im ischémique

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• CV risk factors: smoking 46PY (cessation),

hypertension, dyslipidemia, diabetes mellitus

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

Coronary angiography

• TTE: Akinesis in the basal inferior segment, LVEF 30% LVEDD 65mm LVESD 54mm, ERO 60 mm2, RV 66ml vena contracta 8 mm

• No left ventricular viability

• 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?

ClassPatients with NYHA function class III/IV,LVEF ≤35%,QRS ≥120 ms,SROptimal medical therapyClass IV patients should be ambulatory

IA

ESC Guidelines CRT-P/-D

to reduce morbidity and mortality

• 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

Medical history

Evaluation of functional MR: Mechanism

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)

• 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


Tenting The volume of regurgitation is related to the importance of tenting and not to LVEF

Tenting areaTenting area (Yiu et al. Circulation 2000;102:1400-6)


Criteria Mitral RegurgitationSpecific signs of severe regurgitation

• Vena contracta width 0.7 cm with large central MR jet (area > 40% of LA) or with a wall impinging jet of any size, swirling in LA

• Large flow convergence• Systolic reversal in pulmonary veins • Prominent flail mitral valve or ruptured papillary

muscleSupportive signs • Dense, triangular CW Doppler MR jet

• E-wave dominant mitral inflow (E > 1.2m/s) • Enlarged LV and LA size (particularly when normal

LV function is present)Quantitative parameters Organic MR Functional MR Reg. Vol (ml/beat) 60 30 RF (%) 50 ERO (cm²) 0.40 0.20

Evaluation of functional MR: Quantification

(ESC Guidelines)

Back to Mr G

• 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?

MR

WORSE MR VOLUME OVERLOAD

LV DILATION

Rationale for the Correction of Ischaemic / Functional MR

Options: Medical treatmentSurgery: MVR/valve repairMitraclip

The Role of Medical Therapy

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

• Prosthetic valve replacementPreservation 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

n=

Operative Mortality (%)

Replacement ± CABG Grossi (J Thorac Cardiovasc Surg 2001) 71 20 Mantovani (J Heart Valve Dis 2004) 41 7.3 Calafiore (Ann Thorac Surg 2004) 20 10 Repair ± CABG Grossi (J Thorac Cardiovasc Surg 2001) 152 10 Mantovani (J Heart Valve Dis 2004) 61 8.2 Calafiore (Ann Thorac Surg 2004) 82 3.9 Diodato (Ann Thorac Surg 2004) 51 3.9 Glower (J Thorac Cardiovasc Surg 2005) 141 4.3 Fedoruk (Ann Thorac Surg 2007) 97 8.2 Braun (Ann Thorac Surg 2008) 100 8.0

Surgery for Ischaemic MROperative Mortality

Ischaemic MR (n=141)

Non-Ischaemic MR (n=394)

p

Age (yrs) 69 [61-75] 59 [51-69] <0.001 Hypertension (%) 39 24 0.001

Diabetes (%) 35 8 <0.001

Renal disease (%) 18 7

<0.001

Lung disease (%) 22 8 <0.001

NYHA IV (%) 72 38 <0.001

LVEF 40 [30-43] 50 [40-56] <0.001

Coronary disease (%) 100 18 <0.001

30-day mortality (%) 4.3 1.3 0.04

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

Ischaemic and Non-Ischaemic MRConfounding Factors

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

Surgery of Ischaemic MRCABG 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)

• 54 patients with severe ischaemic MR, mean LVEF 27%• Viability on PET scan

Ischaemic MRViability and prognosis

Viability and survival following coronary bypass and MV Replacement

(Pu et al. Am J Cardiol 2003;92:862-4)

Predictors of cardiac event Hazard Ratio [95% CI] p

Sodium (1mMol/l increase) 0.93 [0.90-0.96] <0.0001

Coronary artery disease 1.80 [1.30-2.49] 0.0004

Mean arterial pressure (1 mm increase) 0.98 [0.97-0.99] 0.0006

Blood urea nitrogen (1 mg/dl increase) 1.01 [1.005-1.02] 0.0009

Cancer 2.77 [1.45-5.30] 0.002

Beta-blockers use 0.59 [0.42-0.83] 0.003

Digoxin use 1.66 [1.15-2.39] 0.007

ACE-inhibitor use 0.65 [0.44-0.95] 0.03

682 patients with functional MR and severe LV dysfunction126 had valve repair, 556 were treated medically

Surgery for Functional MR vs. Medical Therapy

(Wu et al. J Am Coll Cardiol 2005;45:381-7)

Mitral annuloplasty was not a predictor of late cardiac events (death, ventricular assistance, or transplantation)

Impact of Surgery on LV Remodeling • 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)

Before surgery

18 months p

LV end-diastolic dimension (mm) 64 ± 8 58 ± 10 <0.01

LV end-systolic dimension (mm) 52 ± 8 44± 11 <0.01

Left atrium diameter (mm) 54 ± 6 48 ± 6 <0.01

• 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)

Reverse remodeling after surgeryUnsolved questions

Benefits of Surgical Correction of Ischaemic MR

• Decrease of MRbut risk of late recurrence after repair

(Gelsomino et al. Eur Heart J 2008;29:231-40)

• Left ventricular reverse remodelingin 60% of patients, predicted by LV dilatation

(Braun et al. Eur J Cardiothorac Surg 2005;27:847-53)

• Improvement of symptomscontroversial findings

• No proven benefit on survival (Wu et al. J Am Coll Cardiol 2005;45:381-7)

Indications for Surgery in Ischaemic MR

Chronic Ischaemic MR Class

Patients with severe MR, LV EF > 30% undergoing CABG IC

Patients with moderate MR undergoing CABG if repair is feasible

IIaC

Symptomatic patients with severe MR, LV EF < 30% and option for revascularization

IIaC

Patients with severe MR, LVEF > 30%, no option for revascularization, refractory to medical therapy, and low comorbidity

IIbC

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

(ESC Guidelines)

What about the MitraClip System ?

Percutaneous Valve Repair Using the MitraClip System

Everest-II*HRR (n=78)

Franzen et al.†(n=26)

Mean age (yrs) 77 70

Functional MR (%) 59 100

NYHA III-IV 90 100

MR ≥ 3/4 (%) 100 100

Mean LVEF (%) 54 22

Implant success (%) 96 92

Implant success and MR ≤2/4 (%) 81 92

(* EuroPCR 2009 † ESC 2009)

Everest HRR34 patients with functional MR

83% symptom improvement74% NYHA I-II at 12 months

(EuroPCR 2009)

Percutaneous Valve Repair Using the MitraClip System

Grade 3+/ 4+Grade 1+/ 2+

97%

18% 21%

82% 79%

Franzen et al.

At 3 months87% MR reduction

Symptoms86 % of patients in NYHA class I-II

Mean LVEF 23% 28%

(ESC 2009)

Baseline 30 days 12 months

When to propose a Mitraclip in functional MR?

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 G

• He benefited from the MitraClip system• No per-procedural complication• Favourable evolution (out of hospital at D+3)

Post-procedural TTE

Conclusion: evaluation of ischaemic MR• 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)

• 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

• Operative mortality is higher and long term results are less satisfying than for organic MR even when using valve repair

Conclusion: treatment of ischaemic MR

im ischémique

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