Mitral Regurgitation Epidemiology Pathophysiology and When to Repair

Mitral Regurgitation: Epidemiology, Pathophysiology and When to Repair Robert O. Bonow, M. D.

Mitral Regurgitation: Epidemiology, Pathophysiology and When to Repair Robert O. Bonow, M. D. Consultant Edwards Life Sciences

Lancet 2006; 368: 1005 -1011

Moderate-Severe Mitral Valve Disease 10 Percent 8 CARDIA, ARIC, CHS Population-Based Studies 9. 5% Lancet 2006; 368: 1005 -1011 11, 911 subjects in CARDIA, ARIC, CHS 6 4 2 0 <45 45 -54 Nkomo et al Lancet 2006; 368: 1005 -1011 55 -64 Age 65 -74 ≥ 75

Moderate-Severe Mitral Valve Disease 10 Percent 8 6 CARDIA, ARIC, CHS Population-Based Studies 9. 5% Lancet 2006; 368: 1005 -1011 11, 911 subjects in CARDIA, ARIC, CHS Olmstead Cty. Olmstead County 7. 3% 16, 501 subjects 4 2 0 <45 45 -54 Nkomo et al Lancet 2006; 368: 1005 -1011 55 -64 Age 65 -74 ≥ 75

The Mitral Apparatus Anterior annulus Anterior leaflet Anteromedial commissure Posterolateral commissure Posterior leaflet Posterior annulus Anterolateral papillary muscle Chordae tendineae Posteromedial papillary muscle Left ventricular free wall from Otto N Engl J Med 2001: 345: 740 -746

The Mitral Apparatus Anterior annulus Anterior leaflet Anteromedial commissure Posterolateral commissure Posterior leaflet Posterior annulus Anterolateral papillary muscle Left ventricular free wall Chordae tendineae Posteromedial papillary muscle Functional Mitral Regurgitation from Otto N Engl J Med 2001: 345: 740 -746

Carpentier’s Functional Classification Type IIIa Type IIIb Carpentier. J Thorac Cardiovasc Surg 1983; 86: 323 -337

Mitral regurgitation Indications for mitral valve surgery: • Symptomatic patients class I

Mitral regurgitation Indications for mitral valve surgery: • Symptomatic patients • Asymptomatic patients • LV systolic dysfunction class I

Mitral regurgitation Indications for mitral valve surgery: • Symptomatic patients • Asymptomatic patients • LV systolic dysfunction LVEF <60% LVSD >40 mm class I

Mitral regurgitation Indications for mitral valve surgery: • Symptomatic patients • Asymptomatic patients • LV systolic dysfunction • Pulmonary hypertension class IIa

Mitral regurgitation Indications for mitral valve surgery: • Symptomatic patients • Asymptomatic patients • LV systolic dysfunction • Pulmonary hypertension • Atrial Fibrillation class IIa

Mitral regurgitation Indications for mitral valve surgery: • Symptomatic patients • Asymptomatic patients • • LV systolic dysfunction Pulmonary hypertension Atrial Fibrillation Normal LV function, repair feasible? class IIa ?

Mitral Regurgitation Natural History of Severe Asymptomatic MR Asymptomatic with normal LV function 100 Alive, Asymptomatic without Surgery (%) Medicare data 80 Average hospital mortality: 8. 8% 60 40 • Low volume centers: 13. 0% Rosen 20 • High volume centers: 6. 0% 0 Data from national Medicare database 1994 -1999 0 2 4 6 8 10 684 hospitals Time (years) 142, 488 AVRs Rosen et al. Am J Cardiol 1994; 74: 374 -380

Mitral Regurgitation Natural History of Severe Asymptomatic MR Asymptomatic with normal LV function 100 Alive, Asymptomatic without Surgery (%) Medicare data 80 Sarano Average hospital mortality: 8. 8% * 60 40 • Low volume centers: 13. 0% Rosen 20 • High volume centers: 6. 0% 0 Data from national Medicare database 1994 -1999 0 2 4 6 8 10 684 hospitals Time (years) 142, 488 AVRs Rosen et al. Am J Cardiol 1994; 74: 374 -380 Sarano et al. N Engl J Med 2005; 352: 875 -883

Mitral Regurgitation Natural History of Severe Asymptomatic MR Asymptomatic with normal LV function 100 Alive, Asymptomatic without Surgery (%) Medicare data 80 Sarano Rosenhek Average hospital mortality: 8. 8% * 60 40 • Low volume centers: 13. 0% Rosen 20 • High volume centers: 6. 0% 0 Data from national Medicare database 1994 -1999 0 2 4 6 8 10 684 hospitals Time (years) 142, 488 AVRs Rosen et al. Am J Cardiol 1994; 74: 374 -380 Sarano et al. N Engl J Med 2005; 352: 875 -883 Rosenhek et al. Circulation 2006; 113: 2238 -2244

Mitral Regurgitation Natural History of Severe Asymptomatic MR Asymptomatic with normal LV function 100 Alive, Asymptomatic without Surgery (%) Medicare data 80 Sarano Rosenhek Average hospital mortality: 8. 8% * 60 40 * • Low volume centers: 13. 0% Grigioni Rosen 20 • High volume centers: 6. 0% 0 Data from national Medicare database 1994 -1999 0 2 4 6 8 10 684 hospitals Time (years) 142, 488 AVRs Rosen et al. Am J Cardiol 1994; 74: 374 -380 Sarano et al. N Engl J Med 2005; 352: 875 -883 Rosenhek et al. Circulation 2006; 113: 2238 -2244 Grigioni et. J Am Coll Cardiol Img 2008; 1: 133 -141

Mitral Regurgitation Natural History of Severe Asymptomatic MR Asymptomatic with normal LV function 100 Alive, Asymptomatic without Surgery (%) Medicare data 80 Kang Sarano * Rosenhek Average hospital mortality: 8. 8% * 60 40 * • Low volume centers: 13. 0% Grigioni Rosen 20 • High volume centers: 6. 0% 0 Data from national Medicare database 1994 -1999 0 2 4 6 8 10 684 hospitals Time (years) 142, 488 AVRs Kang et al. Circulation 2009; 119: 797 -804 Rosen et al. Am J Cardiol 1994; 74: 374 -380 Sarano et al. N Engl J Med 2005; 352: 875 -883 Rosenhek et al. Circulation 2006; 113: 2238 -2244 Grigioni et. J Am Coll Cardiol Img 2008; 1: 133 -141

Mitral Regurgitation Natural History of Severe Asymptomatic MR Asymptomatic with normal LV function 100 Alive, Asymptomatic without Surgery (%) Medicare data 80 Sarano Average hospital mortality: 8. 8% * 60 40 20 • Low volume centers: 13. 0% • High volume centers: 6. 0% 0 Data from national Medicare database 1994 -1999 0 2 4 6 8 10 684 hospitals Time (years) 142, 488 AVRs Sarano et al. N Engl J Med 2005; 352: 875 -883

Mitral Regurgitation Natural History of Severe Asymptomatic MR Alive, Asymptomatic without Heart Failure or AF (%) Survival without Heart Failure or Atrial Fibrillation 100 Medicare data 80 ERO <20 mm 2 Average hospital mortality: mm 2 * ERO 20 -39 8. 8% 60 40 20 • Low volume centers: 13. 0% ERO ≥ 40 mm 2 • High volume centers: 6. 0% 0 Data from national Medicare database 1994 -1999 0 2 4 6 8 10 684 hospitals Time (years) 142, 488 AVRs Sarano et al. N Engl J Med 2005; 352: 875 -883

Mitral Regurgitation Natural History of Severe Asymptomatic MR Alive, Asymptomatic without Heart Failure or AF (%) Survival without Heart Failure or Atrial Fibrillation 100 Medicare data 80 ERO <20 mm 2 Average hospital mortality: mm 2 * ERO 20 -39 8. 8% 60 40 20 • Low volume centers: 36% 13. 0% ERO ≥ 40 mm 2 • High volume centers: 6. 0% 0 Data from national Medicare database 1994 -1999 0 2 4 6 8 10 684 hospitals Time (years) 142, 488 AVRs Sarano et al. N Engl J Med 2005; 352: 875 -883

Surgery for Acquired Cardiovascular Disease J Thorac Cardiovasc Surg 2003; 125: 1143 -1152

Surgery for Acquired Cardiovascular Disease Mitral Regurgitation Survival After Mitral Valve Surgery Survival (percent) 100 Expected 80 n=488 60 64% J Thorac Cardiovasc Surg 2003; 125: 1143 -1152 40 20 0 p<0. 001 0 2 4 6 8 Time (years) 10 12 14 David et al, J Thorac Cardiovasc Surg 2003; 126: 1143 -1152

Surgery for Acquired Cardiovascular Disease Mitral Regurgitation Survival After Mitral Valve Surgery Survival (percent) 100 FC I-II 80 81% FC III-IV n=488 60 58% J Thorac Cardiovasc Surg 2003; 125: 1143 -1152 40 20 0 p<0. 001 0 2 4 6 8 Time (years) 10 12 14 David et al, J Thorac Cardiovasc Surg 2003; 126: 1143 -1152

Mitral regurgitation Indications for mitral valve repair in asymptomatic MR: • Chronic severe MR • Preserved LV function • Experienced surgical center • Likelihood of successful repair class IIa with out residual MR > 90%.

Mitral regurgitation Indications for mitral valve repair in asymptomatic MR: • Chronic severe MR • Preserved LV function • Experienced surgical center • Likelihood of successful repair class IIa with out residual MR > 90%. • Preserved LV function • Likelihood of durable repair • Low risk for surgery class IIb

Mitral regurgitation Indications for mitral valve repair in asymptomatic MR: • Chronic severe MR • Preserved LV function • Experienced surgical center • Likelihood of successful repair class IIa with ! out residual MR > 90%. • Repair better than mitral valve replacement • Patients should be referred to centers experienced in repair class I

Ischemic Mitral Regurgitation Restricted leaflet closure Mitral regurgitation Tethering of posterior leaflet Levine, N Engl J Med 2004; 351: 1681 -1684

Survival After MI Survival (percent) 100 80 MI without MR 60 ERO 1 -19 40 47% ERO ≥ 20 20 0 61% 29% p<0. 001 0 1 2 3 Time (years) 4 5 Grigioni et al. Circulation 2001; 103: 1759 -1764

Development of Heart Failure (percent) 100 p<0. 001 80 68% 60 ERO ≥ 20 40 ERO 1 -19 MI without MR 18% 20 0 46% 0 1 2 3 Time (years) 4 5 Grigioni et al. Circulation 2001; 103: 1759 -1764

Functional mitral regurgitation can be repaired.

Functional mitral regurgitation can be repaired. But should it be repaired?

National Heart Lung and Blood Institute People Science Health CARDIOTHORACIC SURGICAL TRIALS Gardner and O’Gara. J Thorac Cardiovasc Surg 2010; 139: 830

National Heart Lung and Blood Institute People Science Health CARDIOTHORACIC SURGICAL TRIALS Moderate ischemic MR protocol (MMR) • CABG vs CABG plus MV repair Gardner and O’Gara. J Thorac Cardiovasc Surg 2010; 139: 830

National Heart Lung and Blood Institute People Science Health CARDIOTHORACIC SURGICAL TRIALS Moderate ischemic MR protocol (MMR) • CABG vs CABG plus MV repair Severe chronic ischemic MR protocol (SMR) • MV repair vs MV replacement Gardner and O’Gara. J Thorac Cardiovasc Surg 2010; 139: 830