You are asked to consult on an 82-year-old woman with a long history of mitral valve prolapse and regurgitation for thoughts on further management. She reports worsening dyspnea on exertion and is limited to walking one block. She denies chest pain, orthopnea, or paroxysmal nocturnal dyspnea.
Medical History: Her comorbidities include obesity, stage 3 chronic kidney disease, obstructive sleep apnea, hypertension, hyperlipidemia, and mild dementia. She needs assistance with activities of daily living, and she lives with her granddaughter, who is her primary caregiver.
Negative History: She has no history of coronary disease, valve surgery, peripheral vascular disease (PVD), cerebrovascular disease, diabetes, hemodialysis, endocarditis, or immunosuppression.
Vitals:
Height - 4 feet, 7 inches
Weight - 63 kg (body mass index [BMI] 32.5 kg/m2)
Heart Rate - 58 beats per minute (BPM)
Blood Pressure - 132/60 mm Hg
Oxygen Saturation - 100%
Physical Exam:
General Appearance - Pleasant, cooperative Romanian female, appearing her stated age, and in no acute distress.
Neck - Jugular venous pressure of 12 cm measured with the patient reclined at 45 degrees.
Cardiovascular - Regular rhythm, III/VI blowing holosystolic murmur heard best at the apex, no gallops.
Extremities - Trace pedal edema.
Neurological - She is oriented to person, place, time, and situation.
Laboratory Data:
B-Natiuretic Peptide (BNP) - 586 pg/mL
Creatinine - 1.2mg/dL
White Blood Cell - 6.8 K/uL
Hemoglobin - 11.3 g/dL
Hematocrit - 33%
Platelet Count - 203 K/uL
Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were within normal limits.
Transthoracic Echocardiogram: Mild left ventricular (LV) enlargement with an indexed LV diastolic volume of 112 mL/m2. LV ejection fraction is 60% by biplane with no regional wall motion abnormalities. Right ventricular size and systolic function are normal. The left atrium is severely enlarged with an indexed left atrial volume of 40 mL/m2. There is mitral valve prolapse with a prominent eccentric, anteriorly-directed jet of mitral regurgitation (MR). The peak E wave velocity is 1.5 m/sec, effective mitral valve regurgitant orifice area is 59 mm2, and mitral regurgitant volume is 105 mL – all values consistent with severe MR. The estimated pulmonary artery systolic pressure is at least 39 mm Hg plus central venous pressure.
Transesophageal Echocardiogram: There is an anteriorly-directed, wall-hugging jet of severe MR. Systolic flow reversal is seen in the right upper pulmonary vein. The etiology of MR is degenerative valve disease (primary MR). There is bileaflet prolapse with severe prolapse of the P2 scallop and mild prolapse of P1. There is myxomatous thickening and mild prolapse of A2.
Cardiac Catheterization: LV end diastolic pressure is elevated at 18 mm Hg and pulmonary capillary wedge pressure is elevated at 15 mm Hg. The mean pulmonary artery pressure is 23 mm Hg with V waves to 45 mm Hg. Angiography shows right dominant coronary anatomy with 95% stenosis of the mid left anterior descending artery and 70% stenosis of the proximal right coronary artery.
Her case was reviewed by two cardiac surgeons. The mitral valve was felt to be amendable to mitral valve repair. However, her Society of Transthoracic Surgeons (STS) Surgical Risk Sore for mitral valve repair with two vessel bypass was elevated as follows:
Mortality - 7 %
Morbidity or Mortality - 30 %
Long Length of Stay - 15 %
Short Length of Stay - 12 %
Permanent Stroke - 3.5 %
Prolonged Ventilation - 18 %
Deep Sternal Infection - 0.2 %
Renal Failure - 8 %
Reoperation - 11 %
Additionally, the patient and her family express concerns about the recovery period after open surgery; they favor a less invasive option, if possible.
Which of the following statements describes your choice for this 82-year-old female with severe degenerative MR and two-vessel coronary artery disease?
Show Answer
The correct answer is: C. Consultation with the heart valve team and referral for staged percutaneous coronary intervention (PCI) and MitraClip procedure.
Treatment with medical therapy alone was not felt to be the best option for this patient, as she had developed symptomatic severe MR. An intervention to decrease the degree of MR would be more likely to give her sustained improvement in quality of life.1 A palliative care referral in itself was also not considered an appropriate course, given the patient was active with her family and had only recently become limited by symptoms from her MR.
Although this patient's mitral valve was repairable, her STS Surgical Risk Score was 7% risk of mortality. Additionally, both the patient and her family were concerned that the patient would have a difficult time rehabilitating from surgery. She was seen by the multidisciplinary heart team (including two cardiovascular surgeons, interventional cardiologists, heart failure specialists, and echocardiographers) at a center capable of percutaneous mitral valve repair. The patient was deemed appropriate for percutaneous mitral valve repair, and a strategy of PCI followed by MitraClip placement was proposed. This option was discussed with the patient, her family, and her primary cardiologist; all involved were in favor of proceeding.
The 2014 American College of Cardiology (ACC)/American Heart Association (AHA) Guideline for the Management of Patients with Valvular Heart Disease acknowledges the emerging transcatheter therapies for valve disorders. For severe symptomatic MR, there is a Class IIb recommendation for transcatheter mitral valve repair in the face of high surgical risk and NYHA class III or IV symptoms despite guideline-directed medical therapy2.
This recommendation is based in part on the results of the EVEREST II (Endovascular Valve Edge-to-Edge REpair STudy II) clinical trial which compared outcomes of percutaneous mitral valve repair to mitral valve surgery in patients with moderately severe to severe chronic MR. 279 patients with 3+ or 4+ MR were randomized to MitraClip placement or conventional mitral valve surgical repair or replacement. Inclusion criteria stipulated that the primary regurgitant jet in these patients originated from malcoaptation of the A2 and P2 scallops3. At 12 months, mitral valve surgery was significantly more effective at reducing MR than percutaneous repair. However, the rate of major adverse events (a composite including death, stroke, prolonged ventilation, and need for two or more blood transfusions) was significantly lower in the percutaneous mitral valve repair group1. Both the surgical and the percutaneous repair groups experienced a decrease in left ventricular size and reported improved quality of life.
We felt that the preferred option for our patient was percutaneous mitral valve repair given her comorbidities and severe symptomatic primary (degenerative) mitral valve regurgitation. With her surgical risk and concern regarding recovery from sternotomy, she meets guideline recommendations for percutaneous mitral valve repair and can be informed that the risk of major adverse events is lower with this treatment than with mitral valve surgery. However, she should also be counseled that conventional mitral valve surgery is more effective at reducing MR than the percutaneous approach.
Successful percutaneous coronary intervention was performed on her left anterior descending and right coronary artery lesions. A week later, she returned for MitraClip placement. After placement of a single clip, her MR was reduced to mild. One month later, her exercise tolerance had improved. She reported walking twice the distance she was able to walk prior to the procedure. She was able to return to the gym and resume her exercise routine of walking on the treadmill and water aerobics.
In October 2013, the United States Food and Drug Administration (FDA) approved the MitraClip device for patients with severe degenerative mitral valve regurgitation who are at high risk for surgery. At the time of this article, there is only FDA approval for the use of the MitraClip device in patients with severe primary (degenerative) MR. Our patient, with anterior and posterior leaflet prolapse, met the criteria of degenerative MR at high risk for surgical repair.
The COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) trial is currently enrolling patients with severe secondary (functional) MR to study the effects of percutaneous mitral valve repair in this population. Our patient would not have been eligible to enroll in COAPT, as the COAPT trial is specifically designed to study people who have functional MR secondary to decreased left ventricular systolic function. The findings of the COAPT trial will provide insight on whether the benefit seen after percutaneous mitral valve repair for degenerative MR also extends to those with functional MR.
Video 1: 2-D and Color Doppler of the Mitral Valve Pre-MitraClip by Transesophageal Echocardiography
In the 130 degree mid esophageal view, there is prolapse of the P2 segment with an eccentric, anteriorly-directed jet of severe mitral regurgitation with proximal isovelocity surface area formation.
Video 2: Color Doppler of the Mitral Valve post-MitraClip by Transesophageal Echocardiography
A well-positioned MitraClip is present with restricted motion of the mitral leaflets. Mitral regurgitation has been reduced to mild.
References
Feldman T, Foster E, Glower DD, et al. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med 2011;364:1395-406.
Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:e57-185.
Mauri L, Garg P, Massaro JM, et al. The EVEREST II Trial: design and rationale for a randomized study of the Evalve MitraClip system compared with mitral valve surgery for mitral regurgitation. Am Heart J 2010;160:23-9.
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