GUIDELINES IN ASYMPTOMATIC MR
DECISION MAKING DEL
CARDIOCHIRURGO
NELL’
NELL’INSUFFICIENZA MITRALICA:
ISTRUZIONI D’
D’USO PER IL
CARDIOLOGO
ACC/AHA
ESC
Antonio Miceli
Heart Hospital – Monasterio Foundation
NATURAL/ MEDICAL MR HISTORY
Organic MR is a condition with adverse events
•
•
Under medical management MR due to flail leaflets display excess mortality
compared with the genaral population
Sudden death 0.8% per year
Sarano. Lancet 2009;373:1382-94
3%
9%
6%
12%
In patients with organic MR, surgery is almost unavoidable
•
High likelihood of developing symptoms or LV dysfunction in 6-10 years.
•
Patients in their 50s, rate of surgical indication is 7-10% per year
•
Patients in their 60s, rate of death or cardiac surgery is 20% per year;
@ 10 years after diagnosis, 90% of patients either are dead or surgery
•
Mortality rate in patients with severe MR with flail leaflets is 6-7% per year.
THE QUESTION IS NOT “IF” BUT “WHEN”
SURGERY SHOULD BE PERFORMED
RATIONALE FOR EARLY SURGERY
Class I indications are associated with worse outcomes
EARLY SURGERY
VS
WATCHFUL WAITING
Tribouilloy C et al. Circulation 1999;99:400-405
RATIONALE FOR EARLY SURGERY
RATIONALE FOR EARLY SURGERY
Class I indications are associated with worse outcomes
Class I indications are associated with worse outcomes
Tribouilloy C et al. Circulation 1999;99:400-405
Tribouilloy C et al. JACC 2009;54:1961-8
RATIONALE FOR EARLY SURGERY
ATRIAL FIBRILLATION
RATIONALE FOR EARLY SURGERY
ERO
ERO>40mm is associated with :
- doubling of the mortality risk
- quadrupling of the risk of cardiac events
Sarano et al. Circulation 2010;121:804-812
RATIONAL FOR EARLY SURGERY
Sarano et al. Circulation 2010;121:804-812
Survival in asymptomatic severe MR: the
MIDA registry
B-TYPE NATRIURETIC PEPTIDE
Sarano et al. Circulation 2010;121:804-812
Suri et al., The JAMA (2013) 310:609310:609-616
Study design
Design
Initial medical management
Echo - Flail leaflet
Murmur detected
• MIDA Registry: 2097 consecutive patients with
flail mitral valve regurgitation (1980-2004).
Mean follow-up is 10.3 year and is 98%
complete.
• Routine cardiac practice at six tertiary centers
(France, Italy, Belgium and USA)
Mitral surgery
within 3 Months
Suri et al., The JAMA (2013) 310:609-616
MIDA Registry International Sites
Suri et al., The JAMA (2013) 310:609310:609-616
Participants
• One-thousand-and-twenty-one patients with mitral
regurgitation and without class I triggers
- 446 pt underwent mitral valve surgery within 3
months following detection
Rochester, MN, USA
- 575 pt initially medically managed
Brussels, Belgium
Amiens, France
Bologna, Italy
Marseille, France
Modena, Italy
Suri et al., The JAMA (2013) 310:609310:609-616
• Association between treatment strategy and
survival, heart failure, and new-onset atrial
fibrillation.
Suri et al., The JAMA (2013) 310:609310:609-616
Exclusion criteria
Baseline Characteristics
Overall
• Ischemic mitral regurgitation
• Significant concomitant aortic valve disease,
congenital heart disease, mitral stenosis, and
previous valve surgery
• Current heart failure symptoms due to mitral
regurgitation as defined per Framingham criteria
• Overt left ventricular dysfunction defined as either
ejection fraction<60 % or end-systolic diameter
≥40 mm
• Contraindication to surgery due to comorbidity
Characteristic (%)
Medical management
n=575
Early surgery
n=446
Total
n=1,021
P
Age, mean (SD) (yr)
Men
67 (13)
72.1
62 (13)
73.0
65 (13)
72.8
<0.001
0.56
Charlson index, mean (SD)
Minimal subjective manifestation
0.9 (1.2)
32.5
0.8 (1.1)
52.2
0.8 (1.2)
41.1
0.05
0.001
Ejection fraction, mean (SD) (%)
Hypertension
68.6 (6)
37.4
68.7 (6)
36.5
68.7 (6)
37.0
0.65
0.78
10.0
11.8
12.4
16.8
11.0
14.0
0.21
0.02
19.1
75 (14)
27.1
74 (16)
22.6
74 (15)
0.002
0.28
LVEDD, mean (SD) (mm)
56.0 (6.1)
57.7 (5.9)
56.7 (6.1)
<0.001
LVESD, mean (SD) (mm)
32.2 (4)
33.5 (4)
32.8 (4)
<0.001
LVESD/BSA mean (SD) (mm/m2)
17.6 (2.5)
17.9 (2.6)
17.7 (2.6)
0.04
LA diameter, mean (SD) (mm)
48.0 (8.0)
49.2 (7.6)
48.5 (7.9)
0.03
86.0
87.4
86.6
0.52
Atrial fibrillation
Pulmonary hypertension
Class II indication
Heart rate, mean (SD) (bpm)
Flail posterior
Suri et al., The JAMA (2013) 310:609310:609-616
Characteristic (%)
Age, mean (SD) (yr)
Men
Charlson index, mean (SD)
Minimal subjective manifestation
Ejection fraction, mean (SD) (%)
Hypertension
Atrial fibrillation
Pulmonary hypertension
Class II indication
Heart rate, mean (SD) (bpm)
LVEDD, mean (SD) (mm)
LVESD, mean (SD) (mm)
LVESD/BSA mean (SD) (mm/m2)
Propensity score-matched cohort
Medical management Early surgery
Total
n=324
n=324
n=648
64 (12)
64 (12)
64 (12)
76.2
76.2
76.2
0.8 (1.2)
0.8 (1.2)
0.8 (1.2)
10.1
44.1
42.1
68.5 (6)
68.2 (6)
68.3 (6)
40.1
36.4
38.3
9.9
13.7
11.8
10.8
17.0
13.9
18.2
28.7
23.52
74 (14)
74 (16)
74 (15)
56.1 (6)
57.6 (6)
56.9 (6)
32.6 (4)
33.7 (4)
33.1 (4)
17.5 (2.5)
18.0 (2.4)
17.8 (2.5)
P
0.75
>0.99
0.79
0.30
0.46
0.33
0.14
0.02
0.002
0.48
0.004
0.001
0.03
Unmatched survival in the MIDA registry
100
94.6
80
84.2
85.7
Survival (%)
Baseline Characteristics: Propensity scorematched cohort
Suri et al., The JAMA (2013) 310:609-616
60
Flail posterior
48.0 (7.4)
49.3 (7.7)
48.7 (7.6)
0.04
86.2
88.5
87.3
0.38
Suri et al., The JAMA (2013) 310:609-616
63.2
53.7
40
40.9
20
Medical
Early surgery
Log rank p < 0.001
0
0
LA diameter, mean (SD) (mm)
74.1
69.4
2
4
6
8
10 12 14 16 18 20
Time (years)
Suri et al., The JAMA (2013) 310:609-616
Matched survival in the MIDA registry
100
Unmatched chronic heart failure in the
MIDA registry
50
94
Medical
Early surgery
84
87
72
76
60
40
60
63
52
40
20
Log rank p = 0.002
0
2
6
4
8
35
28
30
23
20
16
10
Medical
Early surgery
0
Heart failure (%)
Survival (%)
80
7
4
0
2
6
4
Time (years)
8
10 12 14 16 18 20
Time (years)
Suri et al., The JAMA (2013) 310:609-616
Matched chronic heart failure in the MIDA
registry
50
Unmatched atrial fibrillation in the MIDA
registry
50
30
24
15
18
11
11
11
8
10
Atrial fibrillation (%)
40
Heart failure (%)
Suri et al., The JAMA (2013) 310:609-616
Medical
Early surgery
20
10
Log rank p < 0.001
0
10 12 14 16 18 20
10
Medical
Early surgery
43
40
36
30
26
31
27
20
15
10
14
23
4
Log rank p < 0.001
0
0
2
4
6
8
10 12 14 16 18 20
Time (years)
Log rank p = 0.33
0
0
2
4
6
8
10 12 14 16 18 20
Time (years)
Suri et al., The JAMA (2013) 310:609-616
Suri et al., The JAMA (2013) 310:609-616
Matched atrial fibrillation in the MIDA
registry
Atrial fibrillation (%)
50
Medical
Early surgery
40
32
30
35
31
25
Summary
• Early-surgery was not associated with excess short
term (3 months) mortality or heart failure, but does
carry a small increased risk of early atrial fibrillation
• Long-term results are coherent regardless of the
statistical methods employed (direct comparison,
adjusted comparison, propensity-matching,
Inverse-probability weighting) and demonstrate :
26
20
– a net survival benefit (total mortality decrement of
approximately 40%)
24
16
14
10
Log rank p = 0.33
0
0
2
4
6
8
10 12 14 16 18 20
– A diminished risk of heart failure (reduction of
approximately 60%)
Time (years)
Suri et al., The JAMA (2013) 310:609-616
What is new in Mitral Surgery?
Suri et al., The JAMA (2013) 310:609-616
Heart Hospital 10year Experience in MIMVS
Baseline Characteristics
October 2003 - April 2013
1392 Patients underwent MIMVS through right thoracotomy
Overall Logistic EuroSCORE (%)
Results
7 (4-15)
Baseline Characteristics of 978 repair
Central Aortic Cannulation
1108 pts (80%)
Femoral Artery Cannulation
287 pts (20%)
Direct Aortic Cross-Clamp
1189 pts
Endoaortic Ballon
148 pts
Ventricular Fibrillation / Beating Heart
55 pts
Conversion to sternotomy 49 patients (3.5%)
Principles of Reconstruction
Results
• Preserve or restore full leaflet motion
• Create a large surface of coaptation
• Remodel and stabilize the annulus
Results
Freedom from Reoperation
98% ±5%
Median Follow-up 3 (1-5 years)
TAKE HOME MESSAGES
1.EARLY SURGICAL INDICATIONS
1.ADVANTAGES OF MIMVS