Post on 18-Apr-2018
10/2/2016
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Primary vs. Secondary Mitral Regurgitation: What the Guidelines
Say and Why
Linda D. Gillam, MD, MPH, FACC, FASEChair, Department of Cardiovascular Medicine
Morristown Medical Center/Atlantic Health SystemProfessor of Medicine
Sidney Kimmel Medical College at Thomas Jefferson University
No Disclosures
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Functional DisturbanceWhy? How bad?
Anatomic Change Disease
Valve Dysfunction
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Mitral Valve is More than
Leaflets
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Primary vs. Secondary MR
• Structural (leaflets and chords) =
Primary MR
– Degenerative (myxomatous/Barlow’s, fibroelastic deficiency)
– Endocarditis
– Rheumatic
• Functional (ventricle and annulus) =
secondary MR
– Cardiomyopathy
– Coronary disease ( “ischemic cardiomyopathy”)
Emphasized the distinction between primary
and secondary (functional)MR
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As well as…..
–Indications for intervention
–Outcomes of intervention
–Echocardiographic grading of severity
Primary
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Degenerative MR
Barlow’s
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Fibroelastic Deficiency
Rheumatic
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Functional (secondary)
regurgitation
• Occurs in the presence of anatomically
normal leaflets and chords when there
is left ventricular dysfunction
– Non-ischemic
– Ischemic
Why is there regurgitation
when the valve apparatus is
structurally intact?
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Apical Tethering is the Marker
of Functional Mitral
Regurgitation
Normal Apical Tethering
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Mechanisms of Ischemic Mitral
Regurgitation
Decreased
closing force
MR
Increased
tethering
Bulging
Papillary
muscle
traction
Annular dilatation
Papillary muscle function
• Papillary muscle dysfunction per se
does not cause functional mitral
regurgitation
• early studies: dogs (ligation,
formaldehyde)– Miller GE et al: J Thorac Cardiovasc Surg 1968; 56: 611
– Mittal AK et al: Circulation 1971;44:174
– Tsakiris AG et al: Mayo Clin Proc 1970;45:275
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When MR is caused by outward bulging of the inferior base,
extending the ischemic zone to include the papillary muscle can
paradoxically diminish MR by reducing tethering.
LV
LA
Normal
AoM
R
Post-Infarct PM functioning
PM
contraction
increases
tethering
Post-Infarct PM ischemic
Restores
coaptation
PM
stretching
decreases
tethering
Take home message
The term papillary muscle
dysfunction should be abandoned!
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LV Systolic Function
Papillary muscle displacement
Papillary muscle function
Annular dimension
Pathophysiology
Impact of Loading Conditions
LV Systolic Function
Papillary muscle displacement
Papillary muscle function
Annular dimension
Loading
Conditions
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Impact of anesthesia
BP SVR
MR
? Impact on LV Fxn,
Annular Dimensions.
Papillary M. Geometry
Karanir et al AJC 2000:85;199-203, Gemayel et Circulation 2001
Effect of Systemic BP
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Functional MR is
Prognostically Important
Bursi et al Am. J Med (2006) 119:103-112
Impact of mitral regurgitation on prognosis post MI
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Prognosis worsens with
increasing MR severity
Survival (±SE) after diagnosis according to degree of MR as graded by RVol ≥30 mL/beat or <30
mL/beat.
Francesco Grigioni, Sarano, Zehr, Bailey and Tajik
Circulation. 2001;103:1759-1764
Copyright © American Heart Association, Inc. All rights reserved.
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Survival (±SE) after diagnosis according to degree of MR as graded by ERO ≥20 mm2 or <20 mm2.
Francesco Grigioni et al. Circulation. 2001;103:1759-1764
Copyright © American Heart Association, Inc. All rights reserved.
Since we know it carries a bad
prognosis we should fix it!
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Does MV Repair help?
Castleberry (Duke) Circulation
2014
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CABG vs CABG +MVR3-4+MR LVEF<45%
Mihaljevic et al JACC 2007: 49;2191 (Cleveland Clinic)
CTSurgical Network
• Moderate ischemic MR: Randomized
trial CABG alone vs CABG plus ring
repair
• n = 250
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Original Article
Surgical Treatment of Moderate Ischemic Mitral
Regurgitation
Peter K. Smith, M.D., John D. Puskas, M.D., Deborah D. Ascheim, M.D., Pierre
Voisine, M.D., Annetine C. Gelijns, Ph.D., Alan J. Moskowitz, M.D., Judy W. Hung, M.D.,
Michael K. Parides, Ph.D., Gorav Ailawadi, M.D., Louis P. Perrault, M.D., Michael A.
Acker, M.D., Michael Argenziano, M.D., Vinod Thourani, M.D., James S. Gammie, M.D.,
Marissa A. Miller, D.V.M., Pierre Pagé, M.D., Jessica R. Overbey, M.S., Emilia
Bagiella, Ph.D., François Dagenais, M.D., Eugene H. Blackstone, M.D., Irving L.
Kron, M.D., Daniel J. Goldstein, M.D., Eric A. Rose, M.D., Ellen G. Moquete, R.N., Neal
Jeffries, Ph.D., Timothy J. Gardner, M.D., Patrick T. O'Gara, M.D., John H. Alexander, M.D.,
Robert E. Michler, M.D., for the Cardiothoracic Surgical Trials Network Investigators
N Engl J Med
Volume 371(23):2178-2188
December 4, 2014
Conclusions
• Mitral-valve repair was associated with a reduced prevalence of moderate or severe mitral regurgitation but an increased number of untoward events (longer pump run, LOS, neurologic events).
• In patients with moderate ischemic mitral regurgitation, the addition of mitral-valve repair to CABG did not result in a higher degree of left ventricular reverse remodeling.
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Conclusions
• Thus, at 1 year, this trial did not show a clinically meaningful advantage of adding mitral-valve repair to CABG (survival, CVA, QOL, readmissions, NYHA class)
• Longer-term follow-up may determine whether the lower prevalence of mitral regurgitation translates into a net clinical benefit.
NYHA Class and Death, According to Treatment Group.
Smith PK et al. N Engl J Med 2014;371:2178-2188
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Treatment
Medical vs Intervention
Primary MR
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Medical vs Intervention
Secondary MR
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Repair vs. replacement
Equipoise??
Original Article
Mitral-Valve Repair versus Replacement for Severe Ischemic Mitral Regurgitation
Michael A. Acker, M.D., Michael K. Parides, Ph.D., Louis P. Perrault, M.D., Alan J. Moskowitz, M.D., Annetine C. Gelijns, Ph.D., Pierre Voisine, M.D., Peter K. Smith, M.D., Judy W. Hung, M.D., Eugene H. Blackstone, M.D., John D. Puskas, M.D.,
Michael Argenziano, M.D., James S. Gammie, M.D., Michael Mack, M.D., Deborah D. Ascheim, M.D., Emilia Bagiella, Ph.D., Ellen G. Moquete, R.N., T. Bruce
Ferguson, M.D., Keith A. Horvath, M.D., Nancy L. Geller, Ph.D., Marissa A. Miller, D.V.M., Y. Joseph Woo, M.D., David A. D'Alessandro, M.D., Gorav Ailawadi, M.D.,
Francois Dagenais, M.D., Timothy J. Gardner, M.D., Patrick T. O'Gara, M.D., Robert E. Michler, M.D., Irving L. Kron, M.D., for the CTSN
N Engl J MedVolume 370(1):23-32
January 2, 2014
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Grading Mitral Regurgitation
Direct Measures
Collateral Damage (LV, LA
enlargement, PHTN)
How are the Criteria Different?
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Grading Mitral Regurgitation
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Does “prognostically
important” mean that the
regurgitation is severe?
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Should we be using 2D
PISA to measure
regurgitant volume and
effective regurgitant
orifice in patients with
secondary MR?
Is effective regurgitant
orifice the best way to
identify severe mitral
regurgitation?
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Summary
• Primary and Secondary MR are
fundamentally different diseases
– Pathophysiology
– Anatomy
– Outcomes
– Approaches to treatment
• Grading severity is challenging for
secondary MR
– Use integrated approach