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About 6. A small percentage of these patients also have moderate-to-severe or severe secondary MR, increasing the risks and complicating the treatment of their heart failure. With this new approval, this small percentage of patients could be indicated as candidates for treatment with the MitraClip device when combined with optimal medical therapy. Optimal medical therapy includes combinations of different heart failure medications along with, in certain patients, cardiac resynchronization therapy and implantation of cardioverter defibrillators.

The approval of the new indication is based on the COAPT study of patients , which represented a paradigm shift in how heart failure patients will be managed in the future. For years the focus on heart failure has been on the ventricles and secondary mitral regurgitation MR has been seen as a symptom of worsening heart failure, with little attention paid to fixing it.

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COAPT looked at patients with heart failure who had moderate-to-severe or severe secondary MR and were randomly assigned to get either continuation of their optimized medication treatment plus the MitraClip MitraClip group or continuation of their optimized medication treatment only control group. The risk of being re-hospitalized for heart failure symptoms was reduced by approximately 47 percent in the MitraClip group compared to the control group. In addition, the risk of death within two years was decreased by approximately 37 percent in the MitraClip group compared to the control group.

It is the first time we have ever seen in any randomized, controlled trial an outright reduction in heart failure hospitalizations, all-cause mortality, and improvements in quality of life and exercise to a tremendous magnitude. Potential adverse events from the device and implant procedure include death, stroke, major bleeding, and erratic heart beat atrial fibrillation. The MitraClip is contraindicated in patients who cannot tolerate blood thinners during or after the procedure, who have active inflammation endocarditis of the mitral valve, rheumatic mitral valve disease or evidence of blood clots in the heart or veins leading to the heart.

In patients with SMR the mitral valve itself is usually normal, lacking anatomical evidence for why the valve is leaking. Instead as noted above , a combination of papillary muscle displacement, annular dilatation and wall motion abnormalities cause tenting of the valve leaflets, preventing closure. These abnormalities should be detectable by echocardiography that also demonstrates severe LV dysfunction.

When caused by previous myocardial infarction, there are usually extensive areas of akinesis; while in dilated cardiomyopathy, there is usually global LV dysfunction. However, an end diastolic dimension that exceeds 65 mm may indicate a worse prognosis; thus, this measurement should be made during echocardiography.

Ischemic heart disease and myocardial infarction are often the cause of SMR. However, severe coronary disease CAD may lead to viable but non-functioning myocardium, referred to as hibernation. Revascularization may dramatically restore function and in some cases concomitantly improve SMR.

Functional mitral regurgitation

Thus, assessment of myocardial viability should be made in preparation for possible coronary revascularization. Stress echo, MRI, and nuclear perfusion scanning are all satisfactory for assessing viability. Typically, institutions have greater expertise in one modality versus the others, and that modality is the one chosen for assessing viability.

If surgical correction of SMR is contemplated, cardiac catheterization to assess hemodynamics and coronary anatomy is performed first. Left ventriculography can help assess the severity of MR if it is unclear following echocardiography. Virtually all patients with SMR also have systolic heart failure and should be treated for that condition.


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ACE inhibitors, or angiotensin receptor blockers, beta blockers and aldosterone antagonists that are standard therapy for heart failure should be instituted. Diuretics should be adjusted to control the symptoms of pulmonary congestion when they exist. As noted above, wall motion abnormalities frequently cause or exacerbate SMR. Because conduction abnormalities, when present, may cause wall motion abnormalities, electrical resynchronization CRT may in some cases dramatically reduce SMR while simultaneously improving LV function. Unlike in primary MR, where there are specific changes in cardiac size and function that dictate when mitral surgery should be undertaken, no such benchmarks exist for SMR.

While one study recommended surgery prior to the LV enlarging to an end diastolic dimension of 65 mm, it is not clear that repeated echocardiograms to monitor LV size are warranted. There is little question that when SMR complicates heart failure, prognosis worsens. Thus, it would seem logical that correction of SMR would be beneficial. Unfortunately, data regarding this concept are quite discordant, with some studies suggesting no benefit to mitral surgery, while others suggest the opposite.

No randomized exist to give a definitive answer. Further, unlike in primary MR where mitral repair is of clear benefit over mitral replacement, no such agreement exists in SMR.

Indeed a recent randomized trial demonstrated no benefit of valve repair over valve replacement, opposite to accepted practice for primary MR. In SMR, the main disease is the LV muscle dysfunction, either from myocardial infarction or dilated cardiomyopathy; thus, correcting MR corrects only part of the problem so that its impact on outcome is reduced and mixed.

No randomized trial yet demonstrates improved survival, although some indicate improved peak oxygen consumption and reduction in LV volume after surgery. A recent randomized trial found no benefit in correcting moderate SMR at the time of coronary bypass surgery. Thus, SMR mitral surgery is only recommended for patients who have severe symptoms after maximum medical therapy including CRT when appropriate has been applied. Recently, percutaneous application of a device Mitraclip that clips the 2 mitral leaflets together in their mid-portions has been utilized in the treatment of SMR in Europe and has been used experimentally in the US.

Just get it done. Too frequently, the surgical referral is delayed until damage to the ventricle is irreversible, with a resultant worsened prognosis. In a recent study of 1, patients with primary MR, the investigators showed that the ratio of B-type natriuretic peptide BNP to the upper limit of normal BNP, adjusted for age and sex, was a powerful independent predictor of this risk J Am Coll Cardiol.

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Minimally invasive mitral valve repair for functional mitral regurgitation

Thus, the current guidelines recommend surgery only for patients who are still severely symptomatic despite maximal guideline-directed medical therapy for heart failure as well as cardiac resynchronization therapy, provided they have a conduction system abnormality and qualify for the device therapy. Carabello said. In the United States, the MitraClip transcatheter device is approved only for the treatment of primary MR in inoperable patients. But in the rest of the world, roughly three-quarters of these devices are used for treatment of secondary MR.

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