Perspectives sur lvaluation clinique et chocardiographique Erwan - - PowerPoint PPT Presentation

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Perspectives sur lvaluation clinique et chocardiographique Erwan DONAL Cardiologie CHU Rennes erwan.donal@chu-rennes.fr Dclaration de Relations Professionnelles Disclosure Statement of Financial Interest J'ai actuellement, ou j'ai

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Perspectives sur l’évaluation clinique et échocardiographique

Erwan DONAL Cardiologie – CHU Rennes erwan.donal@chu-rennes.fr

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Déclaration de Relations Professionnelles Disclosure Statement of Financial Interest

  • Grant/Research Support
  • Consulting Fees/Honoraria
  • Novartis
  • BMS
  • General Electric Healthcare
  • Siemens
  • Astra Zeneca

I currently have, or have had over the last two years, an affiliation or financial interests or interests of any order with a company or I receive compensation or fees or research grants with a commercial company :

Affiliation/Financial Relationship Company

J'ai actuellement, ou j'ai eu au cours des deux dernières années, une affiliation ou des intérêts financiers ou intérêts de tout ordre avec une société commerciale ou je reçois une rémunération ou des redevances ou des octrois de recherche d'une société commerciale :

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Study* Patients / type of study N° EVEREST I (Feasibility) Feasibility 55 EVEREST II (Pivotal) Pre-randomization 60 EVEREST II (Pivotal) Registry (High Risk Study) 78 EVEREST II (Pivotal) Randomized trial (2:1 PMVR vs Surgery) 184 Clip REALISM (Continued Access)Registry 727 Compassionate Emergency UseRegistry 43 ACCESS Europe Phase I Registry 566 ACCESS Europe Phase II Registry 191

⇒Over 10,000 patients have been treated with the MitraClipTherapy (6,000 in January 2013)

  • 75% are considered high risk for mitral valve surgery
  • 67% have SECONDARY MR

6712 TOTAL

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Primary MR Secondary MR

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77 23

2nd MR Iary MR

  • ACCESS EU: 566 Patients
  • Device time 118 min
  • Implant rate 99%

Maisano et al JACC 2013

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Critères d’inclusion

  • Insuffisance mitrale sévère de type secondaire
  • Sévérité évaluée ETT/ETO :

– volume de régurgitation > 30 mL/batt – SOR > 20 mm²

  • Classe fonctionnelle NYHA ≥ II
  • FEVG entre 15 et 40%
  • Au moins une hospitalisation pour ICC dans les 12 mois qui précédents
  • Traitement médical optimisé de l’ICC
  • Patient jugé non éligible à une chirurgie par « heart team »

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Clinical state point Imaging State point

  • 1. Neuss et al. Eu J Heart Fail 2013; 15: 789
  • 2. Lancellotti et al. Eur H J 2013; 34: 1597
  • 3. Cavalcante et al. JACCim 2012; 5:733

Heart valve clinic Multidisciplinary decision making process

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Prevalence and Outcomes of Unoperated Patients with Severe Symptomatic Mitral Regurgitation and Heart Failure: Comprehensive Analysis to Determine Potential Role

  • f MitraClip for this Unmet Need.

5737 MR >2 were identified between 1/1/2000 and 12/31/2008 1095 MR >2 + IC  Surgery 53 %  OMM 47 %

EF=42 % EF=27 %

Medically treated patients 36 % eligible for Mitraclip Goel et al. JACC 2013(in press)

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Clinical state point

Euroscore Co-morbidities Coronary artery status LV EF Clinical status: NYHA, 6 min walk test, CP Ex test, natriurétic peptides

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Lancellotti P et al. Eur Heart J 2013;34:1597-1606

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Angelo Auricchio , et al

Correction of Mitral Regurgitation in Nonresponders to CRT by MitraClip Improves Symptoms and Promotes Reverse Remodeling

JACC 2011; 58,: 2183 - 2189

51 severely symptomatic CRT non- responders with FMR ≥ 2

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Changes Over Time of Echocardiographic Parameters Sequential changes of (A) left ventricular diameters, (B) left ventricular volumes, (C) left ventricular ejection fraction. LV diam mm LV Vol ml LV EF %

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Neuss M et al. Eur J Heart Fail 2013;15:786-795

We treat secondary MR, so with some degree of LV dysfunction but do not wait that the  heart is too remodeled and  the Heart failure too severe

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Freedom from heart failure rehospitalization in successfully treated patients with secondary mitral regurgitation, differentiated by size ranges of left ventricular end-diastolic volume (LVEDV).

Rudolph V et al. Eur J Heart Fail 2013;15:796-807

Not a good idea to wait LV enlargement > 270 ml

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P1

Imaging State point

 Indentation?  Mitral ring area > 4cm²  Calcifications  Size of the posterieur leaflet (not too short)

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Think at this new treatment strategy in Secondary MR > 2/4 At every TTE performed in DCM, Ischemic heart disease…

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Importance of the TTE

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Offline 3D MV analysis

Quantitative semi-automated analysis in mid-systolic frame A-P diameter AL-PM diameter Annulus 3D area Anterior leaflet area Posterior leaflet area Tenting height Tenting volume Sphericity

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Vertical Coaptation Length (FMR) Calcification in the Grasping Area

11mm tenting 2 mm coaptation

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80-110˚ View: Bicaval 15-45° View: Short Axis at Base

The poncture of the Atrial Septum should be posterior 3-4 cm from the plane of the mitral ring

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Take home messages

Mitraclip is part of the treatments available for the Heart Team potential candidate have to be precisely assessed by a predefined person of the heart team Echo is specific and has to include a real 3D in TTE and TOE+++

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www.escardio.org/EACVI

3-6 December 2014, Vienna Austria

GET READY FOR THE

CALL FOR ABSTRACTS 1 April - 31 May 2014

Main Themes

  • Three-dimensional

imaging

  • Imaging in acute cardiac

care

ARE YOU READY FOR THE WORLD’S LARGEST CARDIOVASCULAR IMAGING CONGRESS?

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Functional MR and Survival in CHF Survival for patients with heart failure is shown for varying severities of MR.

Blase A. Carabello

The Current Therapy for Mitral Regurgitation

Journal of the American College of Cardiology Volume 52, Issue 5 2008 319 - 326

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Núñez-Gil I J et al. Heart 2013;99:1502-1508

Long-term follow-up to hospital re-admission due to congestive heart failure depending on the severity

  • f the MR

Long-term follow-up to hospital re-admission due to major adverse cardiovascular events (MACE) depending on the presence or absence of mitral regurgitation

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ECG, Pharmacological treatment >> discussion CRT-ICD >> discussion required with Surgeons and Anesthesiologists

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Full-Volume with Color - 3D Vena Contracta Area

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0° Views: Superior

  • Shows A1/P1 scallops or lateral aspect of the MV.
  • It is important to interrogate the valve with and without color to

determine the presence of a jet in the A1/P1 region.

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0° Views: Central

  • Shows the A2/P2 scallops of the MV.
  • It is important to interrogate the valve with and without color to

determine the presence of a jet in the A2/P2 region.

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0° Views: Inferior

  • Shows the A3/P3 scallops or the medial aspect of the MV.
  • It is important to interrogate the valve with and without color to

determine the presence of a jet in the A3/P3 region.