Clinician-to-Clinician Update Clinician-to-Clinician Update

Mitral Valve Repair for High-Risk Patients

September 2016

Mitral regurgitation (MR), a systolic flow reversal from the left ventricle to the left atrium, is the most common valve disease in the United States. The number of individuals in the United States affected by moderate or severe MR is estimated to reach almost 5 million by 2030.1 MR is classified as either degenerative/primary, in which the defect is in the valve itself, or as functional/secondary, in which the MR is caused by ventricular dysfunction.

The natural history of degenerative MR is characterized by progressively worsening left ventricular failure, pulmonary hypertension, and atrial fibrillation. With medical treatment alone, severe MR has a mortality rate of 6-7% each year.2 However, when valve repair surgery is performed early in the course of the disease and when the patient reports minimal to no symptoms and has an ejection fraction of at least 60%, the mortality rate for MR drops to that of persons of similar age and sex who never had MR or cardiac surgery.3 Unfortunately, because MR predominantly affects patients over 65 years of age, not all patients are candidates for traditional, open-chest valve repair surgery due to their age, frailty, or comorbidities. For this population of patients, a novel, catheter-based option for percutaneous mitral valve repair was approved in 2013. A less-invasive alternative, the MitraClip® device (Abbott Vascular, Menlo Park, California, USA) allows the mitral valve leaflets to be clipped together, rather than sutured as they are in open-chest surgery.

Hybrid-operating-room-Heart-Care-Sept-2016-Feature-Image
— Hybrid operating room at University of Minnesota Medical Center. University of Minnesota Health Heart Care surgeons perform procedures in the space, which functions as part operating room, part endoscopy suite.

Outcomes with MitraClip are excellent, as confirmed by a large phase III study that randomized 279 patients with moderate-to-severe MR into groups that either underwent open-chest surgery or percutaneous mitral valve repair with MitraClip.4 Although MitraClip placement was somewhat less effective than traditional surgery in reducing MR, it was associated with superior safety.

Major adverse events occurred in only 15% of patients in the MitraClip group compared to 48% of patients in the surgery group at 30 days (p<0.001). Importantly, both groups exhibited similar improvements in long-term outcomes. At 5 years follow-up, mortality rates were 20.8% in the MitraClip group and 26.8% in the open-chest surgery group, a nonsignificant difference.5

To date, University of Minnesota Health Heart Care surgeons have performed more than 35 MitraClip procedures with excellent results. The coordination and support provided by the M Health Heart Care multidisciplinary team of heart care specialists help ensure good outcomes for these patients, including those with severe MR and co-morbidities. The device, in our experience, has allowed MR repair for patients who would not be candidates for open-chest surgery.

References

  1. Nkomo VT, et al. Burden of valvular heart diseases: a population-based study. Lancet. 2006;368:1005–1011.
  2. Ling LH, et al. Clinical outcome of mitral regurgitation due to flail leaflet. N Engl J Med. 1996;335:1417–1423.
  3. Grigioni F, et al. Outcomes in mitral regurgitation due to flail leaflets a multicenter European study. JACC Cardiovasc Imaging. 2008;1:133–141.
  4. Feldman T, et al. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med. 2011;364:1395–1406.
  5. Feldman T, et al. Randomized comparison of percutaneous repair and surgery for mitral regurgitation: 5-year results of EVEREST II. J Am Coll Cardiol. 2015;66:2844–2854.

When to refer

Patients with exertional angina or fatigue, shortness of breath, or syncope should be referred for consultation with the University of Minnesota Health Heart Care team. Upon referral, each patient’s unique case is evaluated by our multidisciplinary team and an individualized plan of care is designed.

Please call 612-365-5000 for patient referrals. We will work with your patient to complete the registration process and schedule an appointment at the patient’s convenience. You will be notified once the appointment is scheduled.

Mitral Program Coordinators

Cindy Western, RN
pager: 612-899-9801

Deb Dempsey, RN
pager: 612-527-7729

Patients with urgent medical or surgical needs are given priority in the appointment system. Appointments for nonurgent medical problems are scheduled several days to several weeks from the request for an appointment.

M Health Heart Care multidisciplinary team of interventional cardiologists, echocardiographers, imaging cardiologists, cardiovascular surgeons, vascular surgeons, anesthesiologists, and professionals from the cardiac catheterization laboratory and operating room work together to ensure the best possible outcome for your patient. They bring special skills to the treatment and management of complex conditions, including severe mitral regurgitation presenting with co-morbidities.

Collaborative Care

Primary care physicians and regional cardiologists play a critical role in identifying and referring patients for prompt medical and surgical intervention for MR. Patients frequently assume that symptoms such as fatigue, shortness of breath, or pre-syncope are simply part of the natural aging process. When you refer your patient to our program, we are committed to partnering closely with you to obtain the best possible patient outcome. We value our relationship with you, your patients, and your office staff. We work hard to keep you informed of your patients’ care by providing detailed reports, from diagnosis to treatment and follow-up. Our goal is to provide you with prompt service and communication for the patients that you refer to us.

To view current clinical trials available through M Health providers, visit studyfinder.umn.edu.

Related Articles

September 2016

Successful Repair of Severe Mitral Regurgitation in a High-Risk Patient

An elderly patient with MR and COPD undergoes percutaneous mitral valve repair. At follow-up, the patient’s MR was downgraded to mild, and she no longer requires supplemental oxygen.

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September 2016

Heart Care Specialty Updates

Clinical trial for MitraClip now enrolling, and a registry allows physicians to monitor the effectiveness of new transcatheter valve procedures.

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