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IM ischémique

IM ischémique. Tout ce que vous avez toujours voulu savoir sur l’IM ischémique!! Cas clinique mis à disposition par Claire BOULETI. Case Study. 69-year old man Chronic renal failure: creatinine 170 µmol/l

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IM ischémique

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  1. IM ischémique Tout ce que vous avez toujours voulu savoir sur l’IM ischémique!! Cas clinique mis à disposition par Claire BOULETI

  2. Case Study • 69-year old man • Chronic renal failure: creatinine 170 µmol/l • CV risk factors: smoking 46PY (cessation), hypertension, dyslipidemia, diabetes mellitus

  3. Medical history • 1997 acute pulmonary oedema revealing coronary artery disease with asymptomatic RCA occlusion. • No symptom until December 2003 : • 2nd severe pulmonary oedema without triggering factor. LVEF 40%. Ischaemic MR 2/4. Coronary arteriography: not modified. Favourable evolution • Dyspnea NYHA class II-III without hospitalisation until July 2011 • 3rd pulmonary oedema in July 2011, with fast improvement under medical treatment

  4. Coronary angiography

  5. TTE

  6. TTE: Akinesis in the basal inferior segment, LVEF 30% LVEDD 65mm LVESD 54mm, ERO 60 mm2, RV 66ml vena contracta 8 mm • No left ventricular viability • ECG: Q wave in inferior leads. LBBB (QRS =140ms) • NYHA class III dyspnea refractory to medical treatment (B-, ACE-Inhibitors, diuretics) management of this patient?

  7. TTE: Akinesis in the basal inferior segment, LVEF 30% LVEDD 65mm LVESD 54mm, ERO 60 mm2, RV 66ml vena contracta 8 mm • No left ventricular viability • ECG: Q wave in inferior leads. LBBB (QRS =140ms) • NYHA class III dyspnea refractory to medical treatment (B-, ACE-Inhibitors, diuretics) management of this patient?

  8. ESCGuidelines CRT-P/-D to reduce morbidity and mortality

  9. Medical history • No clinical improvement • 4th pulmonary oedema in October without triggering factor • TTE : no major changes LVEF 25% Akinesis of the basal inferior segment, LVEDD 65mm LVESD 54mm, ERO 60 mm2, RV 66ml vena contracta 8 mm, sPAP 50 mmHg • TEE : same findings

  10. Evaluation of functional MR: Mechanism • Local remodelling ± wall motion abnormalities • Displacement of papillary muscles • Traction on mitral leaflets (tethering) • Tenting • Restriction of anterior leaflet opening • Incomplete mitral leaflet closure (Levine et al. Curr Cardiol Rep 2002;4:125-9)

  11. Evaluation of functional MR: Mechanism • Restriction in the leaflet motion (Carpentier type 3) • Incomplete leaflet closure in systole • is the consequence of changes in geometry • and/or motion of the left ventricle • Normal structure of leaflets and subvalvular apparatus • Imbalance between tethering and closure force

  12. Evaluation of functional MR: Mechanism • Tenting • The volume of regurgitation is related to the importance of tenting and not to LVEF Tenting area (Yiu et al. Circulation 2000;102:1400-6)

  13. Evaluation of functional MR: Quantification (ESC Guidelines)

  14. Back to Mr G • 69-year old male, chronic renal failure • LVEF 25% • Severe functional MR, with symptoms refractory to maximal medical treatment and resynchronisation. • No viability= no possible revascularisation Do we have to correct MR?

  15. Rationale for the Correction of Ischaemic / Functional MR Medical treatment Surgery: MVR/valve repair Mitraclip Options:

  16. The Role of Medical Therapy • Treatments which reduce the degree of • ischaemic MR= treatment of systolic heart failure • ACE inhibitors, AT1 receptors blockers • Beta-blockers • Biventricular pacing • But clinical relevance/pronostic impact on MR remains unclear

  17. Surgery for Functional MR • Prosthetic valve replacement • Preservation of subvalvular apparatus • Valve repair • Undersized annuloplasty • Restores coaptation but does not correct tethering • Limitations of intra-operative TEE • Risk of residual MR > organic MR • + CABG

  18. Surgery for Ischaemic MROperative Mortality

  19. Ischaemic and Non-Ischaemic MRConfounding Factors 535 patients operated on for mitral valve repair (1993-2002) (Glower et al. J Thorac Cardiovasc Surg 2005;129:860-8)

  20. Surgery of Ischaemic MRCABG With or Without Valve Repair • 2 groups, ischaemic MR  3/4 : - 54 had isolated CABG - 54 had CABG + valve repair • No significant difference in survival and NYHA class III-IV • Recurrence of MR after valve repair (Mihajlevic et al. J Am Coll Cardiol 2007;49:2191-201)

  21. Ischaemic MRViability and prognosis • 54 patients with severe ischaemic MR, mean LVEF 27% • Viability on PET scan • Viability and survival following coronary bypass and MV Replacement • (Pu et al. Am J Cardiol 2003;92:862-4)

  22. Surgery for Functional MR vs. Medical Therapy 682 patients with functional MR and severe LV dysfunction 126 had valve repair, 556 were treated medically Mitral annuloplasty was not a predictor of late cardiac events (death, ventricular assistance, or transplantation) (Wu et al. J Am Coll Cardiol 2005;45:381-7)

  23. Impact of Surgery on LV Remodeling • 87 patients operated for ischaemic MR (2000-2004) • 86% MR grade 3/4, LVEF 32 ± 10% • Valve repair (downsized ring) + 86% CABG • 30-day mortality 8.0% • 60% of pts had reverse LV remodeling (10% decrease in LV EDD) at 18 months FU • Thresholds predicting reverse LV remodeling • EDD < 65 mm • ESD < 51 mm (Braun et al. Eur J Cardiothorac Surg 2005;27:847-53)

  24. Reverse remodeling after surgeryUnsolved questions • Role of coronary revascularisation? • Recovery of viable myocardium • Role of MR correction? • Removal of volume overload • Experimental studies suggest that isolated MR correction does not significantly impact LV remodeling. (Guy et al. J Am Coll Cardiol 2004;43:377-83) (Enomoto et al. J Thorac Cardiovasc Surg 2005;129:504-11)

  25. Benefits of Surgical Correction of Ischaemic MR • Decrease of MR • but risk of late recurrence after repair • (Gelsomino et al. Eur Heart J 2008;29:231-40) • Left ventricular reverse remodeling • in 60% of patients, predicted by LV dilatation • (Braun et al. Eur J Cardiothorac Surg 2005;27:847-53) • Improvement of symptoms • controversial findings • No proven benefit on survival • (Wu et al. J Am Coll Cardiol 2005;45:381-7)

  26. Indications for Surgery in Ischaemic MR (ESC Guidelines) • surgery can be considered only in selected patients with severe symptoms despite optimal medical therapy

  27. What about the MitraClip System ?

  28. Percutaneous Valve Repair Using the MitraClip System (* EuroPCR 2009 † ESC 2009)

  29. Percutaneous Valve Repair Using the MitraClip System Grade 1+/ 2+ Franzen et al. At 3 months 87% MR reduction Symptoms 86 % of patients in NYHA class I-II Mean LVEF 23%  28% (ESC 2009) Everest HRR 34 patients with functional MR 83% symptom improvement 74% NYHA I-II at 12 months (EuroPCR 2009) Grade 3+/ 4+ 18% 21% 97% 82% 79% 30 days Baseline 12 months

  30. When to propose a Mitraclip in functional MR? • The device is safe and the technique is feasible. • Efficacious in lowering MR • BUT • No long-term outcome • Only 1 single randomised study (only 27% of functional MR) • AND • Will the patient benefit from this reduction of MR? • Same problem as for surgical treatment of MR… • but at a lower risk

  31. Back to Mr G • He benefited from the MitraClip system • No per-procedural complication • Favourable evolution (out of hospital at D+3)

  32. Post-procedural TTE

  33. Post-procedural TTE

  34. Post-procedural TTE

  35. Conclusion: evaluation of ischaemic MR • Functional MR is a totally different disease than organic MR. • It is frequently associated with severe ischemic heart disease which carries a poor prognosis in itself, and worsens the prognosis. • Quantification of the regurgitation uses specific (lower) thresholds for ischaemic etiologies • Need for a complete evaluation of ischaemic MR • Echocardiography (quantification, mechanism) • Viability and ischemia (radionuclide, stress echo) • LV function • Coronary angiography • Functional tolerance (symptoms)

  36. Conclusion: treatment of ischaemic MR • Operative mortality is higher and long term results are less • satisfying than for organic MR even when using valve repair • Thus, risks/benefits of surgery remain debated and indications are far more restrictive than in organic MR: • if symptoms are refractory to maximal medical therapy • in case of CABG • MitraClip system is of potential interest since the risk of the procedure is low • Need for long-term outcome and randomized studies

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