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MR Etiology Degenerative MR Prolapse Functional MR Ischemic vs.. nonischemic Degenerative MR Flail Normal... Secondary Functional MR: The disease is the LV!. MR grade None Mild Moder

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

Ischemic MR Outcomes

Eur Heart J 2005;26: 1528–1532

In fact…even with small amounts of iFMR - it’s poor !

Options to Treat Seconday MR

MR grade

None Mild Moderate Severe

No

9,405 2,062

Even with GD medical therapy

Hickey et al: Circulation 78:1-51, 1988

The Treatment of MR is Much More

Complicated than for AS

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”

van Bommel R J et al Circulation 2011;124:912-919

Copyright © American Heart Association

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

374;20 nejm.org May 19, 2016

Two-Year Outcomes of Surgical Treatment of Severe Ischemic Mitral Regurgitation

1 OUS commercial experience

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

( 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%)

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

P=0.007

HR [95%CI] = 1.86 [1.05 to 3.29]

P=0.04

MitraClip

OMT

MitraClip OMT

0.5 0.8 1.0

heart failure and secondary (functional) MR

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