Cardiopatie strutturali: esistono gli Heart Team? Esperienze condivise di insufficienza mitralica Luigi Fiocca

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1 Cardiopatie strutturali: esistono gli Heart Team? Esperienze condivise di insufficienza mitralica Luigi Fiocca Cardiologia Interventistica Ospedale Papa Giovanni XXIII Bergamo

2 Interventistica strutturale sulla valvola mitrale Valve-in-valve Valve-in-ring Paravalvular leak closure Riparazione: Sostituzione: Mitraclip Carillon Cardioband NeoChord CardiAQ Tendine Tiara Twelve

3 Numero MITRACLIP - Italia + 43,1% Fonte: adattato da Società Italiana di Cardiologia Invasiva GISE IL GIORNALE ITALIANO DI CARDIOLOGIA INVASIVA N

4 HEART TEAM MR is cause of symptoms? Global assessment of the heart Sistolic and diastolic function, contract. Reserve, LV/annulus dilatation, PAP, TR, RV function Global assessment of the patient mainly in FMR: stage of HF, comorbidities, life expectancy Assess feasibility of repair Anesthesiologist support

5 The Heart Valve Team and Heart Valve Centers of Excellence Recommendations COR LOE Patients with severe VHD should be evaluated by a multidisciplinary Heart Valve Team when I C intervention is considered Consultation with or referral to a Heart Valve Center of Excellence is reasonable when discussing treatment options for 1) asymptomatic patients with severe VHD, 2) patients who may benefit from valve repair versus valve replacement, or 3) patients with multiple comorbidities for whom valve intervention is considered IIa C

6 MitraClip: Bergamo Experience - Baseline clinical profile Early (first Year) vs Advanced phase Early (9) Advanced (25) p Age 74±5 72±11 Comorbidity N 2,3±1,7 1,4±0,97 0,048 Diabetes Mellitus 4 (44%) 7 (28%) Chronic Kidney D. 6 (66%) 10 (40%) Anemia (Hb 11 g/dl) 5 (55%) 9 (36%) COPD 4 (44%) 5 (20%) Previous cancer 3 (33%) 4 (16%) Peripheral ATS 2 (22%) 2 (8%) Prior Stroke/TIA 1 (11%) 2 (8%) BNP 816± ±294 0,04 Atrial Fibrillation 5 (55%) 12 (48%) Ischemic DCM 5 (55%) 10 (40%) Primary DCM 3 (33%) 12 (48%) DMR 1 (11%) 3 (12%) ICD 4 (44%) 15 (60%)

7 EARLY vs ADVANCED EXPERIENCE IN BERGAMO RISK-SCORE

8 EARLY vs ADVANCED EXPERIENCE Hospitalization Lenght

9 DEAD vs ALIVE ANALYSIS 1Y Mortality Early 44% Advanced 20%

10 MitraClip: Selezione dei pazienti Predittori di mortalità Multivariate analysis HR (95% CI) p-value Multivariate analysis HR (95% CI) p-value NT-proBNP > μg/l 3.5 ( ) NT-proBNP > 5000 μg/l 5.4 ( ) Age > 80 years 2.2 ( ) Previous valve surgery 4.5 ( ) TAPSE < ( ) TR grade > ( ) 0.02 NYHA class IV 1.7 ( ) Absence of MR reduction 2.1 ( ) 0.01 Neuss M. et al. Eur J Heart Failure 2013 Multivariate analysis HR (95% CI) p-value NYHA class IV 1.62 ( ) 0.02 Anaemia 2.44 ( ) 0.02 Prev. ao valve int. 2.12( ) Creatinine 1.5 mg/dl 1.77 ( ) Peripheral artery disease 2.12 ( ) LVEF < 30% 1.58 ( ) 0.01 Severe TR 1.84 ( ) Procedural failure 4.36 ( ) Boerlage-vanDijk K et al. Int J Cardiol 2015 Multivariate analysis HR (95% CI) p-value NYHA class IV 3.38 ( ) <0.001 Ischemic etiology 2.12 ( ) Procedural success 0.18 ( ) Capodanno D. et al. AHJ 2015 Puls M et al. (TRAMI) EHJ 2016

11 Senni M et al. Int J Cardiol App: 3CHF

12 Il 3CHF score è in grado di predire fedelmente la mortalità a 1 anno senza correzione dell IM Giannini C, et al. Am J Cardiol ,3% High-Risk: Mitraclip vs Med Tx Duke database Eric J. Velazquez, et al. Am Heart J 2015 NNT 10 35,7% 60 pts per group propensity-matched 22,4% 32% 239 pts each group RR 0.64 (95% CI ; log-rank P =.013) St. Antonius Hospital,Nieuwegein,the Netherlands Swaans MJ et al. J Am Coll Cardiol Intv 2014;7: % Propensity: HR 0.41 p = ,3%

13 Clinical Case: DMR in DCM Case N 18 in BG 52 ys, male, 102 Kg, 171 cm Relevant clinical history Risk factors / Comorbidities: heavy smoker; obesity; COPD Evidence of idiopathic dilated cardiomyopathy with severe left ventricle dysfunction (EF 30-35%). Normal coronary arteries ICD Implantation and medical therapy optimization No events. Periodical FU-visits admission for heart failure and NSVT episode: TTE showed dilated left ventricle and Moderate Mitral Regurgitation due to bileaflet prolapse and annular dilation Re-admission for acute heart failure : TTE shows dilated ventricle (EDD 69mm; EDV 272 ml) with chordal rupture and P2 flail resulting in Severe Eccentric Mitral Regurgitation. NYHA III. EF 45%. TAPSE 25; TR 1+; PAP 35mmHg. TEE shows a large Prolapse/flail of the posterior leaflet.

14 TEE evaluation

15 TEE evaluation Basal xplane color Basal 3D image

16 TEE Evaluation of MitraClip feasibility F.G. 1,1 cm Flail width 2.4 cm EVEREST II limit 1.5 cm Flail Gap 11 mm EVEREST II limit < 10 mm Mitral Valve Area: 9.2 cm 2 EVEREST II >4 cm 2

17 Risk factors Comorbidities Risk scores obesity, heavy smoker, COPD. Dilated left ventricle, EF 40% (with severe MR) EuroSCORE (mortality logistic) 3,2 % EuroSCORE II 2,2 % STS score 1,3 % 3CHF 15 % Heart team evaluation Surgical MV repair: higher risk vs MitraClip; more probability of success; durability; annuloplasty Percutaneous edge-to-edge strategy: less invasive; no ECC; possibility of further reparative surgery?; less durability without annuloplasty?

18 Molti pazienti con IM severa isolata non vengono operati Mirabel, Eur Heart J 2007

19 MitraClip vs Chirurgia 74% DMR FMR De Bonis et al. Eur J Cardiothorac Surg Mar 23

20 Chirurgia dopo MitraClip possibile Prevalentemente sostituzione N repair Ann Thorac Surg (27%) J of Cardiac Surgery Circulation (11%) Texas Heart Institute J (50%) Eur J Cardioth Surgery

21 Date of the case: 19/06/2014 Strategy of intervention: Multi-Clip strategy from medial to lateral in a zip fashion From postero-medial to antero-lateral After the second clip implantation

22 Final result after 3 Clip implantation ZIP TECHNIQUE Levosimendan; Dopamine 2,5 g; Adrenaline 0.035g. Procedure time 6 hours

23 Final result: 3D view and transvalvular gradient

24 Intensive care Unit Cardiology Ward: Extubated after few hours. Transferred in Cardiology Ward within 24 hours Asymptomatic. Good clinical conditions. No complications Discharge In 5 Day 12 Months Follow-up Asymptomatic. No Hospital Admission. NYHA Class I

25 12 months follow-up

26 LV remodeling Pre-proc. EDV 272 ml ESV 146 ml EF 46% SV 50 ml 12 m. after EDV 159 ml ESV 93 ml EF 41% SV 60 ml 18 m. after EDV 145 ml ESV 84 ml EF 42% SV 61 ml

27 Dati Ecocardiografici basali e a 6 mesi Esperienza di Bergamo

28 Conclusioni Il trattamento percutaneo della valvulopatia mitralica è un campo in grande espansione Le scelte terapeutiche implicano grande conoscenza ed esperienza e coinvolgono figure professionali diverse che devono interagire per il bene del paziente