10 
10 
36 18 30 
0.3 
0.5 
0.8 
1.0 
Follow-up in months No. at risk: 
MitraClip 
OMT 
0 6 
0.0 
12 
60 
60 
33 
33 
13 
18 
24 
6 
8 
36 18 30 
0.3 
0.5 
0.8 
1.0 
heart failure and secondary (functional) MR 
to MitraClip vs. GDMT or MV Surgery 
• As of June 10th, 2016, 736 patients 
 have been randomized: 
- COAPT – 430/555 (77%) 
- MITRA-FR – 201/288 (70%) 
-RESHAPE-HF-2 – 76/380 (20%) 
 -MATTERHORN – 29/210 (14%) 
-EVOLVE-HF – 0/168 (0%) 
 MitraClip RCTs in Functional MR 
• 5 trials randomizing ~1641 patients with 
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