DEBATE Mitral Regurgitation: What is the ideal therapeutic option for my patient with mitral regurgitation - Anene Ukaigwe, MD, discusses the percutaneous options.
um Thank you very much to the organizers for having me do this talk and I'm going to be doing the interventional cardiology perspective from what's the ideal therapeutic option for my patient with mitral regurgitation. These are my disclosures. So it goes without saying that all mitral regurgitation is bad and mitral regurgitation gets worse. The older we get, what does this mean? That the people who actually need micro valve therapies have lots of coma abilities that precludes them from getting these therapies. The mitral valve is complex, a little bit more complex than the aortic valve because my opponent alluded to the different parts of the, of the mitral valve, including its attachment to the ventricle and the ventricle that can affect its function. And therefore it's a little bit more technically challenging to address it appropriately. So what do Beyonce? And these two microbe of surgeons have in common. They like to put rings on stuff. I don't know how many people know and they say that just my opponent just said that the gold standard of surgical mitral valve repair is a ring and you know, plastic, they use it on everything. Is it on the primary mitral regurgitation? The secondary mitral regurgitation. And the goal is the goal of every single mitral valve repair procedure is to increase and ensure that you restore co optation. Now for degenerative mitral regurgitation, mitral valve repair has been clearly demonstrated to be better than mitral valve replacement, just as my opponent said, and this is durable out about 20 years. And it makes sense because if you have mitral valve replacement, you're increasing your risk of infective endocarditis, repeats intervention. If the valve degenerates or leading anthropological risk, if it's a mechanical valve. However, they tried to put this same ring on patients who have, who were undergoing surgery for ischemia correction that's cabbage and had moderate mitral regurgitation and the ring didn't help these people. And in fact earlier on there was a higher risk of stroke and super ventricular arrhythmias. And there are four other randomized control studies that actually demonstrate something similar. This is another study that then went to compare micro valve repair versus replacement for patients who have secondary mitral regurgitation. And it did demonstrate that if you follow these patients after two years, there was no difference with respect to mortality. But in fact there's a higher chance of recurrent mitral regurgitation. If you try to repair these valves. And so the durability of the repair was a little bit more questionable now to, you know, I'm gonna I'm gonna be fair and say that secondary mitral regurgitation is a different beast. There are several different things that can possibly cause the same pathology and therefore that's where all the other techniques that my opponent was talking about may not have all been consistently used. But this is the data, this is what we have Now, what's the use of having these fancy techniques and technologies. If people don't get it. Now, the top figure is patients from Europe and the bottom is from the United States, people who have mitral regurgitation as the commonest valvular disorder. Less than 10% of them have access to mitral valve surgery. And there are people who say, you know, it's because there's decreased referral. But if you look at the top figure, those patients were actually in the hospital with mitral regurgitation and only about 8% of them ended up having surgery. So that's that's that's and this. And in addition to the fact that, you know, there may be issues with access to care. The thing is that cardiac surgery is not for everyone because not everyone is a good clinical candidate for it. And that's where interventional cardiologists swooped in to save the day with trans catheter actually repair. And they're now two commercially available devices for trans catheter actually repair. I'm not going to be label what the study showed that a decreased risk of adverse events when you use metro clip compared to surgery driven primarily by increased risk of bleeding. But even after one year, when there was an increased risk of recurrent majority vegetation with trans catheter repair, which was what I was alluding to in that paper after that from 1 to 5 years, the need for intervention is similar between both. This is a recently published study that compared mitra clip and this new device pascal was also just recently approved for degenerative mitral regurgitation as you can see that there is excellent outcomes at least up to six months and we're waiting for further data. Now the secondary mitral regurgitation where the surgeons have tried and the secondary mitral regurgitation has led to increased risk of re operation. We attack this with the metro clip device and in this study the co ops are not going to believe about the points, but the co ops demonstrated that there was a decrease hospitalization, improved mortality and it was a very safe procedure. Even the Metro air Fire that was not overwhelmingly positive. Recent landmark analysis actually did show that there was decreased heart failure, hospitalization and mortality that was in favor of clip out to two years. Now there are several different things that we can do for the mitral valve from a trans catheter perspective that are still in development and to answer the question of this debate, the ideal therapeutic option is that it really does depend on what does it depend on. So the first of the patient factors who has low intermediate or high risk for adverse operative events. Those what anatomical factors. And we're trying to determine who is going to have a higher risk of repeat or recurrent mitral regurgitation and institution factors do you have like clinical trial devices, What are your commercially available therapy options? And do you have skilled operators that can deliver these devices? Now irrespective of what the strategy is recurrent mitral regurgitation after either surgery on the right or trans catheter therapy is bad and it's potentially lethal. And so these are some of these, like I said the way we risk stratify base of a primary what the risk profile of the patient is and all the therapeutic options that both me and my opponents have alluded to. And for secondary mitral regurgitation. We have data from co ops that trans capital repair is beneficial in these patients but if they are not suitable we can consider them for clinical trial trans capital mitral valve replacement and surgery basically a caudal sparing micro valve replacement was favored in most recent valve guidelines. So this is a 77 year old gentleman that was seen by one of the two esteemed mitral valve surgery colleagues that I showed earlier who has mixed micro regurgitation with the prolapse. And there is a dilated annual as an injection fraction of cardiac camera. That was 18% atrial fibrillation created enough 2.7 he had stopped walking on his farm because he was limited severely functionally. And you can imagine that my surgical colleagues said no this patient has a high operative risk and so he was taking for trans catheter repair. And this was successfully done with three clips. And I can see the bottom picture this elimination of the mitral regurgitation. Left atrial pressure is what patients feel this patient felt better after this and it was back to his family a couple of days and this is what the follow up echocardiogram looks at a five weeks when patients are not candidates for micro clip therapy like this patient has mixed M. R. And M. S. You can have a trans catheter mitral valve replacement as part of a clinical trial which was what this patient had with elimination of the M. R. And elimination of the micro stenosis. There's previous surgical repair that fails and they're not operative candidates. We can also address that and as a team, we help each other out if there's failed metro clips that don't work their strategies that we can use that are in development to try to remedy that trans catheter ultimately might evolved approaching retroviral therapies involving two box of both trans Catherine surgical options and a team of clinicians that are well versed and passionate about delivering quality care to these patients. And in conclusion the management is rapidly evolving. There several disruptive technologies the mitral valve heart team will be charged with selecting what the best tailor therapies are and these patients are often complex and would be best served at valve centers with surgical and trans catheter options by skilled operators that can appropriately deliver these therapies just as we have in uhh, thank you