Show notes
CardioNerds (Amit Goyal) join University of Mississippi Medical Center cardiology fellows (Catherine Lowe, Chris Latour and Adi Sabharwal) as they sit at the reservoir enjoying a great view of the water at the Pelican Cove Grill in Jackson, MS. They discuss and educational case of decompensated heart failure and shock in the setting of severe functional mitral regurgitation treated with MitraClip. Dr. Kellan Ashley provides the E-CPR and program director Dr. Trey Clark provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Richard Ferraro with mentorship from University of Maryland cardiology fellow Karan Desai.
Jump to: Patient summary - Case media - Case teaching - References
Episode graphic by Dr. Carine Hamo
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.
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Patient Summary
A man his mid 70s with a history of non-ischemic heart failure status post CRT-D placement, A-Fib, and chronic kidney disease presented with progressive shortness of breath with limited exertion. The patient was found to have severe secondary mitral regurgitation. Listen to the episode now to learn about treatment options for severe mitral regurgitation in heart failure and specifically the evaluation for MitraClip!
Case Media
ABCDEClick to Enlarge
A. Right atrial pressure B. Right ventricular pressureC. Pulmonary artery pressureD. Wedge pressureC. Pre and post MitraClip left atrial pressure
Episode Teaching
The CardioNerds 5! – 5 major takeaways from the #CNCR case
1. What is Comprehensive Disease Modifying Therapy in HFrEF?
Comprehensive disease modifying therapy for heart failure with reduced ejection fraction (HFrEF) has become both more robust and better understood by practitioners inside and outside the cardiology community. Comprehensive therapy is generally considered to consist of beta-blockade, mineralocorticoid receptor antagonist (MRA), sodium-glucose cotransporter-2 inhibitors (SGLT2i) and angiotensin receptor neprilysin inhibitor (ARNI), with ARNI being the preferred agent over angiotensin converting enzyme inhibitor (ACEi) or angiotensin II receptor blocker (ARB). Despite a greater understanding of HFrEF therapy by the medical community, significant gaps remain with recent data showing few patients on concomitant beta blockade, MRA, SGLT2i and ACE/ARB/ARNI, and even fewer at target doses. Compared to ACE, BB, and MRA alone, comprehensive therapy with MRA, BB, SGLT2i and ARNI could add an additional 6 years for middle-aged patients.
2. What role does Mitral Valve Disease have in Heart Failure Exacerbations?
For patients that remain symptomatic or with repeated hospitalizations for decompensated heart failure despite comprehensive therapy, it is important to look for additional pathology contributing to heart failure exacerbations. Mitral valve disease is one such etiology, particular secondary mitral valve regurgitation (MR) which can be seen in heart failure due to changes in left ventricular anatomy. Severe MR is associated with worsening left ventricular function and heart failure. For some time, however, it was an open question if functional MR was secondary to heart failure or an independent cause of heart failure exacerbations. Recent major trials suggest severe MR may act independently to worsen or lead to more frequent heart failure exacerbations.
3. How Do we Assess Mitral Valve Function in Heart Failure?
MR is primarily quantified by echocardiography, which allows for close observation of regurgitant flow. Once a diagnosis of secondary MR has been established by evaluating mitral valve morphology and leaflet motion (e.g., Carpentier Classification), there are several parameters including objective quantification of MR hemodynamics that are utilized to assess MR severity. However, the AHA/ACC guidelines and the ESC guidelines have different thresholds for severe secondary MR. In the ACC/AHA guidelines, important quantitative measures include calculation of the effective regurgitant orifice area (EROA), regurgitant volume (RVol) and regurgitant fraction (RF). When the MR is holosystolic and accounting for several limitations of these measures, EROA ≥0.4cm2, regurgitant volume ≥60mL, regurgitant fraction ≥ 50% are highly specific for severe MR. Vena contracta, the narrowest diameter of the regurgitant jet, is a semi-quantitative measure of MR severity and ≥0.7 cm (with a single jet) is consistent with severe MR. Remember, MR is dynamic and is dependent on the loading conditions. Thus, it is critical to record the patient's blood pressure, estimated LV systolic pressure in the setting of aortic stenosis, rhythm and heart rate when reporting echocardiographic measures.
4. What are the Therapeutic Options for Mitral Valve Disease?
Repair options generally include chordal-sparing mitral valve replacement (generally preferred in secondary MR rather than surgical mitral valve repair) and MitraClip. Mitral valve replacement is generally performed by surgeons, and with some exceptions is performed via open heart surgery. MitraClip placement consists of a small device that enters the left atrium via a trans-septal approach, and attaches to and approximates the mitral valve leaflets to reduce the burden of MR.
5. How Does the Data Substantiate these Options?
The EVEREST II trial was the first major trial to show similar clinical improvement and improved safety of MitraClip placement as compared to conventional mitral valve replacement surgery. The MITRA-FR and COAPT trials subsequently looked specifically at GDMT versus GDMT with percutaneous mitral valve repair in the treatment of heart failure. While MITRA-FR did not exhibit improvement in hospitalization for heart failure or mortality, the COAPT trial did show exhibit improvement in these markers. While the topic is of much discussion, differences in heart failure severity and achievement of GDMT was suspected to drive in part the different findings in these two trials. Furthermore, the concept of proportionate and disproportionate MR is thought to also lead to differences in the two trials. Patients with "disproportionate" MR – the severity of the MR is unexpected to the degree of LV dilation – were more well-represented in the COAPT trial. These patients seemingly are more likely to respond to interventions on the valve in addition to GDMT. COAPT was therefore the first trial to show improvement in mortality and outcomes in patients with moderate-to-severe MR secondary to LV dysfunction.
References
Greene, S. J., Butler, J., Albert, N. M., et. al (2018). Medical therapy for heart failure with reduced ejection fraction: the CHAMP-HF registry. Journal of the American College of Cardiology, 72(4), 351-366.Feldman, T., Foster, E., Glower, D. D. et. al. (2011). Percutaneous repair or surgery for mitral regurgitation. New England Journal of Medicine, 364(15), 1395-1406.Obadia, J. F., Messika-Zeitoun, D., Leurent, G. et. al (2018). Percutaneous repair or medical treatment for secondary mitral regurgitation. New England Journal of Medicine, 379(24), 2297-2306.Stone, G. W., Lindenfeld, J., Abraham, W. T., et. Al (2018). Transcatheter mitral-valve repair in patients with heart failure. New England Journal of Medicine, 379(24), 2307-2318.
CardioNerds Case Reports: Recruitment Edition Series Production Team
Bibin Varghese, MDRick Ferraro, MDTommy Das, MDEunice Dugan, MDEvelyn Song, MDColin Blumenthal, MDKaran Desai, MDAmit Goyal, MDDaniel Ambinder, MD