Update on Ischemic Mitral Regurgitation: A/Prof Phạm Mạnh Hùng, MD.PhD FACC.FESC Director – Cardiac Cath Lab VNHI Secretary General - VNHA MR Etiology Normal Degenerative MR (Prolapse) Degenerative MR (Flail) Functional MR Ischemic vs nonischemic Ischemic MR Pathology Cardiol Clin 31 (2013) 231–236 Secondary (Functional) MR: The disease is the LV! Ischemic cardiomyopathy Idiopathic dilated cardiomyopathy Asgar, Mack, Stone 2015;65:1231–48 Ischemic MR Outcomes Eur Heart J 2005;26: 1528–1532 In fact…even with small amounts of iFMR - it’s poor ! Options to Treat Seconday MR GDMT Resynchronization (when LVEF impaired and LBB or QRS width 150-180ms) Court M Mack TCT 2015 Even with GD medical therapy 1.0 FMR survival is not optimal! survival 0.8 0.6 0.4 MR grade None Mild Moderate Severe 0.2 No 9,405 2,062 210 171 0.0 Years Hickey et al: Circulation 78:1-51, 1988 The Treatment of MR is Much More Complicated than for AS Secondary MR (FMR) Class I Indications Pts with chronic secondary MR (stages B to D) and HF with reduced LVEF should receive standard GDMT therapy for HF, including ACE inhibitors, ARBs, beta blockers, and/or aldosterone antagonists as indicated Cardiac resynchronization therapy with biventricular pacing is recommended for symptomatic pts with chronic severe secondary MR (stages B to D) who meet the indications for device therapy Class IIb Indication MV surgery may be considered for severely symptomatic pts (NYHA class III/IV) with chronic severe secondary MR (stage D) COR LOE In pts NOT undergoing other cardiac surgery Nishimura RA et al J Am Coll Cardiol 2014;63:e57–185 CRT Reduces FMR Severity DiBiase et al, Europace, 2011: 13, 829-838 CRT < half eligible, < half “respond” Improvers: reduction in ≥ grade of FMR van Bommel R J et al Circulation 2011;124:912-919 Residual FMR is BAD, but they OK ? Copyright © American Heart Association Is MV Surgery Beneficial in FMR? 4,989 pts with CAD and mod/sev ischemic MR at Duke between 19902009 treated with MED only (1,800; 36%), PCI only (1,295; 26%), CABG only (1,651; 33%) and CABG + MV repair or replacement (243; 5%) Propensity adjusted multivariable outcomes at median FU 5.4 yrs: Median adj survival Medical treatment 5.6 years 6.8 years PCI 9.7 years CABG only 8.1 years CABG + MVRR 1.0 0.9 Survival 0.8 0.7 0.6 0.5 0.4 0.3 PCI vs Med: Adj HR (95%CI) = 0.83 (0.76 - 0.92), P=0.0002 CABG vs Med: Adj HR (95%CI) = 0.56 (0.52 - 0.62), P