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Treatment of Chronic Mitral Regurgitation

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Physical exam (murmur, S3, diastolic rumble) Electrocardiogram (LAE, LVH, Afib) ... NYHA Class III or IV heart failure (any duration) EF 60 ... – PowerPoint PPT presentation

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Title: Treatment of Chronic Mitral Regurgitation


1
Treatment of Chronic Mitral Regurgitation
  • Howard A. Cooper, M.D.
  • Georgetown University Medical Center
  • Washington, D.C.

2
Prevalence
  • True prevalence unknown
  • CARDIA Study 10.9 of young adults
  • Cardiovascular Health Study (Agegt65)
  • 30.1 of participants had MR
  • 26.6 of MR cases had moderate-to-severe
  • In 1995 , 26,000 mitral valve surgeries in U.S.
    medicare patients

3
Etiology
  • In U.S., etiology changed over last 40 years
  • 1965 primarily rheumatic (40)
  • 1985 primarily degenerative (42-62) and
    ischemic (12-30)

4
Natural History
  • Morbidity
  • Congestive Heart Failure
  • Atrial fibrillation
  • Pulmonary hypertension
  • Embolization
  • Mortality
  • 5-year mortality of 31-54 for severe MR

5
Assessment of Severity
  • Physical exam (murmur, S3, diastolic rumble)
  • Electrocardiogram (LAE, LVH, Afib)
  • Chest Xray (cardiomegaly, LAE)
  • Cardiac catheterization (V-wave, ventriculogram)

6
Assessment of Severity (Cont.)
  • Echocardiogram
  • Qualitative assessment of regurgitant jet
  • Volumetric flow analysis
  • Proximal convergence analysis (PISA)
  • Vena contracta

7
Medical Therapy
  • Not appropriate for symptomatic patients (unless
    surgery contraindicated)
  • Hemodynamic improvement
  • Nitroprusside
  • Hydralazine
  • Captopril
  • Nifedipine
  • Long-term benefits unproved

8
Surgical Therapy - Timing
  • Surgery reduces morbidity and mortality from
    severe MR but exposes patient to risk of surgery
    and prosthetic valve
  • Surgery should be performed before onset of
    severe symptoms or development of LV contractile
    dysfunction

9
Symptoms
  • Class III or IV symptoms (even if transient)
    always indicate need for surgery
  • Class II symptoms indicate need for surgery in
    patients with repairable valves
  • ETT may reveal concealed symptoms

10
Ejection Fraction
  • Strongest predictor of outcome following surgery
  • Should be assessed quantitatively
  • Surgery indicated if LV EF is below normal (60)
  • If EF normal, follow every 6 to 12 months
  • If EF lt30, medical management (valve repair
    experimental in this setting)

11
Load-Independent Measures of LV Function
  • Complex measurements
  • LV dP/dT
  • End-systolic stress-strain
  • Myocardial Elastance
  • Peak systolic pressure/end-systolic volume
  • End-systolic diameter
  • LVIDs gt45 predicts poor outcome
  • End-systolic volume index
  • ESVI gt50cc/m2 predicts poor outcome

12
Other Indications
  • Flail mitral leaflet
  • Left atrial dimension gt45mm
  • Paroxysmal atrial fibrillation

13
Surgical Technique
  • Valve replacement
  • Mortality 2-7
  • Anticoagulation
  • Decreased LV EF
  • Valve repair
  • Mortality 2-3
  • No anticoagulation
  • Preservation of LV EF
  • Valve repair always preferable
  • Feasible in 70-90 of patients

14
Indications for Surgery Severe, Isolated,
Chronic MR
  • Definite (major criteria)
  • NYHA Class III or IV heart failure (any duration)
  • EF lt60
  • EF gt60 but decreasing on serial measurements
  • LVIDs gt45mm
  • ESVI gt50cc/m2

15
Indications for Surgery Severe, Isolated,
Chronic MR
  • Emerging (minor criteria)
  • Any symptoms of heart failureor
    suboptimalexercise tolerance test
  • Flail mitral leaflet
  • Left atrial diameter gt45mm
  • Paroxysmal atrial fibrillation
  • Abnormal exercise end-systolic volume index or
    ejection fraction
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