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Dr. Raphael Rosenhek ,
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This is the summary of a very comprehensive session on mitral regurgitation, that encompassed the whole spectrum from imaging to pathophysiology of mitral regurgitation, detailing techniques that allow more advanced assessment of left ventricular function and remodeling, and which was concluded by a discussion of the indications and types of intervention.
Dr. Judy Hung (Boston, USA) presented an overview of the echocardiographic imaging of the mitral valve. Understanding the anatomy and the pathophysiology is important when imaging the mitral valve. The mitral valve consists of the anterior and the posterior leaflet, which are both subdivided into 3 segments each according to the classification proposed by Carpentier. The mechanism of regurgitation and the location of the lesion need to be exactly identified. The distinction between functional and organic disease is of clinical importance. A systematic approach is required. While 2D-transthoracic echocardiography represents the standard imaging technique, transoesophageal echocardiography is a complimentary method yielding more precise morphological assessment. 3D-echocardiography is routinely available nowadays for integration in clinical practice and allows very nice representation of mitral valve pathology.
The presentation by Dr. Julien Magne (Liege, Belgium) focused on the advanced evaluation of left ventricular function in degenerative mitral regurgitation. Preoperative ejection fraction is a recognized marker of postoperative survival after mitral valve surgery. The prognostic significance of the end-systolic left ventricular diameter was highlighted. However these parameters may not be ideal to detect subclinical left ventricular impairment. Spherical remodeling of the left ventricle is known to occur even before substantial left ventricular dilatation. Recent data suggest that global longitudinal strain may predict outcome in patients with mitral regurgitation. Furthermore, post-operative ejection fraction can be predicted by contractile reserve as assessed by exercise echocardiography. However, the exact role of these newer parameters for clinical decision-making still needs to be determined.
The assessment of left ventricular remodeling in functional mitral regurgitation was highlighted by Dr. Sanjay Prasad (London, UK). The mechanism of functional mitral regurgitation is an imbalance between closing forces acting on the mitral valve (due to reduced ventricular contractility and or dyssynchrony) and tethering (due to apical and lateral papillary muscle displacement and annular dilatation). Left ventricular remodeling can be assessed by a measure of left ventricular volumes and the sphericity index. Other signs of local remodeling include apical displacement of the postero-medial papillary muscle. At the level of the mitral valve, the systolic tenting area, the coaptation distance and the postero-lateral angle can be measured. While the mainstay of the diagnosis of remodeling is based on echocardiographic criteria, cardiac magnetic resonance (CMR) offers an incremental value, both in the assessment of left ventricular morphology and with regard to the determination of late enhancement.
In the concluding presentation of this session, Dr. Bernard Iung (Paris, France) discussed the important topic of the timing and type of intervention in mitral regurgitation. He highlighted the recently published joint ESC/EACTS guidelines for the management of valvular heart disease (Eur Heart J 2012;33:2451-96), which for the first time also mention percutaneous treatment approaches. On a general basis, surgery remains the treatment of choice in organic mitral regurgitation and valve repair should be favoured. The percutaneous edge-to-edge procedure may be considered in patients with symptomatic severe primary mitral regurgitation who have suitable anatomical conditions, are judged inoperable or at high surgical risk by a ‘heart team’, and who have a life expectancy of more than 1 year.
Indications for surgery in functional mitral regurgitation are more restrictive than in organic mitral regurgitation, since a survival benefit has not been conclusively demonstrated to date. Mitral valve surgery is indicated in patients with severe secondary mitral regurgitation undergoing coronary bypass surgery. The percutaneous edge-to-edge procedure may be considered in patients with symptomatic severe secondary mitral regurgitation despite optimal medical therapy (including cardiac resynchronization therapy, if indicated), who fulfill the echocardiographic eligibility criteria, are judged inoperable or at high surgical risk by a team of cardiologists and cardiac surgeons, and who have a life expectancy >1 year. At the same time, it is evident that randomized trials are needed to assess the potential benefit of these novel percutaneous techniques.
Mitral valve regurgitation
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