Evaluation & Management of Mitral Regurgitation

What are the guidelines for the management of patients with Mike for graduation? This is the topic of this lecture. In addition, however, I also want to go a little bit beyond to take a look at how modern technology that we have at hand with ultrasound can help us here now. Usually when you read the guidelines, you kind of skip the preamble, but I think this is a very important thing to look at as well. Now here is what is in the preamble, not only in the guidelines on mitral regurgitation, but in all guidelines. The guidelines are here to summarize and to evaluate available evidence. The important word here is available. Be aware that of course the guidelines have to look at the publications which are present, which are always a little bit delayed with respect to what the forefront of medicine really is. But they have to of course focus on what is really, really known and what is firmly established in the medical evidence. The other very important point is that it should assist healthcare professionals in selecting. The best management strategy. So it's the word assist which is so important it is not something you have to do in every case, but it's just a guideline. In other words, a guidance to your treatment of patients, and there are certain other things that you always need to consider in specific situations. Very important, it facilitates decision making of healthcare professionals in daily practice. So yes, that's a very important fact as well. Now, what guidelines do not do is they should not override in any way whatsoever the individual responsibility. So at the end of the day, you're responsible for the treatment of your patients and there will be situations where you probably need to stretch the guidelines to some point because the specific situation that you're dealing with is simply not covered in the guidelines. So be aware that the guidelines are always very conservative. What guidelines do not provide us? They do not cover all the different combinations of conditions that you will encounter, especially also in my true graduation, there might be many different variants of might regurgitation which specifically have never really been looked at in detail in large studies. They do not include your individual experience, which I believe is also very important and they do not of course consider economic factors. The price, for example of a micro clip procedure and the availability in your individual country. So in essence they do not always cover the newest advances. Should we still use them or not? What I believe yes, and I will show you how you can use them in the setting of mitral regurgitation. Here is a very famous quote from Hippocrates who says declare the past diagnosed to present and for tell the future. And I exactly that is what you're supposed to do. In some situations you will have new technologies at hand and you will have to look at them and somehow extrapolate them, but still use them even though they might not be in the guidelines. Let's take a look at some specific questions that we are confronted with when it comes to mitral regurgitation. How do we actually assess mitral regurgitation? When do we intervene? How do we intervene? And finally, how do we follow up patients? I'll go through all of these individual points step by step. Let's start with how to assess mitral regurgitation. Well, I guess it's quite clear that the primary diagnostic tool and the best tool to follow up patience is definitely transthoracic, at choreography that does not need to be actually stayed in. The guidelines is quite clear, but we also have trans esophageal echocardiography, and we have stress testing. What is the role of stress testing? Well, in the latest guidelines the importance was downgraded. Why? Because there's just not enough evidence to clearly show how we should use stress testing, how it should be performed. And what information we can really extract from the stress test to help us in the management of patients does not mean you cannot use it, but it just means that the evidence is just not there to put it in the guidelines. We also have global launch. Will strain. This tool is not definitely in the guidelines in the sense that we should use it, but it is mentioned and it is said that actually global launch will strain. Could be a parameter that would help us, but that at present there is just not enough evidence to show us how to use it. And finally we have a parameter that is not an echo parameter. Neural hormone of BNP is a very important one to follow up patients because we know it predicts symptoms and it is important prognostic factor. So yes, I believe BNP should also be used in many of the patients we have with chronic mitral regurgitation. What is the role of pulmonary pressure? These two is a very good parameter. Why? Because it correlates with symptoms and it also points to maybe the necessity of performing some form of intervention. Be aware though, and this is also stated in the guidelines that echo sometimes can be a little bit unreliable when it comes to measuring a right heart pressures, and that to confirm it it would always be good to use right heart catheter. Now let's come to Transthoracic Echo, and let's look at some of the points that Echo can actually help us with. First of all, quantification. We can look at the mechanism. We can look at the etiology of Metro graduation. Furthermore, it provides us very important prognostic information, and it can also display the severity of the problem, the urgency of the problem. A very important thing, again, when it comes to timing, will talk more about that later. Transit salvage, Ilektra Cardiography is important. It should be used, especially if you have poor image quality, but we in our laboratory use it also for other indications. If we have an unclear mechanism, we cannot clarify the reason why the patient has mitral regurgitation. We use it in conjunction with 3D T. In other words, where we want to display the pathology or the morphology better than we use 3D echocardiography. Be aware that the guidelines also state that 3D echo is an important adjunct that can an should be used in specific indications. We use trans esophageal cardiography to determine whether or not an edge to edge repair is possible or feasible. And finally we use it obviously to monitor patients during such a procedure. To jump right into the topic of transit salvage electrocardiography. Here is just a representative image of a T study that we performed and here is a 3D representation of a pathology where we have a coaptation defect. In other words, a functional form of my trigger rotation. Just to demonstrate how nicely we can actually differentiate the different forms of my true graduation primary versus secondary. What you see here is you see that there is a coaptation defect. Between the anterior and the poster leaflet. And we see that the regression jet comes exactly from the middle region. Here this is for example very important when it comes to deciding whether or not a patient is a good candidate for an edge to edge repair. This actually would be a good candidate. Also take a look at the very round circumference here of the mitral valve, which is very typical of functional mitral regurgitation. Another example, now we are monitoring a procedure and you see how nicely we can actually look at the position of the clip relative to the leaflets. In this case, we probably need to rotate a little bit to be perfectly aligned to the coaptation defect. Now you see there is a number of ways we can use modern technologies to enhance our decision-making in patients with MoD for graduation. If you come back to the guidelines, you will see that there is a large table of different things that we should actually assess, with echo ranging from qualitative parameters to semi quantitative and quantitative parameters. Now of course these are all very important and there is no time to go into all of these individual parameters, but what is very important is that despite these guidelines, we still have a number of different problems when it comes to quantifying and assessing patients with mitral regurgitation, so I want to. Highlight some of these problems to display that there is a need for new technologies that could overcome these problems. Here is an example or actually 3 examples of patients with mitral regurgitation. Take a look at them. And I guess you will all agree that all of these three patients have severe mitral regurgitation. But, uh, they're all the same. Well, yes, we've got different mechanisms here, but only looking at the magnitude of module rotation, I always ask myself, is it really enough if we quantify regurgitation as mild, moderate, severe? In this case, we have severe and very severe and maybe severe severe forms, so probably these patients need different forms of treatment. Probably it also affects the left ventricle different. You can probably expect the even more hyperdynamic left ventricle function. In a patient who has severe severe mitral regurgitation, so are the cutoff values that I'll show you later. Really the right values or not. Another problem. The issue of dynamic mitral regurgitation. A patient where we have significant match regurgitation, he had high blood pressure as soon as we lowered it, we got. Only mild mitral regurgitation, so you see these effects are something that occur quite quickly in individual patients, and it makes it sometimes very difficult not only to quantify Amar, but also to manage these patients. In this specific case, obviously blood pressure treatment would be the upfront therapy that you would recommend. Let me show you another problem where sometimes confronted with. This specific patient received a T study to evaluate mitral regurgitation. Here is the transthoracic study if you can. Try to estimate left ventricle function. I guess it's quite clear that function is quite normal, but then we sedated him. We performed AT study and take a look at his left ventricle function right now. So from a suitable interventions or anesthesia can greatly affect not only left ventricle function but also the magnitude of mitral regurgitation, a difficult problem, very difficult to moreles predict how much regurgitation will be once the patient, for example, is off anesthesia. Now let me turn to the mechanism of mitral graduation and talk a little bit about why it is important. Well, it's important because it dictates the likelihood of mitral valve repair. We determine the method of intervention based on the mechanism, and finally, if you go to the guidelines, you will see that there are different recommendations whether or not a patient has, for example, functional or structural mitral regurgitation. Let me go back to 3D echocardiography again to display what echocardiography has to offer. If you look at the. Normal trans esophageal study you will see that there is a prolapse. I guess the diagnosis is quite clear, but can you really appreciate which parts the valve are affected? What the magnitude of prolapse really is? Which parts of the valve actually need to be repaired or not? Well, if you use the 3D image, it's quite clear here we have and are fast view from the left atrium to the micro valve. This is the anterior leaflet. Here we have the poster leaflet and here we have the poster middle, sure, and this would be the anterolateral commissure. And if you look closely, you will see that there is little billowing elements here of the poster leaflet, and you can appreciate that the entire Metro valve is actually involved and that the. Most prominent part of Prolapse is located here in the P3 region. You cannot get this with two D and this is certainly an important piece of information that you can communicate to your surgeon. Now an example of a patient with functional or secondary mitral regurgitation. Here on the 2D image you nicely see that the patient has severe mitral regurgitation, and at the jet originates here from the middle of the valve, and if you look at this dual view here on the right hand side where you can see the micro valve once from the HL side and once from the ventricular side, you will also appreciate the specific morphology of the analyst, which is more round and the coaptation defect in the origin of the jet. But I believe there's even more than 3D Echo can actually offer us. Here is an example of a so called easy valve analysis. What we're doing here is we're tracking the motion of the analysts and the motion of the leaflets in this specific case, the patient has a so called seizes module, angle, calcification, or toothpaste lesion. In reality, these forms of calculations, no matter if you have this pathology there or not, is able to measure certain parameters such as the length of the leaflets. The motion of the analysts, and I believe that these parameters in the future might even help us to predict which patients have a higher likelihood of mitral valve repair. And maybe even guide the surgeon to the correct intervention. One thing which I also want to mention is that frequently will have a discrepancy between the degree of morphologic abnormalities and the degree of mitral regurgitation. Here is such an example in the 2D image, you don't have the impression that anything is wrong with the mitral valve. If you look closely, however, you will see that there is a very small flail portion. The leaflet here. However, if you look at the regurgitation jet, you will see that Mer is actually very severe. An important point to consider. You need experience as well. Coming back to the specific questions, in math rotation we already talked about how to assess module graduation. Now I would like to focus on when to intervene. Let's start with primary micro rotation and see what the guidelines say. Here are some important rules that we can draw from the guidelines. Rule #1 mitral valve repair should be the preferred form of mitral valve surgery. Why? Because we end up with a better left ventricle function, we're preserving the subvalvular apparatus to a greater degree. We also have less complications of prosthetic valves. For example, prosthetic valve obstruction or bleeding to do anticoagulation therapy or thrombosis of a prosthetic valve. Here is a beautiful example of a patient who received mitral valve repair. A dual view, but we can clearly denote that there is a paravalvular leakage right here. Now, if this is the case, then the results are not optimal and such patients of course do not have the same prognosis as a patient where everything went right with the operation. Again, this emphasizes how important it is that you not only have a good surgeon that performs optimal mitral valve repair, but that we also help in the selection of patients who will have a favorable outcome after mitral valve repair. Well, which patients are no good candidates. Primarily, patients who have involvement of the anterior leaflet. They are more difficult to repair. Problems in the commissural regions. Extensive disease and the best pathology, the pathology that all surgeons wish to repair is the medial scallop of the poster leaflet. But then there are other factors, factors that we can measure with echocardiography and that have been published. The Coaptation distance seems to play a role. The tenting area. Complex jets. A poster lateral angle, which is more than 45 degrees. Large diameters and specific shapes of the ventricle might also be a problem when it comes to repair, but this is just to show you that this whole field is evolving and we will definitely get cardiography to assist us here. Rule #2 it's an easy one. If the patient has symptoms, an is ejection fraction is above 30%, you should operate him. Why do we have this cutoff value of 30%? Well, because we know if the ejection fraction drops below 30%, the prognosis of the patient is not really good. He does not have a survival benefit. His mortality is high and usually especially in functional match rotation you have a high recurrence of might regurgitation. In this situation, the ventricle can simply not cope with the increased after load that you get if you repair or if you operate on the mitral valve. Let's come to rule #3 perform surgery if a patient is asymptomatic and his ejection fraction is below 60 or his end systolic diameter is more than 45 millimeters. Now here we're entering this very exciting arena of what do you do in patients or asymptomatic? Should we operate them as well? Well, as rule #3 says, only if we see some form of change in the ventricle that predicts that left local function is about to deteriorate. Rule #4 if a patient is asymptomatic and the criteria I just mentioned are not met, there are some I would say soft criteria which also point to the direction of some form of intervention. First of all you have to have a high likelihood of successful repair. If patients have atrial fibrillation, then they also might be candidates because it shows that the Atria are now being stretched and the likelihood that they would remain in April fibrillation if they're not operated, is increasing. You should look at pulmonary pressure, which I already mentioned is an important correlate of symptoms and of left ventricle dysfunction. So if that is above 50 millimeters of Mercury, you should consider surgery. But be aware that echocardiography in many situations might be wrong, so sometimes it might be good to reconfirm that with the help of right heart catheter. Finally, if you have a large left atrial volume, then this might also be a point that puts you in the direction of cardiovascular surgery. In all of these situations is always recommended to have a good surgeon and to bring patients to a heart valve center where the experience is high so that you don't end up with a patient who was asymptomatic at the beginning that is now symptomatic because repair was simply not successful or not. But what do we do with patients who have very poor left and your function? For example, in the ejection fraction below 30%? Well, here is rule #5. You should not perform surgery unless their refractory to medical therapy. And if they have a high likelihood of repair then you can consider mitral valve intervention. Rule #6 I already mentioned this. Look at the neurohormones. B&P is a very good predictor of outcome, and it predicts the occurrence of symptoms. We know that a low B&P has a high negative predictive value. This is how we can put all this together in a decision tree. If you have a patient who has severe chronic primary micro graduation, the most important thing to look at is the patient, symptomatic or not. If you're symptomatic, we have to have an ejection fraction which is above 30%. If this is the case, then yes, it's quite clear the patient needs cardiovascular surgery, preferably with repair. If ejection fraction is. Below 30% you want to know if he is refractory to medical therapy. You want to know if repair is possible an if the comorbidity is low. In other words, the operative risk is low and if this is the case you would also bring the patient to surgery. If the patient has a high operative risk and repair is probably not possible then you would have to look for alternatives, preferably the edge to edge repair. What you do in patients who are not refractory to medical therapy? Well, if they're not refractory, you can give them medical therapy and then you would treat them conservatively. Of course, you have to be aware that they might crossover to this branch if they do get refractory to medical therapy. Now let's turn to the other part of the decision tree. To those patients who do not have symptoms where it's a little bit more difficult to decide what to do. Here we have to look at secondary findings of heart failure. In this case an ejection fraction which is below 60% or an end systolic diameter above 45%. If the ventricle is very large and ejection fraction is start to deteriorate, yes, despite the fact that the patients are asymptomatic, you should operate them. If these criteria are not met, then you can look at other criteria. For example at pulmonary artery pressure. If it's above 50 millimeters, or. Mercury, or if the patient has April fibrillation, then two. You would have to consider other forms of treatment, especially if they have a high likelihood of a durable repair and the operative risk is relatively low. You would bring them to surgery as well. If not, you would simply follow up the patients, so this is the general scheme of the guidelines and how you would approach patients who are symptomatic and those who are asymptomatic. Now let's turn to secondary or functional mitral regurgitation rule #1. If bypass surgery is performed is indicated, an ejection fraction is above 30%. Well, you'd also perform some form of repair of the microvalve. Rule #2 if there is an option for bypass surgery and ejection fraction is below 30 but there is some evidence that the left ventricle function will improve after surgery. Based on the fact that there is viability then you should also consider micro valve repair favorably again to micro valve replacement. One thing which is important, be aware that when we quantify madruga rotation in functional model, we have lower thresholds for the severity of mitral graduation. Let me highlight this again here. In this table you see that for primary mitral rotation we have an effective orifice area of more than 40 square centimeters as the cutoff value for severe, while in secondary the cutoff value is 20 square centimeters and the same also holds true for the regurgitant volume. In primary might regurgitation 60s. The cut off value and for secondary 30 milliliters is the cutoff value. Rule #4 surgery cannot generally be recommended in patients with functional or secondary mitral regurgitation, and there's a reason for this. The prognosis of this patient cannot be improved. There is no evidence that we truly help the patients. But we have an option in these patients as well, especially if left ventricular function is very poor and there have a high surgical risk. In this situation we can use the edge to edge repair the procedure. Most of you are most familiar with is the mitral clip procedure, a procedure where we clip the anterior to the post your leaflet and thereby cost coaptation of leaflets and reduce mitral regurgitation. You have to be aware though, that it's in fear to surgery to reduce module graduation. We often have some residual Mr present that, however, it does improve symptoms, but there is not yet any. Evidence that we really really increase the survival of patients, but we do help the patient in the sense of a better quality of life and higher functional capacity. And we know that the left ventricle shows remodeling. If we are successful in clipping these patients. We have one more thing that we have to discuss and that is how do we actually follow up patients, specifically, patients who are asymptomatic have. And ventricle with an injection fraction above 60% and who have primary mitral regurgitation. The guidelines tell us that we should observe these patients every six months, ideally in a center which is specialized in valvular heart disease. On a personal note, during the intervals between the different exams, also tell the patients that they should observe themselves more closely and I make them aware of the typical symptoms of mitral regurgitation which are dyspnea. A drop in exercise capacity and also arrhythmias. So for example, I tell a patient that if you always walks a certain distance, for example. From work to home, he should observe how easy he can actually manage this distance, and if he notices that this is more stranius, it might indicate that is exercise capacity is dropping. But remember that the intervals at which you see the patient should be fairly flexible. For example, if you don't have a previous exam and you don't know how rapidly someone might be deteriorating, it's good to use shorter intervals and the same holds true. If a patient does show some dynamic change. For example, if you have. Exam A he has a certain size of the ventricle and at exam P it is starting to increase. So there I would probably use a shorter interval to see if this increase in the size of the ventricle is progressive. And finally if a patient only has moderate mitral regurgitation it might be enough. If you see the patient only every two years. What are some of the knowledge gaps we have at present and this is also stating the guidelines well for one, we're not really sure if there might not be better early markers. To help us determine if a patient should be brought, the surgery not in the beginning of the lecture already mentioned issues such as strain, but maybe even better ways of quantifying module rotation where we can truly in a more exact way quantify regurgitant volumes. Maybe there is a cutoff value which is better suited to determine whether or not a patient benefits from surgery or not, so a lot must be done on the technological front. And of course in studies to prove that we have better early markers. The question whether or not elective surgery should be performed in asymptomatic patients. This is a huge field, of course. Cardiovascular surgery is improving and the outcomes are improving, so why not operate patients before we even get to a range where patients are at risk of developing left ventricle dysfunction? Here again, lot of studies must be performed and we need better imaging techniques which help us to find such markers which will indicate that asymptomatic patients. Would benefit from surgery. We have to define or we have to look at the thresholds to perform mitral valve surgery in secondary Mr and my personal feeling is that there's probably a subgroup of patients with severe Mar and left frontal as function who would truly benefit from surgery, but which are these patients? How can we better define these patients? Again, technology and studies. I believe in the future will help us. Maybe one of these technologies is advanced imaging and maybe also stress echocardiography. We also don't have a lot of information on the impact of interventions. Edge to edge repair for example. Or surgery on the prognosis in patients with secondary Mar. So we will need some time to figure that out as well. And finally we are working on completely new technologies that will help us to perform micro valve repair intervention. Lee. So a lot of these techniques are now being studied. Of course they're not approved yet, but that does not mean that we should definitely develop these techniques because ultimately these might be solutions that will solve many of the problems we have at present. Let me summarize what we said about the guidelines in a very emotional and challenging case. It's that of a only 21 year old woman who we saw first when she was pregnant in her 23rd week. She had a genetic cardiomyopathy and an ejection fraction is only 32% and it was known that you had much for graduation. She got pregnant anyway. Well, we had to of course, deliver the baby prematurely because the patient was deteriorating during pregnancy. She was doing really bad. Fortunately, the baby is doing fine and everything was OK, but the problem did not stop them. Why? Because the patient still had very bad symptoms of heart failure and deteriorated further. Let me take a look at the images. Here is the parasternal window with the short axis view you see that left ventricle function is very poor here. Even more important, look at the motion of the microvalve it hardly opens and it also hardly closes. You see that there is a coaptation defect present right here. You can appreciate that as well in. The four chamber view and the apical long axis view. We've got angled adaptation and we've got some form of restriction. The leaflet note that the poster leaflet is also not moving now. This is clearly a functional form of my trigger education. A secondary form of micro graduation and here is a beautiful example of the micro valve. We're looking from the left ventricle to the micro valve and you can nicely see the coaptation defect here. Now of course this is only possible. If we have very high volumes per second, which is the case, here we have 17 volumes per second, so these are images that definitely help us. Also, remember we now know that if we actually can see the cooptation effect, then might regurgitation is definitely severe. This is actually one of the morphologic criteria which is in the guidelines now. Not surprisingly, the patient has very severe module reputation. Remember if you go to the guidelines, you will note that one of the morphologic criteria. If you see a coaptation effect, NMR is severe and this is just here to confirm that Mr is very, very massive. We have a broad jet. Huge jet which fills almost the entire atrium, not surprisingly. The question, however, is how severe is Matt regurgitation really? Can we actually perform some form of calculation that allows us to tell us we have the pizza method and many of you are aware that there is a two DP, some method, an also a 3D piece of method. So what do we need to perform the piece of calculations we need to look at the flow across the microvalve and this can actually be done automatically. Here you see the measurement that is performed and automatically we get the velocity time integral. Of micro graduation. On a side note, also take a look at the shape of the Mr Signal. It's triangular and the velocity is not very high, why not? Well, because of blood pressure is very low, she's almost in shock. After we performed his measurement, we need to also look at the color Doppler signal and measure the pizza hemisphere. Here we picked an appropriate frame where we can nicely see the pizza and we already calculated the regurgitant orifice area which is 77 square millimeters. To confirm this, we also performed a 3D measurement. This is the same patient of course. Now we're performing the 3D measurement where selecting an appropriate loop. Then we. Freeze the image to find the optimal frame. We now point the arrow down towards the direction of flow. We've got an automatic calculation of the piece of hemisphere you see very nicely now that we get a piece of calculation already. But what is really important or what is something that you should consider is that there are sometimes variations in the Mr from beat to beat and with the 3D system you can analyze several beats at the same time. Now we performed a second calculation. You see that there is a. Different regarding office area in the first opposed to the second. Not a big difference, but at least we see that there are variations in not only the regression office area, but also in the peak regarding volume. Let's put all of these findings together we have. Are urgent office area of 77 millimeters square, both with a 2 DP's and the 3D pizza method. The reference value in the guidelines is 20. In other words, if you have a regurgitant orifice area above 20, it's severe, so this is 3 times the upper normal of severe. If you look at the regression volume, we have 63 milliliters, which is also twice as much. Actually as the guideline state for severe regurgitations. One thing to understand in this specific situation is that because the patient has such a low pressure, there is relatively little resistance and therefore we have not so much flow going backwards. Still, despite the fact that she's almost in shock, we have a very high regurgitant volume. The next thing we have to look at is left ventricle function. You now know how important it is. What ejection fraction is? If you want to decide what to do with the patient. If you perform a visual assessment of the left ventricle, you will probably appreciate that ejection fraction. This is seem to be so bad. This is not surprising because the patient has very severe mitral regurgitation and a reduction in after load. But we do need. Parameters we need to calculate ejection fraction and the best methodology at hand is definitely 3D echocardiography. Why? Because it does not rely on any geometric assumptions or hemodynamic assumptions. And if we perform this calculation you will see that ejection fraction is not so bad, it's 45%. But I would not stop here when it comes to assessing left frontal function. We have another very important modality at hand and that is speckled tracking. Here we performed an analysis of the longitudinal function in the four Chamber view, looking at how good the ventricle contracts in launchable direction. And this is such an important parameter because it has predictive importance. There are studies that definitely show that if you have a reduction in lanja strain, patients have a poor prognosis. In mitral regurgitation, well, it's not surprising that this patient has a reduction in Lanja tool string. We see a value of minus 14.1%, but this is not such a severe form of reduction that you would say the ventricle is completely dysfunctional. What can we now say and how can we actually manage the patient? Well, we have to go back to the guidelines. Remember, if you have secondary mitral graduation. Surgery is not generally recommended, especially if the ejection fraction is below 30%. But as we now saw both with the visual assessment with the 3D echocardiogram, and also with strain ejection, fraction is not so bad. It's 45%. Still we must consider that this patient has very very severe module rotation and that maybe would have to even use a different cut off value in this patient, but what are the options? We have the first option we have is. Mitral valve repair. The second option we have is the edge to edge repair. We can. Forward the patient to transplantation or we also have the option of giving the patient an assist device, maybe for a bridge to transplantation. We have to of course make this decision in a heart team. This is very important because we have to get all different sides and aspects of surgical aspects and the clinical aspects of the cardiologists interventionists. But in this specific situation, I think all of these parameters point to the fact that there might still be an option that this patient could benefit from Michael Valve operation. I do not think that the micro clip or edge to edge procedure is the best procedure. Is the patient's function is still too good? However, it probably would be wise that if you perform such a mitral valve repair, you would do it with a so called El Vert standby, or may be implanted elevate in the initial phases after operation so that the patient has time to stabilize. Still, I think such decisions are very, very difficult to make at times, but with all the methodologies we have at hand, I think we can get closer to the truth. What came out of this patient while we actually did operate the patient, an surprisingly the patient did quite well. Let me now come to my conclusion. The guidelines are important. You have to know them because they are the foundation of what we do. Still do not forget the very famous quote from William Ostler, who said medicine is a science of uncertainty and the art of probability. Probability is the guidelines. It's what we know based on our scientific evidence. And the uncertainty is what we have to live with, where we sometimes have to extrapolate and use modern analyzing technologies and techniques to aid us to extrapolate those guidelines, essentially to help our patients.

New onset Symptoms Refractory to medical LVEF or LVESD 245 mm LVEF Management of severe chronic primary mitral regurgitation 3D Volume calculations Yes of AF or SPAP >50 mmHg new techniques of interventional MV repair therapy Options CW signal of regurgitant jet l)ense/tnangular Symptoms LVEF s60% or LVESD mm Parasternal window 3D PISA calculation Volume calculations 3D PISA 2D PISA Hoi ass mitral regurgitation CW Doppler signal - MR Coaptation defect The ventricle calculation LVEF New onset l)ense/tqiangular LVEF or LVESD 245 mm LVEF s60% or LVESD 245 mm Refractory to medical early markers of surgery? 3D - TEE of AF or SPAP mmHg Preamble Surgery not generally recommended How to assess mitral regurgitation Primary mitral regurgitation Rules for What Guidelines do not provide Functional MR Follow up for asymptomatic patients (EF >60%) Secondary mitral regurgitation Severe vs very severe mitral regurgitation Mitral regurgitation No Hoi to assess mitral regurgitation Mitral Regurgitation Dynamic MR LVEF or LVESD mm of AF or SPAP >50 mmHg CW Doppler signal - MR LVEF or LVESD 245 mm LVEF s60% or LVESD 245 mm LVEF therapy No CW signal _arge flow zonvergence zone _arge flow :onvergence zone No Yes 2D PISA calculation Symptoms eSieValvesTM advanced analysis package A4K Follow up for asymptomatic patients Speckle Tracking Regurgitant orifice area = 77mm2 severe > 20mm2 No Yes Symptoms NO LVEF s60% or LVE-SD 245 mm LVEF or LVESD 245 mm LVEF Very large central jet or eccentric jet adhering. swirling 3D PISA calculation 3D Volume calculations Surgery can NOT be generally recommended Of mitral New onset Refractory to medical If EF less than Color flow regurgitant jet LVEF Ml: Options CW signal of regurgitant jet Dense/triangular Surgery if asymptomatic and Especially if EF S 30% Especially if EF 30% LVEF or LVESD mm LVEF or LVESD 245 mm Coaptation defect LVEF Parasternal window Qualtitative Quantiticative High likelihood of durable 0.869 The ventricle Transthoracic echo 11/22/2017 Medical therapy 78 bpm Monitoring of a MitraClip procedure Management Of severe primary mitral Of severe primary mitral Valve morphology 0.82 0.82m Current problems Transesophageal echo Transthoracic echo LVEF s60% or LVESD 245 mm LVEF Surgery not generally recommended How to assess mitral regurgitation Primary mitral regurgitation Primndary mitral regurgitation Why is the mechanism important Flail leaflet / ruptured papillary muscle / large MR Vmax = 4.51 m/s MR Vmax = 4.51 mfs therapy of AF or SPAP mmHg Secondary mitral regurgitation Sew to assess mitral regurgitation 11 vps / 140 11 vps/ 140 Beyond „simple mechanisms" Specific questions in mitral regurgitation What Guidelines do not provide Change in function (Midazolam) Unfavourable for repair Preamble Mitral regurgitation Severe vs very severe mitral regurgitation Hoi ass mitral regurgitation Mitral Regurgitation Morphology vs MR severity Dynamic MR Step 1; Step 3: Edge to edge repair No TEE New onset repair, low surgical risk, Flail leaflet / ruptured papillary muscle / large CW signal Grad = 81.5 mmHg Large flow convergence zone _arge flow zonvergence zone dn monoJ coaptation defect 10 bpm / 10 bpm / alig Refractory to medical consider if LVEF s60% or LVESD mm (8 ror biplane Other ein 082 42 fps / 130 mm Liuememp: <37• C 42 130 mm 42 fps / 130 mm Valve morphology EF < ESD > < ESD > 11 140 mm Mean Grad 40.2 mmHg Regurgitant orifice area = 77mm2 0.8 18 fps / 180 mm Why not? of AF or SPAP mmHg No Beat 1/1 coaptation defect Coaptation distance therapy 19 fps 180 mm Transesophageal echo NO Yes 109 bpm / NTHI allgemein In asymptomatic pat. „Declare the past, diagnose the present, foretell the future." • 09 bpm NTH t O bpm NTH bpm NTH NTH and presence of risk Repair when ever possible LVEF Very large central jet or eccentric jet adhering, swirling therapy Lv Eov of AF or SPAP >50 mmHg Beat Medical therapy LVEF New onset 105 bpm / Allgemein 2.8 Hz Refractory to medical Color flow regurgitant jet reaching the posterior wall Of the LA 34 1 SO 43 fps / 180 mm Yes Refractory to medical Yes Surgery can NOT be generally recommended 34 Regurgitant volume = 63ml Regurgitant volume brought to gou by severe > 20mm2 of or SPAP 50 mmHg 43 mm LV ESV From Guidelines to Practice: Durable valve repair is Mitral valve repair ET = and reaching the posterior wall of the LA Surgery if symptoms If bypass surgery is indicated 34 t I OO Ægemein 99 "gemein dB 108 bpm / NTHI angemein Of or mmHg of AF or SPAP mmHg Linsentem C Linsentetn dB 14 dB / 4 dB Very large central jet or eccentric jet adhering, swirling Especially if EF New onset 10B bpm I NTHI allgemein 107 bpm I NTHI allgemein high likelihood of repair High likelihood of durable Ligh likelihood of repair High likelihood Of durable 10B bpm NTH' allgemein 10B bpm NTH' ailgemein 55 Vena contracta factorsa / Allg. Systoli(l pulmonary flow reversal Systolic. pulmonary flow reversal 73.3 ml repair, low surgical risk, Refractory to medical of AF or mmHg consider if: Color flow regurgitant jet therapy therapy Edge to edge repair brought to you by TEO: 21 Offset: -2 dB produced by TEO: 2/ Offset: -2 dB Look at neurohormones 2 MR VTl=o.775m 2 MR dc H4.3MHz 5 dB dB OR; 65 dB 65 dB 73.3 H4.3MHz / 5 dB LVEF s60% or LVE-SD 245 mm -v NTH' Genet* -v General NTH' Generi General 4. Dense/triangular CW signal of regurgitantjet Diagnosis -v Transthoracic echo Transesophageal echo New onset and reaching the posterior wall of the LA likely and low comorbidity Siemens HSSMH2 dB H4.3MHz Of AF or SPAP mmHg DB: 69 dB DB: dB 69 dB 65 bpm AJg, MR vrnax = 3.83 WEF or LVESD mm or LVESD mm 25 25 8ü 25 gu LVEF Cover all different combinations of conditions No Of or mmHg TEQ: 2 / Offset: -1 dB / S / 5 dB LA of or mmH (8 for biplane (8 ror biplane TEQ 2,' -1 dB H4.3MHz 5 dB H4.3MHz / 5 dB 4.1 ml 2' 42 COV 2,SMHz COV • do not override in any way whatsoever the individual responsibility TEC: 2/ 2 dB TEQ: 21 Offset: -1 dB Refractorsa medical and presence of risk Mitral Valve 21 year old woman of AF or SPAP mmHg 71 719m therapy LA esv • (2.5 Hz 12.5 Hz Mitral Regurgitation CW signal Regurg V Large flow convergence zone 107 107 NTH' 120 men t20mm '20 men COV Z COV Z Hz DB: 69 dB TEQ: 2/ Offset: -1 dB New onset TEQ 2/ Offset: -1 dB Coaptation distance closer FU if: coaptation defect atrial fibrillation CW signal of regurgitant jet 5.3 % Dense/triangular Refractory to medical DB: dB DB: 69 43 Yes Yes 43 fps/ 43 fps / 69 dB dB s/ 20 2/20 Option for bypass surgery • summarize and evaluate available evidence 77.3 High likelihood of durable dB 4, Regurgitant volume = 63ml Regurgitant volume severe > 30ml2 severe > 20mm2 Mitral valve repair Upstream vein flow Ann AP Medical therapy wave dominant vvave dominant 107 Bpm —Farbe— assisting health professionals in selecting the best management strategies use DB: 69 dB bpm NTH AT • of AF or SPAP >50 mmHg bpm Healthineers bprn High likelihood of durable 6 months —F Vena contracta Medical therapy Systolic pulmonary flow reversal Transesophageal echo • Inferior to surgery to reduce MR AT = 119 msec Semi uantative • Transesophageal echo Poor image quality (Stress testing) • (Stress testing) • Poor image quality Ann AL-PM 20 TEC: .2 Bypass Graft TE02,'Oßfset, TE02,'Offset, TEC)' 2,' onset Yes factorea No 100% CDV High likelihood Of durable 71 bpm 0,34 am op moH CW signal Large flow convergence zone 250 of or SPAP mmHg CDV / 2_0MHz therapy repair. low surgical risk. repair, low surgical risk, 0.00 0B: 60 de 0B: 60 60 de 0B: 0B: 60 Cover all different combinations of conditions dB repair, low surgical risk, New onset New o ET = 293 msec ET = 2g3 msec Refractory to medical Bpm Ann AP Diam'AL-PM . Ann AP Diamn'AL-PM Ann AP Diam'AL-PM 107 Bpm 5 dB dB High of durable Pregnancy - 23 week dB if EF < 30% and evidence of 5.2 5.2 ltmin • Include individual experience TEC: PHT >50mmHg) de Durable valve repair is and presence Of risk and presence of risk Of mmHg Of AF or SPAP mmHg of AF or SPAP mmHg Of of AForSP Of mm of AF or SPAP mmHg 30/34 126/34 t 2/34 Tenting area Other therapy > (8 for biplane) TEQ 2/ Offset: TEQ Offset: dp likely and low comorbidity How to assess mitral regurgitation Secondary mitral regurgitation Hoi ass mitral regurgitation Mitral regurgitation Primndary mitral regurgitation 69 Wtral covi Medical therapy Durable valve repair is Mitral valve repair rrVs 61.4 High like hood of durable An t Arm t Arm 70 Upstream vein flow -wave dominant -wave dominant 1_.5m/s Semiquantati emiquantati 0B: 69 and presence of risk factors • factors' High likelihood of durable Re No survival benefit no previous exam eo Current Medical therapy SIEMENS high likelihood of repair Likelihood of repair Ligh likelihood of repair -v VI nitral//T\/l aortic - V nitral// r VI aortic Systoli(. pulmonary flow / reversal - V aortic - V aorti( - V ntral// aorti( • (Stress testing) • Improves symptoms Post Ann POS t Ann 89.9 19.5 High likelihood Of durable • Unclear mechanism (Stress testing) likely and low comorbidity Unclear mechanism Systolic pulmonary flow reversal NO No Vena contracta No of repair, low surgical risk, 10.12 crn2 10.12 cm2 viability nce of risk isk, Mitral valve repair (valve center) valve repair Medical therapy presented by • Include individual experience Total Ann 151.3 1541.3 repair. I surgical risk, TEC: mm (Global longitudinal strain) Durable valve repair is u 28 u 28 30.28 genetic Follow-up factorsa LA large (60ml/m2 BSA) pair, low surgical risk, factors• > (8 for biplane) Other repair, low surgical risk, Yes and presence of risk Hoi ass mitral regurgitation Mitral regurgitation Extended HF treatmentb/ F-wave dominant 1Sm/s Yes Complex jets No When to intervene New onset A Clinical Case Volume n Rate E-wave dominant > 1.5m/s 278.29 278.29 m vs 100 Upstream vein flow Yes Refractory to medical Other Refractory to medical Refractory to medical therapy r VI mitral//TVI aortic >l.z V VI mitral//TVI aortic >l.z eo es Mitral valve repair No Economic factors High likelihood Of durable Ligh likelihood of repair High likelihood of durable fac orsa Medical therapy Measurement Current peak Measurement Current Peak likely and low comorbidity likely and low comorbidity sence of risk likely and low comorbidi Peak RF Yes No Volumen • Further deterioration • High mortality Method of intervention 100% • (Global longitudinal strain) Durable valve repair is Dist • Quality of life Quality of life IOW and presence Of risk Vena contracta 123Sonographg • 3D -TEE Systolic pulmonary flow reversal • 3D - TEE and presence of risk 0.82 m 0.82m 082 m Healthineers High likelihood of durable factors' Volume PISA 10,12 11,7 cm2 Qemiquantitative percutaneous dynamic changes of AF or SPAP mmHg TVI mitral//TVl aortic >1.4 and p Economic factors therapy Durable valve repair is lihood of durable good surgeon Fol low-up EF 32% Extended H F treatmentb/ Durable valve repair is Mitral valve repair Ann Height Height Aliasing Velocity 0,28 0,28 0,28 0,28 m/s Mitral valve repair 67 0.67 0.67 067 Mitral Regurgitation factorsa Posterolateral angle >45% Higher high likelihood of repair •tat' factors* edge-to-edge repair factorsa factore Yes E-wave dominant > 1.5m/s When to intervene Upstream vein flow An n Ann likely and low comorbidity peak percutaneous t, Qualtitative Inst Flow Rate No 278,29 321,72 Different recommendations Follow-up Nonplanarity Anglo 166.0 Dog • BNP BNP High reoccurrence of MR Functional capacity repair Yes High likelihood of durable edge-to-edge repair Edge to edge repair? likely and low comorbidity Mitral valve repair Durable valve repair is Edge to edge repair Transplantation LVAD 250 Medical therapy 290 - posterior tethering Regurgitant orifice area = 77mm2 peak RF Medicine is a science of uncertainty and an art of probability. Newest advances High likelihood of repair High likelihood of repaire = 45% and presence of risk EROA TVI mitral//TVl aortic >1.4 Orineo Area Orifieo Area Area 1541.3 1741.5 mm 2 >40 primary, 20 secondary (cm2) >40 primary, 20 secondary (cm?) ego EROA EROA Yes MR moderate - every 2 years 167 ml 0,82 m 082 m Durable valve repair is How to follow up patients repair, low surgical risk, up Mitral valve repair percutaneous 35.7 Follow-up Follow-up HF treatments/ Extended HF treatrnene/ Extended HF treatmeneb/ Extended HF treatmene/ EDV 167 ml 600- EDV 167 ml Ann Pulmonary pressure (echo vs AP.Dm 26.0 23.7 mrn 228 mrn 22.8 27.0 mrn LV remodeling nn mm mrn Regurgitant volume primary, secondary (ml) High likelihood of durable Follow-up Monitoring of procedures ERO 0,67 0,77 cm2 0,67 0,77 cmn2 0,77 crn2 0,69 crn2 Large diameters percutaneous per -cutaneous Extended HF treatmentb/ Surgery (repair whenever possible) Ann AL An Ann AP AL-PM . 31,7 mm "6 mm 33.8 mm 34.6 mm 33,2 34, 6 34.6 28.4 2.0 mm Yes No ml A3 Length Al Length nun mm ESV 92 ml 14. S 14 S mm Predictor of outcome (especially symptoms) and presence of risk primary, 20 secondary (cm2) William Osler Follow-up MR PISA Radius 1.16 cm e$to•edge repair repair >40 primary, 20 secondary (cm2) Regurgitant volume primary, 330 secondary (ml) >40 primary, 20 secondary (cml) primary, secondary (ml) ESV 92 ml k Regurg systolic threshold to perform MV surgery in A3 Length 30.82 35.7 30.8 right heart cath) ml Enlargement Of chamber/vessels LV/LA MR Aliasina velocitv = 0.35 Durable valve repair is Mitral valve repair nl Follow-up Surgery (repair whenever possible) LVOT systolic A3 A3 Length 19-5 Mitral valve repair Durable valve repair is Consider! EROA primary, 20 secondary (cm2) air percutaneous percutaneous Extended HF treatmentb/ e repair edge-to-edge repair Edge to edge repair Ann AP -O Edge to edge repair Transplantation LVAD High likelihood of durable MR EROA 0.77 cm2 MR cm2 AR Flow Medical therapy Shape of the ventricle Quantification Quantiticative Mechanism Etiology argemento chambedvéSse s Thomas Binder MD argement o chamber/vesse s argehnent o chamber/vesse s Prognosis Severity of the problem Avg elective surgery in asymptomatic patient? edge-to-edge repair secondary MR percutaneous Mitral Valve Mitral Inflow I Inflow SV 76 ml likely and low comorbidity Surgery (repair whenever possu Hippocrates Tonting Regurgitant volume Enlargement of chamber/vessels llargement of chamber/vessels Extended HF treatmentb/ Low BNP has a high negative predictive value repair, low surgical risk, Follow-up M IOW 2017 ESC/EACTS Guidelines for the management of valvular heart disease e-to-ed e re air But EF is 45% But EF is rep systolic Flow Flow eSieValvesTM advanced analysis package Consulting Cardiologist Surgery (repair whenever possible) impact of intervention / surgery on prognosis in secondary MR impact of intervention / surgery on Enlargement of chamber/vessels RVOT Systolic Flow LV/LA and presence of risk Circ Cardiovasc Imaging. 2013 Jan 1;6(1):125-33. doi: 10.1161 600- Follow-up 2017 ESC/EACTS Guidelines for the management of valvular heart disease 2017 ESC/EACTS Guidelines for the management Of valvular heart disease But is percutaneous TR vmax Int J Cardiovasc Imaging. 2014 doi: 10.1007/<0554-014-0496-7. Epub 2014 Jul 19. Int J Cardiovasc Imaging. 2014 doi: Epub 2014 Jul 19. Med Image Comput Comput Assist Interv. 3):512-9. No Extended HF treatmentb/ Durable valve repair is General Hospital, Vienna CIRClMAGlNG.112.980383. Epub 2012 Dec 5. Kongsaerepong Am J Cardiol 2006 Surgery (repair whenever possible) factors' edge-to-edge repair Follow-up des He 2017 ESC/EACTS Guidelines for the management of valvular heart disease Surgery (repair whenever possu Yes likely and low comorbidity Edge to edge repair