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Mitral Regurgitation Advanced echocardiography

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Mitral Regurgitation Advanced echocardiography Powered By Docstoc
					                                                                        Disclosures
Degenerative Mitral Regurgitation
Echocardiographic Planning for Operation
                                                                        • NeoChord
                                                                             Mayo owns equity through license agreement
                                                                             Royalties
  Advanced Echocardiography 2011
         Charles J. Bruce, MBChB, FCP(SA), FACC
                   Professor of Medicine
               Director Interventional Imaging
  Division of Cardiovascular Diseases & Internal Medicine
                  Mayo College of Medicine
                       Rochester, MN
                                                                                                                          3029554-2




Overview                                                                Question 1
                                                                        54 yo symptomatic pt with severe MR
• Why is accurate assessment of MR critical?
• Important role of echocardiography
  Lesion severity
  Mechanism
  3D TEE

• Timing of surgery
                                                                        1.     Should undergo MV repair with > 90%
• Newer advances                                                               chance of success
                                                                        2.     Should undergo MV replacement
                                                            3029554-3   3.     Does not need surgery at this time



                                                                                                                                      1
Question 2                                             Why is Echo Assessment Important
This 48 yo asymptomatic fireman
                                                       • Timing of surgery
                                                       • Type of surgery
                                 EF 65%                • Who will do the surgery
                                 ESD 35 mm
                                 ERO 0.4 cm2
                                 RV 40 cc
1.   Should undergo MV repair with > 90%
     chance of success
2.   Should undergo MV replacement
3.   Does not need surgery at this time                                                                                                 3029554-6




Asymptomatic Severe Mitral Regurgitation               Mitral Regurgitation
More Liberal Surgical Referral                         Improved Surgical Results

                                                                           100




                                                        Overall survival
                                                                           80                                               68%

                                                                           60        P=0.0004




                                                             (%)
                                                                                                                            52%
                                                                           40
                                                                                     Expected
                                                                                     Repair
                                                                           20
                                                                                     Replacement

                                                                            0
                                                                                 0      2          4           6       8          10

                                                                                                       Years

                                           3029554-7
                                                                                                               Enriquez-Sarano: Circ, 1995
                                                                                                                                        3029554-8




                                                                                                                                                    2
 Asymptomatic MR                                                            Preop Echo Assessment
 Natural History                                                            Principles
           100

                                                       91±3%
            90
                                                                              • Lesion severity
            80
Survival
  (%)
            70
                     P<0.01
                                                       66±6%
                                                                              • Mechanism
                     ERO 1-19   mm2         P=0.03

            60       ERO 20-39 mm2
                                         vs expected
                                                                              • Concomitant abnormalities
                     ERO ≥40 mm2                       58±9%
            50
                 0     1         2           3     4      5
                                     Years
                                                                3029554-9                                                       3029554-10




 Mitral Regurgitation                                                       Mitral Regurgitation
 Associated Findings                                                        Lesion Severity

      • LV size and function                                                                   Quantitative
                                                                                                 Doppler
                 ESD > 40
                 LVEF <60%
                                                                                         PW Doppler   CW Doppler

      • LA size
                                                                                      2-D       Functional    Color flow
                                                                                    imaging      anatomy       Doppler
      • RVSP
                                                                                                                           CP1305721-2
                                                               3029554-11                                                       3029554-12




                                                                                                                                             3
Lesion Severity                                                          Lesion Severity
Quantitation                                                             Quantitation
• PISA                                                                   • PISA

                                                                         Grade MR                     ERO (cm2)          RV (cc)
                                                                         Mild                           <0.2                <30
                                                                         Moderate                      0.2-0.39          0.3-0.59
                                                                         Severe                         0.40               60
                                                            3029554-13                                                                       3029554-14




Degenerative Mitral Regurgitation                                        Chronic Mitral Regurgitation
Mechanism: Carpentier Triad                                              Underlying Disease
• Underlying disease                                                     • Chronic CAD                          LV, pap muscles, annulus
                                                                            Ischemic MR
  Etiology e.g. Barlow’s or FED
                                                                         • Myxomatous degeneration              Leaflets, chordae, annulus
                                                                            Fibroelastic deficiency
• Lesion                                                                    Barlow’s

  Chordal elongation/rupture
  Leaflet distension
  Calcification
  Annular dilatation

• Dysfunction
  Systolic position of leaflet margin relative to annular plane

                                                            3029554-15                                                                       3029554-16




                                                                                                                                                          4
        Chronic Mitral Regurgitation                                                                     Mitral Regurgitation
        Underlying Disease                                                                               Mechanisms of Leaflet Dysfunction
            • Chronic CAD                              LV, pap muscles, annulus




                                                                                                 Normal
                  Ischemic MR                                                                                                                            Annular                Leaflet
                                                                                                                             Normal                      dilatation             perforation
            • Myxomatous degeneration                  Leaflets, chordae, annulus
                  Fibroelastic deficiency
                  Barlow’s
            •   Nonischemic dilated CMO                LV, pap muscles, annulus
            •   RHD                                    Leaflets, chordae
            •   Healed IE                              Leaflets, chordae




                                                                                                                                                  Restricted
                                                                                                 Excessive
            •   HOCM                                   AML, pap muscles, LV
            •   MAC                                    Annulus, leaflets
            •   Congenital                             Anterior leaflet
            •   Connective tissue diseases             Leaflets, annulus
            •   Radiation                              Leaflets, chordae                                     Flail leaflet    Leaflet prolapse/
                                                                                                                             chordal elongation
                                                                                                                                                                Chordal
                                                                                                                                                               thickening/
                                                                                                                                                                               Papillary
                                                                                                                                                                                muscle
            •   Drug                                   Leaflets, chordae                                                                                          fusion     displacement
                                                                                                 O’ Gara et al: J Am Coll Cardiol Img, 2008
                                                                                    3029554-17                                                                                          3029554-18




        Degenerative Mitral Regurgitation                                                                Mitral Valve Prolapse
        Dysfunction: Mitral Valve Prolapse                                                               Echo Diagnosis
                                                                                                         • PLAX view
Normal




                                                     Annular
                                                     dilatation                                          • >2 mm systolic displacement of one/both leaflets
                                                                                                             into LA below plane of mitral annulus
                                                                                                         •   More specific if leaflets are thickened >5 mm
Excessive




                Flail leaflet    Leaflet prolapse/
                                chordal elongation

O’ Gara et al: J Am Coll Cardiol Img, 2008
                                                                                    3029554-19                                                                                          3029554-20




                                                                                                                                                                                                     5
Mitral Valve Prolapse                                 Mitral Regurgitation
Echo Diagnosis                                        Mitral Valve Prolapse




                                         3029554-21                                         3029554-22




Degenerative MV Disease                               Degenerative MV Disease
Barlow’s vs Fibroelastic Deficiency                   Barlow’s vs Fibroelastic Deficiency

• Barlow’s results in myxoid MV
  degeneration
     Excess tissue multiple segments
     Chordal thickening and elongation
     Annular dilation
     Tendency to calcification

• Chordal rupture uncommon
• Dx in young adulthood
• Often asymptomatic with preserved
  LV size and function for years


                                         3029554-23                                         3029554-24




                                                                                                         6
Degenerative MV Disease                             Degenerative MV Disease
Fibroelastic Deficiency                             Fibroelastic Deficiency
• FD results from loss of mechanical
  integrity due to abnormalities of
  connective tissue structure and/or
  function
      Chordal thinning, elongation,
       and/or rupture

• Classic prolapse and MR of varying
  severity
• Prolapsing segment may be
  distended but remaining segments
  may be normal
• Most common form organic MV
  disease requiring surgery
                                       3029554-25                             3029554-26




2D Transesophageal Echo
Mitral Valve




                                       3029554-27                             3029554-28




                                                                                           7
        Mitral Valve Anatomy                                 3D Transesophageal Echo
        View from the Left Atrium                            Mitral Valve
Carpentier Nomenclature




                                          A3
                               A1    A2
                                           P3
                          P1
                                    P2




                                                3029554-29                             3029554-30




 3D Transesophageal Echo                                     3D Transesophageal Echo
 Mitral Valve                                                Mitral Valve




                                                3029554-31                             3029554-32




                                                                                                    8
Intuitive Accurate Morphology                                      Intuitive Accurate Morphology
3D TEE Assessment                                                  3D TEE Assessment




Approach to Degenerative MR                                        Approach to Degenerative MR
Summary                                                            Summary
                                                                               Asymptomatic?
              Symptoms?
                                                                                  MR severe?
              MR severe?                        *                                LV function?
                                                                   EF <60%                              EF >60%
             EF >30%                                               ESD >40mm                           ESD <40mm
                                                                                   PASP > 50 at rest
             ESD < 55mm                                                            PASP > 60 with ex

   Surgery: Preferably repair                                    MV surgery               or
                                                                                     New onset AF
                                                                                                       MV repair
                      Class I
          * If EF < 30%; ESD >55mm surgery
                                                                      Mechanism?            Experienced surgeon
          appropriate if chordal preservation                    >90% successful repair? Hi vol center of excellence
          possible with repair or replacement
                                                    3029554-35                                                   3029554-36




                                                                                                                              9
  Approach to Degenerative MR
  Summary
              Asymptomatic?
                 MR severe?
  EF <60%       LV function?           EF >60%
  ESD >40mm                           ESD <40mm
                  PASP > 50 at rest
                  PASP > 60 with ex
MV surgery               or
                    New onset AF
                                      MV repair
     Mechanism?            Experienced surgeon
>90% successful repair? Hi vol center of excellence
                                                3029554-37   3029554-38




     DaVinci Robotic Mitral Repair




                                                3029554-39   3029554-40




                                                                          10
                                          The Future?
 One Month Postoperative                  Beating Heart Mitral Valve Repair




                             3029554-41                                       3029554-42




Positioning the Instrument                Chordal Tension Titration




                             3029554-43                                       3029554-44




                                                                                           11
                                               3029554-45   3029554-46




Conclusion

• Successful mitral valve repair is the goal
• Integrated assessment
  Severity
  Etiology
  Pathophysiology
• Collaborative decision making
  Clinician
  Echocardiographer
  Surgeon

                                               3029554-47   3029554-48




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