14


Structural heart disease


August 2013


Transcatheter Valve News Optimising management of mitral regurgitation in heart failure patients


PIOTR PONIKOWSKI COMMENT & ANALYSIS


Piotr Ponikowski reviews mitral regurgitation in the context of heart failure, discussing incidence and management options— including percutaneous therapy


H


eart failure has become increasingly prevalent in the developed world, particularly among the elderly population, and it is estimated to affect more than 10 million people in Europe. Recent data from the USA indicate that in the next 20 years, the number of patients with heart failure will increase by 25% and more than 70% of these patients will be older than 70 years of age1


. This projected increase is predicted to cause a dramatic rise in healthcare costs, reaching US$70 billion by 20301


.


Currently, an increase in recurrent hospitalisations is a major problem in the management of heart failure as recurrent hospitalisation is an independent factor for poor outcome and for poor quality of life, and it is also responsible for the majority of heart failure related costs. In the EURObservational Research Program nearly half of those with decompensated heart failure and one-third with stable chronic heart failure were admitted to hospital within one-year follow-up (figure 1)2


.


Several publications prove that the heart failure mortality and morbidity rates increase with disease progression. In the EURObservational Research Program, patients in New York Heart Association (NYHA), class III-IV had a much higher rate of mortality than those in class I-II (13.5% vs. 4.8%)2


. In another study, NYHA


class IV patients had about a five times higher risk of hospitalisation due to heart failure worsening than those with NYHA class I (figure 2)3


. Therefore diagnosis,


assessment and earlier referral for the appropriate treatment of heart failure can help reduce the mortality


Figure 2: Kaplan-Meier plots for cumulative probability of all-cause hospitalisation due to worsening heart failure by NYHA functional class


and hospitalisation rates. Functional mitral regurgitation occurs commonly in pa- tients with heart failure. Bursi et al, who studied ambulatory patients with moderate heart failure, reported that mitral regurgitation was present in 95% of patients, 45% being moderate to severe4


. Myocardial damage and resultant left


ventricular remodelling (left ventricular dilation, increased left ventricular sphericity and local remodelling of mitral valve apparatus) all contribute to functional mitral regur- gitation. At the same time functional mitral regurgitation begets left ventricular remodelling, creating a vicious circle. Functional mitral, regurgitation in ischaemic and non- ischaemic cardiomyopathies is associated with more severe symptoms and increased mortality as shown in figure 34


.


Current management options for functional mitral regur- gitation in heart failure patients are not well established. There is no doubt that, in all cases, pharmacological therapy recommended in the heart failure guidelines should be implemented and optimised. In selected patients, resynchro- nisation therapy may be also considered5


.


Surgical correction of functional mitral regurgitation is much more controversial. It has been suggested that early surgical referral for organic mitral regurgitation should be considered while patients are asymptomatic6-7


.


On the other hand with functional regurgitation, as the underlying problem lies in the diseased ventricle rather than in the mitral valve itself, it is less obvious that functional mitral regurgitation correction would be curative or even beneficial8


. Isolated surgery for functional mitral


Figure 1: Kaplan–Meier curves for all-cause death (A), admission to hospital for heart failure (B), divided into hospitalised patients with acute heart failure (continuous line) and ambulatory patients with chronic heart failure (dotted line).


regurgitation is generally considered as a class IIb, level of evidence C indication (only in those with severe functional mitral regurgitation, left ventricular ejection fraction >30% with low comorbidity) in the European Society of Cardiology (ESC) /European Association of Cardio- Thoracic Surgery (EACTS) guidelines since there are no


Figure 3: Event-free survival according to the presence and degree of functional mitral regurgitation. Blue line indicates patients without functional mitral regurgitation or with Grade I functional mitral regurgitation, green line indicates patients with Grade II functional mitral regurgita- tion, yellow line indicates patients with Grade III functional mitral regurgitation, and red line indicates patients with Grade IV functional mitral regurgitation


Piotr Ponikowski is at the Medical University, Centre for Heart Disease Clinical Military Hospital Wroclaw, Poland. He has received consultancy fees and speaker’s honoraria from Abbott Vascular


randomised controlled trials proving a survival benefit. Recently, percutaneous MitraClip therapy (Abbott Vas- cular) has become an attractive option for functional mitral regurgitation9-10


. It has been shown to reduce mitral regur- gitation and left ventricular volumes, improve symptoms and exercise tolerance in patients with NYHA class III-IV heart failure and functional mitral regurgitation9


. In this


high-risk group, cumulative survival at six-month follow- up was 81%. Similarly, MitraClip ACCESS-EU registry data demonstrated freedom from all-cause mortality at one year of 82%. The data strongly suggest that the MitraClip system may offer a safe and effective alternative for heart failure patients with clinically significant functional mitral regurgitation and advanced left ventricular dysfunction.9 Currently, MitraClip therapy has been assigned as a thera- peutic option for selected patients with functional mitral regurgitation by the ESC/EACTS and ESC heart failure guidelines.


The RESHAPE-HF trial aimed at evaluating the ef- fectiveness of MitraClip in functional mitral regurgitation patients with heart failure has been initiated. Over 40 sites are currently preparing to randomise heart failure patients and the first patient has already been enrolled.


Conclusion To reduce heart failure morbidity and mortality, we need to optimise therapy (both, pharmacologic and device-based) by referring patients for heart failure treatment at the earlier stage of disease progression.


References


1. Heidenreichet PA. Circ Heart Fail 2013; 6 (In Press) 2. Maggioni AP, et al. Eur J Heart Fail 2013; 15:808–17 3. Ahmed A et al. Am Heart J 2006 151: 444–50 4. Bursi F et al. Eur J Heart Failure 2010; 12:382-88 5. Rutger J. Circulation 2011; 124:912–19 6. Gillinov AM, et al. Annals of Thoracic Surgery 2010; 90:481–88 7. Sarano et al. New England Journal of Medicine 2005; 352:875–83 8. Carabello BA. JACC 2008; 52:319–26 9. Franzen O, et al. Eur J Heart Fail 2011; 13:569–76 10. Maisano F, et al. J Am Coll Cardiol 2013 Epub


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40