This document discusses the conundrum of managing mitral regurgitation (MR) in patients with heart failure. It highlights the importance of using multimodality imaging to: 1) Assess the severity of MR at rest and with exercise to determine risk and need for intervention. 2) Evaluate left ventricular function, dyssynchrony, viability and ischemia to determine indications for cardiac resynchronization therapy or revascularization. 3) Assess left ventricular remodeling and mitral valve deformation to predict risk of recurrent MR after repair and determine the best repair/replacement option. Imaging provides essential information to optimize treatment strategies for MR in heart failure.

1. The Conundrum of
Mitral Regurgitation
in Heart Failure
Multimodality ImagingMultimodality Imaging
Philippe Pibarot, DVM, PhD,Philippe Pibarot, DVM, PhD, FACC, FASE, FESCFACC, FASE, FESC
CanadaCanada Research Chair in Valvular HeartResearch Chair in Valvular Heart DiseaseDisease
UniversitéUniversité
LAVALLAVAL
InstitutInstitut UniversitaireUniversitaire de Cardiologiede Cardiologie
et de Pneumologie de Québec /et de Pneumologie de Québec /
Québec Heart & Lung InstituteQuébec Heart & Lung Institute

2. Disclosure related to thisDisclosure related to this
presentation:presentation: NoneNone

3. Etiology of Chronic Mitral regurgitation
Primary MR
Myxomatous (MVP)
Secondary MR
Ischemic CM Dilated CM
Disease of the Valve
(Abnormal MV Leaflets)
Disease of the Left Ventricle
(MV Leaflets are normal but tethered)

4. Management of MR in HF
Treatment
MedicalMedical
CRTCRT
PCI / CABGPCI / CABG
SurgicalSurgical MVA/MVRMVA/MVR
PercutaneousPercutaneous MitralClipMitralClip / Annuloplasty/ Annuloplasty
TETHERING
FORCE CLOSING
FORCE
Multimodality Imaging:
1- MR severity at rest and exercise (echo, stress echo)
2- LV function: EF/dyssynchrony/viability/ischemia (stress echo, CMR, PET)
3- LV remodeling and MV deformation (echo, 3D echo, CT, CMR)
Clinical: HF symptoms, episodes of decompensation

5. Indications forIndications for MV SurgeryMV Surgery inin ChronicChronic
Secondary MRSecondary MR
Vahanian et al. ESC/EACTS 2012 Guideline

6. Multimodality Imaging – Step 1
Assessing of MR Severity at rest and during
exercise
- To stratify risk
- To determine indication for MV intervention

7. Assessing MR Severity
NOT VALID
Lancellotti et al, Eur J Echo 2010
Qualitative
Mitral valve morphology
Colour flow MR jet
Flow convergence zone
CW signal of MR jet
Semi-quantitative
VC width (mm)
Pulmonary vein flow
Mitral inflow
TVI mit/TVI Ao
Quantitative
EROA (mm²)
R Vol (ml)
Repercussions
LV/LA/sPAP/TA

8. ERO =
MR VPeak
RV = ERO × MR VTI
VC width
Quantitation of MR SeverityQuantitation of MR Severity
2πr2 × Valiasing
Vena Contracta PISA Method

9. Imaging of ischemic MR
Quantitation of MR SeverityQuantitation of MR Severity
Volumetric Method

11. Quantitation of MR Severity
Severe
Primary MR
ERO ≥ 40 mm2
RV ≥ 60 mL
“Severe”
Secondary MR
ERO ≥ 20 mm2
RV ≥ 30 mL
Enriquez-Sarano et al. NEJM, 2005 Grigioni et al Circulation 2001, 103; 1759

12. VC 6.1 mm
RV 41 ml
EROA 22 mm2
Man of 52 y old , History of inferior MI, PCMK
NYHA III, Episodes of acute dyspnea
Grigioni et al Circulation 2001, 103; 1759
Lancellotti et al Circulation 2003, 108:1713
Severity of Secondary MR and Outcome

13. 103 fatigue
58 dyspnea
Dynamic MR on Exercise : Relationship with
Symptoms and Outcomes
Lancellotti et al Circulation 2003; Eur Heart J 2005Piérard et Lancellotti NEJM, 2006

14. Lancellotti et al, 2012
Dynamic PHT and Outcomes in HF with
Secondary MR
AUC: 0.7 for
61 mmHg
- 161 HF pts with ischemic LV dysdunction
- SPAP > 61 mmHg at exercise: 38% of patients
- Predictors of outcome: rest EROA, ΔERO, ΔSPAP
AUC 0.73

16. REST EXERCISE
VC 7.3 mmVC 6.1 mm
RV 41 ml
EROA 22 mm2
CASE
RV 81 ml
EROA 38 mm2
TTPG = 77 mmHgTTPG = 36 mmHg

17. Secondary MR is a disease of the left ventricle!
So look at MR Severity and …. at the left ventricle

18. Multimodality Imaging – Step 2
Assessing LV function/ synchrony / viability/
ischemia
- To stratify risk
- To determine indication for CRT
- To determine indication and options for
revascularization

19. • LV function: LVEF, contractile reserve
Echo, Stress echocardiography
• LV dyssynchrony
Echo, Stress echocardiography
• Viability/ischemia
Stress echocardiography, SPECT/PET, or CMR
• Coronary artery stenosis
Cardiac CT angiography or coronary angiography
Assessing LV Function/ Synchrony /
Viability/ Ischemia
Indication for CRT a/o revascularization

20. CASE
• QRS > 130 ms with LBBB QRS morphology
• LVEF <30%
• Coronary Angio: no significant stenosis
--> Indication of CRT (Class I)
Lancellotti et al,
Am J Cardiol
2004, 94
R Vol 41 ml
R Vol 81 ml R Vol 41 ml
R Vol 23 ml
Diff 18 ml
Diff 44 ml
REST OFF REST ON
EXER OFF EXER ON

21. Verhaert et al Circulation: Cardiovascular Imaging.2012; 5: 21-26
Outcome of Patients not Responding to CRT

22. CASE: 1 Year later
Back in severe heart failure

23. Secondary MR in HF
Extent of Myocardial Necrosis/Viable Myocardium
Postero-Lateral Scar
Bleeker GB et al. Circulation 2006

24. Postero-Lateral Scar
Lancellotti et al Eur J Echo 2009
Bleeker GB et al. Circulation 2006
Global LV Contractile Reserve
Rest examination
LV EF = 36%
Low dose dobutamine
LV EF = 45%
Secondary MR in HF
Extent of Myocardial Necrosis/Viable Myocardium

25. Penicka et al Circulation 2009MR ↓ in 47% of patients
MR ↓
MR ↓MR ~
MR ~
12 month-Fup

26. DSE  Biphasic response

27. CASE
Woman of 61 y old who was in NYHA I
Patient’s history
• RF: Smoker, Non-insulin dependent diabetes, HPT
• COPD
Clinical features
• Acute pulmonary edema

28. CORONARY ANGIOGRAPHY

29. EuroSCORE, STS, and Ambler score
- provide relatively good discrimination
- a gross estimation of risk category
- cannot be used to estimate the exact operative mortality in
an individual patient because of unsatisfactory calibration
Lancellotti et al Heart 2008

30. Cas présentation NB: Non inidcation for reva
Other case with option?RESTREST
EXERCISEEXERCISE
No contractile reserve
No evidence of inducible ischemia

31. Multimodality Imaging – Step 3
Assessing LV remodeling & MV deformation
- To predict risk of persistent / recurrent MR
following MV annuloplasty
- To determine best option for MV intervention

32. MV Repair vs. Replacement in Severe IMR
0
5
10
15
20
≥ Moderate MR at 1 Year
18%18%
44%%
0
10
20
30
40
≥ Moderate MR at 1 Year
33%33%
2%2%
Magne et al. Circulation 2009 Acker et al NEJM 2013
MVRp MVR MVRp MVR

33. CABG Alone vs. CABG + MV Repair in
Moderate IMR
0
10
20
30
40
≥ Moderate MR at 1 Year
31%31%
11%11%
Smith et al. NEJM 2014
CABG
Alone
CABG+
MVRp

34. Incidence of postoperative ≥ Moderate MR
after MV Annuloplasty
Magne et al. Cardiology 2007

35. LV Remodeling and MV Deformation
Global LVGlobal LV
RemodelingRemodeling
Local LVLocal LV
RemodelingRemodeling MV DeformationMV Deformation

36. Predicting Risk of MV Annuloplasty Failure:
Severity of MV DeformationSeverity of MV Deformation
Pérard et al. European Heart Journal ; 2010: 31, 2996–3005

37. Global LV remodelling
EDD ≥ 65 mm, ESD ≥ 51 mm (ESV ≥ 140 mL)
Local LV remodelling
Interpapillary muscle distance ≥ 20 mm
Posterior papillary-fibrosa distance ≥ 40 mm
Lateral wall motion abnormality
Mitral valve deformation
Coaptation distance ≥1 cm
Tenting area ≥ 2.5 cm2
Posterior leaflet angle ≥45○
Complex jets
Echo Features of LV Remodeling and MV
Deformation To Predict Persistent/Recurrent
MR for MV Repair
Lancellotti et al. EHJ; 2010:11,307–332
EACVI Recommendations

38. FUTURE PERSPECTIVES
Secondary MR is not ONLY a disease of the
left ventricle!
It is ALSO a maladaptation of the MV
leaflets
So look at the MV leaflet size

39. Beaudoin et al., SCCT 2012
Anterior leaflet
Posterior leaflet
F
A B
DC
Measuring the surface of MV leaflets by CT
or 3D Echo

40. Beaudoin et al. JACC 2013

41. Beaudoin et al. JACC 2013
Total MV Leaflet Area vs. LV End-Diatsolic
Volume

42. • Patients with secondary MR have inadequate
leaflet compensation, as expressed by decreased
ratios of leaflet area / annulus area
• Imaging will play a key role to understand why
some patients have adequate vs inadequate valve
adaptation
• Medications targeting the TGF-beta pathway may
help to reduce the leaflet/annulus size mismatch
and thus secondary MR in HF
Total MV Leaflet Area vs. LV End-Diatsolic
Volume

43. SEVERE MR (ERO ≥20 mm2)
LV EDD ≥65 mm
Severe Mitral Valve
Deformation
CABG+MVS
MVA+Adjuvant Technique
Mitral Valve Replacement
Optimization of HF
Therapy including
CRT if indicated (I)
Myocardial Viability / Ischemia
Indication / Options for revascularization
Heart Transplant
Mitraclip?
MVS (IIb) /
Mitraclip
Moderately Depressed
LVEF (>30%)
Severely Depressed
LVEF (<30%)
No Yes NoYes
(IIa)(I) Optimization of HF
Therapy including
CRT if indicated (I)
No
Improvement
No
Improvement

44. MODERATE MR (ERO <20 mm2)
LV EDD ≥65 mm
Severe Mitral Valve Deformation
CABG+MVS (IIa)
MVA + Adjuvant Technique
Mitral Valve Replacement
Manage as
severe MR
Indication for CABG
Dynamic Increase in MR /
SPAP
NoYes
Optimization of HF
Therapy including
CRT if indicated (I)
MR and SPAP stable
Exercise Stress Echo