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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 isch mique
IM ischémique

Tout ce que vous avez toujours voulu savoir sur l’IM ischémique!!

Cas clinique mis à disposition par Claire BOULETI


Case study
Case Study

  • 69-year old man

  • Chronic renal failure: creatinine 170 µmol/l

  • CV risk factors: smoking 46PY (cessation), hypertension, dyslipidemia, diabetes mellitus


Medical history
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




  • 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?


  • 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?


ESC 65mm LVESD 54mm, ERO 60 mmGuidelines CRT-P/-D

to reduce morbidity and mortality


Medical history 65mm LVESD 54mm, ERO 60 mm

  • 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


Evaluation of functional MR: Mechanism 65mm LVESD 54mm, ERO 60 mm

  • 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)


Evaluation of functional MR: Mechanism 65mm LVESD 54mm, ERO 60 mm

  • 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


Evaluation of functional MR: Mechanism 65mm LVESD 54mm, ERO 60 mm

  • 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)


Evaluation of functional MR: Quantification 65mm LVESD 54mm, ERO 60 mm

(ESC Guidelines)


Back to mr g
Back to Mr G 65mm LVESD 54mm, ERO 60 mm

  • 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?


Rationale for the Correction of Ischaemic / Functional MR 65mm LVESD 54mm, ERO 60 mm

Medical treatment

Surgery: MVR/valve repair

Mitraclip

Options:


The Role of Medical Therapy 65mm LVESD 54mm, ERO 60 mm

  • 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


Surgery for Functional MR 65mm LVESD 54mm, ERO 60 mm

  • 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


Surgery for Ischaemic MR 65mm LVESD 54mm, ERO 60 mmOperative Mortality


Ischaemic and Non-Ischaemic MR 65mm LVESD 54mm, ERO 60 mmConfounding Factors

535 patients operated on for mitral valve repair (1993-2002)

(Glower et al. J Thorac Cardiovasc Surg 2005;129:860-8)


Surgery of Ischaemic MR 65mm LVESD 54mm, ERO 60 mmCABG 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)


Ischaemic MR 65mm LVESD 54mm, ERO 60 mmViability 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)


Surgery for Functional MR 65mm LVESD 54mm, ERO 60 mm

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)


Impact of surgery on lv remodeling
Impact of Surgery on LV Remodeling 65mm LVESD 54mm, ERO 60 mm

  • 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)


Reverse remodeling after surgery 65mm LVESD 54mm, ERO 60 mmUnsolved 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)


Benefits of Surgical Correction 65mm LVESD 54mm, ERO 60 mm

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)


Indications for surgery in ischaemic mr
Indications for Surgery in Ischaemic MR 65mm LVESD 54mm, ERO 60 mm

(ESC Guidelines)

  • surgery can be considered only in selected patients with severe symptoms despite optimal medical therapy


What about the MitraClip System ? 65mm LVESD 54mm, ERO 60 mm


Percutaneous valve repair using the mitraclip system
Percutaneous Valve Repair Using the MitraClip System 65mm LVESD 54mm, ERO 60 mm

(* EuroPCR 2009 † ESC 2009)


Percutaneous Valve Repair Using the MitraClip System 65mm LVESD 54mm, ERO 60 mm

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


When to propose a mitraclip in functional mr
When to propose a Mitraclip in functional MR? 65mm LVESD 54mm, ERO 60 mm

  • 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


Back to mr g1
Back to Mr G 65mm LVESD 54mm, ERO 60 mm

  • He benefited from the MitraClip system

  • No per-procedural complication

  • Favourable evolution (out of hospital at D+3)


Post procedural tte
Post-procedural 65mm LVESD 54mm, ERO 60 mm TTE


Post procedural tte1
Post-procedural 65mm LVESD 54mm, ERO 60 mm TTE


Post procedural tte2
Post-procedural 65mm LVESD 54mm, ERO 60 mm TTE


Conclusion: evaluation of ischaemic MR 65mm LVESD 54mm, ERO 60 mm

  • 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)


Conclusion: treatment of ischaemic MR 65mm LVESD 54mm, ERO 60 mm

  • 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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