Cardiologia - la gestione dell'insufficienza mitralica

Gestione insufficienza mitralica

Severe organic MR

Symptoms
No
Yes
LVEF > 60% and LVESD < 45mm
Yes
No
Atrial fibrillation or sPAP > 50mmHg at rest
No
Yes
LVEF > 30%
Refractory to medical therapy
Yes
No
Valve repair is likely and low comorbidity
Yes
No
Follow-up*
Surgery (repair whenever possible)
Medical therapy**
Transplantation
Medical therapy
Figure 3 Management of severe chronic organic mitral regurgitation.

Gestione insufficienza mitralica

Severe organic MR
Symptoms
No
LVEF > 60% and LVESD < 45mm
Yes
No
Atrial fibrillation or sPAP > 50mmHg at rest
No
Yes
LVEF > 30%
Refractory to medical therapy
Yes
No
Valve repair is likely and low comorbidity
Yes
No
Follow-up*
LVEF > 30%
Yes
No
Refractory to medical therapy
Yes
No
Valve repair is likely and low comorbidity
Yes
No
Surgery (repair whenever possible)
Medical therapy**
Transplantation
Medical therapy
LV = left ventricle, EF = ejection fraction, sPAP = Systolic Pulmonary Pressure, ESD = end-systolic dimension
*Valve repair can be considered when there is a high likelihood of durable valve repair at a low risk.
**Valve replacement can be considered in selected patients with low comorbidity
Figure 3 Management of severe chronic organic mitral regurgitation.

Mitra clip

The New England Journal of Medicine
Incomplete coaptation of mitral leaflets resulting in regurgitation
Left atrium
Anterior leaflet
Posterior leaflet
Mitral valve clip is advanced through a catheter and, placed in an atrial view, grasps the leaflets and, once closed, reduces the regurgitation.
Catheter
Inferior vena cava
The device is steered until aligned over the origin of the regurgitant jet, and then the open clip is advanced into the left ventricle.
Left atrium
Left ventricle
The mitral leaflets are grasped and the clip closed to coapt the leaflets.
Reduced regurgitation with closed clip
Mitral valve during systole
Mitral valve during diastole
Edge-to-edge approximation of leaflets by the clip
N Engl J Med 2011;364:1395-406

Mitra clip system and procedure

(A) The MitraClip delivery system consists of a guiding catheter and nested delivery catheter which can be steered in multiple planes with control knobs.
(B) The MitraClip attached to the clip delivery system. The leaflets are grasped between the two clip arms (covered with Dacron) and two gripper elements.
(C) 3D TEE view showing the MitraClip delivery system across the interatrial septum with the clip in the left atrium.
(D) The MitraClip is oriented perpendicular to the coaptation plane of the mitral valve.
(E) Final appearance of the MitraClip in place at the A2/P2 interface with generation of a double orifice valve.

MR severity

Baseline:

• No MR - 1%
• MR 1+ - 21%
• MR 2+ - 28%
• MR 3+ - 50%

• No MR - 30%
• MR 1+ - 15%
• MR 2+ - 54%
• MR 3+ - 1%

NYHA functional class

Baseline:

• NYHA I - 1%
• NYHA II - 23%
• NYHA III - 50%
• NYHA IV - 26%

• NYHA I - 32%
• NYHA II - 16%
• NYHA III - 51%
• NYHA IV - 1%

Mitra clip statistics

n (patients)
EVEREST/ non-EVEREST eligibility
Degenerative/ functional aetiology
Age, mean
Baseline LVEF, %
STS score/ logistic EuroSCORE, mean
Baseline NYHA III/IV, %
Follow-up NYHA III/IV, %
Mean MR grade at baseline
MR ≤ 2+ at follow-up
Echocardiographic core laboratory
Procedural mortality/ in-hospital death

EVEREST trials

• EVEREST II Roll-In Registry (USA), Feldman et al.
• 107 patients
• 100%/0% EVEREST eligibility
• 79%/21% Degenerative/functional aetiology
• Age 71
• Baseline LVEF 62
• 46% Baseline NYHA III/IV
• 8% Follow-up NYHA III/IV at 12 months
• Mean MR grade 3.3
• 74% MR ≤ 2+ at discharge, 66% at 12 months
• Yes Echocardiographic core laboratory
• 0% Procedural mortality, 0.9% in-hospital death

• EVEREST II Randomized Trial (USA), Feldman et al.
• 184 patients
• 100%/0% EVEREST eligibility
• 73%/27% Degenerative/functional aetiology
• Age 67
• Baseline LVEF 60
• 52% Baseline NYHA III/IV
• 2% Follow-up NYHA III/IV
• Mean MR grade 3.2
• 79% MR ≤ 2+ at 12 months
• Yes Echocardiographic core laboratory
• 0% Procedural mortality, 1% in-hospital death at 30 days

• German experience, Franzen et al.
• 51 patients
• 31%/69% EVEREST eligibility
• 31%/69% Degenerative/functional aetiology
• Age 73
• Baseline LVEF 36
• 98% Baseline NYHA III/IV
• 33% Follow-up NYHA III/IV at discharge
• Mean MR grade 3.6
• 94% MR ≤ 2+ at discharge
• No Echocardiographic core laboratory
• 0% Procedural mortality, 0% in-hospital death

• Italian experience, Tamburino et al.
• 31 patients
• 100%/0% EVEREST eligibility
• 42%/58% Degenerative/functional aetiology
• Age 71
• Baseline LVEF 42
• 87% Baseline NYHA III/IV
• 0% Follow-up NYHA III/IV at 30 days
• Mean MR grade 3.9
• 97% MR ≤ 2+ at 30 days
• No Echocardiographic core laboratory
• 0% Procedural mortality, NR in-hospital death

EVEREST I trial

Percutaneous Mitral Repair With the MitraClip System
Safety and Midterm Durability in the Initial EVEREST (Endovascular Valve Edge-to-Edge REpair Study) Cohort
EVEREST trial

Primary efficacy end point at 12 months and major adverse events at 30 days in the intention-to-treat population