MANAGEMENT OF MITRAL HEART

DISEASE
Aldhi Pradana H
2020
 DISCLOSURE STATEMENT OF FINANCIAL INTEREST
• I DO NOT HAVE A FINANCIAL INTEREST/ARRANGEMENT OR AFFILIATION WITH ONE OR MORE
ORGANIZATIONS THAT COULD BE PERCEIVED AS A REAL OR APPARENT CONFLICT OF INTEREST
IN THE CONTEXT OF THE SUBJECT OF THIS PRESENTATION.
INTRODUCTION

• Increasing over time

• Switching between rheumatic and
degenerative
INTRODUCTION
INTRODUCTION
Management
MITRAL STENOSIS
Medical Therapy
MITRAL STENOSIS
Intervention
 MITRAL STENOSIS
Intervention

Contraindication
for PTMC
Mitral Stenosis
Intervention

Unfavourable characteristic
including:
• Old age
• History of PTMC
• NYHA IV
• Permanent AF
• Severe PHT

• Wilkins score >8

• Cormier score >3
(calcification extent)
• Small MVA
• Severe TR
 Mitral Stenosis
Intervention

Medical therapy remains the first line and should be given when there is
a suspicion based on clinical manifestation or simple diagnostic tool

Percutaneous intervention (PTMC) should be done when

• Symptomatic or there is any exercise-induced symptom
• No contraindication
• Anatomy and clinical favourable condition

Surgery should be performed when there is any CI of PTMC or

unfavourable condition
Mitral Stenosis
Intervention
Mitral Stenosis
Intervention
Mitral Regurgitation

Acute MR Chronic MR
Mitral Regurgitation
Acute MR

Poor prognostic
The best treatment is surgery to replace or repair
Medical therapy is not a substitute for surgery, but to
stabilise the patient en route to surgery
Nitroprusside and dobutamine are some agents that
help stabilising hemodynamic
 Mitral Regurgitation
Chronic MR

Normal Prolapse Flail Dilated

Anatomy leaflet leaflet Annulus

PRIMARY MR SECONDARY MR
 Mitral Regurgitation
Chronic MR
 Mitral Regurgitation
Chronic MR
 Mitral Regurgitation
Chronic MR
• In general, MR management is initially treated with medical therapy
• Surgery (I) is recommended over percutaneous intervention (IIb)
• Valve repair surgery is preferable over replacement
• Key points for MR undergoing surgery
Primary MR
Symptomatic pts with any EF despite optimal medical therapy
Asymptomatic pts with LV dysfunction OR preserved LV with AF OR pulmonary HT OR high chance of repair
Secondary MR
Any MR undergoing CABG as well
Severe symptomatic MR despite optimal medical therapy
• Percutaneous repair is eligible if there is high surgical risk AND suitable anatomy confirmed by echo
 Mitral Regurgitation
Percutaneus Mitral Repair
 Mitral Regurgitation
Percutaneus Mitral Repair

Summary of Percutaneous Mitral Valve Repair

Device Currently in Evolution

Mitralign
 Mitral Regurgitation
Percutaneus Mitral Repair MitraClip
 Mitral Regurgitation
Percutaneus Mitral Repair MitraClip
 Mitral Regurgitation
Percutaneus Mitral Repair MitraClip

COMPLICATION

Access site bleeding

Clip detachment from a single leaflet
Clip embolisation
de novo mitral stenosis
 Mitral Regurgitation
Percutaneus Mitral Repair MitraClip
EVEREST II
EVEREST II trial (2011)
Degenerative MR (75%), functional MR (25%)
Device vs surgical (n=279) in 2:1 ratio (184 vs 95)
 Mitral Regurgitation
Percutaneus Mitral Repair EVEREST II

CONCLUSION
• Of this population, there was a decreased MR grade more in surgery group
• Surgical group had more improvement in LV index, NYHA, QoL vs MitraClip group
• MitraClip arm showed lower major adverse event and lesser length of intubation period
 Mitral Regurgitation
Percutaneus Mitral Repair
MitraClip
COAPT trial (2018) - FUNCTIONAL MR
Device vs control group (n=614)
 Mitral Regurgitation
Percutaneus Mitral Repair Pascal
 Mitral Regurgitation
Percutaneus Mitral Annuloplasty Carillon
 Mitral Regurgitation
Percutaneus Mitral Annuloplasty Mitralign

Two clinical trials started since 2013, these are yet to be published
Several cases of TR was using Mitralign
 Mitral Regurgitation
Percutaneus Mitral Annuloplasty Accucinch
 Mitral Regurgitation
Percutaneus Mitral Annuloplasty cardioband
 CONCLUSION

• Mitral valve disease numbers are increasing over decades especially in mitral
regurgitation mostly due to degenerative etiology
• Medical therapy holds the first line of therapy regardless severity of the disease
• Now both mitral stenosis or regurgitation have alternative aside from surgery
• Unlike mitral stenosis which has long established balloon valvulotomy, novel devices
implantation in MR just started since last decade and are trying to take its place into
better recommendation in upcoming guidelines by doing various studies
THANK YOU