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

Luigi Fiocca Cardiologia Interventistica

Ospedale Papa Giovanni XXIII Bergamo

Interventistica strutturale sulla valvola mitrale

Valve-in-valve Valve-in-ring Paravalvular leak closure Riparazione: Mitraclip Carillon

Cardioband NeoChord Sostituzione: CardiAQ

Tendine Tiara Twelve

Numero MITRACLIP - Italia

Fonte: adattato da Società Italiana di Cardiologia Invasiva – GISE

+ 43,1%

IL GIORNALE ITALIANO DI CARDIOLOGIA INVASIVA N. 2 • 2015

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

HEART TEAM

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

intervention is considered I C

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

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±652 468±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%)

MitraClip: Bergamo Experience - Baseline clinical profile Early (first Year) vs Advanced phase

EARLY vs ADVANCED EXPERIENCE IN BERGAMO RISK-SCORE

EARLY vs ADVANCED EXPERIENCE Hospitalization Lenght

DEAD vs ALIVE ANALYSIS

1Y Mortality

Early 44%

Advanced 20%

MitraClip: Selezione dei pazienti Predittori di mortalità

Multivariate analysis HR (95% CI) p-Value

NT-proBNP > 10000 μg/L 3.5 (1.9–3.7) 0.001

Age > 80 years 2.2 (1.2-4.2) 0.008

TAPSE < 15 1.9 (1.0–3.6) 0.038

NYHA class IV 1.7 (1.0–3.2) 0.049

Neuss M. et al. Eur J Heart Failure 2013

Multivariate analysis HR (95% CI) p-Value

NT-proBNP > 5000 μg/L 5.4 (1.8–16.2) 0.003

Previous valve surgery 4.5 (1.7–12.2) 0.003

TR grade > 2 2.8 (1.2–6.8) 0.02

Absence of MR reduction 2.1 (1.2–3.8) 0.01

Boerlage-vanDijk K et al. Int J Cardiol 2015

Multivariate analysis HR (95% CI) p-Value

NYHA class IV 1.62 (1.1–2.4) 0.02

Anaemia 2.44 (1.2–5.1) 0.02

Prev. ao valve int. 2.12(1.3–3.4) 0.002

Creatinine ≥1.5 mg/dL 1.77 (1.2–2.5) 0.002

Peripheral artery disease 2.12 (1.4–3.2) 0.0003

LVEF < 30% 1.58 (1.1–2.3) 0.01

Severe TR 1.84 (1.2–2.8) 0.003

Procedural failure 4.36 (2.4–8.0) 0.0001

Puls M et al. (TRAMI) EHJ 2016

Multivariate analysis HR (95% CI) p-Value

NYHA class IV 3.38 (1.7–6.7) <0.001

Ischemic etiology 2.12 (1.1-3.9) 0 .016

Procedural success 0.18 (0.1-0.5) 0.001

Capodanno D. et al. AHJ 2015

www.3chf.org

App: 3CHF

Senni M et al. Int J Cardiol 2011

Swaans MJ et al. J Am Coll Cardiol Intv 2014;7:875–81

32,3%

15% Propensity: HR 0.41 p = .006

139 53 59

St. Antonius Hospital,Nieuwegein,the Netherlands

Giannini C, et al. Am J Cardiol 2016

60 pts per group propensity-matched

10,3%

35,7%

High-Risk: Mitraclip vs Med Tx – Duke database

RR 0.64 (95% CI 0.45-0.91; log-rank P = .013)

22,4%

32%

NNT 10

Eric J. Velazquez, et al. Am Heart J 2015

239 pts each group

Il 3CHF score è in grado di predire fedelmente la mortalità a 1 anno senza correzione dell’IM

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.

2008 Evidence of idiopathic dilated cardiomyopathy with severe left ventricle dysfunction (EF 30-35%). Normal coronary arteries.

2009 ICD Implantation and medical therapy optimization.

2009-2013 No events. Periodical FU-visits.

2013 admission for heart failure and NSVT episode: TTE showed dilated left ventricle and Moderate Mitral Regurgitation due to bileaflet prolapse and annular dilation.

2014 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.

TEE evaluation

TEE evaluation

Basal 3D image Basal xplane color

TEE Evaluation of MitraClip feasibility

Mitral Valve Area: 9.2 cm2 EVEREST II >4 cm2

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

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?

Mirabel, Eur Heart J 2007

Molti pazienti con IM severa isolata

non vengono operati

MitraClip vs Chirurgia

De Bonis et al. Eur J Cardiothorac Surg. 2016 Mar 23

FMR 74% DMR

Chirurgia dopo MitraClip possibile Prevalentemente sostituzione

N repair

Ann Thorac Surg 2016 33 9 (27%)

J of Cardiac Surgery 2015 3 0

Circulation 2014 18 2 (11%)

Texas Heart Institute J 2014 6 3 (50%)

Eur J Cardioth Surgery 2013 13 0

From postero-medial to antero-lateral

After the second clip implantation

Date of the case: 19/06/2014

Strategy of intervention: Multi-Clip strategy from medial to lateral in a zip fashion

Final result after 3 Clip implantation ZIP TECHNIQUE

Levosimendan; Dopamine 2,5 g; Adrenaline 0.035g. Procedure time 6 hours

Final result: 3D view and transvalvular gradient

Intensive care Unit

Extubated after few hours. Transferred in Cardiology Ward within 24 hours

Cardiology Ward:

Asymptomatic. Good clinical conditions. No complications

Discharge In 5° Day

12 Months Follow-up

Asymptomatic. No Hospital Admission. NYHA Class I

12 months follow-up

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

Dati Ecocardiografici basali e a 6 mesi Esperienza di Bergamo

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