Treatment of Chronic Mitral Regurgitation

1. 3 / 98 1 Treatment of Chronic Mitral Regurgitation Howard A. Cooper, M.D. Georgetown University Medical Center Washington, D.C.

2. 3 / 98 2 Prevalence True prevalence unknown CARDIA Study: 10.9% of young adults Cardiovascular Health Study (Age>65) 30.1% of participants had MR 26.6% of MR cases had moderate-to-severe In 1995 , 26,000 mitral valve surgeries in U.S. medicare patients

3. 3 / 98 3 Etiology In U.S., etiology changed over last 40 years 1965: primarily rheumatic (40%) 1985: primarily degenerative (42-62%) and ischemic (12-30%)

4. 3 / 98 4 Natural History Morbidity: Congestive Heart Failure Atrial fibrillation Pulmonary hypertension Embolization Mortality: 5-year mortality of 31-54% for severe MR

5. 3 / 98 5 Assessment of Severity Physical exam (murmur, S3, diastolic rumble) Electrocardiogram (LAE, LVH, Afib) Chest Xray (cardiomegaly, LAE) Cardiac catheterization (V-wave, ventriculogram)

6. 3 / 98 6 Assessment of Severity (Cont.) Echocardiogram: Qualitative assessment of regurgitant jet Volumetric flow analysis Proximal convergence analysis (PISA) Vena contracta

7. 3 / 98 7 Medical Therapy Not appropriate for symptomatic patients (unless surgery contraindicated) Hemodynamic improvement Nitroprusside Hydralazine Captopril Nifedipine Long-term benefits unproved

8. 3 / 98 8 Surgical Therapy - Timing Surgery reduces morbidity and mortality from severe MR but exposes patient to risk of surgery and prosthetic valve Surgery should be performed before onset of severe symptoms or development of LV contractile dysfunction

9. 3 / 98 9 Symptoms Class III or IV symptoms (even if transient) always indicate need for surgery Class II symptoms indicate need for surgery in patients with repairable valves ETT may reveal concealed symptoms

10. 3 / 98 10 Ejection Fraction Strongest predictor of outcome following surgery Should be assessed quantitatively Surgery indicated if LV EF is below normal (60%) If EF normal, follow every 6 to 12 months If EF <30%, medical management (valve repair experimental in this setting)

11. 3 / 98 11 Load-Independent Measures of LV Function Complex measurements: LV dP/dT End-systolic stress-strain Myocardial Elastance Peak systolic pressure/end-systolic volume End-systolic diameter LVIDs >45 predicts poor outcome End-systolic volume index ESVI >50cc/m2 predicts poor outcome

12. 3 / 98 12 Other Indications Flail mitral leaflet Left atrial dimension >45mm Paroxysmal atrial fibrillation

13. 3 / 98 13 Surgical Technique Valve replacement: Mortality 2-7% Anticoagulation Decreased LV EF Valve repair Mortality 2-3% No anticoagulation Preservation of LV EF Valve repair always preferable Feasible in 70-90% of patients

14. 3 / 98 14 Indications for Surgery Severe, Isolated, Chronic MR Definite (major criteria): NYHA Class III or IV heart failure (any duration) EF <60% EF >60% but decreasing on serial measurements LVIDs >45mm ESVI >50cc/m2

15. 3 / 98 15 Indications for Surgery Severe, Isolated, Chronic MR Emerging (minor criteria): Any symptoms of heart failureor suboptimalexercise tolerance test Flail mitral leaflet Left atrial diameter >45mm Paroxysmal atrial fibrillation Abnormal exercise end-systolic volume index or ejection fraction