what to do with a patient with recurrent mr after ... - aats
TRANSCRIPT
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What to do with a Patient with Recurrent MR after
InterventionJames D. Thomas, MD, FACC, FASEDirector, Center for Heart Valve DiseaseBluhm Cardiovascular InstituteProfessor of Medicine, Feinberg School of Medicine, Northwestern UniversityChicago, Illinois
Conflicts of interest: GE, Abbott, Edwards (honoraria)
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6 pts post MVr, 4 treated successfully with MC
2 pts post MVr treated successfully with MC
18 pts w/ MR post MC: 13 MVR, 2 MVr, 3 LVAD
Limited Data on Clip after Surgery and Vice Versa
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Case 1: 84F w/ Recurrent MR After MVr
• Remote LCx occlusion → severe functional MR• 2007: MVr w/ #27 Duran annuloplasty• 2013: Recurrent MR and Class III sx persist despite
GDMT, BNP 431
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Severe Functional MR w/ Annuloplasty
Large LCx scar
Multicomponent complex jet
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ROA = 0.8 cm2
MRV ~ 100 mLRVSP = 98 mmHg
Marked PV sys reversal
Mean MV gradient 6 mmHg
No Wonder She’s Short of Breath!
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Broadly arising, anteriorly directed jet without flail or prolapse
MVA = 5.34 cm2
Severe Functional MR w/ Annuloplasty
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What to Do?
1. Redo sugery2. Med management3. MitraClip4. Valve-in-valve TMVR
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What’s the Impact of MitraClip on MVA?Reduces valve area by half, but should be OK
27 mm annuloplasty ring5.7 cm2
2 inscribed circles2.9 cm2
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What to Do?
1. Redo surgery: Pretty high risk2. Med management: Already doing it3. MitraClip: Hmmm…maybe4. Valve-in-valve TMVR: Consider if clip
not feasible
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Poor leaflet coaptation
MitraClip Intervention in COAPT
46 mmHg V-waveSteering clip into position
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Grasping Leaflets
Clip advanced into LV
23 mmHg V-wave
Post clip release
Grasping leaflets
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Dual Orifice Valve Partly Obscured by Ring
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Pre-Clip Post-Clip
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ROA = 0.12 cm2
MRV ~ 15 mL PV S>DRVSP = 45 mmHg
Excellent Result at F/U
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· History: Born with Tetralogy of Fallot1954: Systemic-pulmonary shunt1962: VSD closure/PV repair2002: SCD⇒ICD2006: Bioprosthetic PVR2012: Transcatheter valve-in-valve PVR for PR5/2015: Sensed a “pop” in chest, then severe DOECOPD from smoking (FEV1 1.2 L), PAF
· Meds: Bumetidine, spironolactone, coumadin, metoprolol, home O2
· PE: BP 108/60, HR 92 reg, CVP~7, clear lungs, 3/6 HSM
Case #2 60ish yo Man with Dyspnea
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Transthoracic Echo60ish yo Man with Dyspnea
Flail posterior leaflet, worst medially
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Tall E RVSP>70 mmHg
Severe MR, P2-3 flail
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Transesophageal EchoProximal Convergence Analysis
ROA > 1.0 cm2
1.0 cm
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Transesophageal Echo3D Rendering
P2 and P3 flail
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Clinical CourseSummary of MitraClip Procedure
· High risk for surgery so referred for percutaneous clipBaseline: ROA >1 cm2, mean ∆p = 4 mmHgClip 1 (lateral A2-P2): ROA 0.3 cm2, mean ∆p = 4mmHgClip 2 (medial A2-P2): ROA 0.15 cm2, mean ∆p = 5mmHgClip 3 (lateral A3-P3): ROA 0.06 cm2, mean ∆p = 9mmHgGradient unacceptable, Clip 3 removedFinal: ROA 0.1 cm2, mean ∆p = 5mmHg
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One Month Follow-upEchocardiogram
“I feel great. I went dancing last weekend!”
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3 Days Later“I can’t breath”
• Clip dislodged, severe MR• Clip lodged in posteromedial LV
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What to do??
A. Redo MitraClipB. Redo-redo-redo-redo surgery C. Just a bit more bumex, he’ll be fine
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What to do??
A. Redo MitraClipB. Redo-redo-redo-redo surgery C. Just a bit more bumex, he’ll be fine
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To the ORMitral Leaflet Too Mascerated to Repair
• s/p MVR• Good LV function
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Case 3: 71M w/ Recurrent MR After MVr• 1989: RCA occlusion• 2001: CABG x 3, VT→ICD placed• 2007: Functional MR noted but Asx• 2012: ?subtle symptoms, ring annuloplasty at “another”
Midwestern heart center • 2013: Recurrent MR• 2016: Referred back for redo surgery. States he “feels
pretty good, able to go hunting.” Outside cath with patent grafts.
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Severe Functional MR w/ Annuloplasty
ROA 0.3 cm2 RVSP 30 mmHg
Large IPMI Very eccentric jet
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What to Do?
1. Redo redo sugery2. Med management3. MitraClip4. Stress echo
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What to Do?
1. Redo redo sugery2. Med management3. MitraClip4. Stress echo
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10.1 METs, RCA Scar, No Ischemia
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10.1 METs, RCA Scar, No Ischemia
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10.1 METs, Stopped for Fatigue
MR similar RVSP 45 mmHg
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What to Do?
1. Redo redo sugery2. Med management3. MitraClip4. MRI
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What to Do?
1. Redo redo sugery2. Med management3. MitraClip4. MRI
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71M w/ Recurrent MR After MVrOne Year Later
• A little tougher hunting this season, not feeling quite himself
• Echo suggests worsening MR• Repeat exercise echo to assess functional capacity• Cruising through stage III without difficulty when…
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Yikes!
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71M w/ Recurrent MR After MVrVT on ETT
• Cath negative• It was determined SOMETHING needed to be done• But what?• TEE to better assess anatomy
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EF~30% w/ IPMI, Ring Dehiscence
ROA 0.4 cm2
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A1-P1 A2-P2
A3-P3
X-C view A-P view X-C view A-P view
X-C view A-P view
Main pathology A1 & A2
Using X-Plane to Define MV Anatomically
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Preeeety Small PML, 6 mm
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OK, Now What to Do?
1. Redo redo sugery2. Med management3. MitraClip4. Just keep echoing him5. Plug the dehisced ring
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OK, Now What to Do?
1. Redo redo sugery2. Med management3. MitraClip4. Just keep echoing him5. Plug the dehisced ring
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Intraoperative Echo, Bioprosthetic MVR
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Post-Op Echo, Doing Well
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Case 4: 80M w/ Recurrent MR After Alfieri
• 1997: Severe AS→Ross procedure• 2011: Severe PS→Melody valve• 2014: Severe AR/MR→consideration for surgery
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Severe AR A2 prolapse ROA 0.35 cm2
• Pat McCarthy: “This was one of my toughest cases.”• #25 CE AVR and (quick!) Alfieri stitch on circulatory arrest
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3 Years Later: Recurrent Class III dyspnea
• Well-functioning AVR (1.2 m/sec)
• Mild prosthetic PS (2.8 m/sec)• Moderately severe, very
eccentric MR arising medially with ROA 0.4 cm2
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What to Do?
1. Redo redo sugery2. Med management3. MitraClip4. TMVR
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What to Do?
1. Redo redo sugery: No way!!!2. Med management: Already doing it3. MitraClip: Hmmm…maybe4. TMVR: Unproven with prior Alfieri
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MitraClip UndertakenA3 Flail w/ Flow Reversal
Severe MR Flow reversal
Medial clip placement
Normalized
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Post-Procedure EchoTruly Mild MR