Perspectives sur l’évaluation clinique et échocardiographique Erwan DONAL Cardiologie – CHU Rennes erwan.donal@chu-rennes.fr
Déclaration de Relations Professionnelles Disclosure Statement of Financial Interest J'ai actuellement, ou j'ai eu au cours des deux dernières années, une affiliation ou des intérêts financiers ou intérêts de tout ordre avec une société commerciale ou je reçois une rémunération ou des redevances ou des octrois de recherche d'une société commerciale : I currently have, or have had over the last two years, an affiliation or financial interests or interests of any order with a company or I receive compensation or fees or research grants with a commercial company : Company Affiliation/Financial Relationship • Grant/Research Support • Novartis • Consulting Fees/Honoraria • BMS • General Electric Healthcare • Siemens • Astra Zeneca
Study* Patients / type of study N° EVEREST I (Feasibility) Feasibility 55 EVEREST II (Pivotal) Pre-randomization 60 EVEREST II (Pivotal) Registry 78 (High Risk Study) EVEREST II (Pivotal) Randomized trial 184 Clip (2:1 PMVR vs Surgery) REALISM (Continued Access)Registry 727 Compassionate Emergency UseRegistry 43 ACCESS Europe Phase I Registry 566 ACCESS Europe Phase II Registry 191 TOTAL 6712 ⇒ Over 10,000 patients have been treated with the MitraClipTherapy (6,000 in January 2013) -75% are considered high risk for mitral valve surgery -67% have SECONDARY MR
Primary MR Secondary MR
ACCESS EU : 566 Patients Device time 118 min Implant rate 99% 23 2nd MR Iary MR 77 Maisano et al JACC 2013
Critères d ’ inclusion • Insuffisance mitrale sévère de type secondaire • Sévérité évaluée ETT/ETO : – volume de régurgitation > 30 mL/batt – SOR > 20 mm² • Classe fonctionnelle NYHA ≥ II • FEVG entre 15 et 40% • Au moins une hospitalisation pour ICC dans les 12 mois qui précédents • Traitement médical optimisé de l ’ ICC • Patient jugé non éligible à une chirurgie par « heart team » 6
Clinical state point Imaging State point Heart valve clinic Multidisciplinary decision making process 1. Neuss et al. Eu J Heart Fail 2013; 15: 789 2. Lancellotti et al. Eur H J 2013; 34: 1597 3. Cavalcante et al. JACCim 2012; 5:733
Prevalence and Outcomes of Unoperated Patients with Severe Symptomatic Mitral Regurgitation and Heart Failure: Comprehensive Analysis to Determine Potential Role of MitraClip for this Unmet Need . 5737 MR >2 were identified between 1/1/2000 and 12/31/2008 1095 MR >2 + IC Surgery 53 % OMM 47 % EF=42 % EF=27 % Medically treated patients Goel et al. JACC 36 % eligible for Mitraclip 2013(in press)
Clinical state point Euroscore Co-morbidities Coronary artery status LV EF Clinical status: NYHA, 6 min walk test, CP Ex test, natriurétic peptides
Lancellotti P et al. Eur Heart J 2013;34:1597-1606
51 severely symptomatic CRT non- responders with FMR ≥ 2 Correction of Mitral Regurgitation in Nonresponders to CRT by MitraClip Improves Symptoms and Promotes Reverse Remodeling Angelo Auricchio , et al JACC 2011; 58,: 2183 - 2189
LV diam mm LV Vol ml LV EF % Changes Over Time of Echocardiographic Parameters Sequential changes of (A) left ventricular diameters, (B) left ventricular volumes, (C) left ventricular ejection fraction.
We treat secondary MR, so with some degree of LV dysfunction but do not wait that the heart is too remodeled and the Heart failure too severe Neuss M et al. Eur J Heart Fail 2013;15:786-795
Not a good idea to wait LV enlargement > 270 ml Freedom from heart failure rehospitalization in successfully treated patients with secondary mitral regurgitation, differentiated by size ranges of left ventricular end-diastolic volume (LVEDV). Rudolph V et al. Eur J Heart Fail 2013;15:796-807
Imaging State point P1 Indentation? Mitral ring area > 4cm² Calcifications Size of the posterieur leaflet (not too short)
Think at this new treatment strategy in Secondary MR > 2/4 At every TTE performed in DCM, Ischemic heart disease…
Importance of the TTE
Offline 3D Quantitative semi-automated MV analysis analysis in mid-systolic frame AL-PM A-P diameter Sphericity diameter Posterior leaflet Anterior leaflet Annulus 3D area area area Tenting volume Tenting height
Vertical Coaptation Length (FMR) 11mm tenting 2 mm coaptation Calcification in the Grasping Area
80-110 ˚ View: Bicaval 15-45° View: Short Axis at Base The poncture of the Atrial Septum should be posterior 3-4 cm from the plane of the mitral ring
Take home messages Mitraclip is part of the treatments available for the Heart Team potential candidate have to be precisely assessed by a predefined person of the heart team Echo is specific and has to include a real 3D in TTE and TOE+++
ARE YOU READY FOR THE WORLD’S LARGEST CARDIOVASCULAR IMAGING CONGRESS? 3-6 December 2014, Vienna Austria Main Themes Three-dimensional imaging Imaging in acute cardiac care GET READY FOR THE CALL FOR ABSTRACTS 1 April - 31 May 2014 www.escardio.org/EACVI
Functional MR and Survival in CHF Survival for patients with heart failure is shown for varying severities of MR. The Current Therapy for Mitral Regurgitation Blase A. Carabello Journal of the American College of Cardiology Volume 52, Issue 5 2008 319 - 326
Long-term follow-up to hospital re-admission due to major adverse cardiovascular events (MACE) depending on the presence or absence of mitral regurgitation Long-term follow-up to hospital re-admission due to congestive heart failure depending on the severity of the MR Núñez-Gil I J et al. Heart 2013;99:1502-1508
ECG, Pharmacological treatment >> discussion CRT-ICD >> discussion required with Surgeons and Anesthesiologists
Full-Volume with Color - 3D Vena Contracta Area
0 ° Views: Superior • Shows A1/P1 scallops or lateral aspect of the MV. • It is important to interrogate the valve with and without color to determine the presence of a jet in the A1/P1 region.
0 ° Views: Central • Shows the A2/P2 scallops of the MV. • It is important to interrogate the valve with and without color to determine the presence of a jet in the A2/P2 region. 34
0 ° Views: Inferior • Shows the A3/P3 scallops or the medial aspect of the MV. • It is important to interrogate the valve with and without color to determine the presence of a jet in the A3/P3 region. 35
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