Xử trí hở van hai lá quan điểm nội khoa

Mitral Regurgitation Natural History of Severe Asymptomatic MR Survival without Heart Failure or Atrial Fibrillation... Mod/Sev MR after TAVR: CoreValve RegistryIn 1,007 pts at multiple

“Early Surgical” Mitral

 Rheumatic heart disease

 IE, connective tissue

disor- ders,, cleft mitral valve, radiation heart disease…

dysfunction:

 Ischemic HD

 Dilated CM

MR Etiology

Degenerative MR (Prolapse)

Functional MR Ischemic vs nonischemic

Degenerative MR

(Flail) Normal

Prognosis of Untreated MR

Bonow, J Am Coll Cardiol 2013;61:693-701

Rosen et al Am J Cardiol 1994;74:374-380 Sarano et al N Engl J Med 2005;352:875-883 Rosenhek et al Circulation 2006;113:2238-2244 Grigioni et J Am Coll Cardiol Img 2008;1:133-141

Kang et al Circulation 2009;119:797-804

Mitral Regurgitation

Natural History of Severe Asymptomatic MR

Survival without Heart Failure or Atrial Fibrillation

Management of 3+/4+ MR with HF (CCF)

1,095 pts* with 3+/4+ MR and HF between 2000 and 2008

DMR pts (n=226): 84% MV surgery, 16% medical Rx

FMR pts (n=814): 36% MV surgery (77% w/CABG), 64% med Rx

Un-operated pts had lower LVEF (mean 27% vs 42%, p<0.0001 and higher

operated pts

STS score (median 5.8 vs 4.0, p<0.001) compared with

100

Mortality Surviving pts hospitalized for HF

* Excluded MVA ≤2 cm 2 , AR ≥2+, aortic peak velocity ≥2.5 m/s, HCM, endocarditis, concomitant AV, Ao or pericardial surgeries, LVAD or OHT

Goel SS et al JACC 2014;63,:185–90

Mod/Sev MR after TAVR: CoreValve Registry

In 1,007 pts at multiple Italian sites with severe AS treated with 3rd gen

CoreValve, baseline no/mild, moderate and severe MR (site reported)

was present in 67%, 24% and 9% of pts, respectively

Mod/Sev MR after TAVR: CoreValve Registry

In 1,007 pts at multiple Italian sites with severe AS treated with 3rd gen

CoreValve, baseline no/mild, moderate and severe MR (site reported)

was

1-year

present in 67%, 24% and 9% of pts, respectively

outcomes according to baseline MR

MR grade

Moderate (n=243)

No/mild (n=670)

Severe (n=94)

P value trend

0.20 0.09 0.09

in MR severity was not associated with a beneficial effect on survival

Bedogni F et al Circulation 2013;128:2145-53

No at risk No at risk

Mod/severe MR 266 233 216 200 188 178 166 Mod/severe MR 240 195 188 184 180 175 161 None/mild MR 65 58 52 50 47 44 40 None/mild MR 59 45 40 37 34 31 26

At baseline mod/sev MR (core lab) was present in 65/331 (19.6%) TAVR pts and 63/299 (21.2%) SAVR pts.

Survival According to Baseline Mod/Sev MR:

TAVRModerate/severe MR No/mild MR

Months after TAVR Months after SAVR

Barbanti M et al Circulation 2013;128:2776-84

Medical Therapy

For MR

Basic Principles of Medical Therapy

Secondary prevention of rheumatic fever is indicated in

patients with rheumatic heart disease, specifically

mitral stenosis

Prophylaxis against infective endocarditis (IE) is

reasonable for the following patients at highest risk for

adverse outcomes from IE prior to dental procedures

that involve manipulation of gingival tissue,

manipulation of the periapical region of teeth, or

perforation of the oral mucosa:

 Patients with prosthetic cardiac valves;

 Patients with previous IE;

 Cardiac transplant recipients with valve regurgitation

due to a structurally abnormal valve; or (continued

on next page)

Medical Therapy for Degenerative MR

• Medical

 Diuretics

 Afterload reduction (ACE)

 Beta blockers for LV dysfunction

 Anticoagulation for atrial fibrillation

Chronic Primary Mitral Regurgitation:

Medical Therapy

Medical therapy for systolic dysfunction is

reasonable in symptomatic patients with chronic

primary MR (stage D) and LVEF less than 60%

in whom surgery is not contemplated

Vasodilator therapy is not indicated for

normotensive asymptomatic patients with

chronic primary MR (stages B and C1) and

normal systolic LV function

III: No

Chronic Secondary Mitral Regurgitation:

Medical Therapy

Patients 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

Noninvasive imaging (stress nuclear/positron

emission tomography, CMR, or stress

echocardiography), cardiac CT angiography, or

cardiac catheterization, including coronary

arteriography, is useful to establish etiology of chronic

secondary MR (stages B to D) and/or to assess

myocardial viability, which in turn may influence

management of functional MR

Functional MR and Remodeling

Myocardial Insult

?

Ventricular Remodeling

Mitral Apparatus Remodeling

Mitral Valve Dysfunction

Goals of Treatment

• Functional 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

MR reduction inresponders (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

Surgical Repair for Degenerative MR:

Leaflet Repair with Annuloplasty

Surgical Repair for Functional MR:

Annuloplasty

Isolated MV Surgery: STS Database 2002-2010

N = 77,836 cases; 58.4% repair, 41.6% replacement

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

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

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.

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

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)

P=0.08

HR (95%CI) = 0.22 (0.08-0.56)

HR (95%CI) = 0.11 (0.01-0.84)

MACE = cardiac death, repeat MV surgery, and HF hospitalization

Kang DH et al JACC 2014;on-line

No at risk

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

Meta-analysis of Repair vs Replacement

for Ischemic MR

12 non-randomized studies, 2,508 pts, 64% repair, 36% replacement.

Random effects meta-analysis:

[0.38, [0.44, [0.66, [0.92,

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

VHD

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

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)

Predicted risk with surgery

of death or major morbidity (all-cause) >50% at 1 y

procedure-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

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