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Multi-Disciplinary Approach to Mitral Disease

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Multi-Disciplinary Approach to Mitral Disease MULTI-DISCIPLINARY APPROACH TO MITRAL DISEASE CARDIOLOGIST Nikolaos Kakouros, MBBS MRCP PhD MD(Res) FACC FSCAI Director, Structural Heart Disease program Program Director, Interventional Cardiology SHD Fellowship Co-director, TAVR program Assistant Professor of Medicine University of Massachusetts Medical School Conflicts of Interest ▪ I do not have any financial arrangements or affiliations with any of the corporate organizations offering financial support or educational grants for this continuing medical education program Objectives ▪ Understand catheter based approaches to mitral valve disease ▪ Describe the evaluation and indications for catheter based interventions ▪ Describe the common complications associated with catheter based intervention Multi-disciplinary Approach To Mitral Disease Russell C Brock (1903-1980) leading British chest and heart surgeon Pioneer of modern open heart surgery ▪ 1947 - Surgical pulmonary valve dilation and infundibular muscle resection in Fallot’s tetralogy to reduce R-L shunt ▪ Exchange professorships with Dr Alfred Blalock at JHH helped introduce new tech (hypothermia, heart-lung machine) to the nascent field of cardiac surgery Russell C Brock (1903-1980) 1948 – One of first four surgeons to operate on rheumatic mitral stenosis Finger-fracture Valvuloplasty (closed commissurotomy) RC Brock on Intracardiac Surgery ‘Intracardiac surgery is not for the lone worker. Team work is essential … success is due principally to the loyal and unstinted co-operation of my various colleagues who take part with me in this work both at Guy’s and the Brompton Hospital. To give one example, at Guy’s there is a group of some 15 people actively engaged in the work, and as time passes we find that more and more are drawn into the team.’ Peacock Club – 70 years ago ▪ Established 4/21/1948 as meeting of “those concerned in the management of congenital disease of the Heart” convened by RC Brock ▪ Thomas Peacock – author of 19C text on cardiac malformations ▪ Core Members: Guy’s cardiologists Clinical scientists from Medical Research Council Radiologist Anesthetists Surgical assistants Junior doctors and research fellows Invited speakers and named visitors Peacock Club ▪ Discussions of life threatening risks of the invasive investigations ▪ Shared management planning ▪ Self-critical reviews of operations that often went badly Hearts of the patients who died were critically examined in the presence of the whole team ▪ Meticulous documentation of treated and untreated cases. THE MITRAL VALVE MDT approach :MITRAL VALVE DISEASE STENOSIS REGURGITATION MITRAL STENOSIS ETIOLOGY RHEUMATIC CALCIFIC 60%, nearly all adult MS •Misc: Congenital (parachute MV), post-inflammatory, mucopolysaccharidosis, LA myxoma The problem ▪ Rheumatic Heart Disease prevalence: Industrialized nations 1/100 000 Worldwide: 12 000 0000 Rh Fever and Rh Heart Disease cases (Circulation. 2009;119:e211-e219) 0.14/1000 in Japan, 1.86/1000 in China, 0.5/1000 in Korea, 4.54/1000 in India, 1.3/1000 in Bangladesh ▪ Why? Streptococcal GrpA infection → Type II hypersensitivity overpopulation, overcrowding, poverty, poor access to medical care, limited availability of PCN Rheumatic Mitral valve stenosis • Normal Valve area 4-5cm2 • Valve thickening • Commissural fusion • Chordal fusion RHEUMATIC MITRAL STENOSIS RHEUMATIC MITRAL STENOSIS RHEUMATIC MITRAL STENOSIS Mitral Stenosis Severe mitral stenosis: MVA <1.5cm2 Critical mitral stenosis MVA < 1.0 cm2 • Asymptomatic • Present with incapacitating dyspnea • Pulmonary hypertension • Hemoptysis • Right heart failure, peripheral edema, orthopnea • Atrial fibrillation: 80% • Systemic thromboembolism: 20% MitralCommissurotomy 1902 : Proposed by Brunton 1920s: First successful surgical commissurotomy 1940-1950s: Trans-atrial and transventricular surgical commissurotomy were accepted clinical procedures. Open commissurotomy preferred in the US 1980s: PTMV emerged 1994: Clinically approved 21st Century: PTMV is the preferred procedure • Angelo Thomas Pezzella et al: Ann. Afr. Chir. Thor. Cardiovasc. 2012;7(1) • International Children’s Heart Fund Treatment for Mitral Stenosis PMBC vs SURGERY Balloon vs. Open Surgical Turi et al, Circulation, 83, 1179-85, 1991 PMV vs OMC vs CMC MVA at seven years follow-up PMV OMC CMC 3 ) 2 P=NS 2.5 P=0.001 (cm 2.1 2.2 P=0.001 2 P=NS Area 1.5 1.8 1.8 P=NS 1.6 1.3 Valve 1 0.9 0.9 0.9 0.5 Mitral 0 Baseline 6 Months 7 Years Farhat et al. Circulation 1998 CONCLUSIONS • PTMV and OMC have comparable initial results and low rates of restenosis, and both produce good functional capacity for at least three years. • The better hemodynamic results at three years, lower cost, and elimination of the need for thoracotomy suggest that PTMV should be considered for all patients with favorable mitral-valve anatomy. Mechanism of PTMV PTMV relieves mitral stenosis by splitting fused commissures, similar to surgical commissurotomy PTMV Technique Transseptal antegrade approach Double balloon technique Inoue balloon technique Multitrack Cribie dilator Retrograde approach Double Balloon Technique Inoue Balloon Kanji Inoue performed first PTMV with the eponymous balloon in 1984 FDA approved in 1994 Inoue Balloon Stages Transeptal TEE/ICE RHEUMATIC MITRAL STENOSIS post RHEUMATIC MITRAL STENOSIS post RHEUMATIC MITRAL STENOSIS ASD Define success ▪ MVA >2 cm2 or ▪ MV gradient <5 mmHg ▪ Others markers: 50% improvement in valve area MVA increased to >1 cm2/m2 BSA STOP when increase in MR by ONE grade (1-4) Inoue Balloon Stepwise Technique Feldman et al. Cath CV Diag 28: 199, 1993 Inoue vs Double Balloon Procedural time p<0.05 90 75 84 60 Inoue Balloon Technique Double Balloon technique Minute 45 56 30 15 25 15 0 Procedural time Fluoroscopic time Park SJ et al. Am J Coll 1993 Event-free Survival Death, MVR, redoPMV, NYHA≥3 100 (%) 83±5% 80 76±7% survival 60 free - p=NS 40 Inoue Balloon Double Balloon Event 20 0 0 1 2 3 4 5 6 7 Years Kang DH, et al J Am Coll Cardiol 2000 Complications of PTMV • Mortality 0-0.6% • Systemic embolization 0-4.5% • Severe MR(+4) 0.9-3% • Left to right shunt (>1.5:1) <5% • Transient heart block and tamponade <5% • Hemopericardium 0.5-5% Contraindication of PMV • Left atrial thrombus • Apical LV thrombus • MR>2+ • Bleeding diathesis • Severe cardiothoracic deformity Patient selection is fundamental in predicting outcome of PMV Mitral valve morphology Echocardiographic Score !!! Echo Score Mitral valve morphology 1 2 3 4 Rigidity mobile valve immobile valve Thickening thin severe thickening Calcium no bright echos multiple bright echo Subvalvular sparse echos multiple thick chordae apparatus MVA according to ES ES ≤ 8 (n=601) P<0.001 ES > 8 (n=278) 2 ) 2 2.0 (cm 1.5 P<0.001 1.6 Area 1 Valve 1.0 0.8 0.5 Mitral 0 Pre-PMV Post-PMV Palacios Circulation 2002 Success according to ES Post-PMV MVA ≥ 1.5, 50% increase in MVA, MR ≤ 2+ % 100 P=0.0002 80 86.5% 76.6% 60 40 20 0 ES ≤ 8 (n=601) ES > 8 (n=278) Palacios Circulation 2002 Changes in MVA & Success 87% 90% Pre-PMV 80% 3 80% Post-PMV 90% ) 2 80% 2.5 67% 68% 70% (cm 2.2 2.2 2.1 59% 1.9 60% 2 1.8 1.8 50% (%) Area 50% 1.6 1.5 1.4 1.5 40% 29% Success Valve 1 1 1 0.9 0.9 0.9 30% 1 0.8 0.8 0.7 20% 0.5 Mitral 10% 0 0% 4 5 6 7 8 9 1011 12 Echocardiographic score In-Hospital Events ES ≤ 8 (n=601) ES > 8 (n=278) P=0.007 6 % 5 P<0.006 5.7 4 4.3 P=NS 3 P=NS 2 2.2 2.1 1 1.3 0.8 1 1 0 Death Tamponade MVR Stroke Palacios Circulation 2002 Survival according to ES 100 Echo Score ≤ 8 80 (%) Total Group 60 Echo Score > 8 40 Survival P<0.001 20 0 0 20 40 60 80 100 120 140 160 180 Time of Follow-up (months) Palacios Circulation 2002 Event-Free Survival according to ES 100 Death, MVR, redoPMV 80 P<0.0001 (%) 60 Echo Score ≤ 8 40 Survival Total Group 20 Echo Score > 8 0 0 20 40 60 80 100 120 140 160 180 Time of Follow-up (months) Palacios Circulation 2002 Events according to ES Death, MVR, redoPMV 100 80 (%) P<0.0001 60 Echo Score ≤ 8 Survival 40 Echo Score 9 - 11 20 Echo Score ≥ 12 0 0 20 40 60 80 100 120 140 160 180 Time of Follow-up (months) Palacios Circulation 2002 Long-Term Events Independent predictors; Redo MVP, MVR, Death Variables OR CI P Age 1.02 1.01-1.03 <0.00001 NYHA IV 1.35 1.00-1.81 0.05 Prior commissurotomy 1.50 1.16-1.92 0.002 Echo score 1.31 1.02-1.67 0.03 Pre-PMV MR ≥ 2+ 1.56 1.09-2.22 0.02 Post-PMV MR ≥ 3+ 3.54 2.61-4.72 <0.00001 Post PMV Pul A pressure 1.02 1.01-1.03 <0.00001 Palacios Circulation 2002 CONCLUSIONS • PTMV is the procedure of choice the treatment of patients with MS for optimal candidates from morphologic and clinical points • Immediate post-PTMV variables in conjunction with pre-PTMV clinical and mitral morphologic variables identify most likely to benefit long-term Russell C Brock (1903-1980) 1948 – One of first four surgeons to operate on rheumatic mitral stenosis Finger-fracture Valvuloplasty (closed commissurotomy) “the mitral valve was too calcified to permit dilation; immoderate enlargement of the mitral orifice might convert mitral stenosis into severe mitral regurgitation; and patients in whom mitral regurgitation was the chief problem were not candidates for the procedure” CALCIFIC MITRAL STENOSIS ✓ Not amenable to valvuloplasty ✓ Surgery is high risk ✓ Would benefit from specialized mitral valve surgical expertise RHEUMATIC MITRAL STENOSIS 2014 AHA/ACC Valve Disease Guidelines Mitral Regurgitation Normal leaflet Excess leaflet Leaflet restriction Leaflet restriction motion motion systole & diastole systole only Prolapse or flail Endocarditis leaflet Rheumatic Ischemic Heart Dilated annulus Carcinoid disease Atrial fibrillation MVP SLE Dilated CM Restrictive CM Papillary rupture Radiation Trauma Drugs Endocarditis Mitral Regurgitation Degenerative MR Redundant Leaflets Elongated or ruptured chords Functional MR Annular dilation Annular Calcification Pap muscle dysfxn: fixed or transient Rheumatic changes Endocarditis Secondary MR ▪ Secondary MR (cf.
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