I THOUGHT WE HAD GOOD
PRESENTATIONS AND A GOOD
DISCUSSION YESTERDAY AND WE'RE
LOOKING FOR MORE OF THE SAME
TODAY.
THE FIRST SESSION IS ON SURGERY
AND TRANS CATHETER INTERVENTION
AND OUR FIRST SPEAKER IS
DR. MAYRA GUERRERO FROM MAYO
CLINIC.
>> WELL, THANK YOU VERY MUCH.
GOOD MORNING.
THANK YOU FOR THIS OPPORTUNITY.
I WOULD LIKE TO TALK ABOUT
TRANSCATHETER TREATMENT FOR
MITRAL VALVE PROLAPSE.
THESE ARE MY DISCLOSURES.
THE OBJECT IS TO DESCRIBE THE
RATIONALE FOR EDGE TO END REPAIR
OPTIONS.
I WAS HOPING TO ILLUSTRATE A
CASE EXAMPLE OF TRANSSEPTAL
CHORDAL REPAIR.
I WON'T BE ABLE TO SHOW THAT BUT
WE'LL SEE IF I CAN SHOW OR EARLY
OUTCOMES.
AND AT THE END I'M HOPING TO
DISCUSS KNOWLEDGE GAPS AND INPUT
ON FUTURE DIRECTIONS.
REGARDING THE RATIONALE, THE
NEED FOR RE-INTERVENTION AFTER
TEER IS NOT UNCOMMON.
WHEN IT'S NEEDED IT CAN BE
CHALLENGING AND REQUIRES SURGERY
AND TRANS CATHETER OPTIONS ARE
LIMITED.
THESE ARE SOME PATIENTS.
WE KNOW AS A BACKGROUND THAT THE
COMPARISON TO THE TRIALS WITH
SURGERY PATIENTS WHO WERE
TREATED WITH TEER SPECIFICALLY
ILLUSTRATED THEY HAD MORE THAN
20% REQUIREMENT FOR MITRAL VALVE
SURGERY MORE THAN 20%.
ON THE LEFT YOU CAN SEE WHAT
THEY WERE ANALYZED AFTER THE SIX
MONTH MARK MOST RECURRED TO SUB
OPTIMAL RESULTS.
THE BOTTOM LINE IS THE FIVE
YEARS THERE WAS NOTHING IB MORE
TAL AND THERE WERE SYMPTOMS BUT
THE WEAKNESS WAS ISSUE AND WANT
TO EMPHASIZE THE FIRST TEER WAS
IN 2003 IN THE U.S. AND THEN
LATER IN 2013 AND NEXT AND NEXT
AGAIN.
AND OUT OF MORE THAN 100,000
PROCEDURES AND WE KNOW A GOOD
PROPORTION MORE THAN 20% HAVE
PROCEDURAL IMPACT AND THOSE
PATIENTS GRADE III OR GREATER
THE MORTALITY WAS GREATER AND
SOME REQUIRED SOME INTERVENING
BUT HAVE HIGH MORTALITY, RIGHT.
SO WE DON'T SEE TOO COMMONLY
THERE'S MITRAL VALVE PROLAPSE I
KNOW THE PURPOSE OF THE SESSION
IS NOT THAT BUT WE SOMETIMES SEE
COEXIST AND OCCASIONALLY WE GET
A GOOD RESULT.
THIS IS AN EXAMPLE OF A GOOD
RESULT WITH TEER.
WE KNOW SOMETIMES THIS IS A
PROGRESSIONAL CONDITION.
LATELY THERE'S BEEN OPTIONS TO
REMOVE TEER TO ALLOW
TRANSCATHETER REPLACEMENT AND
THIS ALLOWS REPLACEMENT BUT THIS
IS CHALLENGING.
THERE'S BEEN A REPORT OF THE
FIRST IN HUMAN EXCISION AND THIS
WAS PUSHED TO THE SIDE AND THIS
CASE IT WAS REMOVED.
CHALLENGING BUT CAN BE DONE.
THERE HASN'T BEEN CLINICAL
TRIALS AND THE MOST RECENT ONE
AND WE RANDOMIZED FOR ANATOMY.
SOME ARE AT HIGH RISK REGISTRY
AND FOR THE NEXT FEW SLIDES
CLICK NEXT.
SO SIMILAR OUTCOMES.
NEXT IMPROVEMENT IN SYMPTOMS AND
THE POINT OF THIS IS THAT IN TWO
DECAD
DECA
DECADES MORTALITY AND SIMILAR
OUTCOMES AND IT'S HARD TO DO
THAT WHEN I DON'T HAVE CONTROL.
NEXT, NEXT, NEXT.
SOO T
SO, THE BOTTOM LINE WE HAVE TWO
DEVICES APPROVED AND MY POINT IS
I THINK WE NEED TO START SEEING
THAT.
SO THERE ARE MULTIPLE DEVICES
FOR TRANSCATHETER REPAIR BUT
MOST OF THOSE ARE SECONDARY THEY
FOCUS ON ANNULUS REDUCTION AND
APPROXIMATION BUT MAY NOT BE THE
BEST OPTION FOR MITRAL VALVE
PROLAPSE.
SO I THINK THERE'S ROOM FOR MANY
CHANGES HOW WE APPROACH MITRAL
VALVE PROLAPSE.
I THINK SOME PATIENTS WOULD
BENEFIT FOR THE CHORDAL REPAIR
AND WAS GOING TO SHARE WITH YOU
AN EXPERIENCE OF A CLINIC AND
HOPING TO ILLUSTRATE A REAL
CASE.
THE OBJECTIVES OF THIS EFS OR IS
TO HAVE A TRANS SEPTAL OPTION
WITH A SHORT PROCEDURE
RELATIVELY STRAIGHTFORWARD AND
HAVING THE PATIENTS DISCHARGE
NEXT DAY LIKE TEER AND EDGE TO
END REPAIR.
THE REASON FOR WANTING SOMETHING
LIKE LIST IS TO PRESERVE FUTURE
OPTIONS SO WE DON'T WANT TO
CLOSE THE DOOR FOR FURTHER
REPAIR.
SO TRANSCATHETER REPLACEMENT
OPTIONS.
THIS IS VERY STRAIGHTFORWARD FOR
TEAMS THAT ARE USED TO PERFORM
PROCEDURES AND GUYEDED LIKE WE
DO TEER AND YOU PLACE THE CHORD
ON THE VENTRICULAR WALL AND
APPLY TENSION AND YOU CAN ADJUST
THE TENSION VARIETY OF THE
REDUCTION YOU'RE LOOKING FOR.
SO THE EFS LOOKS AT PRIMARY
PERFORMANCE AT 30 DAYS FOLLOW-UP
AND LOOKING FOR ADVERSE EVENTS.
THIS IS HIGH RISK COHORT.
SO THE EXCLUSION CRITERIA.
AND THE COMPOSITE END POINTS FOR
THE PROCEDURE AS A AND FOLLOW-UP
AT 30 IT'S AN AND LOOK AT OTHER
TRIALS AND FOLLOW-UP AFTER 30
DAYS.
UNFORTUNATELY, THE CASE EXAMPLE
IS A LARGE SIZE AND ALLOWED TO
SHARE MY SCREEN.
THIS IS JUST THE LEADERSHIP.
I'M ONE OF THE CO-P.I.s AND
INTERESTED IN YOUR INPUT BECAUSE
WE WANT TO START CLINICAL
TRIALS.
SO WE HAVE OUTCOMES ON MANY
PATIENTS.
THIS IS EARLY EXPERIENCE AND THE
CASE I'M SHOWING IS ONE AT MAYO
CLINIC WHERE WE HAVE SIX-MONTH
FOLLOW-UP.
IMPRESSIVE RESULTS WITH CHEMO
DYNAMIC ASSESSMENTS ON THE
PROCEDURE AND YOU COULD SEE A
DRAMATIC DROP IN A BIG WAY AND
REDUCTION OF MITRAL
REGURGITATION AND THE PATIENT
WAS EXTREMELY HAPPY WITH THE
RESULTS AND SO FAR HAVE NOT HAD
ANY DANGER RELATES TO THE
PROCEDURE.
SEVEN WERE TREATED WITH A SINGLE
CHORD.
TWO REQUIRES TWO CHORDS AND WE
HOPE TO HAVE OUTCOMES TO BE
PRESENTED.
PLEASE KEEP THIS CONFIDENTIAL
BUT WE MOPE TO PRESENT NEXT
YEAR, 2025 SOME OF THE
EXPERIENCE.
SO KNOWLEDGE GAPS AND THE RESULT
S IN THE PROCEDURES CLOSE TO
TEER AND TEST THE INDEX
PROCEDURE MAYBE FOLLOWED BY TEER
LATER ON IF AND WHEN IT FAILS OR
COMBINED WHEN NEEDED.
SO FUTURE DIRECTIONS.
I ASK FOR INPUT AND WE NEED
RANDOMIZED CLINICAL TRIALS.
AND WE NEED TO COMPARE WITH
SURGERY AND WOULD IT BE FAIR TO
JUST COMPARE WITH TEER.
SHOULD WE FOCUS ON WHICH
PATIENTS AND WHAT SHOULD BE THE
PRIMARY END POINTS FOR THE TRIAL
AND THE DURATION OF FOLLOW-UP
WE'D LIKE TO SEE IN THE TRIALS.
I THINK THIS IS MY LAST SLIDE.
IN SUMMARY, SO NEED FOR REPEAT
MVP INTERVENTION IS NOT UNCOMMON
AFTER TEER.
SURGICAL OR PERCUTANEOUS
EXCISION OF THE FAILED TEER
DEVICE AND NON-TEER REPAIR DOES
NOT PRECLUDE FUTURE
INTERVENTIONS AND TRANS SEPTAL
CHORDAL REPAIR MAY BE AN OPTION
AND WE THESE FURTHER STRATEGIES
AND I'M APPRECIATIVE OF THIS
OPPORTUNITY AND WOULD LIKE TO
HEAR YOUR INPUT TO SEE WHERE YOU
WANT US TO LEAD THIS FORWARD FOR
THE NEXT PHASES OF THE TRIAL.
THANK YOU.
>> THANK YOU, DR. GUERRERO.
ARE THERE QUESTIONS OR COMMENTS
ON THIS PARTICULAR PRESENTATION?
>> THIS IS FANTASTIC.
THIS IS THE MOST PHYSIOLOGIC
REPAIR.
REPRODUCING THE ORIGINAL ANATOMY
TO BE CONGRATULATED.
I WOULD THINK ONE OF THE
CHALLENGES IS THE IMAGING.
I SAW TWO OTHERS ON AND WE
CERTAINLY WOULD BE INTERESTED IN
PARTICIPATING.
WHAT CHALLENGES HAVE ENCOUNTERED
IN TERMS OF THE IMAGING
GUIDANCE, PLEASE?
>> THANK YOU.
THAT'S A QUESTION.
WHAT WE DID WAS INCORPORATE THE
LEARNINGS ON SAFETY ANALYSIS.
IF YOU TWO BACK TO THE VIDEO
ANIMATION AND WANT -- I WANTED
TO SHOW WHERE TO PLACE THE
CHORD.
I'M NOT A SURGEON I'M A
CARDIOLOGIST AND FAMILIAR WITH
THE PROCEDURE AND PLACEMENT OF
THE VALVE AND I WASN'T FAMILIAR
ONE WILL THE HYBRID APPROACH AND
WHAT WE DID I ASKED WHERE DO YOU
WANT ME TO PLAY THE END CHORD
AND THEY SAID BETWEEN THE
PAPPILARY MUSCLE AND I KNOW THE
CAMERA ANGLE I NEEDED TO HAVE TO
VISUALIZE THAT.
IN TERMS OF THE LEAFLET IT
WASN'T DIFFICULT.
ANYTHING WITH GOOD SUPPORT
SHOULD BE ABLE TO VISUALIZE THE
PATIENT SELECTION I DON'T SEE
THAT AS A MAJOR PROBLEM AND WE
HAVE THE CONCEPT OF LOOKING AT
THE PRESSURE WHICH I FOUND
HELPFUL TO NOT JUST LOOK AT THE
COLOR WHEN YOU APPLY THE
TENSION, AGAIN, I'M NOT A
SURGEON, SO WE WERE LOOKING AT
THE COLOR AND THE FORM IN THIS
PARTICULAR CASE AND WHEN IT WAS
REDUCED AND APPLIED TENSION IT
CAME BACK AND THAT TOLD US THAT
WAS TOO MUCH TENSION AND
INCORPORATING THE HEMODYNAMICS.
>> GREAT.
THANK YOU.
>> THANK YOU.
>> MAYRA, I ALWAYS THOUGHT THIS
WAS THE REAL FUTURE IF WE COULD
EVER GET TO CHORDAL
RESUSPENSION.
I WAS INVOLVED IN A TRIALING TO
PUNCTURES AND TYING CHORDS BACK
IN TO THE VENTRICLE.
WE HAD SOME IF RESULTS AND SAW
PATIENTS SEVERAL YEARS OUT AND
THE NEXT STEP IS TO GET IT TO A
CATHETER.
THE SELECTION WAS CRITICAL
MEANING THAT WE NEEDED TO HAVE
ENOUGH LINK BETWEEN ANTERIOR AND
P
POSTERIOR AND YOU DON'T HAVE TO
REDUCE THE ANNULUS BACK TO ITS
ORIGINAL SHAPE.
MOST PATIENTS BOAT MORE THAN ONE
CHORD LIKE MANY DO IN SURGERY
UNLESS YOU'RE TREATING AN ELO
ELONGATION AND WHAT WE
DISCOVERED WAS AND WHAT I'M
ALWAYS CONCERNED ABOUT AS WE
MOVE IN THE SPACE SURGERY TREATS
ALL LESIONS OF THE DEGENERATIVE
POSTERIOR LEAFLET PROLAPSE AND
WE STUDIED VERY SPECIFIC
ANATOMIES WITH TRANSCATHETER AND
REWITH RELEASE THEM AND THEY
GO -- WE RELEASE THEM AND TWO
INTO EVERYBODY.
HOW DO WE STUDY THE CONCEPTS
LIKE THIS ONE WHICH I'M
INTERESTED IN AND EXCITED ABOUT
BUT THEN RECOGNIZE WELL, MAYBE
WE SAW 10 OR 15 POSTERIOR
LEAFLET PROLAPSES AND WHAT
HAPPENS ONCE YOU DO A STUDY AND
IT'S APPROVED?
IMMEDIATELY IT STARTS PUTTING
INTO EVERYBODY POST MARKET.
HOW DO WE HAVE LOW RISK
DEGENERATIVE CLIP WEN THE FDA
APPROVED IT FOR HIGH RISK
PATIENTS WHICH IS 5% OF THE
POPULATION.
HOW DO WE DO THAT?
>> WE FOCUS ON THE SCREEN
FAILURE RATE.
>> WE SCREEN FAIL IN TRIALS
BECAUSE WE HAVE TO BE SO CAREFUL
IN WHAT WE STUDY.
I'M ASKING JUST BROADER TO JUST
THINK ABOUT ONCE WE GO THROUGH
ALL THE EFFORT TO APPROVE A
DEVICE AND VERY DISCIPLINED IN
SCREEN FAILURES FOR ANATOMY, THE
NEXT PHASE IS EVERYONE'S A
CANDIDATE IMMEDIATELY.
PEOPLE FORGET TO READ THE
INCLUSION AND EXCLUSION
SOMETIMES OTHERWISE HOW CAN WE
EXPLAIN LOW RISK TEER WHEN IT'S
FOR HIGHER RISK PATIENTS?
AND SAME FOR ANATOMY.
I DON'T THINK THIS HAPPENS IN
THE REPLACEMENT WORLD BECAUSE
YOU HAVE TO PAY ATTENTION TO
VALVE DISLODGING AND WE HAVE TO
THINK ABOUT THE CRITICAL THING
IN VALVE REPLACEMENT BUT IN
REPAIR THERE'S A TENDENCY TO TRY
EVERYTHING WITH A CATHETER ONCE
THE DEVICE IS SITTING ON YOUR
SHELF AND IT'S SO IMPORTANT AS
WE ARE HELPED TO HAVE THESE VERY
ACADEMIC EXPERT DISCUSSIONS THAT
WE WE'LL HAVE TO REINFORCE THE
IMAGING EXPERTISE REQUIRED TO DO
THESE AND THE DISCIPLINE OF
ONES, INTERVENTIONALISTS AND
EC
ECHOCARDIOGRAPHERS TO LOOK AT
THE EVIDENCE WE'VE CREATED.
>> THAT EXPLAINS THE RESULTS,
RIGHT THAT WE SAW.
IT'S APPROVED FOR PRIMARY MR AND
THERE WAS A LITTLE BIT OF
THICKENING WE'LL CALL PRIMARY
AND THEY SUPPORT THE CASES AND
LOOKING AT POORER OUTCOMES AND
NOT JUST FOR TECHNOLOGY BUT FOR
THE PATIENT RIGHT.
THAT'S WHY WE SEE THE POORER
OUTCOMES.
>> ON THE PAPER WROTE FROM THE
TBT REGISTRY AND WHAT WAS SO
FIRST OF WILL ALL A QUARTER OF
THE PATIENTS WERE LOW RISK.
I'M NOT SURE HOW THAT HAPPENED
BUT SOME HAD STENOSIS OR EMR AND
THAT HAD A ONE-YEAR PENALTY IN
DEGENERATIVE DISEASE.
ONE THING WE HAVE TO DO AND I
THINK I MENTIONED YESTERDAY WHEN
JUDY MENTIONED AS WE MOVE DOWN
THE PATH OF TRANS CATHETER VALVE
REPAIR I THINK WE HAVE TO START
TALKING ABOUT INVESTING IN A
LONG TERM CORE LAP BY THE NIH
BECAUSE WE'LL NEED LONGER
FOLLOW-UP MOST MARKET AND IT HAS
TO BE DONE IN A LAP TO
UNDERSTAND WHAT HAPPENS AND
WHETHER THAT DISCIPLINE OF
SELECTION CONTINUES.
>> THANK YOU.
I COMPLETELY AGREE.
>> THANK YOU FOR THE
PRESENTATION AND THE IF
DISCUSSION.
DR. GUERRERO, I APOLOGIZE NOR
SYSTEM LIMITATIONS.
>> SORRY, I GET EXCITED.
I UNDERSTAND THAT IT PERHAPS TOO
LARGE TO SHOW.
THANK YOU.
I HAVE TO GO.
I HAVE A CASE.
THANK YOU VERY MUCH.
>> THANK YOU.
OKAY.
WE'RE GOING OUT OF ORDER AT THE
MOMENT.
DR. ADAMS, ARE YOU ABLE TO GO
NEXT?
>> SURE.
>> OKAY.
>> SO I'M GOING TO TALK TO A
LITTLE BIT ABOUT OUR THOUGHTS
ABOUT VALVE RECONSTRUCTION AND
VENTRICULAR ABLATION FOR
PROLAPSE AND SOME ECHOS LOOK
EXPENSIVE BUT THEY'RE ALL IN RED
AND GREEN AND GIVE COLORS BUT I
THINK WE'LL GET THROUGH IT.
THESE ARE ALL MY DISCLOSURES AND
I'LL REMIND EVERYBODY I HAVE
BEEN INVOLVED IN MANY TRIALS OF
TRANS CATHETER AND ALTERNATIVE
SURGICAL STRATEGIES.
I ALWAYS REMIND PEOPLE WE'RE NOT
DEFENDING THERAPY WE'RE
DEFENDING PATIENTS.
I THINK THAT'S WHY THESE
MEETINGS ARE SO INSTRUCTIVE AND
FRANK, THANK YOU TO YOU AND YOUR
TEAM FOR PUTTING THIS TOGETHER.
WE'RE GOING TO TALK ABOUT
SURGERY FIRST.
I WANT TO START WITH AFLAT --
ANATOMY AND WE WANT A MITRAL
VALVE THAT OPENS COMPLETELY AND
HAS MULTIPLE SEGMENTS AND THE
COMMISSURE AREAS AND THE BLOOD
COMES BACK AND IS LATER EJECTED
AND WE HAVE CORONARY SCIENCES
THAT'S FOR PHYSIOLOGY IN TERMS
OF TRYING TO MINIMIZE ENERGY OR
MAXIMIZE ENERGY TRANSFER AND TO
MINIMIZE STRESS AND TENSION.
WE SPENT YEARS TALKING ABOUT
ISCHEMIC MITRAL VALVE
REGURGITATION AND THANKS TO BOB
AND MANY ON THE CALL THERE WAS A
DECADE OF ISCHEMIC MR.
EVERYTHING WAS AROUND THE
VENTRICLE CAUSING THE MITRAL
VALVE TO HAVE DYSFUNCTION IN
TERMS OF DELTATION AND
REMODELLING AND THE MITRAL VALVE
ANATOMY IMPACTING THE VENTRICLE
AND THAT'S WHAT WE'RE HAVING THE
MEETING FOR IS TO CATCH UP FROM
TWO YEARS AGO.
I FIRST DREW THIS FIGURE AND WE
DREW IT TO HELP SURGEONS
UNDERSTAND THE DIFFERENCES IN
ANATOMY AND HOW TO DEVELOP
REPAIR STRATEGIES BASED ON THE
TISSUE AND SEGMENTAL
INVOLVEMENT.
AND OF COURSE NOW AS YOU SAW
YESTERDAY THIS FIGURE HAS BECOME
VERY USED ALMOST EVERYWHERE AND
IT'S REALLY BECAUSE OF THE
CHARACTERIZATION OF VALVE
DISEASE AND I'LL FOCUS ON THESE.
IF YOU LOOK AT A BOAT AND I
WANTED TO GO FAST, WHAT DO I DO?
I PUT BIG SAILS ON IT AND USE
THIS AS A PARALLEL BETWEEN
BARLOW'S AND I COULD HAVE SAID
ANTERIOR AND POSTERIOR LEAFLET
AND THE FIGURE TEACHES US LATE
ABOUT THE TOPIC AT HAND AND
MITRAL VALVE PROLAPSE.
THIS IS THE ORIGINAL DESCRIPTION
OF PROTRUSION OF THE POSTERIOR
LEAFLET BY JOHN BARLOW AND IT
PRECEDED THE CARDIOGRAPHY AND
THE FIELD IS BEING REDISCOVERED
AND I REMAIN EXCITED ABOUT THE
IMPLICATION FOR PATIENTS WITH
PROLAPSE .
IN THE TEXTBOOK I HELPED THE
THREE PRINCIPLES WERE TO RESTORE
THE LEAFLET ANATOMY AND MOTION
NOT RESTRICTIVE BUT RESTORING
AND CREATE THE NORMAL, WHICH IS
VARIABLE BUT A DEEP SURFACE OF
PRO
PROLAPTATION SO THE VALVE CAN
FLEX WHEN YOU RAISE THE PRESSURE
AND BECAUSE THE FIBROUS PART IS
IN CONTINUITY WITH THE POSTERIOR
ANNULUS DILATES AND WHETHER YOU
DO REDUCTION THE BOTTOM OF THE
VALVE DROPS OUT AND THE GOAL WAS
TO RESTORE THE NORMAL
RELATIONSHIP OR KIDNEY BEAN
SHAPE OF THE AND YOU'LL -- --
ANNULUS AND WE CREATED THIS FOR
THE VENTRICLE.
WE REVIEWED THE LITERATURE
DURING THIS CONFERENCE IN TERMS
OF ALL THE BASIC SCIENCE BEHIND
THIS I WANTED TO PRESENT CASES
AND SHOW YOU EXAMPLES THAT WILL
HIGHLIGHT OUR PHILOSOPHY AS A
TEAM.
FIRST PATIENT, 48 YEARS OLD,
LONG HISTORY OF PROLAPSE SHE'S
GOT EJECTION FRACTION.
SHE'S GET A THICK POSTERIOR
LEAFLET AND THIS TENDENCY OF
BOTH LEAFLETS TO GO ABOVE THE
ANNULAR PLANE AND WHAT IS
TYPICAL AND I'LL ASK ABOUT IT IN
THE DISCUSSION LATER WITH OTHERS
IS WHETHER PROLAPSE VERSUS
RUPTURE MATTERS BECAUSE MY GUESS
IS THERE'S MORE TENSION WHEN YOU
HAVE CHORDAL ELONGATION AND HAVE
A WHOLE HISTOLIC MURMUR AND THIS
IS ABOUT 3.9% WITH PBCs AND
YOU'LL SEE MARK MILLER'S NAME A
LOT AND HE'S THE
ELECTROPHYSIOLOGIST THAT DRIVES
THE PROGRAM TOGETHER WITH ME IN
TERMS OF THE SURGICAL
INTERVENTION.
HERE'S THE HYBRID PET MRI AND
HERE'S A PATIENT WITH LGE IN THE
MUSCLE.
HERE'S THE SURGERY.
LOOK AT THE BILLOWING LARGE
POSTERIOR LEAFLET.
IN TERMS OF ANY OTHER STRATEGY
WE HAVE TO REMOVE TISSUE.
LOOK AT THE BULK AND THICKNESS
OF IT.
THIS IS A QUADGRANULAR RESECTION
AND TAKING A PIECE OF THE
LEAFLET AND TRIM THIS DOWN --
OH, DEAR.
LET'S TRY NOT TO DO THAT SO WE
STAY ON TIME.
LEAVE THE BUTTON AND WE'LL SEE
IF IT WILL FINISH.
IT'S IMPORTANT BECAUSE I WANTED
TO SHOW YOU SOMETHING UNDER THE
VALVE OF THE PATIENT.
I TOOK IT BACK.
A QUADGRANULAR SECTION -- THE
POSTERIOR LEAFLET SHOULD BE
ABOUT ONE CENTIMETER TALL AND
WE'RE REDUCING THE HEIGHT AND
RESUPPORTING IT AND DEALING WITH
THE VOLUME.
LOOK AT THE FIBROSIS AND
CALCIFICATION IN THE PAPILLARY
MUSCLE.
THIS IS ELIMINATING THE ANNULAR
DISJUNCTION PLACING IT BACK AND
TRUE SIZE THE RING AND YOU CARN
SEE THE NORMAL ANATOMY RESTORED
WOMAN THE LEAFLET IN NORMAL FLOW
IN THE VENTRICLE AND DIRECTION
TOWARDS THE APEX AND THE INK
SHOWS THE AMOUNT OF PROLAPSE.
AND HERE'S THE ONE-MONTH POST
MITRAL VALVE REPAIR WITH MINIMAL
PVCs AND SOME HAD PVCs RESOLVED
WITH SURGERY AND THIS PATIENT
ONLY HAD IT BECAUSE THE BURDEN
WAS LOW.
HERE'S THE SECOND PATIENT.
SHE'S 68 YEARS OLD AND HAD P
PALPITATION AND HER REJECTION
FRACTION IS LOW NOW 46%.
HER PBC BURDEN IS 14%.
THERE WAS A STRESS
ECHOCARDIOGRAM AND HAVING
VENTRICULAR CUPLETS AND TRIPLETS
ON EXERCISE.
HERE'S HER TRANS ESOPHAGEAL
ECHOCARDIOGRAM.
MANY HAVE HEIGHT AND HAVE
PROLAPSE.
THERE'S MANY JETS BECAUSE THE
VALVE LEAKS IN MORE THAN ONE
PLACE BUT MOST ARE DIRECTED
CENTRALLY.
HERE'S HER PVC ORIGIN AND THIS
IS IMPORTANT AND I'M SURE
DR. MILLER WILL GET INTO THIS
LATER WHEN HE SPEAKS BUT EKG
MORPHOLOGY DRIVES SELECTION OF
PARTICULAR PATIENTS IN TERMS OF
AN FOCI TO TREAT DURING THE
RECONSTRUCTION OF THE VALVE.
HERE YOU CAN SEE YOU DO NEED TO
WORK WITH AN ELECELECTROPHYSIOLT
AND BIBLE TO GET THE EXPERIENCE
LEVEL THAT'S REQUIRED TO FORGE
INTO A NEW FRONTIER LIKE
PAPILLARY MUSCLE ABLATION.
HERE'S THIS PATIENT'S STUDY
AGAIN.
LGE POSITIVE, FDG NEGATIVE.
LET'S WATCH THE VALVE REPAIR.
THIS IS A TYPICAL PATIENT.
MULTISEGMENT PROLAPSE YOU CAN
SEE.
AGAIN, THIS PARTICULAR PATIENT
WE'RE FOCUSSING ON THE P3 SIDE
BECAUSE WE HAVE A COMMISURAL
PATIENT AND THAT'S THE ABLATION.
SO WE'LL CIRCUMFERENCCIRCUMFERE
AROUND THIS AND WE HAVE PERFECT
VISION TO DO THAT.
THEN WE'LL CREATE A LEAFLET
THAT'S ABOUT A CENTIMETER AND A
HALF IN THE RIGHT POSITION AND
SEE THE POST OPERATIVE ECHO AND
WHAT WE'RE TRYING TO ACCOMPLISH
EACH TIME IS KNOWING MITRAL
VALVE REGURGITATION WITH A
NORMAL FLOW IN THE VENTRICLE AND
SYSTOLIC.
YOU CAN ADVANCE THE SLIDE.
AND THERE YOU CAN SEE THE THREE
MONTH POSTOPERATIVE EVENT
MONITOR WITH A 1% BURDEN OF
VENTRICULAR ARRHYTHMIAS.
THERE'S A ROLE FOR BOTH
PROCEDURES.
THESE ARE WELL SELECTED
PATIENTS.
THEN YOU'LL SHOW THE CASE 72
YEARS OLD.
SHE ALSO HAS PVCs.
SHE'S GOT A 27% BURDEN ON HER
MONITOR.
HERE'S HER TRANS ESOPHAGEAL
TRANSFER AND CHORDALATION IS THE
MAIN HERE NEXT TO LEAFLET.
SHE'S GOT TWO DIFFERENT
LOCATIONS FOR PVCs.
THE DOMINANT PVC IN THE DOMINANT
FOCI AND IN OUR PROGRAM
DR. MILLER IDENTIFIES THESE IN
TERMS OF ABLATION.
INTERESTINGLY ENOUGH IN THIS
PARTICULAR PATIENT, SHE DOES
HAVE FDG POSITIVELY AT THE LV
SUM IT WHICH IS THE LOCATION
WHERE MARK IDENTIFIED THE
PRIMARY FOCI FOR PVC.
AGAIN HERE'S THE PVC AND THE
DOMINANT ONE AND THE SECOND IN
THE POSTERIOR PAPILLARY MUSCLE
WITH A HIGH BURDEN.
SO HERE'S THIS PARTICULAR
PATIENT'S PROLAPSE.
AGAIN, THICKENED CHORDS.
USUALLY THERE'S A LARGE MESH OF
CHORDS.
YOU SEE THE CALCIFICATION AT THE
BASE OF THE VALVE.
AND HERE WE'LL ISOLATE THE
PAPILLARY MUSCLE, RECONSTRUCT
THE VALVE LIKE WE'VE SHOWN YOU
BEFORE.
THESE CREATE TRANS MURAL
LESIONS.
RECONSTRUCT THE VALVE.
WE'RE CREATING THE SECOND LESION
AT THE LV SUMMIT THROUGH THE
TRACT.
THERE'S THE POSTERIOR.
NEXT.
THIS PATIENT WENT DOWN FROM 27%
TO 2% IN THREE MONTHS.
WE PUBLISHED OUR EXPERIENCE IN
THIS WITH ABLATION IN SELECTED
PATIENTS WITH ARRHYTHMIC PRE
LAPSE.
THIS SUMMARIZES OUR CRYO
ABLATION STRATEGY.
WE DO THREE-MINUTE LESIONS FOR
THE PAPILLARY MUSCLE.
NEXT SLIDE.
WE HAVE TO BE ABLE TO IDENTIFY
FOCI AND THOSE WITH GREATER PVC
AND IN OUR PROGRAM THIS IS NOT
DONE CASUALLY AND HAS TO BE
HIGHLY SELECTED AND LUCKY TO
HAVE A GROUP TO TIE THIS
TOGETHER EVERY DAY.
WE DID GET AN AWARD TO CONTINUE
THE JOURNEY HERE FOR THIS AND
WE'RE GRATEFUL TO NHLBI FOR
THAT.
THIS WAS SUMMARIZED BY
DR. TRIVIERI AND WE CAN FOLLOW
PATIENTS NOT UNDERGOING SURGERY
AND GIVE CLINICAL FOLLOW-UP FOR
FIVE YEARS AFTER THEIR MRI AND
HAVE ARMS FOR SURGERY AND WE'RE
TRYING TO TAKE AREAS WHERE WE
IDENTIFIED NATURAL GAS ON
IMAGING BECAUSE WE ARE TRYING TO
ESTABLISH THE INFLAMMATORY
ORIGIN.
WE'RE TRYING TO CORRELATE THAT
AND HAVE FOLLOW-UP AFTER SURGERY
TO LOOK AMOUNT CHANGES IN
INFLAMMATION AFTER SURGERY.
THIS IS A 67-YEAR-OLD PATIENT
WITH AFIB AND MR COMPLETELY
PRESERVED VENTRICULAR FUNCTION
AND LOW PVCs.
YOU CAN SEE SEVERE MR IN DEEP
CLEFT AND THIS IS COMMON IN
BARLOW'S.
HERE'S THE RARE BURDEN OF P --
PVC AS AND THE PET IMAGES BOTH
OF WHICH ARE POSITIVE.
AND HERE'S THE LAST VIDEO I'LL
SHOW YOU WHICH IS THIS MITRAL
VALVE REPAIR.
AGAIN, THICK LEAFLETS ALMOST
ALWAYS SEEN IN PATIENTS THAT
HAVE THIS PARTICULAR ANATOMY.
IT'S PART OF THE REFORM FOR
BARLOW'S DISEASE.
THIS IS DETERMINED BY THE
PATIENT'S OWN ANATOMY.
WE'LL TAKE OUT THE SEGMENT AND
WE'RE NOT GETTING IN THE DETAILS
OF WHY WE DO DIFFERENT THINGS
AND THIS IS A DIFFERENT TYPE OF
RECONSTRUCTION.
SOMETIMES WE DETACH AND
SOMETIMES WE ROTATE THE LEAFLET.
THE GOAL IS TRYING TO CREATE THE
SAME SYMMETRIC HEIGHT OF THE
POSTERIOR LEAFLET.
WE'RE DETACHING ONE SIDE OF THE
LEAFLET AND WILL MOVE THAT TO
THE OTHER SIZE AND GETTING
ACCESS TO THE BASE OF P3 AND
THIS WE'RE GOING THE BIOPSY.
TO THE BIOPSY IS CORRELATED IS
WHERE WE SAW THE POSITIVITY IN
THE MRI STUDY AND THIS THE
CONTROL SAMPLE IN THIS CASE IS
BEING TAKEN BY THE ANTERIOR
SEPTAL WALL.
MANY PATIENTS WE'RE FORTUNATE WE
HAVE A PLACE TO SEE INFLAMMATION
OR IMAGING AND LIGHTING UP SO
WE'RE INTERESTED TO SEE HOW THAT
WORKS OUT AND THINK IT WILL
PROVIDE A LOT OF INFORMATION
REGARDLESS OF WHAT WE FIND ON
THE HISTOLOGICAL SIDE AND YOU'RE
SEEING THIS ALREADY.
SAME GOALS EACH TIME TRYING TO
CREATE THE HEIGHT OF THE
POSTERIOR LEAFLET TO BE
SYMMETRIC AND CLOSE IN A
SYMMETRIC WAY.
THE PRINCIPLES ARE THE SAME
RESTORE NORMAL LEAFLET MOTION
AND DIASTOLIC FUNCTION OF THE
VALVE AS BEST WE CAN AN REMODEL
THE ANNULUS AND THE DEPTH OF
CLOSURE MATTERS.
THIS IS WHAT IT LOOKS LIKE WHEN
IT'S PUT IN SURGICALLY.
AND THEN A RING WILL GO IN AND
THAT WILL SOLVE THAT.
SO AGAIN MANY PATIENTS IN THE
TRIAL ARE BEING DONE AND IT'S
INTERESTING THEY HAVE A LOW
ARRHYTHMIC BURDENS BUT HAVE
POSITIVITY FOR INFLAMMATION IN
THE VENTRICLE.
ED -- I THINK THIS IS RELEVANT
BECAUSE WE SEE PATIENTS WITH
MITRAL VALVE DISEASE EVERY WEEK
INCLUDING SYMPTOMATIC AND
ASYMPTOMATIC AND MONITORING IS
MORE SOPHISTICATED IMAGING AND
ABLATION STRATEGIES WILL END UP
IN THE DISCUSSION OVER THE NEXT
SEVERAL YEARS IF WE CONTINUE TO
DO OUR WORK ON THE PHONE CALL, I
THINK ALL THESE THINGS WILL
BECOME EXTREMELY IMPORTANT AND I
APPRECIATE THE FLOOR, FRANK.
THANK YOU VERY MUCH FOR INVITING
ME.
I'LL STOP THERE.
>> THANK YOU VERY MUCH.
ANY QUESTIONS OR COMMENTS ON
THIS PRESENTATION?
>> DAVID, OUTSTANDING
PRESENTATION AND CONGRATULATE
YOU GUYS ON THE WORK YOU'RE
DOING.
FOR A LOT OF THE CASES YOU'RE
DOING THIS CRYO ABLATION AND
TRACK PATIENTS DOING ANYTHING
OTHER THAN THE MITRAL REPAIR DO
YOU SEE IT REDUCED ALONE?
>> I WONDER IF YOU CAN MAKE A
BRIEF COMMENT ABOUT THAT.
HE RUNS OUR RESEARCH GROUP.
>> GOOD TO MEET YOU VIRTUALLY.
WHAT WE DID FIND OUT IS PATIENTS
THAT HAVE SIMPLE NON-COMPLEX
VENTRICULAR ARRHYTHMIA RIGHT
AFTER A GARDEN VARIETY ANG
ANGIOPLASTY WITH NO RECURRENCE
HOWEVER, THOSE THAT HAD NOT
BURDEN BUT COMPLEXITY AND FREE
AND UP WAS THE MOST COMMON
INDEPENDENT PREDICTOR REGARDLESS
OF VENTRICULAR ECTOPY AND IF YOU
HAVE V.P. RUNS WE NEED TO
REMEMBER THE PATIENTS AND
INVOLVE THE ELECTROPHYSIOLOGISTS
BECAUSE NOT JUST GOING TO TAKE
THE REPAIR OF THE MECHANICAL
PROBLEM.
>> TO SOME EXTENT AT LEAST FOR
SURGERY HAS SOME EFFECT AFTER
REDUCING ARRHYTHMIA BURDEN AS
WELL AT LEAST IN SOME CASES.
>> AND A REAL KEY HERE AND
INTERESTED TO HEAR THE COMMENTS
AND SHE'LL TEACH US SOMETHING
ABOUT WHAT THE NIH TRIAL IS
GOING BUT I THINK IT'S GOING TO
TO BE INTERESTING BECAUSE ONE
ARGUMENT IS THE VOLUME LOAD AND
THE STRETCH THAT HURTS THE
VENTRICLE?
THE OTHER ARM THE ONE I
CERTAINLY BELIEVE AND TRIED TO
REPRESENT THERE IS THE ANATOMY
IS VERY UNUSUAL.
IT'S NOT THE WAY MITRAL VALVES
WERE MEANT TO CLOSE IN SYSTOLE
AND MID SYSTOLIC LEAKS PROBABLY
CREATE THE MOST FORCE WITH WE
DON'T A LOT OF MITRAL VALVE
MITRAL VALVE WITH THOSE WITH
DEFICIENCY.
>> I THINK IT'S MECHANISM
DEPENDENT.
ACROSS THE BOARD THERE SEEMS TO
BE A MODEST EFFECT.
I THINK THE MECHANISM OF THE PVC
SURGERY PROBABLY HAS LESS EFFECT
IF IT'S PURELY MECHANICAL FORCES
LIKE A FLAILED LEAFLET PROBABLY
HAS MORE EFFECT.
ONCE YOU DRAW DOWN TO WHAT'S
CAUSING IT WILL DETERMINE
WHETHER OR NOT THE SURGERY HAS
DIRECT IMPACT.
>> I'M GLAD YOU MADE THE
COMMENT.
>> THE DISCUSSION WE WERE HAVING
YESTERDAY ABOUT DOING SOME
TRIALS WITH EARLIER INTERVENTION
AND POTENTIALLY THE EARLIER
INTERVENTION IS IN THE
ARRHYTHMIC PHENOTYPE AND THE
EARLY SURGERY MAY BE THE WAY TO
REDUCE ARRHYTHMIC RISK IN SOME
PATIENTS.
>> I THINK IT WILL REDUCE IT
POTENTIALLY TWO WAYS.
ONE IS OBVIOUSLY THE DIRECT
MECHANICAL FORCES AND WE KNOW
FIBROTIC TISSUE LEADS TO PVCs.
IF YOU CAN REDUCE THE INJURY TO
THE MUSCLE YOU'LL PROBABLY
REDUCE THE RISK IF YOU INTERVENE
EARLY ENOUGH.
>> THOSE PATIENTS DO NOT HAVE A
SCAR SUBSTRATE ONLY INFLAMMATORY
SUBSTRATE IT CAN INTERVENE IN
DISRUPTING THE PROGRESSION TO A
DEFINITIVE SUBSTRATE OF SCAR.
>> THAT'S WHAT WE BELIEVE.
>> THOSE WITH LOW EF -- I THINK
A COUPLE HAD NORMAL EJECTION
FRACTION.
>> YOU HAD THE 57% AND SYSTOLIC
42% AND ALL QUALIFIED FOR THE
DYSFUNCTION AND THEY SHOULD BE
RESPECTIVE OF ARRHYTHMIA AND
THIS IS CLASS 1 FOR SURGERY
BASED ON THE FUNCTION.
SO THE ASSOCIATION OF LV
FUNCTION AND ARRHYTHMIA IS AN
IMPORTANT POINT TO TAKE INTO
ACCOUNT HERE.
>> I LOOKED THROUGH A DOZEN
VIDEOS LAST NIGHT AND WASN'T
PAYING ATTENTION TO EJECTION
FRACTION.
SOME PATIENTS WE'RE INTERESTED
IN TRIGGER POINTS AND NEAR
TRIGGER POINTS THAT'S THE
DIFFERENCE IN CLASS 2A WHETHER
IT'S 70 OR 61.
IT'S MORE NUANCED THAN THAT BUT
I THINK THERE WAS AN EJECTION
FRACTION OF 70%.
>> AND SYSTOLIC DIMENSION WHICH
QUALIFIES--
>> I'LL GO BACK AND LOOK AT THAT
BUT WE HAVE CLINICALLY I HAVEN'T
REALLY TIED THOSE DOTS TOGETHER
BECAUSE MANY PATIENTS AT LEAST
THOSE WE LOOKED AT HAD NORMAL
EJECTION FRACTIONS.
>> THERE'S CASES WHERE THERE WAS
LV DYSFUNCTION AND HIGH PVC
BURDEN AND THE FUNCTION
NORMALIZES AND NOW LEFT WITH
NORMAL DIMENSIONS AND NOP VC.
THEY PROBABLY HAVE AN INDUCED
CARDIO MYOPATHY ON TOP OF IT.
>> THAT WOULD BE GOOD TO HAVE
NUMBERS.
THAT'S INTERESTING.
WE HAVEN'T SEEN TONS OF THOSE
BUT
>> IL -- THEY'LL CALL US TO
REASSESS SOMETIMES THEY OFFER
ABLATION AND VICE VERSA.
>> WHAT WOULD BE INTERESTING IS
TO SEPARATE AND I SEE YOU'VE
BEEN FUNDED TO SEPARATE THE
EFFECT OF THE CLASSICAL FORM OF
LV DYSFUNCTION IN MITRAL VALVE
DISEASE AND THE PEOPLE WHO DO
NOT HAVE THE SCIENCE MAY HAVE
FIBROSIS AND MAY HAVE
ARRHYTHMIA'S AND THE FACTORS ARE
IN A COMPLEX WAY.
>> NOT JUST FUNCTION TO SEPARATE
THE ROLE OF PROLAPSE AND
REGURGITATION IN THE ABSENCE OF
PERCEIVABLE DYSFUNCTION.
BECAUSE THE MAJORITY ARE BEING
REFERRED BY OF WITH NORMAL
PRESENTATION AND NO SYMPTOMS.
>> THANK YOU FOR THE
PRESENTATION AND THE DISCUSSION.
I'M AFRAID WE NEED TO MOVE ALONG
AT THIS POINT.
THERE'LL BE AN OPPORTUNITY FOR
MORE DISCUSSION AT THE END OF
THE SESSION.
DR. ELMARIAH ARE YOU READY TO
GO?
>> YES, I THINK SO.
>> THANK YOU.
>> IT'S A PLEASURE TO HAVE THE
OPPORTUNITY TO SPEAK TO EVERYONE
TODAY.
I WAS GOING TO SHIFT GEARS A
LITTLE BIT.
WE'VE SEEN THE SUPERB IMPACT AND
OUTCOMES THAT SURGERY CAN OFFER
I WANT TO HIGHLIGHT SOMETHING
THAT DID NOT COME UP IN THE LAST
MEETING THE TREATMENT OF MITRAL
REGURGITATION AND THE IMPACT OF
THAT.
DEF
I WANT TO LOOK AT THE ADVERSE
IMPACT OF PATIENTS THAT DON'T
RECEIVE THE THERAPIES.
THERE'S ROBUST DISPARITIES IN
THE MANNER IN WHICH WE TREAT THE
PATIENTS AND TO HIGHLIGHT THOSE
AND THEN TO DISCUSS POTENTIAL
MITIGATION STRATEGY TO OPTIMIZE
MANAGEMENT OF DMR.
SO FIRST SOME HISTORICAL AND
OLDER DATA.
DR. SERRANO HAS BEEN
INSTRUMENTAL IN THE EARLY STAGES
OF DISCOVERY IN ESTABLISHING THE
CLINICAL IMPLICATIONS OF MITRAL
REGURGITATION AND ONE OF THE
FIRST STUDIES IN THE NEW ENGLAND
JOURNAL WE SEE PATIENTS WITH
SEVERE MITRAL REGURGITATION DO
HAVE DIMINISHED SURVIVAL AND
MUCH OF THIS REDUCTION IN
SURVIVAL IMPACTS SPECIFICALLY
THE PATIENTS THAT HAVE CLASS III
OR IV HEART FAILURE OR REDUCED
INJECTION FRACTION AND THERE'S
OTHER IMPLICATIONS AS WELL SUCH
AS INCREASING RATES OF HEART
FAILURE AS WELL AS ATRIAL
FIBRILLATION OVER TIME WHEN THE
PATIENTS ARE NOT TREATED
PROPERLY.
AND WE ALSO KNOW SURGERY WORKS.
AND THERE ARE MULTIPLE STUDIES
THAT DEMONSTRATE THAT SURGERY
CAN REDUCE MORTALITY AND REDUCE
CARDIOVASCULAR DEATHS IN
PARTICULAR AND THAT IS DESPITE
THE ASSOCIATED RISKS OF
UNDERGOING CARDIAC SURGERY.
HEART FAILURE IS ALSO DIMINISHED
AS IS ATRIAL TEE FIBRIL AND
REPEATED INVESTIGATORS
HIGHLIGHTED THE FACT IF
INTERVENTION OCCURS AT AN EARLY
STAGE BEFORE DYSFUNCTION
DEVELOPS MITRAL VALVE REPAIR CAN
RESTORE NORMAL LIFE EXPECTANCY
AND AS DR. ADAMS SHOWED RESTORE
NORMAL ANATOMY.
SO THE AMERICAN HEART
ASSOCIATION AND AMERICAN COLLEGE
OF CARDIOLOGY PUT TOGETHER THE
SYMPTOMATIC PATIENTS WITH SEVERE
PRIMARY REGURGITATION OR THOSE
ASYMPTOMATIC BUT HAVE ELEMENTS
OF LEFT VENTRICULAR DYSFUNCTION
AS DELTATION OF THE VENTRICLE.
THE REPAIR IS STRONGLY
RECOMMENDED OVER REPLACE MANY
A
AND LIKELIHOOD OF OBTAINING
EFFECTIVE REPAIR AND IN PATIENTS
WHO ARE HIGH RISK OR AT EXTREME
RISK FOR SURGICAL INTERVENTION
TRANS CATHETER EDGE TO EDGE
REPAIR IS RECOMMENDED.
WE HAVE EFFECTIVE THERAPIES AND
PROLONG LIFE AND REDUCE
MORBIDITY WITH THE LESION AND
IT'S SURPRISING AND SOMEWHAT
DISAPPOINTING UNFORTUNATELY
DESPITE THE WIDESPREAD
AVAILABILITY OF THE THERAPIES
WE'RE NOTE AS A MEDICAL
COMMUNITY DOING A GOOD JOB IN
TREATING THE PATIENTS SO HERE
I'M SHOWING DATA FROM HOMESTEAD
COUNTY CLOSE TO THE MAYO CLINIC
THAT IDENTIFIED 1500 PATIENTS
WITH MODERATE OR SEVERE MITRAL
REGURGITATION AND WHAT THEY
FOUND OVER MEDIAN FOLLOW-UP OF
ALMOST FIVE YEARS ONLY 25% OF
PATIENTS SO ONE IN FOUR PATIENTS
WITH AN INDICATION FOR SURGERY
ACTUALLY UNDERWENT SURGERY.
AND THAT OF COURSE WAS
ASSOCIATED WITH SIGNIFICANT THE
PATIENTS THAT DID NOT GET
TREATED HAD A ROBUSTLY EXCESSIVE
MORTALITY RATE NEARLY DOUBLE THE
RATE OF MORTALITY AS CAN BE SEEN
IN THE TIME TO EVENT CURVE.
AND IT WAS ALSO CLEAR THERE WERE
DISPARITIES IN DELIVERING
EFFECTIVE MITRAL VALVE
INTERVENTIONS WITH MEN TWICE AS
LIKELY AS WOMEN WITH AN
INDICATION TO RECEIVE AN
INTERVENTION.
UNFORTUNATELY, WHEN ONE DOES NOT
RECEIVE MITRAL VALVE SURGERY THE
FIVE YEAR MORTALITY WAS ALMOST
40% AND NEARLY 50% OF THESE
PATIENTS ACTUALLY EXPERIENCED
HEART FAILURE.
THIS IS NOT A PROBLEM UNIQUE TO
THE UNITED STATES.
I'M SHOWING A SIMILAR STUDY THAT
CAME OUT OF FRANCE.
IT'S A NATIONWIDE STUDY THAT
INCLUDED OVER 100,000 PATIENTS
THAT WERE ADMITTED WITH MITRAL
REGURGITATION AND 8% UNDERWENT
SURGERY FOR THE MITRAL VALVE
LESION IN THE FIRST YEAR, THAT
IS 1 IN 12.
OF THOSE UNDERGOING SURGERY LESS
THAN 40% WERE WOMEN AND OVER ALL
ONLY 5.7% OF WOMEN ACTUALLY
UNDERWENT THE MITRAL VALVE
INTERVENTION COMPARED WITH 10.7%
OF MEN.
NEARLY TWICE THE RATE OF
INTERVENTION IN MEN THAN IN
WOMEN.
THE OTHER THING THAT IS QUITE
INTERESTING IS WHEN YOU LOOK AT
OBSERVED VERSUS PREDICTIVE
MORTALITY RATES THERE IS SOME
DEGREE OF EFFECT MODIFICATION
SUCH THE OBSERVED IS FAR HIGHER,
NEARLY TENFOLD AND IN MEN IT'S
FIVEFOLD INCREASE IN MORTALITY
IN MR WHEN IT'S TREATED.
UNFORTUNATELY, THIS PROBLEM I'M
HIGHLIGHTING AND THE DISPARITIES
AND TREATMENT IS NOT SPECIFIC TO
SURGERY.
IT SEEMS TO BE PREVALENT ALSO IN
THE TRANS CATHETER SPACE AND TO
ENCOMPASS OPTIMAL MANAGEMENT OF
VALVE DISEASE IN GENERAL.
THIS IS A STUDY OUT OF YALE
INCLUDING 10 OF THEIR DIFFERENT
IN-PATIENT INSTITUTIONS AS WELL
AS NEARLY 40 OUT PATIENT
INSTITUTIONS WITH THOSE WITH
PRIMARY REGURGITATION AND CLASS
1 AND GENDER DISPARITIES WERE
QUITE PREVALENT IN ALL THE
METRICS MEASURED.
SO ROBUST DIFFERENCE IN REGARDS
TO WHETHER THE PATIENT UNDERWENT
AN EVALUATION AND THE RATES OF
TRANS CATHETER REPAIR WERE
HIGHER IN MEN THAN WOMEN AND
WHILE NOT STATISTICALLY
SIGNIFICANT THERE'S A ROBUST
DIFFERENCE IN HOW LONG IT TOOK
TO GET THE PATIENTS TO TREATMENT
AS WELL WITH DAYS TO
INTERVENTION MARKEDLY HIGHER IN
PATIENTS AND WOMEN THAN IN MEN
AND A TREND OR A STRONG
STATISTICALLY SIGNIFICANT
DIFFERENCE IN SURVIVAL RATES
DEPENDING ON WHETHER YOU ARE A
MAN OR WOMAN WITH MORE FAVORABLE
OUTCOMES IN MEN.
PRESUMABLY RELATING TO THE FACT
THE PATIENTS RECEIVED
INTERVENTION.
NOW, NOTICE TIER SPACE BEYOND
GENDER DISPARITIES THERE'S ALSO
ETHNIC AND RACIAL DISPARITIES.
HERE I'M SHOWING DATA FROM THE
SDS ACC REGISTRY DEMONSTRATING
82% OF PATIENTS WHO UNDER GO
EDGE TO EDGE REPAIR ARE WHITE
CAUCASIAN PATIENTS.
THERE'S BEEN A SLIGHT UPTICK
OVER THE YEARS IN PROPORTION OF
BLACK PATIENTS WHO RECEIVE THE
THERAPIES AND OTHER RACIAL
BACKGROUND THAT RECEIVE THE
THERAPIES BUT STILL DISCORDANT
FROM THE ETHNIC AND RACIAL MAKE
UP OF THE UNITED STATES.
GEOGRAPHICALLY THERE'S ALSO BIS
PATRIOTS IN THE AVAILABILITY OF
THE ADVANCES THERAPIES AND
MITRAL EDGE TO EDGE REPAIR AND
ACROSS THE UNITED STATES THERE'S
SEVERAL STATES THAT DON'T HAVE
ANY SITES OR HAVE ONE OR TWO
MTEER SIGHT DIFFERENT FROM THE
INSTITUTIONS ABLE TO OFFER THE
THERAPIES ALONG THE COAST AREAS
WHERE THERE'S USUALLY A HIGH
DEGREE OF FINANCIAL -- LESS
DISADVANTAGED POPULATIONS.
SOCIO ECONOMIC DISPARITIES ARE
CLEARLY PREVALENT IN RECEIPT OF
CARE OF DEGENERATIVE MITRAL
VALVE AND THE IMPACT OF VALVE
REPAIR IN DATA FROM CMS
ADMINISTRATIVE DATABASE SPANNING
2012 TO 2019.
WE FIND PATIENTS COMING FROM
DISTRESSED COMMUNITIES HAVE
HIGHER COMORBIDITY AND MORE
FREQUENT HEART FAILURE AND
UNDERWENT REPAIR AT LOWER VOLUME
CENTERS.
NOT CARED FOR BY THE SAME LEVEL
OF EXPERTISE DR. ADAMS JUST
HIGHLIGHTED ELOQUENTLY.
THE PATIENTS ALSO HAVE TO TRAVEL
MORE THAN TWICE THE DISTANCE TO
RECEIVE THE CARE THEY NEED AND
DESPITE THAT EVEN AFTER
RECEIVING THERAPY AFTER
RECEIVING REPAIR ARE STILL LEFT
WITH INCREASED RATES OF
MORTALITY AND INCREASED RATES OF
HEART FAILURE SO BEYOND PRO
PROVIDING THE MITRAL VALVE
REPAIR THERE'S OTHER ELEMENTS
THAT LEAD TO ADVERSE CLINICAL
OUTCOMES.
THE KEY TAKEAWAY IS THOSE WITH
REPAIR A THIRD WILL TIE AND FIVE
WILL DEVELOP HEART FAILURE AND
THERE'S SIGNIFICANT DISPARITIES
IN CARE WITH GENDER CLEARLY
IMPACTING THE RATES OF TREATMENT
WITH WOMEN BEING NEARLY LAX AS
LIKELY TO UNDER GO REPAIR AND
BEING LESS LIKELY TO RECEIVE A
MULTIDISCIPLINARY HEART TEAM
EVALUATION AND HAVING LONGER
TIME TO TREATMENT AS WELL AS
WORSE OUTCOMES AFTER REPAIR WHEN
IT IS PERFORMED.
AND ETHNIC OUTCOMES FOR MITRAL
REGURGITATION.
SO THE QUESTION BECOMES IS THERE
SOMETHING WE CAN TO ALLEVIATE
THE CHALLENGES AND MITIGATE THE
DISPARITY EXIST IN THE
MANAGEMENT OF DMR?
SO SO I THINK WE HAVE TO
CONSIDER THE CONTINUUM OF CARE
FOR MITRAL REGURGITATION AND I
ARGUE IT'S TRUE FOR ALL FORMS OF
HEART DISEASE AND SHOWING DATA
FROM AORTIC STENOSIS AND
INCREASING TREATMENT RATES THERE
AND THINKING ABOUT THE FACT THAT
DISEASE AWARENESS AND PATIENT'S
BELIEFS IMPACT RATES OF UNDER
TREATMENT AND THERE'S CLEARLY
CHALLENGES IN DETECTION AND
DIAGNOSIS AND RECOGNITION AND
INTERPRETATION OF NON-EXPERT
SITES SUCH AS THOSE REPRESENTED
ON THE CALL AND THE STEPS TAKEN
TO REFER AND RECEIVE TREATMENT
DEPEND ON PHYSICIAN BELIEF AND
BIASES AND BARRIERS AND THE
DELIVERY OF HEALTH CARE ACROSS
SYMPTOMS AND MANY RECEIVING THE
MAJORITY OF THEIR MEDICAL CARE
ON THE IN PATIENT SETTING.
SO WHEN SOMETHING LIKE MITRAL
REGURGITATION IS IDENTIFIED
WHILE THAT PATIENT IS ADMITTED,
THERE IS NOT THE APPROPRIATE
TRANSITION TO CARE ONCE THEY ARE
ARE DISCHARGED.
THOSE PATIENTS PRIMARY CARE
PROVIDERS MAY NOT KNOW WHAT
HAPPENED IN THE IN PATIENT
SETTING AND MAY NOT HAVE ACCESS
TO THE SPECIALTY CARE NEEDED TO
FOLLOW-UP AND EXECUTE THE
REFERRAL TO THE APPROPRIATE
SPECIALTIES.
THE CONVENED A PANEL RECOGNIZING
THE FACTS ARE BEING UNDER TREAT
ED AND THEY FELT IT WAS
ACTIONABLE AND PAID PERFORMANCE
PROGRAMS AND MITRAL
REGURGITATION MADE UP SOME OF
THE MEASURES AND ADULTS FOR
CHRONIC OR SEVERE MITRAL
REGURGITATION AND LOOK AT AND
EVALUATE THE PERCENTAGE OF
PATIENTS WITH ECHO WITHIN A 12
MONTH PERIOD HIGHLIGHTING THE
NEED FOR SURVEILLANCE AND
DIAGNOSIS AND SECONDLY A METRIC
THAT FOCUSES ON THE PERCENTAGE
OF EITHER SYMPTOMATIC PATIENTS
OR ASYMPTOMATIC PATIENTS WITH
REDUCED INJECTION FRACTION THAT
UNDER GO MITRAL REGURGITATION
WITHIN THREE MONTHS OF
DIAGNOSIS.
THE RATES OF TREATMENT I SHOWED
BEFORE WERE INDICATIVE OF SEVERE
UNDER TREATMENT OUT TO A YEAR
AND LOW RATES OF TREATMENT UP TO
FIVE YEARS IN SOME STUDIES.
HERE THE METRICS ARE BEING
PROPOSED TO HOLD SITES
ACCOUNTABLE TO TREAT PATIENTS
WITHIN A THREE-MONTH PERIOD.
UNFORTUNATELY THE CONCERN FOR
UNDER TREATMENT IS NOT SPECIFIC
TO MITRAL REGURGITATION AND FOR
STENOSIS AND HOPEFULLY WE CAN
TAKE TIPS FROM THE INITIATIVE
AND PATIENTS WITH A CLASS 1
INDICATION ARE SIGNIFICANTLY
UNDER TREATED PERHAPS NOT TO THE
RATE SEEN IN MITRAL VALVE
DISEASE BUT OVER ALL ONLY HALF
OF PATIENTS WITH AORTIC STENOSIS
TREATED WITHIN THE FIRST YEAR
AND ASSOCIATED WITH
SIGNIFICANTLY IMPROVED CLINICAL
OUTCOMES WITH 72% LOWER ADJUSTED
HAZARD FOR MORTALITY IN SOME OF
THE HIGH RISK GROUPS SUCH AS
THOSE WITH HIGH GRADIENT AND LOW
EJECTION FRACTION AND DESPITE
THE ROBUST IMPACT ON SURVIVAL,
ONLY HALF PATIENTS ARE GETTING
TREATED.
THEY LAUNCHED THE TARGET AORTIC
STENOSIS INITIATIVE THAT SEEKS
TO IDENTIFY MEASURE AND REPORT
ON THE PROCESSES THAT OCCUR
AFTER THE ECHOCARDIOGRAPHIC
DIAGNOSIS AND ATTENTION TO
MITIGATING THE ETHNIC AND RACIAL
DISPARITIES THAT EXIST IN
MANAGING THESE PATIENTS.
THIS PROGRAM SO FAR HAS OVER 40
HOSPITALS TAKING PART, OVER
6,000 PATIENT RECORDS ENTERED
AND 21,000 ENCOUNTERS AND THE
GOAL IS FOR DOUBLING THE SITES
OF THE COMING YEAR AND YOU SEE
THE LIST OF CLINICAL METRICS
BEING UTILIZED WITHIN THE
INITIATIVE.
AND THE AMERICAN ASSOCIATION
RECEIVED A GRANT AND THERE'S
OTHER PARTNERSHIPS WITH
PROFESSIONAL SOCIETIES TO
COLLABORATE AND DELIVER THE M
METRICS TO SUPPORT THE
INITIATIVE.
AND WE SEE AND CENTERS ARE BEING
HEAD ACCOUNTABLE FOR WHAT IS INE
ECHO REPORT.
THERE'S THE AIM TO ENSURE
PATIENTS WITH AORTIC STENOSIS
WHEN THEY HAVE ECHOS THERE'S A
GRADIENT REPORTED AND VERY CLEAR
RECOMMENDATION IN THE ECHO OF
THE SEVERITY OF THE AORTIC
STENOSIS AND HIGHLIGHTING THE
NEED FOR FURTHER REFERRAL AND
THE KEY METRIC IS TIMELY
TREATMENT OF AORTIC STENOSIS
WITHIN 90 DAYS AND TIMELY
DIAGNOSIS.
THIS REQUIRES PATIENT TO SEE
PATIENTS WITHIN 30 DAYS A
DIAGNOSTIC ECHO AND EVALUATE
THEIR SYMPTOM STATUS AND
CANDIDACY FOR INTERVENTION.
THE INAUGURAL AWARDING OF THE
HONOR ROLE BASED ON ACHIEVEMENT
OF 70% METRIC OF TREATMENT
WITHIN 90 DAYS OF PATIENTS WITH
A CLASS 1 INDICATION.
FOR 2025, THEY ARE INCREASING
THE THRESHOLD TO ENTER THE HONOR
ROLE TO 75% OF PATIENTS AND
FWRAERT -- THAN 50% BEING
DETERMINED TO MEET CLASS 1
GUIDELINE PRESENTATION.
THE HONOR ROLL WILL BE
PUBLICALLY REPORTED.
THERE ARE BY THE U.S. NEWS AND
WORLD REPORT AND I DO ANTICIPATE
ULTIMATELY WE'LL CONTRIBUTE TO
HOSPITAL RANKINGS.
THERE'S ELECTRONIC HEALTH RECORD
NUDGES TO FACILITATE TREATMENT
AND THIS IS A STUDY WE'RE
RUNNING FOR AORTIC STENOSIS IN
WHICH THERE ARE ELECTRONIC
HEALTH RECORD MEMOS ESSENTIALLY
SENT IN IN BASKET TO ENSURE THE
PROVIDERS THAT ORDERED THE ECHO
UNDERSTAND THE GUIDELINES AND
HAVE APPRECIATION OF THE
SIGNIFICANT FINDING ON THE
ECHOCARDIOGRAM.
THERE'S REFERRAL PATHWAYS WE'RE
WORKING TO BUILD WITHIN EPIC TO
ENSURE PATIENTS ARE REFERRED AND
NOBODY FALLS THROUGH THE CRACKS.
THIS IS DONE IN A SYSTEMATIC
FASHION.
I'VE LISTED HERE POTENTIAL
SOLUTIONS TO THE UNDER TREATMENT
OF MITRAL REGURGITATION BUT FOR
THE SAKE OF TIME I'LL STOP THERE
AND HAPPY IT TAKE QUESTIONS.
>> THANK YOU.
DOES ANYONE HAVE A BRIEF
QUESTION OR COMMENT?
>> BRIEF QUESTION FOR YOU.
THANKS, I ENJOYED THAT AND
LEARNED A LOT.
THE PAPER YOU SHOWED ABOUT
HOLDING SITES ACCOUNTABLE WHAT
IS THAT?
THREE MONTHS FROM DIAGNOSIS TO
INTERVENTION WHICH I PERSONALLY
THINK IT'S TOO EGRESSION IF YOU
TWO UP A SECOND FLIGHT OF STAIRS
I'M NOT SURE YOU NEED MITRAL
SURGERY WITHIN THREE MONTHS.
YOU GO OFF THE ACTIVE
SURVEILLANCE AND TALK ABOUT AN
ELECTIVE OPERATION BUT I
TYPICALLY FOLLOW THE GUIDELINES
AND GIVE PATIENT SIX MONTH
WINDOWS BECAUSE MANY THEY FIND
OUT IN SEPTEMBER THEY HAVE
MITRAL VALVE DISEASE AND THE
PATIENT DOES TOO IF HE DOESN'T
DROP OUT OF THE COLLEGE PROGRAM
FOR THREE MONTHS?
>> THAT'S A POINT.
A LOT OF THIS STOTT AND AORTIC
STENOSIS HAS GOTTEN MORE
ATTENTION.
>> THERE'S A RISK OF SUDDEN
DEATH.
>> THE LONGER YOU WAIT THE MORE
PATIENTS CAN DIE.
THE DATA IS NOT AS ROBUST FOR
MITRAL REGURGITATION I'LL ARGUE
BUT CLEARLY PATIENTS CAN TEE
COMPENSATE AND DEVELOP HEART
FAILURE AND ATRIAL
DEFIBRILLATION AND THE EXPERT
PANEL DID SUGGEST TREATMENT IS
NECESSARY WITHIN 30 DAYS.
WHEN I SAY HOLDING SITES
ACCOUNTABLE WHAT IS BEING
PROPOSED IS THERE IS PUBLIC
REPORTING OF THE METRICS.
SO A PATIENT WOULD BE ABLE TO
LOOK IT UP AND WE'RE NOT THERE
YET AND I THINK WE'RE FURTHER
ALONG WITH AORTIC STENOSIS.
I WOULD ARGUE THERE'S A NEED
FORMUFOR
MULTI DISCIPLINARY SITES PUT
TOGETHER LITERATURE TO
UNDERSTAND HOW QUICKLY WE NEED
TO ACT.
>> I DON'T THINK THERE'S ANY
DOUBT PATIENTS WITH SEVERE
MITRAL REGURGITATION SHOULD BE
IN THE PROCESS OF IT TREATED BUT
I HAVE A LOT OF CONCERNS ABOUT
TRYING TO COMPARE MITRAL
REGURGITATION NOW WITH AORTIC
STENOSIS WHEN PATIENTS CALL HERE
THEY HAVE AORTIC STENOSIS AND
THE CARDIOLOGIST RISK AND IF ARE
WINDED NOW AND YOUR CARDIOLOGIST
HAS BEEN FOLLOWING YOU AND DID
ECHO AND YOU IT'S SEVERE MR AND
THREE MONTHS FROM THAT STORY TO
SURGERY IS EXTREMELY AGGRESSIVE
FOR PATIENTS WHO HAVE TO PLAN
THEIR LIFE AND DON'T WANT TO
MISS THINGS.
WE NEED SURGERY AND TALK TO YOUR
FAMILY, LOOK AT YOUR CALENDAR
AND FIGURE OUT THE BEST TIME TO
INVEST IN GETTING BETTER AND
DON'T MISS THINGS YOU DON'T WANT
TO MISS AND IF YOU HAVE TO WAIT
LONGER THAN SIX MONTHS YOU HAVE
TO COME BACK FOR A COMPLETE NEW
WORKUP.
I THINK WE HAVE TO BE CAREFUL
ABOUT TRYING TO COMPARE MITRAL
REGURGITATION WITH AORTIC
STENOSIS IN TERMS OF TIMING AND
INTERVENTION FOR PATIENTS THAT
MAY -- LIKE I SAID, YOUR
REJECTION FRACTION IS AT AND
ASSIST -- ASSIST -- ASYSTOLIC
AND THAT'S A LOT OF WOK TO TO
FOR SOMETHING I THINK WE'RE
LOVING THE WORK AND NEED THE
DISCUSSION.
>> I DON'T DISAGREE IT IS
AGGRESSIVE.
THAT WAS MY INITIAL IMPRESSION
AS WELL BUT YOU SEE ROBUST ROW
PROGRESSION.
>> I HOPE YOU USE THE SAME
OPPORTUNITY TO REINFORCE WE
SHOULD FOLLOW THE EVIDENCE AND
FOLLOW THE HAACC THREE
GUIDELINES IF YOU WANT US TO DO
SOMETHING IN THREE MONTHS LET'S
MAKE SURE IT'S THE RIGHT THING
AND LOW-RISK TEER IN TRIALS NOT
BECAUSE THE PATIENT DOESN'T WANT
TO HAVE THEIR CHEST CRACKED.
>> THANK YOU FOR THE TALK.
THE ISSUE IS WHEN WE LOOKED AT
UNDER TREATMENT WE DON'T
UNDERSTAND THE REASON FOR WHY IT
IS NOT DONE.
PEOPLE WHO WILL DO SOMETHING
GIVE A REASON AND THE PATIENT IS
SYMPTOMATIC BUT WHEN YOU HAVE
SOMETHING NOT DONE YOU FIND NO
REASON.
WE'LL SEE THE PATIENT IN THREE
MONTHS OR SIX MONTHS BUT THE
NOTE OF THE PHYSICIAN DOESN'T
SAY WHY THEY DIDN'T DO
SOMETHING.
I WOULD SAY RATHER THAN PUTTING
THE MANDATE IN PEOPLE, IF WE
COULD UNDERSTAND THE REASON FOR
DOING AND NOT DOING WOULD BE
PRELIMINARY TO ACTION BECAUSE IF
WE PUT A MANDATE, OH, YOU HAVE
TO DO SOMETHING IN THREE MONTHS
BUT THE PHYSICIANS ARE NOT
STUPID.
IS IT BECAUSE THEY IGNORE THE
ECHO?
WHAT IS HAPPENING IN HOLDER
SUBJECTS THEY DON'T WANT TO DO
SOMETHING AND HOW CAN WE
PALLIATE THAT BY HAVING A VALVE
CLINIC REVIEW OF THE PATIENT AND
WHEN WE LOOKED AT IT THE
PATIENTS ARE VERY CLOSE.
THEY COULD COME BUT NOT REFERRED
AND WHY.
IS IT BECAUSE THE WORD MODERATE
IS MENTIONED IN THE REPORT OF
ECHO?
IS IT -- WHAT IS THE REASON OF
THE -- AND IT'S NOT EXPRESSED
DIRECTLY.
SO IF WE COULD UNDERSTAND WHY
IT'S NOT DONE WE COULD PUT THE
APPROPRIATE MANDATE TO THE
HEALTH SYSTEM TO SAY OKAY, DO
THE RIGHT THING.
BUT NOW WE'RE IN THE DARK AND
THROWING MANDATES RIGHT AND LEFT
WITHOUT UNDERSTANDING WHAT IS --
WHERE SHOULD THE MANDATE BE
GIVEN, HOW SHOULD IT BE DONE TO
ADDRESS AN ELDERLY POPULATION
THAT IS AT RISK AND PHYSICIANS
ARE RISK AVERSE.
HOW DO WE DO THAT?
>> THERE IS SOME OF THAT AND
I'LL TRY TO BE BRIEF BUT THERE
IS SOME OF THE DATA ON THE
AORTIC STENOSIS SIDE WHERE WHEN
WE LOOK AT WHY PATIENTS AREN'T
TREATED, THERE ARE A MYRIAD OF
REASONS FOR EXAMPLE PHYSICIANS
IN A LARGE PROPORTION FELT IT'S
RELATED TO SOMETHING ELSE.
SOME DESPITE THE FACT FOR
EXAMPLE THERE WERE LOW GRADIENT
AORTIC STENOSIS THERE WAS
TENDENCY TO ASSUME A LOW
GRADIENT CORRESPOND WITH
MODERATE DISEASE AND THEREFORE
THEY CAN WAIT.
THERE WERE INSTANCES WHERE
SYMPTOMS WERE NOT FELT TO BE BAD
ENOUGH TO WARRANT CLINICAL
INTERVENTION THOUGH THERE'S NO
CLEAR THRESHOLD THAT SHOULD
GUIDE THAT DECISION MAKING.
SO SOME OF THE REASONS AT LAND
DID NOT SEEM TO MAKE INTUITIVE
SENSE.
THE LARGE MAJORITY OF THE
DECISIONS HOWEVER, WERE MADE
BEFORE THE PATIENT GOT TO
MULTI-DISCIPLINARY HEART VALVE
TEAM AND NOT EVALUATED AND
CONSIDERED BY THE EXPERTS IN
TREATING THE VALVE LESION AND
INSTEAD THE DECISION WAS MADE BY
THE PRIMARY CARE PROVIDER OR
SOMEBODY ELSE SOMETIMES THINKING
THEY WERE TOO SICK NOT
RECOGNIZING THEY EASILY COULD BE
TREATED FOR PERHAPS TRANS
CATHETER THERAPIES BECAUSE THEY
WERE ELDERLY AND I'LL SAY
THERE'S CLEAR IMPACTS FROM
SOCIAL DETERMINATES AND
FINANCIAL WELL BEING.
AS YOU MENTIONED EVEN IN CLOSE
PROXIMITY TO HIGHLY QUALIFIED
CENTERS AND SOME DATA FROM PENN
WHERE WEST PHILADELPHIA WHERE
PENN IS VERY ACCOMPLISHED
SURGICAL CENTER, VERY
ACCOMPLISHED INTERVENTIONAL
CENTER AND PEOPLE IN DIRECT
PROXIMITY TO THE HOSPITAL WERE
MOST LIKELY TO BE UNDER TREATED.
THOSE ARE PATIENTS WHO PERHAPS
DON'T HAVE THE ABILITY TO TAKE A
DAY OFF WORK.
THERE'S THINGS THAT CONTRIBUTE.
THE ATTEMPT AT PRESENTING THIS
IS A CALL TO ACTION TO PERFORM
THE TYPE OF ADVOCATING YOU'RE
HIGHLIGHTING AND ALLUDING TO.
>> OKAY.
THANK YOU VERY MUCH FOR THAT
DISCUSSION.
WE'RE GOING TO MOVE NOW TO THE
FINAL PRESENTATION FOR THIS
SESSION.
>> THANK YOU.
AS WE PULL THE SLIDES UP I'D
LIKE TO COMMENT ON THE
PERFORMANCE WILL MEASURES OF THE
DOCUMENT AND CLEARLY DESIGN TO
ADDRESS THE UNDER TREATMENT OF
THIS IMPORTANT PATIENT
POPULATION AND CLEARLY WE
INCLUDED RELEVANT EXCEPTIONS.
IT'S PERFECTLY POSSIBLE FOR
PHYSICIANS TO DOCUMENT THE
REASON FOR DELAYING TREATMENT
APPROPRIATELY BEYOND THREE
MONTHS AND THE LIST OF
EXCEPTIONS IS NUMEROUS AND CAN
INCLUDE PATIENT PREFERENCE OR
OTHER REASONS FOR NOT UNDERGOING
AN INTERVENTION.
SO IT'S I THINK AN IMPORTANT
STEP HOPEFULLY IN THE RIGHT
DIRECTION AND WILL BE UTILIZED
TO ADDRESS THE UNDER TREATMENT
OF DEGENERATIVE MITRAL VALVE
DISEASE.
I HAVE A LOT OF ANIMATION SO
I'LL JUST SAY NEXT FOR THE NEXT
SLIDE TO SAVE TIME SO, NEXT.
NO FINANCIAL DISCLOSURES.
I'LL TALK ABOUT GUIDELINES
VERSUS PRACTICE IN THE PRIMARY
TRIAL.
NEXT.
FIRST OF ALL WHEN TO REPAIR.
NEXT.
YOU HAVE A LADY IN THE OFFICE
WHO FEELS FINE AND PLAYS PICKLE
BALL EVERY DAY AND A LITTLE BIT
FATIGUED AND NO HISTORY OR RISK
FACTORS.
THIS IS HER ECHO.
SEE THE PT PROLAPSE AND
RELATIVELY STRAIGHTFORWARD
REPAIR.
YOU HAVE OPTIONS AND ONE IS TO
REPEAT ECHO IN THREE MONTHS.
AND MAY WANT TO REQUEST STREK
ECHO OR LOOKING FOR
RECOMMENDATIONS OR WHETHER TEER
IS APPROPRIATE.
AND I THINK YOUR APPETITE FOR
INTERVENING ON THESE PATIENTS
DEPENDS ON WHAT YOU THINK THE
RISK OF MORTALITY, SUDDEN DEATH,
HEART FAILURE AND STROKE IS IN
THE POPULATION OF ASYMPTOMATIC
PATIENTS.
WE'VE SEEN THE SLIDE A COUPLE
TIMES NOW.
THIS IS SURVIVAL FROM SEVERE
MITRAL REGURGITATION.
IT'S NOT GREAT.
THE PATIENTS ARE AT RISK OF
SUDDEN DEATH.
WE'VE SEEN THE SYMPTOMS AT THE
TIME OF MITRAL SURGERY AND THE
SURVIVAL OUTCOME.
THIS IS A STUDY OF MULTIPLE
CENTERS.
STRATIFIED BY WHERE PATIENTS
UNDER WENT SURGERY AT THE TIME
THEY ARE WENT CLASS 1
INDICATIONS OR WHETHER IT WAS
DELAYED THREE MONTHS AND THE
LOWEST SURVIVAL CURVE IS THE
THREE-MONTH DELAY.
THIS IS THE RATIONALE FOR
PATIENTS.
I'M GOING TO ASK YOU TO CLICK
THROUGH THE SLIDES ABOUT ONE
EVERY 10 SECONDS.
THE STRATIFICATION BY SURVIVAL
EF AND SURGERY SURVIVAL.
IN PATIENTS WITHOUT SYMPTOMS DO
WE WAIT FOR EJECTION FRACTION TO
TROP.
DEPENDS ON WHETHER YOU THINK
EJECTION FRACTION IS EFFECTIVE
IN MITRAL REGURGITATION AND THIS
IS A EXPERIMENT HERE YOU CAN
CALCULATE EJECTION FRACTION AND
THE STROKE VALUM DIVIDED BY 150.
THIS IS 67%.
JUST KEEP CLICKING.
AND THE ACUTE MITRAL
REGURGITATION AND EJECTION
FRACTION IS 140 DIVIDED BY 170.
THIS WOULD BE 82%.
AND THE PATIENT WITH CHRONIC MSH
AND ASYMPTOMATIC PATIENTS AND
EJECTION FRACTION CONTRACTION IS
79% SO HYPERNORMAL AS WE OFTEN
SEE PATIENTS WITH EXCELLENT
EJECTION FRACTION AND THE
PATIENT WITH MITRAL
REGURGITATION EJECTION FRACTION
85 TO 65 AND DILATED TO THE
VENTRICLE 60% AND WHY WE DON'T
WAIT FOR IT TO DROP BELOW 60%
AND IN CHRONIC MITRAL
REGURGITATION YOU'RE MISSING THE
BOAT.
AND IT'S MANAGED BY THE MR.
WE'RE LOOKING AT THE STRATIFIED
40 MILLIMETERS OVER SURGERY AND
CLASS I INCLUDES SYSTOLIC
GREATER THAN 40 MILLIMETERS AND
INCLUDES PROGRESS INCREASE IN
SIZE OF THE VENTRICLE FOR THE
PARAMETERS FROM THE HYPERTENSION
AND CLEARLY IDENTIFIES THE
REPLACEMENT FOR PROLAPSE IS
HARM.
AND THE AGE MATCH POPULATION
THAT DOESN'T RESTORE NORMAL LIFE
EXPECTANCY AND THE ORDINANCE OF
LOW RISK REPAIRS.
THAT'S WHAT IS BEING ACHIEVED
TODAY.
THIS IS STS DATA OUTCOMES
UNSELECTED ALL MITRAL VALVE
REPAIRS AT 4% MORTALITY.
THAT'S INCREDIBLE.
AND IN MOST OF THE SURGEONS AND
CENTERS WITH THE EIGHT YEAR TIME
FRAME THERE WAS NO MORTALITY.
THE VAST MAJORITY OF PATIENTS IN
THE U.S. ARE LOW RISK PATIENTS.
HOW TO REPAIR THE VALVE?
AGAIN IF YOU CLICK THROUGH THIS
ONE, THIS IS GIVING YOU A SENSE
OF THE SPECTRUM OF MITRAL VALVE
DISEASE.
THIS IS A PROLAPSE.
YOU SEE THE LEAFLETS ARE
EXTREMELY FLIMSY IT GIVES YOU A
SENSE THAT YOU'VE GOT
ESSENTIALLY A PROLAPSE AND THAT
IS VERY DIFFERENT.
WHAT YOU SEE HERE ON THE
FOLLOWING WHICH IS THE VIDEO WE
STARTED WITH.
AGAIN THE PROLAPSE AND LOOK AT
THE QUALITY OF THE LEAFLETS IN
THIS SURGICAL VIDEO.
YOU GET A SENSE THIS IS A
COMPLETELY DIFFERENT LOOKING
MORPHOLOGY OF THE VALVE.
IT'S PERFECTLY POSSIBLE TO
REPAIR THESE.
IT WOULD HAVE GIVEN YOU THE
RELIEF IS THINGEN -- THICKENED
AND CALCIFIED AND AND THIS IS A
VIDEO OF A LEAFLET REPAIR AND
GIVES A SENSE WHEN YOU SEE THE
VIDEOS TEER IS VERY GOOD AT
APPROXIMATING LEAFLETS BUT CAN'T
DEAL WITH THE PROLAPSE AND
SURGICAL REPAIR IT'S POSSIBLE TO
EFFECT THAT.
WE TALKED ABOUT RECOMMENDING
TEER.
WE DIDN'T TALK ABOUT EXAMINING
THE PATIENT AND FINDINGS LIKE
THIS HELP YOU UNDERSTAND THERE'S
A SPECTRUM OF FRAILTY AND
ABILITY TO TOLERATE SURGERY.
AND YOU CAN SEE THIS SCANS PAST
THE ANNULUS AN IF THEY WERE
ASYMPTOMATIC YOU'D GO DOWN THE
SURGICAL ROUTE EARLY.
IT SPEAKS TO THE POINT ABOUT
PERFORMANCE MEASURES.
NOT ALL PATIENTS WOULD GO TO THE
BASKET OF PROHIBITIVE RISK AND
HEART FAILURE AND IT'S CURRENTLY
THE CRITERIA FOR TEER AND
RANDOMIZED TRIAL OF 466 PATIENTS
AND FUNCTIONAL MR AND TEER AND
PROCEED KATE--PREDICATED ON SUR
AND MANY CLAIM IT'S FUNCTIONAL
AND DEGENERATIVE.
A QUARTER ARE LOW RISK OF
MORTALITY LESS THAN 2.5.
AND SOME HAVE MITRAL
REGURGITATION AND STENOSIS AND
EVEN MODERATE AORTIC STENOSIS OR
MITRAL REGURGITATION HAD WORSE
OUTCOMES IN ONE YEAR AND
MORTALITY IN ONE YEAR.
THE ABILITY TO RESTORE NORMAL
ANATOMY AND HUMAN DYNAMICS
SAFELY IS CRITICAL IN THE
PATIENTS.
WE LEARN FROM SURGICAL SERIES
HERE ARE FOUR WITH LONG-TERM
OUTCOMES AFTER SURGICAL REPAIR
AND THE FREEDOM FROM MR IS GOOD
GREATER THAN 95% EIGHT TO 10
YEARS WITH THE EXCEPTION OF ONE
SURGICAL EXPERIENCE BY THE GROUP
AND THAT'S THIS ONE AND THE
DIFFERENCE IN THIS WAS EDGE TO
EDGE REPAIR FORMED IN
DEGENERATIVE PATIENTS AND THAT
HAS OBVIOUS IMPLICATIONS FOR
EDGE TO EDGE REPAIR.
THIS IS ONE OF THE REASONS TIER
FAILS AND HERE'S A SECOND REASON
WHY TEER FAILS WITH THE RESIDUAL
PROLAPSE.
IT'S POSSIBLE TO REREPAIR THE
FAILED TEER.
IT'S NOT APPROPRIATE TO TELL
PATIENTS THEY ARE CAN GET A TEER
AND THEN REPAIR BECAUSE 95% OF
THE PATIENTS IN THE UNITED
STATES WILL END UP WITH A
REPLACEMENT.
THEY'RE TECHNICALLY DEMANDING
REPAIRS.
WHY THERE'S VARIABILITY IN
SURGICAL REPAIR ON THE LEFT IS
NEW YORK CENTER PROGRAM IN
DEGENERATIVE REPAIR IS DOWN TO
30% AND THE VARIABILITY IS
DRIVEN BY INDIVIDUAL ON ABILITY
TO REPAIR THE VALVE CONSISTENTLY
AND THE RED DOTS ARE INDEPENDENT
SURGEONS.
AND DURABILITY VARIES BY SURGEON
AND THE MITRAL VALVE MORE THAN
25 TIMES A YEAR AND 1% FAILURE
RATES COMPARED TO THREE TO FOUR
TIMES THAT OF LESS EXPERIENCED
SURGEONS.
AND ECHO WHICH WE RELY ON TO
GIVE US AN IDEA WHETHER A
PATIENT IS APPROPRIATE FOR
SURGERY IS NOT ENTIRELY RELIABLE
WITH DISCORDANT GRADING THAT CAN
CHANGE OUTCOMES AND THIS
REMARKABLE SERIES IS OVER 80% OF
PATIENTS WITH DISCORDANT GRADE
ANTHAD PROCEDURE CANCELED AND
SURGE I HAVE WAS REQUIRED WHICH
WOULD HAVE OTHERWISE BEEN
INDICATED AND HUGE VARIANT IN
ECHO AS WELL.
AND ESSENTIALLY WE'RE VERY
UNSURE WHETHER THIS KIND
TRANSLATES TO POORER SURVIVALS
AFTER TEER VERSUS SURGERY IN
TATE AND QUESTION BY A
RANDOMIZED TRIAL.
THE PRIMARY TRIAL IS WORTH A
MINUTE OR TWO TO TALK ABOUT.
AND THIS IS FOCUSSED ON HIGH
RISK PATIENTS ON THE INFERIORITY
END POINT AND PRIMARY WHICH IS
AN IMPORTANT NIH FUNDED
INITIATED TRIAL FOCUSSED ON ALL
COMERS OVER 60 WITH THE DESIGN.
THE REGURGITATION OF PATIENTS IS
60 YEARS AND ABOVE.
THE NEXT SLIDE IS RAN BY THE
NETWORK SPONSORED BY THE NIH AND
EFFECTIVENESS OF THE SAFETY OF
MITRAL REGURGITATION REPAIR BY
THE APPROACH AND ESSENTIALLY WE
ARE RECRUITING ALL PATIENTS WITH
REGENERATIVE MRH OVER 60 AND THE
PRIMARY ELIGIBILITY COMMUNITY
SHOULD GET A GOOD RESULT WITH
THERAPY.
AT LEAST THREE YEARS AND UP TO
SIX YEARS AT FOLLOW-UP IS
ALL-CAUSE MORTALITY.
ANY MITRAL VALVE INCLUDING
REPLACEMENT HEART FAILURE
ADJUDICATED BY A PRIMARY
COMMITTEE AND REGURGITATION AND
YOU HAVE TO BE ALIVE THREE TO
SIX YEAR WITH A MITRAL REPAIR
AND NO HEART FAILURE OR
HOSPITALIZATIONS AND TO THE
PRIMARY END POINT.
AND THE SEQUENTIAL TRIALS
THERE'S ALREADY THE DEGREE OF
EQUIPOISE AND TRIALS WOULD TAKE
OVER A DECADE TO PERFORM THE
DATA.
THE PATIENTS ARE ASKING ABOUT
NOW AND THE EXPERT TEER IS SAFER
AND ABLE OF BETTER RESULTS AND
THE TIME THE TRIALS STARTED AND
WE HAVE THE FUND BEING FROM THE
NIH TO DO THIS AND THAT'S
IMPORTANT FOR TWO REASONS.
ONE IT'S ALLOWED INVESTIGATORS
TO COME UP WITH THE APPROPRIATE
TRIAL AND THERE'S A PHENOMENAL
SUPPORT WE'VE HAD AS A RESULT OF
SUPPORTING TRANSLATIONAL
RESEARCH TO THE UNRAEANSWERED
QUESTIONS AND THE FIRST IS
SURGERY AND UNDERSTAND SUDDEN
DEATH WITH PATHOPHYSIOLOGY THAT
CONTRIBUTE TO THE PATIENT
POPULATION.
PERFORMING MONITORING BEFORE AND
AFTER REPAIR TO LOOK AT MITRAL
REGURGITATION AND AORTIC
STENOSIS AND COMPARING SURGERY.
WE'LL ALSO CREATE DIGITAL TWINS
BY MECHANICAL SIMULATIONS TO
EXAMINE AND RISK STRATIFY MORE.
AND TAKING BIOPSIES AT THE TIME
OF SURGERY TO LOOK AT FIBROSIS
AND CONDUCTING TRANSCRIPTIONAL
ANALYSIS ON MITRAL CHORDAL AND
LOOK AT GENE SIGNATURES AND
PHENOTYPES AND WE'RE GRATEFUL TO
THE CAROL FOR SUPPORTING AND
ALLOWS US TO TAKE LESSONS FROM
INDUSTRY RUN TRIALS SUCH AS THIS
ONE PUBLISHED TWO WEEKS AGO IN
THE NEW ENGLAND JOURNAL OF
MEDICINE AND I THINK IN THE
ACCOMPANYING TRIAL SHOWS THE
SUPPORT OF THE NHLBI IN THE
SPACE.
IF WE'RE GOING TO ANSWER THE
QUESTIONS WITH NEED THESE KINDS
OF TRIALS.
THE PRIMARY TRIAL IS ENROLLING
IN 65 SITES AND COUNTRIES IF.
WE CONTINUE TO ENROLL THE TRIAL
WILL BE COMPLETED BY DECEMBER OF
NEXT YEAR.
THANK YOU VERY MUCH AND I'M
HAPPY TO TAKE ANY QUESTIONS.
>> THANK YOU.
WE HAVE A COUPLE MINUTES FOR
QUESTIONS IF ANYONE HAS A BRIEF
QUESTION OR COMMENT.
THANK YOU AGAIN.
>> IF I CAN ASK A QUICK
QUESTION.
THE MECHANICS, JOE, THAT'S
FASCINATING.
TELL ME MORE ABOUT THE SPECTRAL
AND IMAGING TRYING TO LOOK AT
POST REPAIR FUNCTION BETWEEN
TEER AND MITRAL VALVE REPAIR.
>> WE'RE LOOKING PRE AND POST.
IN ABOUT 200 PATIENTS IN THE
TRIAL WILL GET HAVE BEEN GETTING
MIRs IN ADDITION TO THE STANDARD
WORKUP PRE AND POST INTERVENTION
AND THE GROUP ARE INTERESTED IN
TRYING TO IDENTIFY EARLY MARKERS
OF FIBROSIS, PROGRESSION OF
FIBROSIS AND TO TRY AND GET A
BETTER READ ON PRE AND POST
MITRAL REGURGITATION BECAUSE
IT'S DIFFICULT TO QUANTIFY AND
PARTICULARLY AFTER TEER.
WE WANT TO ADDRESS THE PRACTICE
VARIATIONS WHERE YOU GET
DISCORDANT ECHOS AND SEE IF CMR
CAN GIVE US A BETTER IDEA AND
CORRELATE THAT WITH THE
PREVALENCE OF VENTRICULAR
ARRHYTHMIA AND ALL THE PATIENTS
ARE MONITORING IN TERMS OF THE
IDEA AND HOPEFULLY WE'LL GET A
BETTER SENSE OF WHAT
NON-INVASIVE IMAGING CAN TELL US
ABOUT WHICH PATIENTS ARE AT RISK
AND WE COULD BE MORE TARGETED.
SOME PATIENTS ARE HIGHER RISK
AND SOME I SUSPECT TEER DOESN'T
OFFER THE KIND OF MECHANICAL
IMPROVEMENTS SURGERY IS IT AND
WE'LL SEE MORE FIBROSIS AND
ARRHYTHMIA.
>> IT MAY TAKE TIME BUT I AGREE.
I'M GLAD YOU'RE DOING THAT
BECAUSE I THINK WE'RE GOING TO
LEARN SOMETHING THAT'S
IMPORTANT.
THE OTHER QUESTION REAL QUICK,
JOE, YOUR PAPER LOOKING AT THE
REGISTRY.
MY THEORY AND THE QUICK COMMENT
I WANT IS MORE SITES CLULGD OURS
I THINK THEY UNDER REPORT
OPPOSED TO OVER REPORT.
I DON'T BELIEVE -- I THINK WHILE
IT'S REPORTED MY GUESS IS FOR
MANY PATIENTS IT'S WORSE.
AND MITRAL STENOSIS AND I DON'T
THINK WE'RE OVER READING THEM I
THINK PEOPLE ARE UNDER READING
THEM.
ISN'T IT STRANGE HOW A SURGEON
ALWAYS WANTS TO SHOW YOU THE
WORSE VIEW AN INTERVENTIONIST
WANTS TO SEE THE BEST VIEW.
>> I SAW A LOT OF TIER CASES AND
I ALWAYS NOTICE I GET ONE QUICK
VIEW AND SOMEONE TELLS ME ABOUT
A V WAVE.
YOU DO A SURGICAL REPAIR I
GUARANTEE THEY'RE CALLING YOU
BACK FOR EVERY CORPUSCLE AND
WILL BE INTERESTING TO SEE FROM
THE TRIAL.
THANK YOU FOR THE PRESENTATION.
>> SORRY, I'M DRIVING HOME TO DO
MY PRESENTATION FROM HOME FROM
THE INTERNET CONNECTION IS
BETTER.
BRILLIANT PRESENTATION AS
ALWAYS.
I WANT TO MAKE ONE COMMENT ABOUT
THE PRIMARY TRIAL.
I DON'T THINK WE SHOULD THROW
THE BABY OUT WITH THE WATER AND
SAY ALL INDUSTRY SPONSORED
TRIALS ARE BAD.
THE INDUSTRY SPONSORED TRIALS
ARE DONE FOR A NEW INDICATION.
AND WE'VE LEARNED A TREMENDOUS
AMOUNT FOR EXAMPLE FROM THE
INDUSTRY SPONSORED TRIALS.
IF THERE IS NO POTENTIAL
INDICATION OR IF THE INDUSTRY
ALREADY HAS A DE FACTO
INDICATION THEY'RE NOT GOING TO
DO THE TRIAL.
THAT'S ONE OF THE THINGS I WAS
ARGUING FOR STRONGLY AT THE
INITIAL STAGES WHEN YOU FIRST
PROPOSED THE TRIAL AND AS YOU
REMEMBER THERE WERE MITRAL VALVE
SURGEONS IN AMERICA HESITANT TO
START THE TRIAL.
IS THAT THE THING THAT SEPARATES
THE TYPES OF TRIALS SUPPORTED
FROM THE NIH FROM THE INDUSTRY
TRIALS IF A GOOD STRONG CLINICAL
TRIALIST CALLS THE MVP OF A
COMPANY AND SEE A NEW INDICATION
YOU HAVE A PROTOCOL WRITTEN THE
NEXT DAY AND ETHICS APPROVAL
SHORTLY THEREAFTER.
WHEREAS THE STUFF WE DO INDUSTRY
IS NOT INTERESTED IN IS LONG
DIFFICULT WORK SUPPORTED, THANK
GOODNESS BY BODIES LIKE THE NIH
BUT WE HAVE A THREE-YEAR THEY
ARE TO CATCH UP.
IT WAS SO IMPORTANT TO PUSH WITH
THE TRIAL, THE PRIMARY TRIAL
INSTEAD OF ALWAYS TRYING TO
CATCH UP WHEN SUCH AU TRIAL MAY
NOT BE MORE RELEVANT OR NOT DONE
BECAUSE THE INDUSTRY HAS THEIR
DE FACTO INDICATION WITH LOW
RISK MR PATIENTS THEY PLAY START
TO FROM THE REPAIR MR RESULTS
ONCE THE APPROVAL COMES YOU GET
THE INDICATION CREEP LEADING TO
THE MORE RISK PATIENTS.
THEREFORE JUST WANTED TO
CONGRATULATE YOU ONCE AGAIN OR
SPEARHEADING THIS AT FIRST
CONTROVERSIAL BUT NOW I THINK
ACCEPTED TRIAL.
THANKS A LOT.
>> I APPRECIATE IT, MICHAEL.
>> A SHORT QUESTION.
CONGRATULATIONS FOR THE EFFORT.
THE WHOLE IDEA OF SPECTO
TRACKING WE KNOW THE MECHANICS
BEFORE AND DURING THE SEVERE MR
AND WHAT HAPPENS WITH THE ACUTE
CHANGE AFTER REPAIR.
WHAT DO WE THINK IS THE UTILITY
OF ADDING THIS TO THE PRIMARY
TRIAL ON SOMETHING WELL KNOWN
AND WELL ESTABLISHED REGARDLESS
OF HOW YOU WORK THE VALVE?
>> YOU'RE THE EXPERT HERE.
YOU KNOW WAY MORE ABOUT THE
PECTO TRACKING THAN I DO.
IT GOES BACK TO TRYING TO PICK
THE PATIENTS TO OPERATE AND THE
RIGHT TIME TO OPERATOR THE RIGHT
TIME TO INTERVENE.
THERE'S DEFINITELY A COHORT OF
PATIENTS HIGHER RISK THAT DRIVE
THE MORTALITY YOU SEE WITH
UNTREATED MITRAL REGURGITATION
AND WE'RE CONFIDENT NOT EVERY
PATIENT SHOULD BE OPERATED ON
WITHIN THREE MONTHS BUT IF YOU
CAN BE MORE SOPHISTICATED IN WHO
IS AT RISK OF VENTRICLE
DECOMPENSATING AND PICK THE
PATIENTS MORE ACCURATELY I THINK
IT WOULD IMPROVE TREATMENT AND
OUTCOMES AND SPENTO TRACKING IS
PROBABLY NOT GOING TO BE THE
ANSWER BUT I SUSPECT MRI MAYBE
AND THAT'S THE HOLISTIC VIEW OF
WHAT WE'RE TRYING TO DO HERE.
STRATIFY AND PICK OUR PATIENTS
BETTER.
>> THANK YOU.
>> THERE'S A QUESTION THERE'S
BEEN A SUB GROUP OF PATIENTS
WITH MYOCARDIAL BIOPSY TO
MAPPING ABNORMALITIES ON CMR.
>> WE CAN'T DO THAT IN TEER BUT
IN SELECTED PATIENTS WITH
CONSENT WE VERIFY WHAT WE SEE ON
CMR AT THE BASE, AT THE APEX OF
THE VENTRICLE.
>> THANK YOU VERY MUCH FOR THE
PRESENTATION AND DISCUSSION.
WE'RE RUNNING A LITTLE BEHIND AT
THIS POINT SO WE'RE GOING TO
TAKE A BREAK UNTIL 15 MINUTES
AFTER THE HOUR.
THANK YOU EVERYONE.
AND A PAPER SHOWING INTRABASAL
FIBROSIS AT THE REGIONS HE
SHOWED IN HIS PRESENTATION BUT
IN FACT IF WE GO ON USING DARK
BLOOD IMAGE AND T1
QUANTIFICATION AS MICHAEL BORGER
HAS DONE YOU CAN SEE FIBROSIS IN
UP TO 89% OF PATIENTS WITH
ARRHYTHMIC MITRAL VALVE PROLAPSE
CORRELATING WITH HISTOPATH LOGIC
VERIFICATION DURING SURGERY.
IN FACT IT'S A COMMON THING IN
PATIENTS WITH ARRHYTHMIC MVP.
AND LINKED WITH THAT A DOWNWARD
MOTION FROM THE PAPILLARY MUSCLE
LEAFLETS WITH THE UPWARD MOTION
OF THE POSTERIOR ANNULUS AND
THIS IS CALLED CURLING AND THIS
IS FROM A PAPER SHOWING THE SAME
ANIMATION AND SEEING THE SAME
ABNORMAL MOTION OF THE PAPILLARY
MUSCLES WITH EXPANSION OF THE
MITRAL ANNULUS AND THERE'S ONE
IN THE VENTRICLE AND PAPILLARY
TRACTION AN UPWARD MOTION OF THE
ANNULUS AND THE SYSTOLIC
CONTRACT OF THE ANNULUS.
AND AS SOME HAVE SHOWED THERE'S
AN EXPANDED SKWAJ RATED LATE
SYSTOLIC SUSPENSION OF THE
ANNULUS IN PATIENTS WITH MITRAL
VALVE PROLAPSE AND THAT WILL
INCREASE THE FORCE EXERTED ON
THE VENTRICLE BECAUSE THAT FORCE
IS THE PRESSURE TIMES THE
ANNULAR AREA.
IF THE ANNULAR AREA WILL FORCE
MORE ON THE PAPILLARY MUSCLE AND
UNDERLYING VENTRICULAR WALL WE
PRESUME STIMULATING FIBROSIS.
AND THERE WAS TALK EARLIER AND
TALKING ABOUT THE ANANYNULAR
DYSFUNCTION AND TEE COUPLED IT
FROM THE ANNULUS AND CAN
INCREASE THE SYSTOLIC ANNULAR
DISJUNCTION.
IT STANDS TO REASON THIS WOULD
ALSO BE ASSOCIATED WITH
INCREASED FIBROSIS.
WE HAVE THIS HYPOTHESIS THAT MVP
DRIVEN MECHANICAL STRESS
INCREASED LOCALIZED FIBROSIS BY
EXPANDING THE ANNULUS SO THE
MYOCARDIUM IS STRETCHED IN BOTH
DEGREES.
THIS WAS STUDIED AND THEY'RE
SUPPORTING PAPERS RECENTLY ABOUT
THE HYPOTHESIS.
FIRST THE LOCALIZED NATURE OF
THE FIBROSIS THAT WAS SHOWN BY
JORDAN MORNING STAR AND CHIP'S
GROUP WITH INFLAMMATION AS WELL
BOTH IN PATIENTS STUDIED IN
MICHAEL BORGER'S GROUP AND
TRANSGENIC MICE AND WE WORKED
WITH JOE WU SHOWING IF YOU
INDUCE MVP IN VITRO IT INCREASES
THE TUGGING FORCE ON THE PATHWAY
MUSCLES AND FINALLY BOTH
FIBROSIS AND ABNORMAL MECHANICS
INCREASED COMPLEX VENTRICULAR
ARRHYTHMIAS.
WE CAN SEE THE SPECKLE TRACKING
IN A PATIENT WITH MVP WITH A
MARKEDLY ABNORMAL MOTION IN THE
INTERIOR BASE WHICH SHOWS UP ON
THE RIGHT IN THE TRACINGS.
MOST THE SEGMENTS CONTRACT
NORMALLY AND SHORTEN WITH THE
CURVES GOING DOWN AND LENGTHEN
IN DIASTOLE AND THERE'S
POST-SYSTOLIC CONTRACTION.
IN MID SIS STOLEE THE SHORTENS
BUT IN LATE SIIN LATE SIS SIS
LENGTHENINGS AND LOOKING AT THE
FIBROSIS BY MRI IN THE SAME
PATIENTS PREDICTED VENTRICULAR
ARRHYTHMIAS OF THE COMPLEX TYPE
AND THERE'S AN ADDITIONAL VALUE
TO THE MECHANICS ABOVE AND
BEYOND THE PREDICTIVE VALUE OF
THE ENHANCEMENT FIBROSIS.
BOTH TOGETHER PROVIDE A STRONG
PREDICTIVE CONSTELLATION FOR
SUBSEQUENT VENTRICULAR
ARRHYTHMIAS.
NOT ONLY IS THE FIBROSIS AS
OTHERS HAVE TALKED ABOUT A
SUBSTRATE FOR ARRHYTHMIA BUT THE
MECHANICAL MOTION CAN BE A
TRIGGER.
THE CENTRAL HYPOTHESIS MVP HAS
ASSOCIATED ELECTROPHYSIOLOGIC
CHANGES AND IN ORDER TO
DEMONSTRATE WHETHER THIS IS THE
CASE WE THOUGHT IT WOULD BE BEST
TO PROVIDE A MODEL TO START WITH
THE NORMAL HEART AND SEPARATE
OUT THE EFFECTS OF MECHANICS AND
ANTONIO VAN CAMPEN A FELLOW FROM
LEIPZIG DEVELOPED AND CHAMPIONED
THIS MODEL MAKING IT A
REPROTUESDAYABLE LARGE ANIMAL
MELD TO STUDYING THE EFFECTS OF
MECHANICS AND AWARD THE VIVIAN
A. THOMAS CAREER AWARD AND THIS
IS A COLLABORATION WITH MICHAEL
BORGER AND CHIP NORRIS FOR THE
BASIC SCIENCE PART OF IT.
WE ARE GRATEFUL FOR THE CAROL
ACT FUND WILL OF THE NIH AWARD
FOR STUDYING THE NEXT SLIDE 1:
STUDYING THIS.
REVERSING THE EFFECT OF A MITRAL
VALVE REPAIR AND THE CREATE OF
THE PROLAPSE IN A CONTROLLED
MODERATE WITH MODERATE NOT
SEVERE MITRAL REGURGITATION AND
SIX MONTHS LATER THIS INDUCES
FIBROSIS AS WE'VE SEEN IN SOME
PATIENTS SHOWN TODAY.
UNDERLYING THE MEDIAL PAPILLARY
MUSCLE SOMETIMES EXTENDING UP
TOWARDS THE INTRAVENTRICULAR
SPECTRUM AND IN THE CONTROLLED
REGION WITHIN THE HEART THERE'S
LITTLE INTERSTITIAL TISSUE AND
INCREASED IN THE SUB PAPILLARY
REGION AND THIS OCCURS
CONSISTENTLY.
THIS IS IN THE MITRAL VALVE
LINKED REGION THERE'S FIBROSIS
BY CONTROL NORMAL.
ELECTROPHYSIOLOGISTS HAVE SHOWN
THAT IN THIS FIBROTIC REGION
THERE'S FRACTIONATION WE THE
MUSCLE ELECTROGRAM INDICATING A
PRE DISPOSITION TO CARDIAC
ARREST AND RESTITUTION SO IT
REMAINS AQUI -- ACQUIESCENT TO
ARRHYTHMIAS AND LOOK AT BULK AND
NUCLEAR RNA SEQUENCES WITH CHIP
NORRIS' GROUP AND THE BULK
SEQUENCING IS CONFIRMED.
THE PRESENCE OF FIBROSIS WHICH
IS OBVIOUS AND POTENTIAL
MECHANISTIC LEADS LEADING TO
THIS FIBROSIS AND WE'VE SHOWN
THAT GENETIC MARKINGS CAN ADD TO
THE REGIONS.
LET'S TALK ABOUT INTERVENTIONAL
STUDIES AND WHAT HAPPENS IF WE
REMOVE THE MECHANICAL STIMULUS
AND THIS IS SOMETHING AN
ADMINISTRATIVE SUPPLEMENT TO THE
FANTASTIC STUDY DR. CHIKWE
DESCRIBED AND THE SURGICAL
VERSUS THE TRANSCATHETER REPAIRS
OF MITRAL VALVE PROLAPSE.
THE AIM HERE IS TO LOOK AT THE
OPTIMAL REPAIR NOT ONLY IN TERMS
OF THE VALVE BUT VENTRICULAR
MECHANICS AND THIS IS BEING
STUDIED PROPOS -- PROSPECTIVELY
AND THIS IS AN EXAMPLE FROM
STUDIES HERE SHOWING THE
ABNORMAL MECHANICS ON THE LEFT
AND UNTREATED MVP AND THE
NORMALIZATION IN TERMS OF NOT
ONLY THE VALVE BUT THE SPECKLE
TRACKING AND ON THE LOWER RIGHT
THE DOUBLE PEAK PATTERN IN THE
BASAL AND POSTERIOR REGION PRE
OPERATIVELY IS NORMALIZED.
THIS IS COMING DOWN THE ROAD BUT
WOULD BE FASCINATING AS
DR. ADAMS WAS TALKING ABOUT THE
DIFFERENTIATION BETWEEN THE TWO
APPROACHES IN TERMS OF
NORMALIZING VENTRICULAR MECH
MECHANICS AS A TRIGGER OF
ARRHYTHMIA.
WE'RE COMBINING THE STUDIES AND
PRIMARY TRIAL STUDY TO ACHIEVE
THE AIM OF IMPROVING PREDICTION
THROUGH IMAGING AS OTHERS TALKED
ABOUT AND WE'LL TALK ABOUT.
AND THE PREVENTION OF FIBROSIS
IN ARRHYTHMIAS.
AND AS RECENTLY WRITTEN RISK
STRATIFICATION IS STILL IN ITS
INFANCY.
AND A WORKING HYPOTHESIS WOULD
BE BASED ON THE DATA THAT MAJOR
RISK FACTORS FOR ARRHYTHMIC MVP
INCLUDE AND SHOULD INCLUDE
MECHANICAL DEFORMATION AS WELL
AS THE FIBROSIS WE CAN SEE FROM
CMR AND THE PRESENCE OF
ARRHYTHMIA PATIENT ALREADY
ACHIEVING THE END POINT.
IN SUMMARY, ARRHYTHMIC RISK IN
MVP RELATE TO THE VALVE
INTERACTS WITH THE VENTRICLE AND
ANNULUS.
THE ABNORMAL MECHANICS ARE
ASSOCIATED WITH MYOCARDIAL
FIBROSIS AND ARRHYTHMIC RISK AND
THIS SUGGESTS THERE MAY BE TWO
WAYS OF REDUCING RISK BOTH
STRUCTURAL IN TERMS OF
SUCCESSFUL REPAIR AND SURGERY
AND BIOLOGICAL INTERVENTION TO
UNDERSTAND WHY THE MECHANICS
INDUCES FIBROSIS IN ARRHYTHMIA
AND HOW WE MIGHT BE ABLE TO
PREVENT THAT.
THANK YOU VERY MUCH.
>> THANK YOU, BOB.
DOES ANYONE HAVE QUESTION OR
COMMENTS ON THIS PRESENTATION?
>> I HAVE A QUESTION.
THAT WAS A GREAT PRESENTATION,
BOB.
IN TERMS OF OTHER PARAMETERS
EVALUATED IN ADDITION TO THE
DOUBLE PEAK WILL THERE BE AN
ASSESSMENT OF MECHANICAL
DISPERSION OR I'M INTERESTED IN
THE BIOPSIES AND CORRELATION
BETWEEN STRAIN AND FINDING OF
BIOPSY AND WE PUBLISHED HOW
POSTMORTEM -- THE DES PERSIAN.
>> THE FIRST PAPER THE
MECHANICAL DISPERSION WHICH
CHANGES IN PARALLEL WITH THE
DOUBLE PEAK PATTERN.
SO THERE ARE MULTIPLE MEASURES.
I WAS JUST FOCUSSING ON THE
TRAUMATIC TROUBLE PEAK FINDING
BUT MECHANICAL DISPERSION IS
IMPORTANT.
AND THERE ARE OTHER MECHANICAL
CHANGES.
YOU CAN MEASURE THE PATHWAY
MUSCLE DISPLACEMENT.
FOR EXAMPLE, THERE WAS JUST
PUBLISHED THIS YEAR SOME
PATIENTS HAVE MORE PATHWAY
MUSCLE DISPLACEMENT AND
ARRHYTHMIAS AND THOSE WITH NO
ARRHYTHMIAS DON'T HAVE MUCH
PAPILLARY MUSCLE DISPLACEMENT.
THERE'S A NUMBER OF MEASURES AND
WE SHOULD BE MEASURING ALL OF
THEM.
NOT ONLY IN GENERAL BUT IN THE
PRIMARY TRIAL.
>> THANK YOU.
>> THERE'S ALSO THE PICKLE SIGN
HE MENTIONED AND JUDY HUNG
MENTIONS.
I THINK WE HAVE A GOOD NUMBER OF
WAYS AS IMAGERS TO CORRELATE
THOSE AND THE MODEL CAN BE
CREATED FROM STARTING WITH THE
NORMAL HEART TO TRY TO LOOK AT
GENETIC PREDISPOSITION IN
COMBINATION WITH MECHANICS WITH
A POTENTIAL GENETIC
PREDISPOSITION OR WHATEVER KIND
OF PREDISPOSITION YOU FIND IN
TERMS OF THE UNDERLYING
SUBSTRATE.
>> YES, BECAUSE MECHANICAL
DISPERSION I WONDERED IS IT ONLY
THE MECHANICS AND YOU SEE IN THE
CARDIOMYOPATHY.
HAVING IT IN AN ANIMAL MODEL AND
SORTING THIS OUT IS IT MECHANICS
OR DIFFUSED FIBROSIS NMR.
>> A QUESTION FROM NHLBI, IS
THERE A ROLE FOR DIFFUSION OF ME
MYOCARDIAL -- I WISH I COULD SAY
I UNDERSTAND IT CONTINUES TO
WORK AND WE'LL WORK TO CONVEY
THIS IN THE PROSPECTIVE
EXPERIMENTAL STUDIES THEY CAN BE
DOING DIFFUSION TENSER IMAGING.
FOLLOWING UP ON YOUR PAPER, AS
WELL IN WHICH YOU DESCRIBED THE
ROLE.
I THINK IN CARDIOMYOPATHY BUT AN
IMPORTANT MEASURE OF MECHANICS.
>> IT'S FASCINATING TO SEE THIS
AND VERY INTERESTING FINDING.
I JUST WANT TO KNOW IF YOU FIND
SOME TYPES INSIDE THE CELLS AS
DESCRIBED BY OTHERS A FEW YEARS
AGO IN PATIENTS WHO EXPERIENCE
THE MITRAL VALVE COLLAPSE.
DID YOU REMEMBER THE PAPER WITH
SORT OF THE CELL AND ASSOCIATED
WITH FIBROSIS
>> I'LL ADDRESS THE QUESTION TO
HIM AND I CAN SAY IN THE PAPER
FROM MORNING STAR FROM THREE
YEARS AGO AND ACCURATE MOUSE
MODEL THERE WERE MYOCARDIAL CELL
AB NONORMALITIES IN THE REGION
LOCALIZED FIBROSIS.
SO YES, THERE ARE ADDITIONALLY
MYOCARDIAL AND MYOCYTE
ABNORMALITIES THAT CAN
CONTRIBUTE TO THE ARRHYTHMIC
GENESIS.
>> THERE WERE OXIDATIVE STRESS I
THINK WE'LL SEE THE ULTRA
STRUCTURAL CHANGES WITH OTHER
PROTEINS IT WILL BE INTERESTING
TO HAVE OUR OWN HISTOLOGY
RESULTS.
>> AND IN THE STEDESIGN OF THE
TRIAL DR. CHIKWE TALKED ABOUT IN
IT FROM DIFFERENT REGIONS WILL
ALSO BE VERY HELPFUL AT
EXPLORING NOT ONLY THE FIBROTIC
GENE EXPRESSION BUT CHANGES IN
THE MYOCARDIUM AND STRUCTURAL
CHANGES.
IT'S A GOLDEN OPPORTUNITY AND
URGE PEOPLE TO AS MUCH AS
POSSIBLE TO GET THOSE VERY
DIFFICULT TO OBTAIN SAMPLES.
>> AND ON THAT NOTE, NEXT
SPEAKER IN THE SESSION IS
DR. BORGER.
>> THANKS VERY MUCH, FRANK.
THANKS FOR THE INVITATION TO
SPEAK AT THIS TREMENDOUSLY
INTERESTING SYMPOSIUM.
THESE ARE MY DISCLOSURES.
MY HOSPITAL DOES RECEIVE
CONSULTING FEES AND I DO NOT
RECEIVE ANY MONIES BUT I'M A
CARDIAC SURGEON AND THIS IS THE
PERSPECTIVE OF THE TALK.
SO BOB HAS GIVEN BACKGROUND TO
THE DISCUSSION WE'VE HAD AND A
PAPER WE RECENTLY PUBLISHED
CHANGES THAT OCCUR IN MITRAL
VALVE PROLAPSE AND THE
ALTERATION OF THE VALVE,
VENTRICLE AND ALSO WITH THE
PAPILLARY MUSCLE FIBROSIS WHICH
IS NOT SO COMMONLY KNOWN WITHIN
THE GENERAL CARDIOVASCULAR
COMMUNITY.
MARK MILLER PUBLISHED THIS
LOVELY PAPER AND THIS OF COURSE
WHAT WE'VE BEEN TALKING ABOUT
THE LAST FEW DAYS.
ARRHYTHMIC GENIC MITRAL VALVE
PROLAPSE IS NOT COMMONLY KNOWN
IN THE COMPOUND AND THANKS TO
THE NIH AND CONGRESSMAN BARR AND
WE THOUGHT ABOUT THE HYPOTHESIS
THE STRESS ON THE PAPILLARY
MUSCLE.
THE SUBSTRATE CAN LEAD TO
ARRHYTHMIAS AND SUDDEN CARDIAC
DEATH AND PULLING TENSION ON THE
MYOCARDIUM IS AN ONGOING
TRIGGER.
AND LOOKING AT PROLAPSE AT THE
TIME WITH YOUNGER AND LOWER RISK
PATIENTS WITH A LONGER LIFE
EXPECTANCY AND MORE POTENTIAL
FOR ARRHYTHMIAS AND SUDDEN
CARDIAC DEATH.
AND HERE BASED ON HARD WORK ONE
FRANCESCA AND BOB LAVINE AND
OTHERS AMONGST OTHERS
IDENTIFYING THIS DEFECT IN A
FAMILY THAT HAD HIGH PENETRATION
OF MITRAL VALVE PROLAPSE AND HE
DEVELOPED THIS KNOCK IN MODEL
YOU HEARD ABOUT YESTERDAY WHICH
HAS TYPICAL HISTOLOGICAL CHANGES
IN THE MISSING.
WE COMPARED THE FINDINGS IN OUR
PATIENTS WITH LEIPZIG WE TOOK A
BIOPSY IN THE ONLY THE AREA
AROUND THE PAPILLARY MUSCLES YOU
SEE HERE AND THE PATIENT'S
MYOCARDIUM IS EXPOSED TO VOLUME
OVERLOAD WHEREAS THE PAPILLARY
REGION IS EXPOSED TO THESE
FORCES FROM THE PROLAPSE AND WE
COMPARED THIS TO CHIP'S D ZIP 1
MICE AND FOUND SIMILAR FINDINGS
IN THE LOCAL MECHANICALLY
INDUCED AREA COMPARED TO THE
APEX OF CONTROL AND IN THE WILD
TYPE MOUSE THERE WAS NO OBVIOUS
FIBROSIS IN EITHER THE APEX OR
INTRABASAL MIEE CARDIUM AND THIS
IS THE -- MYOCARDIUM AND THE
PAPER REFERRED TO.
AND LOOKING AT FIBROSIS WITHOUT
ENHANCEMENT AND DEMONSTRATED
HIGHER CARDIOVASCULAR EVENT
RATES IN THE PATIENTS WITH THE
ENHANCEMENT REGARDLESS OF THE
DEGREE OF MITRAL REGURGITATION.
WE FOUND MORE CELLULAR VOLUME IN
THE PAPILLARY MUSCLE REGION AS
YOU SEE HOWEVER, IT'S DIFFICULT
TO IMAGE AND HE TOGETHER WITH
ONE OF OUR MR SPECIALISTS USED
THE PROTOCOL BUT IT'S
INTERESTING AND THIS CORRELATED
WITH THE BIOPSY WITH LITTLE
EVIDENCE OF FIBROSIS AND THIS
SHOWED POSITIVE ENHANCEMENT
SHOWN ON THE THIRD IMAGE.
THE BLOOD IS DARK ENABLING YOU
TO DETECT THIS FIBROSIS WHICH
WOULDN'T NECESSARILY NORMALLY
SEE AND CORRELATED WITH MODERATE
FIBROSIS AND THIS IS A PATIENT
WITH ENHANCEMENT ON BOTH
TECHNIQUES AND NOT SURPRISINGLY
THE BIOPSY SHOWS FIBROSIS IN THE
PATIENT.
AND WE COMPARED AND THE HIST
HISTOGRAM AN ENHANCEMENT ON THE
LEFT THIRD AND MIDDLE THIRD IS
THE DARK BLOOD AND YOU SEE
ESPECIALLY AROUND THE PAPILLARY
MUSCLE REGIONS A HIGH RATE OF
FIBROSIS DETECTED WITH THE DARK
BLOOD AND CORAL -- CORRELATED
WITH THE HISTOLOGICAL FINDINGS.
AND WE SPOKE WITH JOE WU WITH
HIS EXCELLENT MODEL AND YOU'LL
SEE THESE VERY SENSITIVE SENSORS
THAT ARE ATTACHED TO THE
PAPILLARY MUSCLES IN ORDER TO
MEASURE FORCES.
ON THE LEFT IS THE SHEET MITRAL
VALVE WITH LITTLE REGURGITATION.
ON THE MIDDLE IS WHERE THEY
SIMPLY CUT ONE OF THE CHORDE AND
HAD MITRAL REGURGITATION AND ON
THE RIGHT IS THIS INDUCED
PROLAPSE THE OFF SIT OF THE
TECHNIQUE MY FORMER BOSS
DEVELOPED TO CORRECT PROLAPSE.
THE OPPOSITE OF CORRECTING
PROLAPSE.
WE CUT THE CORDS AND PUT IN
NEEDLE CHORDAE ON PURPOSE TOO
LONG INDUCING MILD TO MODERATE
MRI AND THE SHEET DON'T TOLERATE
SEVERE MR AND IT'S A FINE TUNING
MODEL IN ORDER TO GET THE AMOUNT
OF MR CORRECT AND YOU CAN SEE
THE FORCED DISTRIBUTION ON THE
PAPILLARY MUSCLES IS THE MOST
WITH THIS MILD TO MODERATE
REGURGITATION AND PROLAPSE.
IT'S VERY IMPORTANT THOUGH TO
POINT OUT THAT THIS MITRAL VALVE
LOOKS NOTHING LIKE THE MITRAL
VALVES DAVID ADAMS WAS SHOWING
IN HIS PRESENTATIONS.
THESE ARE NORMAL MITRAL VALVES
SLIGHTLY ALTERED.
THEY DON'T HAVE LARGE ANNULUS OR
BIG REDUNDANT TISSUE THAT ACT AS
SAILS IN ORDER TO INCREASE THE
AMOUNT OF FORCE BEING PLACED ON
THE MYOCARDIUM.
AND THIS UNDER SCORES HOW
IMPORTANT THE PROBLEM IS AND THE
SHEET MODEL AND A SHOUT OUT TO
THE WELL ESTABLISHED MITRAL
VALVE SURGEON IN BOSTON AND
SHOWED AN TONIA HOW TO TO THIS
WHICH IS A TRICKY OPERATION TO
DO.
YOU'RE BASICALLY CUTTING THE
PRIMARY CHORDS AND INSERTING
WHAT IS ON PURPOSE TOO LONG BUT
NOT TOO TOO LONG.
AND THIS IS VERY SUBTLE BUT THEY
CAN HAVE MODERATE PULMONARY
EDEMA AND WON'T SURVIVE BUT IF
THE ANNULUS IS NOT ENLARGED AND
MR IS NOT SEVERE AND WE SEE GOES
HISTOLOGIC EVERYDAY AND THE
ELONGATED CHORDAE AND HERE YOU
SEE EASILY THE GROSS MYOCARDIAL
FIBROSIS COMPARED TO THE OTHER
PAPILLARY MUSCLE WHERE THERE WAS
NO ELONGATED CHORDS AND PET
SCANNING INDICATING SOME
INFLAMMATION AS WELL.
THIS NEXT SLIDE I BELIEVE WE
HAVE SEEN AND THE CMR WITH
FIBROSIS AND IT'S A FEW MONTHS
IN MILD TO MODERATE MR WITHOUT
SEVERE PROLAPSE.
AND WE'RE TRYING TO GET A BETTER
VIEW IN A MOMENT.
THE EXTENSIVE GROSS FIBROSIS YOU
SEE ON THE PAPILLARY MUSCLE SO
YOU SEE THESE PATCHES OF
FIBROSIS AND ALSO IN THE
INTRABASAL REASON IS THE AREA WE
DO THE BIOPSIES FROM WE DON'T
WANT TO BIOPSY THE PAPILLARY
MUSCLE BUT AS WE GO FURTHER DOWN
THE VENTRICLE YOU HAVE A 2-D
VIEW OF A 3-D STRUCTURE AND THE
APEX IS SIX, SEVEN CENTIMETERS
AWAY AND NOT THE SAME AS YOU SEE
ON THE SCREEN HERE.
HERE IS A MITRAL REPAIR.
REABLATE THE MUSCLES AND LAD
GOOD RESULT FROM THE SURGERY AND
ONE YEAR LATER HE'S COMPLETELY
FINE AND HAD NO MORE DISCHARGES
OF HIS ICD.
HIS PVC RATE DROPPED OVER 95%.
AND HE HAS NO MORE SYMPTOMS FROM
HIS MITRAL REGURGITATION EVEN A
CARDIOLOGIST THEMSELVES DON'T
KNOW IT'S A PROBLEM AND THERE
ARE SOLUTIONS TO IT.
SO PRIMARY STUDY YOU HEARD MANY
TIMES HERE AND WITH REGARD TO
THEIR EFFECT ON PATIENT RELEVANT
OUTCOMES.
WE ALL KNOW THAT THIS IS ALREADY
GIVING A GROSS REPRESENTATION
WITH THE ADT8 OR 10 YEARS OLD
AND NOT A NORMAL LOOKING
PHYSIOLOGIC MOVEMENT OF THE
MITRAL VALVE COMPARED NO THE
PATIENT ON THE RIGHT WHO'S HAD
CHORDS IN THE LOOP TECHNIQUE TO
THE POSTERIOR AND ANTERIOR
LEAFLET AND YOU DON'T HAVE TO BE
A SPECIALIST TO SAY IT HAS TO BE
MORE PHYSIOLOGIC.
AND WE KNOW MITRAL VALVE REPAIR
SURGERY AT LEAST IN GERMANY IS
ON THE DECREASE PARTLY DUE TO
THE INCREASE IN TIER WHICH WE
ALL KNOW THERE'S DATA SHOWING AN
ANNUAL PROCEDURE FOR FUNCTIONAL
MR LEAFLETS AND THIS IS VERY
DIFFERENT ON THAT A PATIENT
UNDER GOING TO TEER WHERE THERE
IS NOT NEARLY THIS NORMALIZATION
OF FORCES.
THIS NORMALIZATION OF THE BIO
MECHANICS MAYBE WHY WE SEE GOOD
RESULTS THOUGH IT'S AN ALL
COMERS PAPER WITH MORTALITY OF
1.6 FOR THE ENTIRE GROUP AND
MORBIDITY OR MORTALITY OF 8.7%.
AND LOW MORTALITY IN THE LOWER
RISK PATIENTS.
IS THIS A CURE?
IF YOU LOOK AT MY ORIGINAL
MENTOR YOU SEE WITH THE LARGE
NUMBER OF PATIENTS EXCELLENT
RESULTS REGARDING MORTALITY EVEN
WITH PATIENTS EARLIER IN THE
DISEASE PROCESS AND IN THIS
PAPER IN CIRCULATION IT WAS
DEMONSTRATED NORMALIZATION OF
THE SURVIVAL CURVES FOR HEART
DISEASE THIS IS THE ONLY
TREATMENT I KNOW OF THAT
NORMALIZES ONLY SURGICAL OR
INTERVENTIONAL TREATMENT THAT I
KNOW OF THAT NORMALIZES THE
SURVIVAL AFTER THE INTERVENTION.
SO MAYBE THIS IS A CURE?
BUT WE NEED MORE DATA AND THIS
IS SOME OF THE DATA WE'RE
GATHERING.
SO THIS IS JUST SHOWING OUR
TECHNIQUE, DAVID SHOWED YOU HIS
WITH THE KNIFE.
SO WHAT I USE IS A VERY HANDY
THROUGH THE APPROACH AND SEE
WHAT YOU'RE DOING WITH THE ENDO
SCOPE AND THIS IS THE AREA OF
INTEREST BETWEEN THE PAPILLARY
MUSCLES AND THE NEXT VIDEO --
SORRY.
WE'RE MISSING A VIDEO SHOWING
THE CONTROL FROM THE APEX OF THE
LEFT VENTRICLE BUT YOU
UNDERSTAND THE POINT.
WE'RE LOOKING AT ARRHYTHMIA'S
AND CMRs AND THE SPECKLE TRACK
AND DOUBLE PEAK SIGN AMONGST
OTHER ON ECHO CARDIOGRAPHY AND
THE PROLAPSE IS A COMMON DISEASE
AND ASSOCIATED WITH VENTRICULAR
ARRHYTHMIAS AND MECHANICAL
STRESS IS ASSOCIATED WITH THE
FIBROSIS.
IT COULD BE THE SUBSTRATE BUT BY
DOING THE VENTRICULAR
ARRHYTHMIAS AND BY DOING THE
SURGERY YOU CAN ELIMINATE THE
TRIGGER MAYBE NOT THE SUBSTRATE
BUT THE TRIGGER AND MAYBE WHY
THE PATIENTS HAVE A NORMAL LIFE
EXPECTANCY AFTER THE OPERATION
BUT ONGOING TRIALS WILL BE MORE
INFORMATIVE AND WE'RE THANKFUL
TO NIH FOR THE FUNDING BOB SPOKE
TO EARLIER WITHIN THE PRIMARY
TRIAL.
THANK YOU FOR YOUR ATTENTION.
I'LL BE HAPPY TO ANSWER ANY
QUESTIONS.
>> THANK YOU, MICHAEL.
DOES ANYONE HAVE BRIEF QUICKS OR
COMMENTS ON THE PRESENTATION?
>> MICHAEL, LEAPT ME ASK YOU
ABOUT THE BIO MECHANICS AND THE
TRIAL YOU'RE GOING TO SEE
WHETHER YOU ELIMINATE THE EMR
AND THE MECHANISMS TO TO IT.
WHAT ABOUT THE ARRHYTHMIC
PROLAPSE PART OF THIS?
BECAUSE IN GENERAL THE TEER
CANDIDATES -- WELL, YOU CATCH US
UP.
THE TEER CANDIDATES IN GENERAL
WERE SINGLE LEAFLET PROLAPSE.
WE BOTH HAVE SEEN MORE COMMONLY
IN ARRHYTHMIC PROLAPSE.
AND THEY'RE CANDIDATES TO STUDY
THE EFFECT ON ARRHYTHMIC
PROLAPSE AND ELIMINATING
REGURGITATION AND LESS ABOUT
ARRHYTHMIA PRO-LAPSE.
>> GREAT QUESTION.
WE'RE NOT ENROLLING A LOT OF
BARLOW'S TYPE PATIENTS.
THEY'RE USUALLY SCREENED OUT AND
IT'S PICKING THE RUPTURED
DEFICIENCY PATIENTS.
AND THERE MAY NOT BE A
DIFFERENCE BECAUSE OF THE FACT
BUT WE HAVE -- WE'RE LOOKING AT
SO MANY ASPECTS, REVERSE
REMELDING AND CMR AND THE
FIBROSIS ON CMR AND HOW IT
CORRELATES WITH THE HISTOLOGIC
EXAMINATION AND THE FIBROSIS
WILL BE HALTED IN THE SURGICAL
PATIENTS AND PROBABLY PROGRESS
IN THE TEER PATIENTS.
>> MICHAEL, I THINK IT'S
COMPLEMENTARY TO THE WORK OUR
GROUP DOING.
I THINK THE POPULATIONS WILL BE
DIFFERENT.
WE'RE GOING TO LEARN A LOT AT
THE MICROBE SCOPIC LEVEL FROM
BOTH OF THESE I'M PRETTY
CONFIDENT THE VALVE MORPHOLOGY
WILL BE DIFFERENT.
MOST THE PRIMARY CASES WILL HAVE
SINGLE SEGMENTS BUT THEY'RE NOT
GOING TO TO BE THE SAME AS THE
END STATE DEFORMITIES WE'RE
SEEING.
>> DON'T FORGET, DAVID, THEY'LL
BE SIMILAR BY GROUP IN THE
RANDOMIZED TRIALS.
IT HAS TO BE AGREED TO BY THE
ADJUDICATION AND SUITABLE BEFORE
THEY'RE RANDOMIZED.
>> I MEANT IN TERMS OF THE
POPULATION WE'RE STUDYING MORE
HAVE BIG DOUBOUTS AND THINK IT L
BE INTERESTING.
WE'RE GOING TO LEARN A LOT.
>> BRIEFLY, PLEASE.
>> MICHAEL, OUTSTANDING
PRESENTATION AND I ENJOYED IT
AND CONGRATULATIONS ON ALL THE
GREAT WORK.
I NOTED IN AARM OF THE WORK IN
THE BIOPSIES.
ARE YOU DOING IT IN THE BASAL
ANTEARIOR WALL?
>> BETWEEN THE PAPILLARY MUSCLES
AND AS CONTROL ON THE APEX.
WE FIND ON THE SEPTAL SIDE THE
FIBROSIS IS MORE IMMEDIATE WHERE
THE A EX -- APEX IS THE LEAST
AMOUNT OF FIBROSIS.
>> THANK YOU VERY MUCH.
THE NEXT PRESENTATION IS FROM
CRIST
CRISTINA BASSO.
>> THE TALK IT'S NOT EASY FOR ME
TO SPEAK BECAUSE WE WERE
INFORMED ABOUT THE ROLE OF
FIBROSIS.
AS YOU KNOW I'M IN PATH OL BY.
-- PATHOLOGY.
MY EXPERIENCE STARTED MANY YEARS
AGO STUDYING SUDDEN DEATH
VICTIMS.
WE LOOK AT THICKENING OF THE
LEAFLET.
MANY WOMEN WERE DYING WITHOUT
OTHER REASONS NOT FROM THE
DISEASE AND CONGENITAL
MALFORMATION AND WE STUDIED THE
ANNULUS AND PATH LOGICALLY AND
CASES WITHOUT FIBROSIS.
SO FIBROSIS IS NOT ONLY THE
SINGLE EXPLANATION FOR
LIFE-THREATENING VENTRICULAR
ARRHYTHMIAS.
WE OBSERVE THE MOVEMENT OF THE
LEAFLETS AND THERE'S A CLEAR
DEGENERATION WITH THE
THICKENING.
IN THIS CASE BOTH ANTERIOR AND
POSTERIOR AND SEE REDUNDANCE OF
THE TISSUE AND WHEN YOU OBSERVE
HISTOLOGY BOTH AT THE VALVE
LEAFLET AND WE LOOK AT THE MIGHT
RAL VALVE.
--MITRAL VALVE.
THIS IS WHAT WE OBSERVED IN 2015
AFTER MONTHS AND YEARS OF
OBSERVATION.
WE DECIDED TO OBSERVE CAREFULLY
THE MYOCARDIUM AND CLOSE TO THE
MITRAL VALVE AND WERE ASTONISHED
TO OBSERVE THE PRESENCE OF
FIBROSIS IN THE REGION OF THE
LEFT VENTRICLE.
THE BASAL PORTION AND LEFT
VENTRICLE WALL AND PAPILLARY
MUSCLE AND THIS FIBROSIS WAS
INTERSTITIAL BUT MAINLY SCAR
RELATED FIBROSIS.
YOU SEE THE AREA COMPLETELY BLUE
AND YOU SEE THE COLLAGEN FIBERS.
YOU SEE HERE THE ORIGINAL
PUBLICATION OF THE JUNCTION
COMING FROM THE SINGLE CASE
REPORTER.
YOU SEE ON THE DIAGRAM THE EL
ELONGATION OF THE ANNULUS IF YOU
COMPARE IT WITH CONTROL NORMAL
POPULATION MEASURED FREQUENTLY
THERE'S AN ELONGATION OF THE
ANNULUS.
WE PUT TOGETHER THE TWO.
AND THE PAPILLARY MUSCLE PORTION
AND THE REASON IT COULD BE AT
THE MOVEMENT OF THE LEAFLET DUE
TO ELONGATION AS DEMONSTRATED BY
RESONANCE.
THIS IS THE ORIGINAL PAPER
COMPARING THE SUDDEN DEATH
PATIENTS AND YOU SEE THE
PRESENCE OF FIBROSIS IN THE
INTRABASAL WALL IT'S CLEARLY
STATISTICALLY SIGNIFICANT AND
WHAT ABOUT THE CARDIO MYOCYTE.
WE OBSERVED THE MYOCYTES IN THE
AREA OF FIBROSIS IS ABNORMAL AND
THERE'S DISEASE CLEARLY INJURY
PROBABILITY DUE TO MECHANICAL
STRESS.
SUDDEN DEATH IN PATIENTS WITH
MITRAL VALVE PROLAPSE WE HAVE
IMAGING AND NOT ALL THE
PROTOCOLS ARE EQUAL IN THE
IMAGING SETTING PARTICULARLY IN
MRI AND THEN FIBROSIS.
IT'S THERE BUT THERE ARE MANY
TYPE OF FIBROSIS AND MANY
POSITION BECAUSE THEY CAN BE
INTERSTITIAL OR SUB ENDOCARDIAL
SO WE NEED THE TWO
DISTINGUISHING TYPE AND
LOCATION.
AND THERE ARE OTHER POSSIBLE
ARRHYTHMIAS AND PROLAPSE IN THE
ABSENCE OF SCARRING AND MAGNETIC
RESONANCE.
THIS IS OUR EXPERIENCE AND AS
FAR AS THE PREVALENCE OF MITRAL
VALVE PROLAPSE AND VICTIMS
WITHOUT MITRAL REGURGITATION 8%
IN THE SERIES OF SUDDEN DEATH
AND UNDER THE AGE OF 40 WAS WITH
8%.
AND AND THE POPULATION AND THE
AGE RANGE FROM 18 TO 90
INCLUDING ELDERLY PEOPLE AND SEE
2% AND THE COMPARISON BETWEEN
SOME PATIENTS WITH PROLAPSE YOU
SEE THE FIBROSIS CHARACTERISTICS
IS MOSTLY INTERSTITIAL CLOSE TO
100% AND REPLACEMENT OF FIBROSIS
IS PRESENT ONE THIRD OF THE
CASES.
THEY DIFFERENTIATE REPLACEMENT
FOR INTERSTITIAL FIBROSIS FOR
MOSTLY THE MAJORITY OF PATIENTS.
THIS IS ANOTHER IMPORTANT PAPER
PUBLISHED IN THIS PAPER FROM AN
AUSTRALIAN GROUP YOU SEE BEEN
THEY LOOK AT THE DISTRIBUTION
AROUND THE LEFT VENTRICLE AND IN
A DIFFERENT LAYER EPICARDIUM AND
SUB ENDOCARDIAL AND THERE'S A
GRADIENT AND PREVALENCE OF
FIBROSIS.
AND YOU SEE A DEMONSTRATION OF
THE MITRAL VALVE PROLAPSE AND
THE FIBROSIS PARTICULARLY IN THE
MID MORALIAL REGION AND LOOK AT
THE PROLAPSE.
THIS IS ANOTHER PAPER
DEMONSTRATING THE PRESENCE IN
THE ONLY OF REPLACEMENT FIBROSIS
AND IT'S VERY IMPORTANT IF YOU
LOOK AT THE SERIES OF PATIENT
WITHOUT MITRAL REGURGITATION YOU
CAN APPRECIATE THE PRESENCE OF
INTERSTITIAL FIBROSIS BY
TECHNIQUE AND MRI AND AGAIN CAN
APPRECIATE THE DISTRIBUTION OF
FIBROSIS IN DIFFERENT REGION OF
THE LEFT VENTRICLE WITH THE
GRADIENT FROM THE ENDOCARDIAL.
THIS IS A META-ANALYSIS OF
CLINICAL STUDY AND SOME STUDIES
INCLUDING OUR STUDY FROM 2015
DEMONSTRATING THE FIBROSIS PLAYS
A ROLE IN THE ARRHYTHMIC
STRATIFICATION BECAUSE THIS
PATIENT IS AT HIGHER RISK OF
ARRHYT
ARRHYTHMIA.
AND AND THE PROPORTION AND THE
PAPILLARY MUSCLE AND THEN THEY
INTRODUCED THE NEW MARKER THE
SO-CALLED APPEARANCE OF THE
PAPILLARY MUSCLE WHICH IS
CORRELATING QUITE BEAUTIFUL WITH
THE AMOUNT OF FIBROSIS AS
DEMONSTRATED BY LEFT VENTRICULAR
BIOPSY.
IF YOU SEE THE CONCLUSION OF THE
QUALITY OF THE SLIDE AND
TRANSFORMATION AND THE IMAGING
FOR THE PATIENT LOOKING AT
PAPILLARY MUSCLE AND COMPARED
WITH OTHER VOLUNTEERS BUT LOOK
TO THE GRAPH AND COMPARE THE
DARK BLOOD APPEARANCE AND VERSUS
THE HISTOLOGY.
YOU SEE THERE'S NO STATISTICAL
DIFFERENCE AND IT'S QUITE
OVERLAPPING THE HISTOLOGY
RESULT.
THE NEW SIGN COMBINED WITH THE
TO THE LEFT VENTRICLE FIBROSIS
IN THE PATIENTS WITH THIS.
AND TO UNDERSTAND THE DIFFERENT
IMPACT OF INTERSTITIAL FIBROSIS
AND REPLACEMENT OF FIBROSIS AND
PROBABLY PUTTING TOGETHER MANY
DATA INCLUDING THE PRESENCE OR
ABSENCE OF MITRAL REGURGITATION
AND BECAUSE IT'S MY IMPRESSION
THE INTERSTITIAL FIBROSIS IS
INCREASING WITH LEFT VENTRICULAR
FIBROSIS AND I DON'T THINK IT'S
SO SPECIFIC OF THE MITRAL VALVE
PROLAPSE AS WELL.
SO THE KNOWLEDGE GAP OF COURSE
BECAUSE WE HAVE PATIENT WITH
ARRHYTHMIAS AND NO FIBROSIS
HISTOLOGY AND THE SUBSTRATE CAN
ACCOUNT FOR ELECTRIC INSTABILITY
AND THIS WOULD ACT AT THE LEVEL
OF FIBERS IN SOME PATIENT OR
FROM THE SUBSTRATE THAT SHOULD
BE CAREFULLY LOOKED FOR.
SO THE OPPORTUNITY FOR SURE ARE
ABLATION AND EXPERIMENTAL.
I WOULD SAY I'M PLEASED AND ONLY
COUR
-- ENCOURAGED TO LOOK APT THE
MYOCYTE AND WHAT IS GOING ON AT
THE LEVEL OF THE SINGLE MYOCYTE
AND THE PORTION CLOSE TO THE
ANNULUS AND AT THE LEVEL OF THE
APEX OF THE LEFT VENTRICLE WAS
IT'S MY IMPRESSION EVERYTHING
STARTED WITH THE INJURY AND HAVE
REPAIR PROBABLY WITH SOME
INFLAMMATORY REACTION AND THE
FINAL STEP IS THE REPLACEMENT OF
FIBROSIS.
I THINK THIS WAS MY LAST SLIDE.
AND THANK YOU FOR YOUR
ATTENTION.
>> THANK YOU FOR THE
PRESENTATION.
DOES ANYONE HAVE BRIEF COMMENTS
OR QUESTIONS?
>> I DO.
NICE TO SEE YOU.
WONDERFUL PRESENTATION.
I THINK YOU WERE ALSO GOING
AFTER THE MYOCYTE AND HAVE YOU
LOOKED AT THE HISTORY LOGICAL
LEVEL?
>> NOT REALLY BUT -- DEF TEF
HISTORY-
THIS IS HAPPEN WHERE THE STRESS
IS IN THE MYOCARDIUM.
THERE IS SOMETHING CONSTANT DUE
TO THE MECHANICAL INJURY TO THE
MYOCYTE.
PROBABLY YOU CAN HAVE SOME
DISRUPTION OF THE CELL JUNCTION
SO PROBABLY WE COULDN'T HAVE
SOMETHING BUT I DON'T THINK IT'S
REALLY SOMETHING WHICH IS
VISIBLE.
IT'S SOMETHING THAT IS ACTING IN
TERMS OF THE MYOCYTE AND THEN OF
COURSE TRIGGERING SOME SIGNAL
FOR CELL DEATH.
>> HAVE YOU LOOKED AT THE EP
LEVEL WITH CLINICIANS ON TRYING
TO UNDERSTAND HOW THE ELECTRICAL
CONDUCTION IS IMPACTED IN THAT
REGION.
>> WE'RE WORKING IN THE CLINICAL
SETTING AND WE'LL PROBABLY TRY
TO ANSWER THE QUESTION.
>> WONDERFUL.
THANK YOU.
>> AND WITH THAT INTRODUCTION
OUR NEXT PRESENTATION IS FROM
MARTINA PERAZZOLO-MARRA.
>> THANK YOU VERY MUCH.
IT'S IMPORTANT FOR ME TO BE HERE
AND MY DISCLOSURE IS I'M NOT AN
ELEC
ELECTROPHYSIOLOGIST BUT WORK IN
THE LAB AND WE KNOW FROM THE
INITIAL OBSERVATION OF THE
PROLAPSE OF THE MITRAL VALVE AND
WE KNOW THAT IT'S NOT ONLY A
SPECIFIC ECG BUT ALSO YOU KNOW
THE PROLONG ED AND DESCRIBED IN
PATIENT WITH OR WITHOUT MITRAL
REGURGITATION.
IT INCLUDE PATIENT WITH A
SPECIFIC ECG BUT ALSO
POLYMORPHIC BOTH WITH A
DIFFERENT MORPH OL GY --
MORPHOLOGY OF ARRHYTHMIA
DESCRIBED IN THE RISK
STRATIFICATION OF THE EUROPEAN
COMMUNITY.
HOWEVER WE KNOW THERE'S MUCH
MORE THAN MITRAL VALVE DISEASE
BECAUSE WE KNOW THE ARRHYTHMIC
PRODUCTS INCLUDE THE JUNCTION
AND FIBROSIS IN THE SPECIFIC
SITE KRICRISTINA MENTIONED AND
ANTEROLATERAL WALL COMPARED TO
THE PORTION AND SO THESE ARE THE
KEY POINTS OF THE PROLAPSE.
THE MORPHOLOGY HAVE BEEN
DESCRIBED BUT LOOK AT THE
FEATURE S
FEATURE DESCRIBED AND THE
PATIENTS WITH FIBRILLATION ARE
WITH A SPECIFIC MORPHOLOGY THAT
MEANS THE SOURCE OF ARRHYTHMIAS
IS THE LEFT VENTRICLE.
MAJOR FROM THE LEFT VENTRICLE IN
THE PORTION.
WITH KNOW WHEN WE SEE A PATIENT
WITH THE MITRAL VALVE PROLAPSE
AND WE HAVE A DIFFERENT TYPE AND
MORPHOLOGY COMING FROM DOT.
BUT FROM THE PREVIOUS TALK WE
LEARNED THE LESSON THAT WE HAVE
A DISEASE WITH ARRHYTHMIAS BUT
THE LIST INCLUDES THE
VISUALIZATION OF FIBROSIS.
WE KNOW FIBROSIS IS A SUBSTRATE
FOR ARRHYTHMIAS AND SOMETIMES
PECULIAR WITH THE VENTRICLE
FIBRILLATION AND THE FIBROSIS IS
THE GOAL OF CMR AND IN THIS CASE
IT'S VERY IMPORTANT BUT THE
AMOUNT IS 2% TO 3% AND LOOKING
AT THE WALL AND THOSE ARE INSIDE
THE MOUSE.
ON THIS BASIS WE EVALUATE THE
POSSIBLE MECHANISM OF THE STRESS
INDUCED ARRHYTHMIAS AND WE SAW
THE MAPPING OF THE PAPILLARY
MUSCLE IS INTRIGUING IN THE
MITRAL VALVE PROLAPSE AND THE
MOST IMPORTANT ACTIVATION
DESCRIBED AND RECOMMENDED FOR
THE ARRHYTHMIC PROLAPSE COME
FROM THE INTERIOR ONE AND THE
POSSIBILITY TO STRATIFY IN THE
CLINICAL SETTING IS IMPORTANT.
CMI IS NOT ABLE TO BE PERFORMED
IN ALL PATIENTS.
THERE'S THE POSSIBILITY OF THE
GAP IN THE AND IMPORTANT TO
STRATIFY THE PATIENT AND USING
THE MORPHOLOGY OF THE ARRHYTHMIA
AND ECG WHEN WE EVALUATE THE
PATIENT.
IN THIS ELEGANT PAPER YOU CAN
APPRECIATE THE MORPHOLOGY OF THE
PATIENT WITH THE MITRAL VALVE
PROLAPSE NOT ONLY RELATED TO THE
MITRAL REGURGITATION AND PLEASE
LOOK AT THE MORPH OLOLOGY WITH
BLOCK AND THE DIFFERENT TYPE
WITH THE THIS IS A CASE OF OUR
SERIES AND APPLY THE MORPHOLOGY
WITH THE BLOCK AND WE LOOKED AT
THE PAPILLARY MUSCLE.
ON THIS WE HAVE THE ALGORITHM BY
THE PATIENT WITH ARRHYTHMIAS
COMPARED TO SIMPLIFY FOR ALL
PATIENT AND FOR IMAGES THE
MORPHOMOR
MORPHOLOGY THAT IS UNCOMMON IN
ATHLETES THE POPULATION IS
TYPICAL FOR THE PATIENT WITH THE
FWAP.
DELAYED GAP.
THE PROBLEM IS THAT WE ARE NOT
ONLY THE MUSCLE BUT THE
MORPHOLOGY WITH THE JUNCTION AND
YOU SEE THE POPULATION AND THIS
IS THE NUMBER OF OUR POPULATION
NOT ONLY PATIENTS WITH
ARRHYTHMIA AND PROLAPSE AND
THERE'S A PROPORTION OF PATIENT
WITH ARRHYTHMIA BUT WITHOUT
FIBROSIS AND THIS IS THE
EXPERIENCE OF OUR GROUP AND ALSO
IN THE PAPER DESCRIBED THE GAP
IS NOT A CONSTANT IN PATIENT
WITH ARRHYTHMIAS AND MITRAL
VALVE PROLAPSE.
AND HOW DO WE JUSTIFY THE
PREVALENCE IN PATIENTS WITH CMR.
WE EVALUATED THE PATIENTS BUT I
WOULD SPECIFY A SELECTIVE
PATIENT BECAUSE WITHOUT
REGURGITATION AND THE PATIENTS
WERE DIVIDED ON THE PRESENCE OF
ARRHYTHMIAS WITH THE DEFINITION
BY THE DOCUMENT OF THE EUROPEAN
SOCIETY.
I CAN APPRECIATE THE NUMBER OF
PATIENTS ENROLLED COMPARED TO
OUR INITIAL PATIENT POPULATION
IS NOT A CONSTANT.
THIS IS THE ANTEROLATERAL WALL
BUT IN THE PAPILLARY MUSCLE MOST
IN THE POSTERIOR PAPILLARY
MUSCLE.
ALSO DEFINIING THE PRESENCE OF
ARRHYTHMIAS.
PATIENTS WITH ARRHYTHMIAS IN
TERM OF PRESENCE OF THIS AND
THERE'S A DIFFERENT ROLE OF THE
ISSUE IN THE GENESIS OF THE
PROFILE.
WE KNOW THE LATE GAP CAN
MAINTAIN ITS ROLE BUT THIS CAN
DEFINE AND DETERMINE THE
PRESENCE OF ARRHYTHMIAS AND THE
ACTION OF THE JUNCTION THAT'S A
BIG PART OF THE ARRHYTHMIC
APPROACH AND WE WERE UNABLE TO
PROVIDE THE PRESENCE OF THE
ARRHYTHMIAS.
THE COMBINATION OF IT WAS
TERRIBLE FOR THE PRESENCE OF
MALIGNANT ARRHYTHMIAS AND THIS
OBSERVES IN MY OPINION OFFERED
THE POSSIBILITY TO COMPREHEND
WHY MAD WAS PRESENCE AND NOT IN
PATIENT WITH DIFFERENT TYPE OF
ARRHYTHMIAS NOW WE CAN TALK
ABOUT THE VENUE OF THE
ARRHYTHMIAS AND OTHER
CARDIOMYOPATHY.
IF THE TRIGGER IS THE MECHANICS,
THEY CAN BE PRESENT ALSO WITH
THE PROLAPSE ON OTHER
CARDIOMYOPATHY AND PATIENTS WITH
ARRHYTHMIC PROFILE CAN HAVE A
DIFFERENT ARIDGE -- ARRHYTHMIC
EVENT.
THIS IS THE SEARCH PRIORITY FOR
VALIDATION OF OUR ANALYSIS TO
VERIFY THE DIFFERENT ROLE OF MAD
AND ALSO LATE GUARD AND THE
SECOND IS THE PROCESSING THE
EVALUATION OF LATE NOW WE ARE
APPLYING THE MAPPING THE
ANALYSIS AND MAPPING SOMETIMES I
THINK THE QUANTIFICATION OF THE
PRE LAPSE ABLE TO APPLY THIS IS
NOT SO EASY DUE TO THE SMALL
AMOUNT OF THIS BUT IS MANDATORY
AND THE IDEA IS ALSO TO EVALUATE
IN VIVO THE COURSE OF THE
PATIENT WITH THE LATE GUARD.
I DON'T KNOW IF IT CAN INCREASE
DURING THE TIME COURSE OF THE
PATIENT AND ALSO TO EVALUATE THE
PATIENT WITH THE NOT LATE GUARD
AND NOT SURE IF TOMORROW THE
PATIENT WILL DEVELOP A LATE GAP.
THANK YOU VERY MUCH.
>> THANK YOU FOR THAT
PRESENTATION.
ARE THERE ANY QUESTION OR
COMMENTS?
>> THAT WAS GREAT.
GREAT TO SEE YOU.
I HAVE A QUESTION TO THE
ELECTROPHYSI
ELECTROPHYSIOLOGY.
WHAT'S THE DIFFERENCE OF THE TWO
ARRHYTHMIA ONE IS AFTER THE
POLARIZATION AND TRIGGER
ACTIVITY CAN YOU GO IN MORE
DETAIL TO THE ELECTROPHYSIOLOGY.
>> I CAN'T ANSWER MORE THE
QUESTION BUT TO OUR POPULATION
ALL THE PATIENT WITH LATE GUARD
AND ARRHYTHMIAS BUT ARE NOT ONLY
BECAUSE DURING THE MONITORING WE
LOOK AT THE RIGHT VENTRICLE TO
THE DOT AND NOT SPECIFIC FOR
MITRAL VALVE PROLAPSE MVP WE'RE
TRYING TO EVALUATE THE ROLE OF
EXERCISE IN THE GENESIS OF THE
ARRHYTHMIAS BUT I THINK THE ONLY
STUDY WITH THE MAPPING -- I KNOW
THE MARKER -- SFWR YOUR
DESCRIBING THE MORPHOLOGY BUT
CURIOUS ABOUT IF IT'S RE-ENTRY
OR THE ELECTROPHYSIOLOGICAL
PROCESS.
>> I CAN JUMP IN.
WE PUT TOGETHER A DIAGRAM
EXPLAINING OF THE FOUR TYPES OF
ARRHYTHMIAS AND VENTRIC CLAR AND
TRIGGER RELATED AND TRIGGER
RELATED PVCs WHAT THE MECHANISMS
ARE TO EACH.
FOUR VT YOU CAN HAVE SCAR
RELATED VT AND FOR PVCs IT'S
TRIGGER RELATED AND DELAYED
AFTER THE POLARIZATIONS EVEN
WHEN IT COMES FROM THE PAPILLARY
MUSCLE.
>> THANK YOU.
>> AND DID YOU SEE BUNDLE BRANCH
BLOCKS LIKE MARTINA IDENTIFIED?
>> IT'S PRETTY CONSISTENT AND
PREDOMINANTLY PAPILLARY MUSCLE
PECs AND THE SECOND MOST COMMON
IS ALPHA TYPE AND WHAT I'D LOVE
SOMEONE TO LOOK AT IS IS WE
LOOKED AMOUNT THE TRACT AS ONE
THIRD BUT IT'S NOT LVOT LOOKING
BACK AT THE ABLATIONS WE'VE
DONE, NEARLY 100% IS LOCALIZED
TO THE RVOT.
IT'S PROBABLY RELATE THE
MECHANICS AND THE EARLIER
LITERATURE DID IT BASED ON EKG
CRITERIA WHICH WAS OFTEN OUR VOT
BUT THEY'RE SO CLOSELY LINKED
WITHOUT MAPPING YOU CAN'T BE
SURE.
>> IT WOULD BE GOOD TO LOOK AT
CONNECTSINS VERSUS VENTRICULAR
MUSCLE TO UNDERSTAND THE
MOLECULAR BASIS FOR THE TYPES OF
ARRHYTHMIAS YOU'RE SEEING.
>> A QUICK QUESTION.
IF THE CURLING IS THE ALMOST
DIVERSE OF THE MITRAL VALVE WITH
THE MOVEMENT OF THE ANNULUS,
THEY'RE ALL CO-LINEAR AND THE
HALF CURLING BECAUSE IT REMAINS
ATTACHED.
SO CAN YOU SORT OUT THE EFFECT
OF CURLING VERSUS MAD ON THE
ARRHYTHMIAS?
IT MUST BE VERY DIFFICULT.
>> YEAH.
THANK YOU FOR THE QUESTION.
I THINK THAT'S VERY DIFFERENT TO
DEFINE THE ROLE OF MAD AND THE
CURLING BUT I WOULD LIKE TO
DISCUSS WITH YOU NOT ONLY THE
CURLING BUT THE PORTION.
DO YOU SEE PATIENT WITH THE THIN
WALL ON THE MID PORTION ON THE
CONTRARY WE HAVE MOVEMENT
WITHOUT IMPRESSIVE AMOUNT AND
THE PROPORTION.
WE LOOK AT THE MYOCYTE OF THE
DIFFERENT LOCATION AND THE TYPE
OF MITOCHONDRIA ARE VERY
DIFFERENT.
I CANNOT QUANTIFY THE ASSESSMENT
AND THE AMOUNT ON CMR IS NOT THE
SAME AS THE ECHO BUT SOMETIMES
WE HAVE THE MOVEMENT AND IT'S
DIFFERENT AND I THINK WE HAVE
ONLY FRAUM OF THE PICTURE NOT
ONLY THE TIME COURSE.
>> IT'S PULLING EVERY BEAD
WITHOUT RESISTANCE SO THE MUSCLE
UNDER THE POSTERIOR LEAFLET AND
COMES BACK LIKE YOU INTRODUCE A
FINGER IN THE GLOVE AND COMES
BACK TO THE NORMAL POSITION AND
IN SYSTOLE YOU HAVE THE RUPTURED
TENDON OF THE ANNULUS AND THE
MUSCLE MUST BE ABNORMAL.
WHEN YOU RE-ATTACH IT BY REPAIR
THEN IT LOOKS NORMAL BUT LOOKS
ECHO BY NORMAL DIDN'T MEAN IT IS
NORMAL.
THE MUSCLE MUST BE ABNORMAL
FUNDAMENTALLY I DON'T KNOW IF
YOU HAVE LOOKED AT THE WALL BUT
WHAT THERE IS THE DETACHMENT AND
THE MOVEMENT AND WHAT IS IS IN
SYSTOLE IS STRIKING.
SFWR
>> THERE'S DIFFERENT PATHOLOGY
AND
>> THEY REATTACH THEM AND COME
BACK LIKE THE REST OF THE
VENTRICLE.
IT'S JUST A MECHANICAL EFFECT OF
THE DETACHMENT WHICH WE OBSERVED
SO IT'S VERY INTERESTING.
WE LOOK FORWARD TO SEEING THE
PAPER.
>> BRIEFLY, MICHAEL.
>> THANKS, FRANK.
THE LEFT OUTFLOW TRACK LOCATION
THERE IS CERTAINLY WOULD NOT BE
THE PORTION I THINK IS MOST
DISTRESSED BY PROLAPSING LEA
LEAFLETS.
IS THAT ADJACENT TO THE SUB
AORTIC MEMBRANE OR THE BODY ON
THE INSERTION INTO THE LEFT
VENTRICLE.
I COULDN'T SEE WHERE HE WAS
ABLATING.
>> THE SECOND MOST COMMON SOURCE
IS OUTFLOW TRACK.
AND LVOT IS THE MOST COMMON.
THE PLACES WE TYPICALLY SEE IT
AND SOMETIMES WE DEFINE IT ON
BEING ABLATED AND THEN WENT
AWAY.
IT'S POSSIBLE WE ABLATE IN THE
CUSP BETWEEN THE LEFT AND RIGHT
COMMISURE BUT IN REALITY IT'S
COMING FROM BENEATH THAT.
THAT WAS IN THE INTERLEUKIN
LOCATION AND IN YEARS PAST WE
PROBABLY ABLATED ON THE AORTA
SIDE AND GAVE ENOUGH ENERGY
UNDERNEATH IT AND IT'S A MEDIAL
REPRESENTATION OF FOR EXAMPLE WE
ABLATE AND KEEP MOVING OUR WAY
OVER.
>> THAT'S THE BETWEEN THE NON
AND LEFT CUSP BUT ISN'T IT
INTERESTING ALMOST ALL THE
CALCIFIED FIBROSIS IN BARLOW'S
IS AROUND THE ANCILLARY MUSCLE.
YOU CAN GET ANYWHERE BUT MOST
THE SCARRING WE SEE IN BARLOW'S
IS IN THE ANTERIOR PAPILLARY
MUSCLE RENAL -- REGION.
I DON'T KNOW WHY THAT IS.
>> THANK YOU FOR THE
PRESENTATION AND DISCUSSION.
DR. MILLER, YOU'RE THE FINAL
PRESENTATION OF THIS SESSION.
>> THANK YOU TO THE ORGANIZERS.
I'VE BEEN ASKED TO SPEAK ABOUT
RISK STRATIFICATION FOR SUDDEN
DEATH IN PATIENTS WITH MILD OR
MODERATE MR.
I LOVE THE QUOTE WE REACHED THE
STAGE OF IDENTIFYING CLINICAL
PROBLEM.
AND SO WHY DOES RISK
STRATIFICATION MATTER IT'S TO
AVO
AVOID SUDDEN DEATH AND ICD.
PRIMARY PREVENTION WILL GO TO
DEVICE COMPLICATION AND THIS IS
WHERE THERE'S YOUNG PATIENTS
WITH PRESERVED FUNCTION OR
INCREASED RISK OF SUDDEN DEATH.
WHETHER PRESENT OR NOT THERE'S
CLEARLY A FEAR OF THE UNKNOWN
DRIVING A LOT OF CLINICAL
DECISION MAKING WHEN IT COMES TO
RISK STRATIFICATION.
THIS IS HOW I VIEW THE PENDULUM
OF SUDDEN DEATH OCCURRING.
SO 1972 THE FIRST DESCRIPTION OF
SUDDEN DEATH IN PATIENTS WITH
PROLAPSE AND FOR MANY YEARS IT
REMAINED RELATIVELY QUIET AND
LOOKED AT THE PROLAPSE SYNDROME
AND PEOPLE STARTED BECOMING
AWARE.
AND DIDN'T KNOW WHAT TO DO WITH
THE INFORMATION BUT THEY WERE
AWARE OF THE CONDITION.
AND OBVIOUSLY THE GROUP CAME
TOGETHER A FEW YEARS AGO AND
PUBLISHED AN IMPORTANT DOCUMENT
OF RESEARCH OPPORTUNITIES IN
MITRAL VALVE PROLAPSE AND MORE
PEOPLE BECAME.
OVER THE NEXT FOUR YEARS YOU
HAVE FEAR OUT THERE.
IF YOU LOOK AT THE PUBLICATIONS
OF PEOPLE WITH SUDDEN DEATH
SKYROCKETED AND SO THEY'RE AWARE
BUT NOT SURE WHAT TO DO.
I WANT TO USE AN EXAMPLE FROM
TWO OTHER CONDITIONS.
THERE'S THE FEAR OF DROPPING
DEAD.
FROM THE PATIENT AND PHYSICIAN
PERSPECTIVE.
AT THAT TIME THERE WAS A
PETITION FROM A CITIZEN IN THE
U.K. WHO SUED BECAUSE HE PASSED
WITHOUT DOCUMENT AND GOT 10,000
SIGNATURES WHICH BASICALLY SAID
THEY WOULD APPROVE AN ICD FOR
ANYONE WITH THE BRUGADA SYNDROME
AND IF YOU LOOK AT THE INCIDENTS
OF SUDDEN DEATH IN THE SYNDROME
IT'S QUITE LOW.
THIS IS SIX MAIN STUDIES AND
PATIENTS WHO DID NOT GET PRIMARY
PREVENTION ICDs AND FOR ALL
COMERS THE RISK OF SUDDEN DEATH
WAS .02%.
THERE'S RISK FACTORS TO DECIDE
WHO WOULD BENEFIT.
AND RISK STRATIFICATION DOES
WORK.
THIS IS HYPERTROPHIC
CARDIOMYOPATHY BASED ON EVIDENCE
AND OVER THE COURSE OF THE LAST
TWO DECADES THE RISK OF SUDDEN
DEATH DROPPED DRAMATICALLY FOR
HYPERCARDY MYOPATHY.
THE MAJORITY OF SUDDEN DEATH
OCCURS IN PATIENTS WITH MODERATE
MR.
AND AS WE ALL KNOW THE INCIDENTS
OF MVP IS 4% OF THE POPULATION
AND INCIDENTS OF SUDDEN DEATH
COULD BE UP TO 1. 8%.
THE QUESTION BECOMES HOW DO WE
IDENTIFY THAT PERSON AND
INTERVENE BEFORE CARDIAC ARREST.
THIS IS HOW I TEND TO THINK
ABOUT AND THERE'S A LARGE
POPULATION OF MVP AND SUDDEN
DEATH.
AS YOU START TO ADD UP ALL THE
RISK FACTORS AND THE RISK GOES
DOWN BUT INCIDENTS GO UP
SIGNIFI
SIGNIFICANTLY.
HOW DO PREVENT THIS FROM
MALIGNANT MVP AND WHO SHOULD BE
RISK STRATIFIED.
ACCORDING TO THE CONSENSUS
DOCUMENT EVERYBODY SHOULD BE
RISK STRATIFIED AND THERE'S
ALGORITHMS OUT THERE.
ALMOST EVERY JOURNAL PUBLISHED A
RISK STRATIFICATION ALGORITHM
AND I RECOGNIZE THERE'S MULTIPLE
AUTHORS OF THE DOCUMENT ON THE
CALL RIGHT NOW.
THIS IS THE EF -- EHR CONSENSUS
STATEMENT AND HAVE SYMPTOMS AND
HAVE SOME PVCs AND THAT'S WHEN
THE ELECTROPHYSIOLOGIST TENDS TO
GET INVOLVED.
AT TWO DECISION POINTS TO THE
LEFT SIDE AND THE PHENOTYPIC
RISK WITH VT OR IF YOU HAVE VT
THEN IT BECOMES A QUESTION OF
HIGH RISK VT.
THOSE ARE THE TWO BRANCH POINTS.
SOME OF THE ISSUES I'VE HAD IS
FOR EXAMPLE YOU HAVE NO
VENTRICULAR TACHYCARDIA AND DO
WE BELIEVE THE INVERSIONS ARE
EQUAL TO PVCs ON THE EKG?
SO THIS HAS BEEN PRESENTED
ALREADY.
THE EARLY DETE SUGGESTED MAD WAS
CORRELATED WITH MSVT AND THE
AMOUNT WAS CORRELATED WITH LGE
AND SEEMED TO BE A HIGH RISK OF
ARRHYTHMIAS IN PATIENTS WITH
MAD.
BUT THERE'S MORE RECENT DATA
SUGGESTS THE MAD IS NOT
PREDICTIVE OF ARRHYTHMIC EVENTS
AND PATIENTS WITH THIS IT WAS
NOT PREDICTIVE AND LGE WAS AND
THIS IS A LARGE RADIOLOGY
STUDIO.
AND MITRAL DYSFUNCTION MAY BE
OVER EMPHASIZED AND
THREE-QUARTERS OF THE PATIENTS
WOULD HAVE BEEN DIAGNOSED AND
THE ONLY MAD RELEVANT IS
ASSOCIATED WITH MITRAL VALVE
PROLAPSE.
AND THIS IS AN INTERESTING
MACHINE LEARNING STUDY.
THE CLUSTER TO THE RIGHT HAD A
FO
FOURFOLD DEATH AND THE PRESENCE
WAS NOT PREDICTIVE IN THE MODEL.
MYOCARDIAL FIBROSIS IS RELATED
AND SEEMS TO BE PREDICTIVE OF
MAJOR ARRHYTHMIC EVENTS AND THE
PRESENCE OF LGE AND IT WAS 7.7%
OF THE PATIENTS OF MAJOR
VENTRICULAR ARRHYTHMIAS AND AND
THE OTHER MRI STUDY LAST YEAR
SHOWED THE PRESENCE OF LVE WAS
ASSOCIATED WAS ASSOCIATED WITH A
TENFOLD HIGHER RISK OF ABORTED
SUDDEN DEATH AND SHOULD WE TREAT
IT EQUAL TO LG?
THEN WE MOVE TO THE RIGHT SIDE
AND LOOK AT FAST NON SUSTAINED
VT GREATER THAN 180 BEATS A
MINUTE.
THIS IS A PATIENT OF MINE,
56-YEAR-OLD FEMALE MINIMAL AR
AND SMALL AMOUNT OF LGE IS
PRESENT AND THIS IS HER EVENT
MONITOR 8.8 SECONDS AT 182 BEATS
A MINUTE.
IF I WERE TO FOLLOW THAT
ALGORITHM DOWN THE PATIENT WOULD
QUALIFY FOR AN LCD.
IF YOU LOOK BACK A LOT OF IT IS
THE DEFINITION OF WHERE DID IT
COME FROM.
FOR THE PATIENTS OF HIGH RISK VT
OF THE STUDIES MOST WOULD MEET
CRITERIA BASED ON THIS OF THE VT
RUN GREATER THAN 180 BEATS A
MINUTE.
THE RISK ASSOCIATED CAME FROM
THE IMPORTANT PAPER ON THE
OUTCOMES OF MITRAL VALVE
PROLAPSE WHICH SHOWED AND
OUTCOMES WERE WORSE WHEN IT WAS
PRESENT.
AND IF YOU LOOK AT WHERE THE
COMBINATION CAME FROM IT CAME
FROM THE PAPER IN 2005 WHICH IS
THREE PATIENTS WHO HAD RVO VT
GREATER THAN 180 BEATS A MINUTE
THAT'S A DIFFERENT POPULATION
COMPLETELY AND I'M NOT SURE ANY
OF OUR DEFINITIONS FOR COMPLEX
VENTRICULAR ARRHYTHMIAS HAVE
BEEN CONTEMPLATED IN PATIENTS
WITH MITRAL VALVE PROLAPSE AND
WILL WE END UP IMPLANTING TOO
MANY AND LOOKING AT THE
MISTAKES.
WHO LOOKED AT THIS?
THEY APPLIED THE CONSENSUS
DOCUMENT STATEMENTS TO THEIR OWN
PATIENT POPULATION OF 169
PATIENTS RETROSPECTIVELY.
IF THEY APPLIED AT THE TIME IT'S
YOUNG PATIENTS GET PRIMARY
PREVENTION ICDs.
I'LL HAVE A COUPLE CASES AND SEE
HOW IT COULD BE MANAGED WITH OR
DIFFERENT THAN THE DOCUMENT.
THIS IS 66-YEAR-OLD MALE WITH
MITRAL VALVE PROLAPSE AND MR AND
RARE PVCs AND BEATS GREATER THAN
200 BEATS PER MINUTE AND SHOWED
DISJUNCTION.
SO THE QUESTION IS WHAT WOULD
YOU DO IN A SITUATION LIKE THIS?
IMPLANT AN ICD OR DO A STUDY OR
BETA BLOCKERS OR ADDITIONAL
IMAGING OR CONTINUING TO
MONITOR?
WE DECIDED TO DO ADDITIONAL
IMAGING TO GET MORE INFORMATION.
WE DID A HYBRID PET MRI AND
LOOKED AT UPTAKE THAT WAS
CONCORDANT IN THE TYPICAL
LOCATION YOU'D EXPECT TO SEE IN
MITRAL VALVE PROLAPSE.
ULTIMATELY THE DECISION WOULD
HAVE BEEN TO PUT IN AN ICD.
MY PERSONAL OPINION WAS THIS
FINDING IS COMMON AND THE CON
STELATIONS OF FINDING AND WE
RECOMMENDED BETA BLOCKERS FOR
THE TIME BEING.
CASE 2 IS A 40-YEAR-OLD FEMALE
AND THE RARE PVCs AND 142 BEATS
A MINUTE AND 12 MILLIMETER OF
DISJUNCTION AND NO LGE BY
REPORT.
YOU'RE MRI SHOWED THE BEATS AND
THE LEFT IS THE LGE MAP AND
UPTAKE IN THE PAPILLARY MUSCLE.
THEY ARE HAVE SLOW SET AND
SUBSTRATE.
IT DOESN'T TAKE INTO ACCOUNT ANY
OF THE POTENTIAL RISK FACTORS
WHICH MAY BE RELEVANT.
WE DECIDED TO DO WORK UP AND IN
THE PATIENT THE STRAIN IMAGING
SHOWED ABNORMAL MECHANICAL
DISPERSION, 86 MILLISECONDS NOW
THE PATIENT HAS MULTIPLE RISK
FACTORS AND SLOW NSBT AND
FIBROSIS AND FDG UPTAKE AND
ABNORMAL MECHANICAL DISPERSIONS
AND THE QUESTION REMAINS WHAT TO
DO WITH THE PATIENT.
PERHAPS AN INTERVENTION IS
NECESSARY.
WE KNOW STRAIN IMAGING MAY BE
USEFUL FOR ADDITIVE VALUE THON
-- ON THE RISK FACTORS AND
THERE'S RHYTHMIC AND
NON-ARRHYTHMIC CAUSES OF SUDDEN
DEATH.
CASE NUMBER 3 IS A FEMALE AND
THIS SHOWED A PICKLE HUB AND PVV
BURDEN OF 6%.
THREE EPISODES OF NSVT AND THE
LONGEST WAS 12 BEATS, 167 A
MINUTE AND TECHNICALLY THE
PATIENT HAD A PVC BURDENED AND
UNDERWENT A HYBRID PET MRI
PROTOCOL.
AND IN THIS PATIENT I BASICALLY
FOLLOWED ALMOST INADVERTENTLY
WHERE THE ARROWS WOULD HAVE LEFT
ME AND RECOMMENDED A LOOP
RECORDER AND NO REAL VT,
MULTIPLE RISK AND WE DECIDED TO
IMPLANT AN IOR.
IT GETS IMPLANTED AND THEN AN
EPISODE OF POLYMORPHIC ICT WITH
A BRIEF EPISODE OF DIZZINESS.
TO ME IT'S ALWAYS CONCERNING AND
RECOMMENDED A PRIMARY ICD IN
THIS PARTICULAR PATIENT.
THIS IS MY BASIC APPROACH AND
NOT VALIDATED IN ANY WAY JUST MY
OPINION HOW I TYPICALLY MANAGE
PATIENTS WHO HAVE MVP WITH
MODERATE MR.
IF THEY HAVE COMPLEX VENTRICULAR
ECTOPY WE HAVE A RECORDER AND IF
THEY HAVE EPISODES OF
NON-POLYMORPHIC MVP WE RECOMMEND
ICD AND WHAT IF THEY HAVE FOUR
OR FIVE OTHER PHENOTYPIC RISK
FEATURES THEN YOU NEED A
DISCUSSION ABOUT THE PATIENT
IT'S ESSENTIALLY A DATA FREE
STONE AT THE TIME BUT WOULD BE
REASONABLE TO CONSIDER AN ICD.
IF THE PATIENT HAS COMPLEX ECTO
I AND SYNCOPE YOU ARE OBLIGATED
TO AN ILR OR ICD AND TRUE S
SYNCOPE IS A BAD PRODOME IN
PATIENTS WITH THIS AND ASSUMING
THEY HAVE FOR EXAMPLE THEY
PASSED OUT WITH NO AWARENESS IT
WAS GOING TO HAPPEN IS SOMETHING
TO BE CONCERNED ABOUT.
THE OTHER COMMON QUESTION THIS
SOMETIMES TONIGHT GET ADDRESSED
WHAT IF THEY HAVE A PVC BURDEN
OF 12% THE PATIENT IS HIGHER
RISK.
I LOOK AT IT DIFFERENTLY.
IF IT JUST COMES FROM THE
PAPILLARY MUSCLE OR OUT LOW
TRACK IT'S A SLIGHTLY DIFFERENT
PATIENT THAN THREE OR FOUR
MORPHOLOGIES.
WE OFTEN RECOMMEND TO TREAT THE
PVCs AND THEN BEGIN THE RISK
STRATIFICATION PROCESS
ESSENTIALLY FROM ZERO.
THERE'S MORE DATA NEEDED TO
CHARACTERIZE THE PHENOTYPE OF
THAT TRANSITIONS TO MALIGNANT
MVP AND BE ABLE TO ASSIGN A
SCORE ON RISK OF SUDDEN DEATH
AND DECIDE WOULD GETS AN ICD
JUST LIKE FOR HYPERTROPHIC
CARDIOMYOPATHY AND THAT'S THE
DATA WE'LL TRY TO COLLECT FROM
THIS ONGOING TO STUDY IN
PATIENTS UNDER GOING TO PET MRI
AND MITRAL VALVE PROLAPSE AND
THE SURGICAL AND NON-SURGICAL
GROUP AND THE NON-SURGICAL GROUP
WE'LL TRY TO LOOK AT THE
CLINICAL CHARACTERISTICS WITH
THE ARRHYTHMIC EVENTS.
AND AS SHOWN BEFORE THIS IS THE
BREAK DOWN FOR MY PARTICULAR
AREA IS THE NON-SURGICAL COHORT
AT THE BOTTOM AND HOPEFULLY WILL
BE ABLE TO IDENTIFY WHICH
PATIENTS ARE HAVING THESE
LIFE-THREATENING ARRHYTHMIAS.
I WANT TO THANK EVERYONE ON THE
RESEARCH TEAM WHO HELPED PUT ALL
THIS TOGETHER AND ALL MY
CO-PRIMARY INVESTIGATORS.
THANK YOU.
>> THANK YOU VERY MUCH.
ANY QUESTIONS OR COMMENTS?
>> A BRIEF ONE.
PATIENTS HAVE SUDDEN DEATH AND
THEY'RE RESUSCITATED.
I'M ALWAYS SURPRISED WHEN I SEE
PATIENTS LIKE THAT AND THE ONES
WE SEE, THREE AND FOUR YEARS AGO
THEY HAD SUDDEN DEATH AND MITRAL
REGURGITATION AND THEY ARE GOT
AN ICD AND BECOME SYMPTOMATIC
AND THEN HAVE SURGERY.
I'M ALWAYS SURPRISED SUDDEN
DEATH IN THE FIELD DOESN'T LEAD
TO LOOKING AT THE MITRAL VALVE.
WE WEREN'T THINKING ABOUT IT
THAT WAY THREE OR FOUR YEARS AGO
BUT TODAY BUT IF YOU HAVE SUDDEN
DEATH IN THE FIELD AND YOU HAVE
SIGNIFICANT PROLAPSE AREN'T YOU
A CANDIDATE FOR SURGERY?
>> TWO COMMENTS.
ONE IS THERE'S A DELAY.
LIKE WE LOOKED AT SOME OF OUR
DATA AND THERE SEEMS TO BE FROM
WHEN A PATIENT GET A SECONDARY
PREVENTION ICD SEEMS TO BE ON
AVERAGE 7 TO 10 YEARS.
THERE'S TWO REASONS THEY'RE NOT
GOING TO FOR SURGERY.
NUMBER ONE IS THEY'RE NOT
RECOGNIZED AS MITRAL VALVE
PROLAPSE IS A CAUSE FOR SUDDEN
DEATH AND EVEN FOR MYSELF I SAW
A PATIENT TWO WEEKS AGO I PUT IN
AN ICD IN 2015 AND NEVER DID IT
DAWN ON ME THE PATIENT'S
PROLAPSE WAS THE CAUSE OF SUDDEN
DEATH.
NOW LOOKING BACK ON IT NOW IT
LOOKS FOOLISH BUT AT THE TIME I
DID NOT RECOGNIZE IT.
THE SECOND ISSUE IS I'M NOT SURE
OUT IN THE FIELD EVENT TODAY
PATIENTS HAVING MVP WITH
MODERATE MR AND HAVING STUDDEN
DEATH RECOGNIZED THE SUDDEN
DEATH AND AWARENESS IS BETTER
THAN 10 YEARS AGO BUT COULD
STILL BE BETTER.
>> YOU LIKE TO BE CONTROVERSIAL
BECAUSE THAT'S AND AT THE TIME
THERE WAS A DESIRE TO PUT ICD AS
IF IT WAS THE ANGEL OF DEATH.
AND WE SAY THE ICD IMPLANTATION
IS BASED ON ARRHYTHMIA AND THE
IMAGING IS THE REASON TO DO MORE
ARRHYTHMIA MONITORING.
THE GENERAL GUIDELINES ON VALVE
DISEASE THE WORD HOLDER IS ONE
TIME PRESENT IN VALVE DISEASE.
WE WANTED TO HAVE THE HOLDER AND
RHYTHM MONITORING AS PART OFF
THE TESTING DONE IN PATIENTS
WITH VALVE DISEASE.
EVIDENTLY THE DATA IS SMALL AND
WE NEED 10,000 PATIENTS HOLDER
AND LONG-TERM SURVIVAL AND HAVE
THE OUTCOME IN 10 YEARS.
FOR NOW WE PRESENTED WHAT WAS
KNOWN AT THE TIME AND MAYBE SOME
OTHER CRITERIA WILL APPEAR IF WE
HAVE THE PROPER STUDIES.
IT'S A NICE HYPOTHESIS WE HAVE
AT LGE BUT IF YOU LOOK AT THE
STUDIES THEY HAVEN'T LOOKED AT
THE MAD.
THE BRITISH STUDY AND DATABASE
AND BIO BANK IF YOU LOOK AT THAT
I'M NOT SURE I TRUST THE
DIAGNOSIS THEY HAVE AND I'M NOT
SURE I WOULD TRUST THE FIBROSIS
DIAGNOSIS.
I REVIEWED THE PAPER.
TO SAY IT'S MORE FIBROSIS THAN
MAD.
WE DON'T KNOW YET.
WE NEED VERY GOOD ATTENTIVE
STUDIES TO SAY OKAY, WHAT IS THE
SPAN OF THE SCIENCE THAT ARE
ASSOCIATED WITH THE ARRHYTHMIC
MITRAL VALVE PROLAPSE AND WHAT
IS ASSOCIATED WITH EXCESS
MORTALITY.
WE'RE JUST AT THE BEGINNING AND
HOPING TO REDO THE GRAPH WHEN WE
HAVE MORE OUTCOME STUDIES BUT I
WANTED TO DEFEND --
>> YOU MAKE A GOOD POINT.
IT'S IMPORTANT THAT FINALLY
MONITORING HAS COME TO SOME
DOCUMENT.
A LOT OF PATIENTS ARE SHOWING UP
WITH THE DEFIBRILLATOR PUT IN
ALREADY OR THEY'RE GETTING A
SECOND OPINION.
THE DIFFERENCE IS FOR EXAMPLE
YOU CAN DECIDE WHAT IT IS AND
MOST OF THE PATIENTS I'VE SEEN
INCLUDING PHYSICIANS SHOWING UP
WITH PRIMARY PREVENTION ICDs AT
THE AGE OF 35 THEY GOT AN MRI
AND THE READER WROTE MITRAL
ANNULAR DYSFUNCTION AND THE
CARDIOLOGIST SENT THEM TO GET'
DEFIBRIL
DEFIBRILLATOR.
>> WE'RE IN AGREEMENT.
WE SEARED IT IN A WAY WE WOULD
NOT BE PUTTING ICDs RIGHT AND
LEFT WITHOUT REASON.
AND WE HAVE TO MOVE TO
DEMONSTRATE SEVERE ARRHYTHMIA
AND THEN WE'LL TALK.
NOW, THE DEFINITION I THINK A
MOVING TARGET AND WE HAVE LITTLE
DATA.
YOU ARE RIGHT.
THE PEOPLE WANT TO PUT ICDs LIKE
THEY FEEL SAFER BUT SAFER WITH
THE ICD.
>> AND I'M AN ELECTROPH
ELECTROPHYSIO
ELECTROPHYSIOLOGIST.
I GET PAID TO PUT IN ICDs.
>> THANK YOU FOR THE
PRESENTATION AND DISCUSSION AND
WE'LL TAKE A BRIEF BEAK UNTIL 20
MINUTES AFTER THE HOUR AND BEGIN
THE FINAL SESSION OF THE
MEETING. THANK YOU.
YOU SEE HERE THE CLASSIC FORM
OF DMR CLASSIFICATION.
YOU SEE THE PAPER IN THE
COMMUNITY WHERE WE HAVE ALL THE
PATIENTS DIAGNOSED WITH ISOLATED
MITRAL REGURGITATION ORGANIC EMR
APPROXIMATELY ONE-THIRD AND THE
MAJORITY, 72% OF THE ORGANIC MR
ARE CAUSED IN THE U.S. CURRENTLY
WITH A FEW PERCENT WITH ALL THE
OTHER CAUSES THOUGH THE MOST ARE
DUE TO FUNCTIONAL MR.
AND THE FIRST THING IS MITRAL
VALVE REPAIR IS CLASS I
INDICATION IN THE EUROPEAN AND
U.S. GUIDE LINES AND REPAIR IS A
SIMPLE BUT THE SURGICAL REPAIR
INCLUDES SEVERAL THERAPEUTIC
PARTS HERE IS RESECTION AND
OFTEN RESECTION AND THREE
THERAPIES TO TREAT THE PATIENTS
AND YOU SEE THE SURVIVAL IS
BETTER THAN MITRAL VALVE
REPLACEMENT ALMOST IDENTICAL TO
THE ORANGE WHICH IS THE EXPECTED
SURVIVAL AND RESTORING LIFE
EXPECTANCY AS MANY SPEAKERS HAVE
INSISTED.
AND THE QUESTION IS DOES THAT
INDICATE HIGH QUALITY VALVE
REPLACEMENT AND WE LOOKED AT THE
REGISTRY AND SEE WITH ANY
ADJUSTMENT REPAIR IS BETTER THAN
REPLACEMENT AND AND YOU CAN HAVE
BETTER OUTCOME THAN REPLACEMENT
AND BECAUSE OF THAT AND
PERFECTION IN THE REPAIR
PERFORMED IS ESSENTIAL.
THE GUIDELINES BASED ON THE
REPAIR, RESTORE LIFE EXPECTANCY
INDICATE ON THE LEFT SIDE THE
PEOPLE WITH EITHER SYMPTOMS OR
LV DYSFUNCTION NEED TO HAVE
MITRAL SURGERY FOR FURTHER
REPAIR BUT THE PATIENT ON THE
RIGHT SIDE ASYMPTOMATIC THINK
ABOUT REPAIR IF YOU THINK YOU
CAN REPAIR THIS VALVE AND MAYBE
THAT ATTITUDE OF DON'T LOOK AT
ANYTHING ELSE HAS NOT BEEN A
POSITIVE THING OF THE GUIDELINE.
YOU SEE THE RISK ASSOCIATED WITH
SEVERE MR AND PROLAPSE THE
BOTTOM CURVE IS FOR MODERATE OR
SEVERE NRM OR REJECTION FRACTION
AND HAVE EXCESS MORTALITY AND IN
THE SYMPTOMATIC MR WITH NORMAL
EF AT THE BEGINNING THERE'S
EXCESS MORTALITY IN THE PATIENTS
WHO HAVE A VERY LARGE DEGREE OF
MR.
SO MR SEVERE IS BAD OUTCOME.
SHOULD WE WAY FOR THE CLASS 1
SYMPTOMS AND LOW EF AND THERE'S
TWO TYPES OF WORK THAT SAY NO,
DO NOT WAIT.
ON THE LEFT SIDE IS THE MAYO
STUDY WE DID ON ALL PATIENTS
OPERATING THOSE WITH CLASS 1 ON
THE LEFT AT THE BOTTOM HAVE IS
THE WORSE SURVIVAL AS COMPARED
TO EARLY SURGERY EVEN ADJUSTING
FOR ALL DIFFERENCES.
AND RECENTLY IN THE EUROPEAN
JOURNAL OF IMAGING A PAPER
SHOWING MORE TRIGGERS ARE
ASSOCIATED WITH MORE MORTALITY
AND IN PARTICULAR CLASS I
TRIGGERS THE MORE YOU HAVE THE
MORE SURVIVAL IS.
THE BEST TIME IS EARLY SURGERY.
IT'S PREFERRED.
WHEN THEY DID THAT IN THE
REGISTRY WE OBSERVED THAT IN THE
OVER ALL POPULATION AND IN
PROPENSITY SCORE MATCHED EARLY
SURGERY HAD A BETTER SURVIVAL
AND LOWER HEART FAILURE RATE
THAN PATIENTS WHO AFTER THE
FIRST THREE MONTHS WERE
MEDICALLY UNTIL THEY REQUIRED
SURGERY.
SO THE OUTCOME WAS BETTER WITH
EARLY SURGERY.
HAVING REPAIR AND THE BEST
TREATMENT AND IN THE COMMUNITY
ONLY 37% OF PATIENTS WITH
MODERATE OR SEVERE MR ARE EVER
OPERATED.
37% ONLY AND BECAUSE OF THAT
THESE PATIENTS WITH MODERATE OR
SEVERE MR IN THE COMMUNITY HAVE
AN EXCESS MORTALITY RATE
COMPARED TO THEIR EXPECTED
MORTALITY IN THE SAME COMMUNITY.
SO WE ARE NOT SUCCESSFUL IN
INDICATING SURGERY IN THE
PATIENTS AND THE GUIDELINES HAVE
NOT ACHIEVED AN ACCOMPLISHMENT
OF TREATMENT BY MITRAL VALVE
REPAIR IN AND OF PATIENTS.
AND THIS LACK OF TREATMENT IS
RELATED TO IMPRESSION OF
MORTALITY.
AND OVERTIME IN THE '90s WE
OBSERVED THAT THE REPAIR FOR
GENERATIVE MR INCREASED MARKEDLY
AND THE MORTALITY DECREASED
MARKEDLY BUT SEE IN THE OLDER
PATIENTS THE RISK IS STILL
SIGNIFICANT AND MORE RECENT WORK
SHOWS THE EXPERIENCE WITH SES
WHERE THE MEDIAN MORTALITY IS
0.43% WHICH IS VERY LOW BUT IF
YOU LOOK AT THE NUMBER OF MITRAL
OPERATIONS DONE BY HOSPITAL, THE
HOSPITALS WITH LESS THAN 10 IS
REPRESENT ALMOST A QUARTER OF
THE PATIENTS OPERATING FOR
MITRAL VALVE DISEASE AND
MORTALITY WHICH IS HIGHER, 2%
AND CONVERSE TO VALVE
REPLACEMENT THE HIGHEST AND WITH
THE HIGHER OPERATING MORTALITY.
SO FOR THE CARDIOLOGIST
REFERRING THE PATIENTS IF YOU
HAVE ACCESS TO A BIG CENTER WITH
LOW MORTALITY IT'S OKAY BUT IN
PATIENTS WITH DMR IN GENERAL IN
THE POPULATION THE RISK INCURRED
AT INTERVENTIONS ARE DETERRENT
TO EARLY SURGERY BECAUSE WE ARE
AS PHYSICIAN RISK AVERSE.
SO WE HAVE TO DO A COMPARISON TO
SOMETHING THAT WE CAN DO FOR THE
PATIENT AND TO THE NATURE
HISTORY.
SO IN THE PATIENTS WITH THE VERY
HIGH RISK THERE IS THE REPAIR
AND THE EVEREST TRIAL HERE YOU
QUAN SEE SURGERY DID BETTER THAN
PERCUTANEOUS TREATMENT.
BECAUSE OF THE IMPROVEMENT IN
FUNCTIONAL CLASS WITH THE
DEVICE, THE DEVICE WAS APPROVED
EVEN THOUGH THE RESULTS IN THE
DEGENERATIVE MR THE PINK ON THE
SECOND LINE OF NOT AS GOOD AS
SURGERY BUT WAS NEVERTHELESS
APPROVED.
WE DON'T KNOW BASED ON THAT
BECAUSE IT WILL NOT BE AN
ADDITIONAL TRIAL VERSUS MEDICAL
TREATMENT WITH THE DEVICE THAT
WE DON'T KNOW THE OUTCOMES OF
THE PATIENTS.
AND SO IT'S BEEN IN THE
GUIDELINES IF THE PATIENT HAS
SURGICAL RISK AND MORE THAN ONE
YEAR OF EXPECTED LIFE THAT THEY
SHOULD HAVE TRANS CAN TER EDGE
TO EDGE TREATMENT.
AND COMPARED THE REGISTRY OF
MULTIPLE CENTERS FOR TER AND FOR
THE UNOPERATED PATIENTS.
YOU CAN SEE COMPARING THE TWO
GROUPS EVEN WITH MATCHING OF THE
BASELINE CHARACTERISTICS WITH
TREATMENT OF THE MR PROVIDED A
BETTER RESULT THAN THE
UNOPERATION OF THE PATIENTS AT
HIGH RISK.
THE PROBLEM IS RESIDUAL MR.
THERE'S OFTEN RESIDUAL MR AND
THAT'S THE GREEN CURVE MODERATE
OR SEVERE RESIDUAL MR THE
SURVIVAL AFTER THE INTERVENTION
IS AS BAD AS THE UNOPERATED
PATIENTS.
SO IT IS CLEAR THAT FOR THE
PATIENT TREATED THERE'S A NEED
FOR PERFECTION IN TREATMENT.
IF WE LOOK AT THE EUROPEAN
GUIDELINES THEY ARE ARE
DIFFERENT FROM THE AMERICAN
GUIDELINES BECAUSE THERE ARE
ADDITIONAL TRIGGERS FOR SURGERY
HERE, ATRIAL FIBRILLATION AND
SYSTOLIC PULMONARY ARTERY
PRESSURE AND WITH THE ADDITIONAL
TRI
TRIGGERS CAN WE DEFINE OTHER
TRIGGERS AND CAN WE HELP IN
INCREASING OR DECREASING THE
UNDER TREATMENT OF MITRAL
REGURGITATION.
SO ATRIAL FIBRILLATION AND
TENSION NOT PRESENT IN THE
U.S. GUIDELINES IN THE FRAMEWORK
OF TREATMENT.
AND ATRIAL FIBRILLATION IS
CORRELATED WITH LONG-TERM
RECOVERY AND BENEFIT FROM MITRAL
VALVE REPAIR WHEN THERE'S A
SMALL ATRIAL FIBRILLATION AND
BELIEVE IT SHOULD BE A CLASS I
INDICATION FOR MITRAL VALVE
REPAIR.
THE OLD STUDY SHOWED PATIENTS
WITH PULMONARY HYPERTENSION HAD
IT IMPROVED AFTER SURGICAL TR
TREATMENT BUT THERE'S RISK
ASSOCIATED WITH PATIENTS WITH
PULMONARY HYPERTENSION POST
SURGERY.
THIS SHOULD BE A CLASS I NOT
CLASS II INDICATION FOR SURGERY.
AND NOW THERE'S THIS PAPER ON
OUR APPRAISAL OF THE
HYPERTENSION AND YOU SEE THE
CURVE OF RISK ASSOCIATED WITH
THE DOPPLER PRESSURE AND AROUND
35 MILLIMETERS OF MERCURY
THERE'S A STEP UP IN RISK AND
THE MODERATE PULMONARY
HYPERTENSION IS ASSOCIATED WITH
MARKEDLY INCREASED RISK AS
COMPARED TO THE PATIENT WITHOUT
PULMONARY HYPERTENSION AND YOU
SEE EARLY SURGERY PERFORMED
ASSOCIATED WITH BENEFIT.
THE MAGNITUDE IS NOT AS BIG AS
THE MODERATE AND SEVERE
PULMONARY HYPERTENSION BUT
THERE'S BENEFIT AT ALL LEVELS
YOU HAVE AN ENORMOUS BENEFIT
BYING TO EARLY SURGERY.
-- BY DOING EARLY SURGERY.
WE BELIEVE WE NEED TO TRANSFORM
IF YOU
IF YOU HAVE ATRIAL FIBRILLATION
ORE OTHERS YOU HAVE SHOULD HAVE
SURGE I HAVE AND THE PEOPLE WITH
THOSE MARKERS ARE HIGH RISK AND
FOR THESE PEOPLE WE NEED TO DO A
RESCUE SURGERY WHICH RELIEVES
THE PATIENT BUT WE HAVE A
MEDIOCRE POSTDOC OUTCOME AND YOU
HAVE PATIENTS WITH NONE OF THESE
AND MAY BE CONSIDERED FOR EARLY
SURGERY.
AND EARLY SURGERY IS RESTORES
LIFE EXPECTANCY AND FOR THAT
PURPOSE THE CARDIOLOGISTS, THE
PHYSICIAN NEED TO BALANCE THE
RISK OF THE INTERVENTION WITH
THE RISK UNDER MEDICAL
MANAGEMENT AND YOU SEE POINTS AT
THE BOTTOM USED IN THE FACTORS
OF THE SCORE AND THE SURVIVAL
AFTER DIAGNOSIS ARE HIGHLY
ASSOCIATED WITH SURVIVAL AND
IT'S BETTER THAN SURVIVAL AND
MEDICAL MANAGEMENT BUT YOU SEE
YOU DISTRIBUTE ALREADY THE
PATIENTS WITH THE COMBINATION OF
THESE SEVEN FACTORS.
BUT NEXT WE HAVE NOW MODIFIED
THAT IN THE MORTALITY THAT
INCLUDES FOR ALL THE SEVERITY
WITH THE POINTS WHEN IT'S LESS
THAN 20 AND FOUR GRADES MODERATE
SEVERE AND VERY SEVERE WHICH AT
POINTS AND SEPARATES PEOPLE WITH
3% MORTALITY AT THE TOP AND
PATIENTS WITH 95% PROBABILITY OF
MORTALITY AT FIVE YEARS.
WE BELIEVE THE SCORE SHOULD BE
LIKE ALL SCORE A LIVING SCORE
MODIFIABLE TO ADDRESS NEW
MARKERS OF OUTCOME BUT WE HAD
THE DISCUSSION YESTERDAY AND
NEED TO USE THE SCORE AND NEED
TO COMPLETE THE STORE WITH NEW
FACTORS THAT WILL COUNT AND WILL
REVIEW SOME OF THOSE RIGHT NOW.
AND LOOK AT NORMALIZE AND YOU
SEE THE ORANGE CURVE IS FOR
INDEX OF MORE AN 60 MILLIMETER
SQUARE.
AND THE VOLUME IS A VERY
IMPORTANT MEASURE IN PATIENTS
WITH MR TO ASSESS THE RISK NOW
WE HAVE THE FUNCTION THAT
APPLIES ONLY IN PATIENTS WITH
SINUS RHYTHM OTHER WISE WE DON'T
KNOW THE INTRINSIC CONTRACTION
OF THE THE ATRIUM AND ON THE
RIGHT ARE THE TISSUE AND THE
RATIO IS HIGHLY PREDICTIVE EVEN
BETTER THAN THE LEFT ATRIAL
VOLUME INDEX AND HAS A BIG
EFFECT ON SURVIVAL OF THE
PATIENT AND IS INCREMENTAL.
THIS MEASURE SHOULD BE IN THE
NEXT VERSION OF THE RISK SCORE
FOR PATIENT WITH MITRAL
REGURGITATION.
THE SCORE HAS THIS PAPER AND
DYSFUNCTION JUST MEASURED BY THE
VISUAL ESTIMATE BY THE PHYSICIAN
AND OBSERVED THE PATIENTS WITH
RIGHT VENTRICULAR DYSFUNCTION
HAVE EXCESS MORTALITY AND
BENEFIT MARKEDLY FROM AN EARLY
INTERVENTION.
SO WE SHOULD NOT ONLY USE THAT
BUT ALSO DEVELOP BETTER MEASURE
FOR ASSESSING RIGHT VENTRICULAR
FUNCTION IN THOSE PATIENTS.
THE STANDARD BNP SO WITHIN THE
NORMAL BLACK CURVE YOU HAVE A
GOOD SURVIVAL.
IF YOU'RE BNP RATIO TO THE UPPER
LIMIT NORMAL IS COMPARED TO FOUR
TIMES THE NORMAL THEN YOU HAVE
CONSIDERABLE MORTALITY AND THIS
FORM OF BNP SHOULD BE INCLUDED
IN THE MARKER OF OUTCOME.
THE FIBROSIS IS ALSO A CANDIDATE
AND YOU SEE THIS AND IT'S
IMPORTANT.
THE MARKER WE'RE NOT SUPPOSED TO
DO ANYTHING FOR PROGRESSIVE
TREATMENT MR NEXT AND I DO
BELIEVE THIS IS THE
CLASSIFICATION WE PUBLISHED THE
OUTCOME ACCORDING TO THIS
QUANTIFICATION AND YOU SEE
SEVERE MR BY QUANTIFICATION IS
ASSOCIATED WITH EXCESS MORTALITY
THIS HAS BEEN CONFIRMED IN THE
STUDY OF THE WORK OF THE ECHO
LAB NOT JUST THE PILOT DATA FROM
THE INVESTIGATORS AND THE
MORTALITY'S EXACTLY THE SAME.
EVEN IN ROUTINE PRACTICE
QUANTIFICATION OF MR IS AN
IMPORTANT PREDICTOR OF OUTCOME.
SO MITRAL REGURGITATION AND IF
YOU HAVE THE MARKERS MORE
YELLOWS WELL ESTABLISHED THE
GREEN ARE LESS ESTABLISHED,
CONSIDER EARLY SURGERY IN USING
THAT MULTIPLICITY OF FACTOR TO
INDICATE AND PUSH THE PHYSICIAN
TO CALL FOR EARLY SURGERY.
AND IN PROLAPSE THERE'S 20% OF
THE PATIENTS WITH PROLAPSE.
THERE'S A RISK SHOWING EXCESSIVE
MORTALITY COMPARED TO THE
POPULATION.
THEY NEED OUR ATTENTION AND
DESERVE TREATMENT.
AND YOU SEE HERE IN THE PATIENTS
WITH MODERATE MR ON THE LEFT,
THE PRESENCE OF MODERATE OR
SEVERE HYPERTENSION HAS A ROLE
ALMOST AS BIG AS WITH PATIENTS
WITH SEVERE MR AND THE FORCES
ALSO WORK FOR MODERATE MR.
AND THIS IS AN UNPUBLISHED DATA
OR PATIENTS WITH MODERATE MR
EXCLUSIVELY EARLY SURGERY IN THE
PATIENTS WITH MODERATE MR AND
SOME HYPERTENSION IS ASSOCIATED
WITH IMPROVED OUTCOME.
SO MODERATE DMR NEEDS OUR
ATTENTION.
THE DMR TREATMENT AND VALVE
REPAIR AND TEER FOR HIGH RISK S
AND ALL REPAIRS TEER OR SURGICAL
AIM AT PERFECTION AND IN THE
RESEARCH PRIORITY TO MY MIND THE
FIRST RESEARCH PRIORITY TO
CONSIDER COMMUNITY STUDIES TO
REDUCE DMR AND TREATMENT TOE
CONSIDER REGISTRIES FOCUSSED ON
MITRAL VALVE DISEASE AND SEE ALL
THE MARKERS THAT SHOULD BE
INCLUDED IN THE TO CONSIDER
CLINICAL TRIAL IN MODERATE DMR.
THANK YOU SO MUCH FOR YOUR
ATTENTION.
>> THANK YOU.
WE HAVE A LITTLE TIME FOR
QUESTIONS OR COMMENTS.
>> I'LL ASK YOU ABOUT THE
HYPERTENSION WHICH I THOUGHT WAS
REALLY INTERESTING.
AND YOU CANNOT THINK AND THE
PROBLEM I WANT TO ASK WAS I GET
ECHO REPORTS EVERY WEEK,
MODERATE TO SEVERE.
AND SOMETIMES I JUST CHUCKLE
BECAUSE THERE'S LIKE FIVE JETS
IN A VALVE AND THEY CALL IT MED
RAT -- MODERATE AND THIS IS
ANOTHER CHALLENGE FOR US TO MOVE
THE FIELD FORWARD HOW DO WE
TRUST WITH MODERATE AND THE
PATIENT WILL GET A TE AND NOW
THEY CALL IT MODERATE BECAUSE
THEY PUT THE PATIENT TO SLEEP
AND DON'T HAVE RUPTURED CHORDS
AND THIS IS ANOTHER REAL ISSUE.
SO THE SIGNS LIKE AFIB, REALLY
LARGE LEFT ATRIUM AND PULMONARY
HYPERTENSION AND ATRIAL
ARRHYTHMIAS AND ALL THESE BIG
THINGS THAT HAPPEN PROBABLY ALL
GO BACK TO YOUR UNDERESTIMATING
THE REGURGITATION.
WHAT ARE YOUR THOUGHTS?
THE PHYSICIAN MAY OVER ESTIMATE
WHEN I THE JET LOOKS LARGE OR
UNDERESTIMATE WHEN IT TONIGHT
LOOK BIG AND THE PRESSURE IS LOW
AND THE NUMBERS WORK BETTER THAN
THE ESTIMATION BY THE DOCTOR.
WE SHOULD PUSH MORE AND MORE
LABS TO BE QUANTITATIVE AND WE
HAVE TO BE CAREFUL IN OUR
INTERPRETATION OF MODERATE
BECAUSE IT TELLS THE PHYSICIAN
DON'T TO ANYTHING.
YOU DON'T NEED TO WORRY.
I WOULD LIKE TO SUGGEST MODERATE
IS NOT BENIGN AND WE NEED TO
REALLY OPERATE THE PATIENTS AND
NEED TO DO SOMETHING FOR THOSE
AT LOW RISK AND NEED MANAGEMENT.
>> YOU'RE COMMUNITY STUDY AND
THE PAPER BOTH SHOW MORTALITY
IMMEDIATELY.
SO THERE'S SOMETHING GOING ON
ABOUT THE ENROLLMENT WHEN SOME
OF THESE PATIENTS GOT IN BECAUSE
THERE IS NO IMMEDIATE MORTALITY
THEY MUST HAVE BEEN MORE END
STAGE AND SHOWED UP IN THE LAST
STAGE OF HEART FAILURE AND HOW
WE GOT TO THREE LINES.
HOW DO WE UNDERSTAND THAT?
>> YOU HAVE TO WORK WITH THE
PATIENTS YOU SEE.
THE MEAN AGE OF MR IS 73.
73 THERE IS COMORBIDITY AND THE
PATIENTS ARE NOT 25 YEARS OLD
WITH NOTHING ELSE.
HOW MANY PATIENTS DIE?
THEY SAY THEY DON'T HAVE
SYMPTOMS BUT THEY HAVE HEART
FAILURE AND MAY DIE OR MAYBE
SOMETHING ELSE.
SO EACH CURB HAS TO BE TAKEN IN
THAT PHASE AND THE THREE MONTHS
IS A REASONABLE TIME FOR PEOPLE
TO MAKE THEIR DECISION.
BUT THERE IS NOTHING SPECIAL
WITH THREE MONTHS.
YOU TAKE SIX MONTHS IT'S THE
SAME THING.
THE SAME OUTCOME THAT YOU
DESCRIBED.
IT'S NOT LIKE IT'S WRITTEN BY
GOD ON A STONE.
WE HAVE TO NOT LET THE PATIENT
TWO AND COME BACK AND THEY
DISAPPEAR AND THEY'RE AFRAID OF
COMING BECOME AND HAVE TO GIVE
THEM TIME TO GET SOMETHING DONE
PROMPTLY.
AND I THINK WE CAN ACHIEVE
SOMETHING IF WE'RE MORE
CONVINCED THAT WE NEED TO REPAIR
MORE OF THESE PATIENTS.
>> THANK YOU.
FRANCESCA, BRIEFLY, PLEASE.
>> VERY BRIEF.
WONDERING WHAT YOU THINK ABOUT
THE BIKE STRESS TESTING THAT
DON'T HAVE HYPERTENSION AT REST
BUT MAYBE WE SHOULD STRESS THEM
MORE OFTEN TO SEE IF THEY ARE
HAVE THAT WITH EXERCISE.
>> IN PATIENTS WHO SAY THEY'RE
SYMPTOMATIC AND HAVE A GREAT
NUMBER.
20% OF PEOPLE WHO SAY THEY'RE
ASYMPTOMATIC HAVE FUNCTIONAL
REDUCED CAPACITY.
WE'VE NOT BEEN SUCCESS IN DOING
RECOME -- RECUMBENT BIKE AND
EXERCISE TESTING ON THE
TREADMILL AND YOU MEASURE
SOMETHING OF THE PHYSICAL
ABILITIES OF THE PATIENT THAT IS
OBJECTIVE.
AND SO OF THE EXERCISE TESTING,
THE TESTING ON THE TREADMILL IS
THE ONE I PREFER.
>> THAT COULD BE AN ALTERNATIVE
WITH SEDATION.
>> ABSOLUTELY.
IT'S A MUCH EASIER -- THE
PROBLEM IS OUR COLLEAGUE AND YOU
SEE A PATIENT WITH MR AND DON'T
HAVE AN APPOINTMENT FOR THE
EXERCISE TEST HOW ARE YOU GOING
TO SCHEDULE THAT?
YOU START BEGGING PEOPLE TO TAKE
THE PATIENT AND IT WORKS
SOMETIMES AND SOMETIMES IT
DOESN'T WORK.
MY BEGGING IS NOT VERY
EFFECTIVE.
>> THANK YOU FOR THAT.
AND JORDAN SEEMS TO BE NODDING
IN AGREEMENT AND HE IS OUR NEXT
PRESENTER.
>> THANK YOU VERY MUCH.
IT'S A PLEASURE AND HONOR TO BE
HERE AND SURROUNDED BY SUCH LUME
NAR
-- LUMINARIES IN THE FIELD AND
THINGS THAT DETERMINE THE
PERIOPERATIVE RISK AND THE
CLINICAL COMORBIDITIES THAT GO
WITH THIS AND ONE COMMON ONE WE
ARE SEEING INCREASINGLY IN OLD
ER ADULTS IS FRAILTY.
I WANTED TO SPEAK A BIT ABOUT
THAT.
I WANTED TO THANK NIH IN
PARTICULAR TO SUPPORT THE
INITIATI
INITIATIVES.
AND I PRESENTED A MOTIVATING
CASE EXAMPLE YOU KNOW A FRAIL
INDIVIDUAL WHEN YOU LOOK AT THEM
BUT QUANTIFYING IS CHALLENGING
AND OFTEN MISSED OR NOT CAPTURED
AND WE KNOW AND OFTEN DON'T
INCLUDE FRAIL PATIENTS AND WE'RE
LEFT WITH CLINICAL PRACTICE AND
GUIDANCE AND THE MORE
CHALLENGING DECISIONS ARE REALLY
EYE FUNCTION OF OUR
UNDERSTANDING OF BOTH TATE AND
ALSO THE PATIENT IN FRONT OF US.
I THINK THIS JUST GOES TO SHOW
YOU IF YOU DON'T HAVE THE
PICTURE HERE YOU HAVE AN
83-YEAR-OLD AND BOTH LOW SOCIO
ECONOMIC STAT AND PRESENTED WITH
THE PERSON ON THE LEFT VERSUS
RIGHT MOST PEOPLE WOULD SAY THE
ONE WITH THE CANE.
I THINK THERE'S A CERTAIN AMOUNT
OF THIS THAT ULTIMATELY GETS
CAPTURED IN THE SURGICAL
DECISION MAKING AND THAT'S
VALUABLE.
MY RESEARCH HAS DATA IN THE
CORNER SUGGESTING ONE OF THE
HIGHEST RISK FACTORS YOU CAN
HAVE FOR UNDERGOING MULTI-VESSEL
ECI IS THE SURGICAL TURN DOWN
AND THE DECISION TO OPERATOR NOT
OPERATE IS A HIGHLY SELECTIVELY
DECISION AND BASED ON THE BASIS
OF A LOT OF DIFFERENT FACTORS.
I WANTED TO TALK MORE ABOUT HOW
FRAILTY AND LOOKS AT VETERANS
ACROSS THE U.S. WITHIN AGE
GROUPS AND STRATIFIED BY SEX AND
LOOKS AT QUANTITATE WILL THE
FRAILTY AND WITHIN THE AGE GROUP
FRAILTY STRATIFIES RISK OF
MORTALITY THAN DIFFERENCES
BETWEEN AGE GROUPS.
SO THIS A POWERFUL RISK MARKER
AND THERE ARE YOUNGER
INDIVIDUALS PARTICULARLY IN THE
65 TO 74 AGE GROUP THAT MAY HAVE
SUBSTANTIAL FRAILTY AND MODIFIED
THEIR PERIOPERATIVE RISK
TREMENDOUSLY.
WHAT IS FRAILTY AND THERE'S
DEFINITIONS OF FRAILTY AND OVER
ALL ONE IS THE PHENOTYPIC
DEFINITION OF FRAILTY WHICH
OTHERS VIEWED FRAILTY AS A
PHENOTYPE ASSOCIATED WITH WEIGHT
LOSS AND REDUCED GAIT SPEED AND
ENERGY AND FRAILTY IS THE SUM
OF THE PARTS AND THE MORE THE
HIGHER DEGREE OF FRAILTY.
THERE'S THE BIOLOGIC
DETERMINATION AND IT'S VERY
CHALLENGING TO DISAGGREGATE THE
TWO.
THE GERONTOLOGY AND LOOKING AT
HOMO STASIS -- HOMEOSTASIS AND
WE'RE TALKING ABOUT LOW ENERGY,
WEIGHT LOSS, EXHAUSTION AND TO
THE EXTENT THOSE CHANGES ARE
BIOLOGIC CHANGES AND WHAT'S
DRIVING THE FACTOR AND HOW THEY
INTERACT WITH THE OUTCOMES
RISKS.
THIS IS FROM 2001 AND LOOKING AT
THE STATE OF UNDER CHRONIC,
UNDER NUTRITION AND NIGHT --
NITROGEN BALANCE AND THE
ASSOCIATION WITH DISEASES THAT
SET PEOPLE BACK FURTHER AND YOU
GET LOSS OF MUSCLE, SARCOPENIA
TRANSLATING TO LOWER VO2 MAX AND
STRENGTH AND POWER AND LOWER
RESTING METABOLIC RATE AND THE
VALUE OF DOING THE CARDIO
PULMONARY TEST AND THE V O2 MAX
AND THE REASON IT'S IMPORTANT IS
PART OF WHAT IT'S DETECTING THE
COMBINATION OF THE VENTRICULAR
AND DISEASES THE SARCOPENIA AND
THE CONDITIONS THAT MAY
CONTRIBUTE.
WE LOOK AT RESTING METABOLIC
RATE AND DECREASED ACTIVITY AND
MORE CHRONIC MAL OR UNDER
NUTRITION AND BECOMES MORE OF A
CYCLE.
AND THERE'S INFLAMMATORY MARKERS
AND THEY'RE NON SPECIFIC AND CAN
HAPPEN IN MULTIPLE DISEASES SO
WHAT IS ASSOCIATED WITH THE
SYNDROME REMAINS TO BE UNCLEAR.
AND THEY'RE ALL ASSOCIATED WITH
INCREASED RISK OF ADVERSE
OUTCOMES.
AND NOW THE COMMON WAY TO
MEASURE THIS HAS BEEN THROUGH
LOOKING AT YOU SAY LOOK AT THE
NUMBER OF HOSPITALIZATIONS AS AN
ACCUMULATION OF THE FRAILTY AND
THIS IS UTILIZATION OF FRAILTY.
THE CHALLENGE IS THERE'S NOT A
OVERLAP BETWEEN THOSE WITH HIGH
UTILIZERS OF HEALTH CARE AND
THOSE WHO HAVE PHENOTYPIC
FRAILTY.
THIS PAPER WAS PUBLISHED IN THE
LANCET ON FRAILTY RISK SCORE AND
LOOKING AT CLUSTERS OF HIGH
UTILIZATION WITHIN HOSPITALS AND
SEE THE CORRELATION OR THE
STATISTIC FOR ASSOCIATION AGREED
WITH THE FRAILTY INDEXES WERE
BOTH FAIRLY WEAK.
THEY DON'T NECESSARILY OVERLAP
WITH AN EXISTING DEFINITION OF
FRAILTY AND WHAT'S MORE THERE'S
NOT REVERSAL OF DIRECTION.
ONCE YOU HAVE A COMORBIDITY YOU
HAVE IT AND SO THE IDEA OF
FRAILTY AS A DYNAMIC PHENOTYPE
WHERE FOR EXAMPLE SOMETHING LIKE
REHABILITATION MAY HAVE AN
EFFECT ON IMPROVING SARCOPENIA
AND MUSCLE PASS AND ULTIMATELY
POSTSURGICAL OUTCOME.
THE CHALLENGING THINGS WITH A
NUMBER OF SCALES AND THIS IS
WITH EVEN WITH THE FREE FRAILTY
PHENOTYPE IT ASSIGNS SIMILAR
WEIGHT AND MAY NOT BE THE CASE.
IT MAY BE FOR ONE TREATMENT
OUTCOME RELATIONSHIP THERE'S
MORE IMPORTANCE FOR ONE PART OF
FRAILTY OR DISEASE ASSOCIATED
WITH FRAILTY THAN ANOTHER.
AND AN EXAMPLE AND IN THE
TREATMENT RELATIONSHIP THAT IT
MAY MORE IMPORTANT TO OUTCOME
THAN SOMETHING LIKE USE OF
WHEELCHAIRS.
THE INDIVIDUAL WEIGHS WE ASSIGN
THE VARIABLES OFTEN ASSUMED TO
BE THE SAME BUT IN FACT ARE NOT.
AND IT'S CHALLENGING ON A CASE
BY CASE BASIS.
WE SEE THIS DISCREPANCY BETWEEN
THE LITERATURE OF FRAILTY
SUGGESTING IT'S UTILITY OF RISK
MARKER AND ACTUAL USE IN
CLINICAL PRACTICE.
SO THIS IS WORK DONE ON BEHALF
OF MY K AWARD LOOKING AT THE
EFFECT OF FRAILTY AND THIS IS
LOOKING AT 1,442 INDIVIDUALS IN
HIGH RISK TRIALS WHICH EXAMINE
VALVE REPLACEMENT AND THOSE WERE
LINKED TO CMS CLAIMS AS PART OF
THE STUDY AND WE LOOKED AT THE
JOHNS HOPKINS CLAIMS BASED
FRAILTY INDEX AND THE REASON WE
FOCUSSED ON THE INDEX WAS IT WAS
VALIDATE AND BASED ON THE
PHENOTYPE BASED FRAILTY INDEX
AND LOOKED AT THE SCALE AND YOU
CAN TAKE ANY DATA SET AND PULL
MULTIDIMENSIONAL ELEMENTS OUT
AND CREATE THE SCALE WHICH IS
WHAT WE DID AS WELL.
WE SHOWED THE INDEX HAS
SIGNIFICANT OR LEADS TO
SIGNIFICANT OR ASSOCIATED WITH
SIGNIFICANT IMPAIRMENTS MEASURED
LIKE SIX MINUTE WALK TIME,
QUALITY OF LIFE, ETCETERA AS
WELL AS DISABILITY.
WHEN YOU LOOK AT WHETHER OR NOT
IT STRATIFIES THE BENEFIT YOU
FIND SOMETHING DIFFERENT.
SO HERE ON THE LEFT IS THE INDEX
ON THE RIGHT IS THE FRIED INDEX
AND WE LOOKED AT A RELATIVE RISK
DIFFERENCE BASICALLY THE SAME.
YOU CAN SEE IN GENERAL A
PREFERENCE WITH A SURVEY WITH
INJURY AND THAT WAS UNIFORM
ACROSS THE BOARD REGARDLESS IF
YOU LOOK AT THE ROCKWOOD AND
ACROSS QUARTILES OF FRAILTY
THERE WAS NOT A CLEAR OUTCOME
AND THERE WAS A HYPOTHESIS FROM
THE START OF THE TRIAL AND THE
PEOPLE WITH INCREASED FRAILTY
WOULD HAVE A GREATER BENEFIT AND
MAY REFLECT MORE OF A
SELF-SELECTED HEALTHIER
POPULATION THAN THOSE SEEN IN
CLINICAL PRACTICE AND MAY
REFLECT THE FACT THAT IN FACT
FRAILTY INCREASES YOUR RISK FOR
BOTH TREATMENTS AND BOTH
TREATMENTS EQUAL.
IT MAY BE IN FACT YOU'RE RISK OF
HOSPITAL IZATION IS HIGHER AND
THE TREATMENT BENEFIT IS NOT
CLEAR AND THIS IS LOOKING AT
DIFFERENT DISEASES WITH
DIFFERENT AFFECTS.
FRAILTY TURNS OUT TO STRATIFY
THE TREATMENT BENEFIT AND PEOPLE
SEEM TO BENEFIT THE MOST FROM
ANTI-COAGULATION AND HIP
FRACTURES SEEMS TO IN GENERAL
THOSE AT HIGHEST RISK OF THE
IDEA IF THEY FALL AND THOSE WITH
HIGHEST DEGREE OF FRAILTY THERE
IS A SIGNIFICANT ACTION BETWEEN
BEN
BENZODIAZMINE USE AND HOW DOES
THIS WORK FOR MITRAL VALVE
DISEASE.
THIS IS WHAT WE WERE LOOKING AT
EARLIER AS PART OF THE K AND
LOOKED AT 2300 INDIVIDUALS AT
HIGH RISK AND CONTINUED ACCESS
STUDIES THAT ARE LINKED TO
MEDICARE CLAIMS.
WE VALIDATED THE HOPKINS FRAILTY
INDEX MEASURED IN THE TRIAL.
IN GENERAL THIS WAS A HIGH
FRAILTY POPULATION.
WE ESTIMATE 20% OF THE GENERAL
POPULATION IS FRAIL AND THE
TRIAL POPULATION IS 65% OF THE
POPULATION.
HIGHER FRAILTY WAS ASSOCIATED
WITH GREATER NUTRITION AND
DISABILITY AND COGNITION AND
RATE OF HEALTH.
AND IN THE RISKS OF ONE
MORTALITY WERE INCREDIBLY
GREATER WITH INCREASED FRAILTY
AND THAT WAS PROVED DESPITE
ADJUSTING FOR ABLE, SEX, CLASS
AND RISK SCORE.
THERE'S SOMETHING FRAILTY ADDS
BUT WHETHER IT HAS BENEFIT
REMAINS UNCLEAR AND DEPENDENT ON
EACH INDIVIDUAL CASE SITUATION.
AND SOME DIMENSIONS OF FRAILTY
HAVE A LARGE EFFECT ON OUTCOMES
AND THOSE ASSOCIATED WITH THE
FRAILTY PHENOTYPE AND CAUSE A
CORRELATION BETWEEN AGE AND
FRAILTY.
WE LOOKED AT THE HEALTH STUDY
PARTICIPANTS THOSE WITH THE
ECHOCARDIOGRAM AND LOOKED AT
DATA AND STRATIFIED SOME FRAILTY
RISKS.
AND SAMPLE VALIDATION LOOKS AT
DEMOGRAPHIC MARKERS AND
ULTIMATELY IDENTIFIED VARIABLES
WITH THE GREATEST DIFFERENCE IN
CORRELATION BETWEEN AGE AND
FRAILTY AND IDENTIFIED THOSE
RELATED TO FRAILTY AND NOT
ASSOCIATED WITH ABLE AND WHAT
CORRELATES WITH THAT AND THE
SPECIFIC OUTCOME AND WITHIN EACH
QUARTILE THE INDEX HAD A BETTER
PREDICTIVE FIT THAN THE FREED
INDEX FOR ALL CAUSE OF
CARDIOVASCULAR DEATH.
IT WAS DEVELOPED ON HEALTH AND
DATA.
WE THOUGHT THIS WAS DATA THAT IS
NOW IMPRESSED.
AND IT SEEMS THAT THOSE RELATED
TO FRAILTY INCLUDED THINGS LIKE
DEPRESSION, INCOME, ALL THE
SUPPORTIVE LITERATURE BEHIND
THEM AS WELL AND EDUCATION.
AND FRAILTY IMPACT ON OUTCOMES
REMAINS UNCLEAR AND WHAT
PROPONENTS ARE MOST ASSOCIATED
WITH RISK.
THE CHALLENGE IS IN FRAILTY IS
IN FEW DATA SETS.
THESE ARE SOME STUDIES PUBLISHED
TO MY KNOWLEDGE AND LOOKED
SPECIFICALLY AT FRAILTY IN THE
POPULATION.
THE FIRST IS A POPULATION PEOPLE
UNDER GOING TO MITRAL VALVE
REPLACEMENT AND HIGH RISK AND
THE PRE-FRAILTY PHENOTYPE AND IT
WAS ASSOCIATED WITH INDEPENDENT
RISK OF MORTALITY.
AND THE STUDY LOOKING AT PEOPLE
WHO HAVE FRAILTY BASED ON THE
CFI AND LOOKED AT MORTALITY AND
LOOKING AT CARDIAC AND
NON-CARDIAC REHOSPITALIZATION
AND THOSE WHO HAD THE HOPKINS
CFI MEASURE ASSOCIATED WITH
HIGHER RISK OF IN HOSPITAL
MORTALITY AND DISCHARGE AND
THERE WAS NO DIFFERENCE IN
LENGTH OF STAY AND LOOKING AT
INDIVIDUALS WHO AND ASSOCIATED
WITH HIGHER TOTAL COST
ATTRIBUTABLE FROM HIGHER RATES
OF LEADING INFECTION.
PEOPLE DON'T DIE OF FRAILTY.
THEY DIE OF OTHER COMPLICATIONS
AND IDENTIFYING WHAT CAUSES THAT
IT WILL HELP INFORM.
AND THIS IS DATA FROM REPORTS
AND 319,000 ECHO REPORTS AND
CAPTURE INFORMATION ON PRESENCE,
SEVERITY AND PRESENTATION MR
SEVERITY AND MITRAL VALVE
DYSFUNCTION TO THE HOPKINS CFI
THROUGH CLAIMS USING LINKAGE
THROUGH ALL PAYER CLAIMS AND
WE'LL LOOK TO SEE WHETHER THOSE
WITH FRAILTY HAVE AN INCREASED
RISK OF MORTALITY AND HOW THAT
IS ATTENUATED REGARDLESS OF THE
AGE AND FRAILTY STATUS BY THE
MITRAL VALVE REPLACEMENT.
I SENT IDENTIFIERS OUT AND
RECEIVED OUT PATIENT AND IN
PATIENT DATA FROM 2004 TO 2011
AND THEY HAVE CLAIMS INFORMATION
ACROSS THE DATA SETS AND WE HAVE
DONE EXPLORATORY ANALYSIS WITHIN
THE CMR SUBSET AT 2018 TO 2024.
THIS FROM AI SUBSET OF DATA AND
THOSE WITH MVP AND NO MVP.
THOSE WITH MVP IN THE DATA SETS
RELATIVELY OLDER THERE'S A SPLIT
AND A POSTERIOR MVP AND RATES OF
MR WERE MUCH GREATER SEVERITY
ABOUT 10% OF THE MVP COHORT HAD
IT VERSUS 21% OF THE NO MVP
COHORT AND LOOKING AT LOVE GE
AND PEOPLE WERE REFERRED ON THE
BASIS OF SUSPICION OF SYSTEM NO
CORE HAD A FAIR AMOUNT OF LGE
BUT THERE'S A DIFFERENCE IN
PATTERN.
YOU SEE THE MUSCLE LG IN
PARTICULAR WAS MOST COMMON
AMONGST THOSE COMPARED TO THOSE
WHO DON'T HAVE MVP.
THOSE WHO HAD A HIGHER RATE OF
SUGGESTIVE OF INTERSTITIAL
FIBROSIS.
I REALIZE I'M RUNNING OUT OF
TIME.
THIS IS PRELIMINARY LOOK AT
ACROSS THE ABLE GROUPS AND YOU
CAN SEE THE PREVALENCE OF MVP IN
THE CMR DATA WAS INCREASED WITH
AGE GROUPS.
AND THE YOUNGER POPULATION
TENDED TO PRESENT MORE WITH
BILEAFLET PRO PROLAPSE AND THE
OLDER POPULATION WITH PROLAPSE
THREE OR FOUR PLUS MR WAS
GREATER ACROSS THE BOARD AND
IT'S A SMALLER GROUP BUT THE
PEAK INCIDENTS FOR PREVALENCE OF
THE DISJUNCTION ARE AGE 50 TO 65
AGE GROUP AND THEN SEEMED TO
DROP OFF AND IT WILL BE
INTERESTING TO SEE WHETHER OR
NOT THE FINDING CONTINUES AS WE
CONTINUE THE DATA ANALYSIS.
AND THEN AGAIN SIMILARLY THESE
ARE SMALL NUMBERS LOOKING AT
PATHWAY MUSCLE LGE AND THE RATES
WERE COMPARING MVP WERE GREATEST
IN THOSE MIDDLE AGED GROUP.
ALL AGE GROUPS SEEM TO HAVE AN
INCREASED RATE OF INTERSTITIAL
FIBROSIS AND WE JUST GOT THE
CLAIMS TWO WEEKS AGO AND ARE
SORTING THROUGH THIS SO
HOPEFULLY WE'LL BE ABLE TO GET
INTO THE ROLE OF FRAILTY IN
MANAGEMENT AND OUTCOMES.
WITH THAT THEY ENROLLED A YOUNG
POPULATION AND LOOK AT LOOK AT
THE MORE COMMON COHORT IN THOSE
OF 50 TO 65 AND THE AGING AND
FRAILTY OUTCOME INDICATE REMAINS
TO BE DETERMINED.
THANK YOU VERY MUCH.
>> THANK YOU VERY MUCH, JORDAN.
ONE OF YOUR ASSISTANTS I TAKE
IT.
WE ARE RUNNING SHORT ON TIME SO
I'D LIKE TO MOVE AHEAD DIRECTLY
TO ALEXANDER IRIBARNE.
>> GOOD AFTERNOON, EVERYONE AND
THANK YOU FOR THE OPPORTUNITY TO
PRESENT THIS AFTERNOON.
SO I'M GOING TO DISCUSS A
PATIENT CENTERED APPROACH FOR
TREATMENT DECISIONS IN MITRAL
VALVE PROLAPSE.
SOME SLIDES WE TALK ABOUT
ALREADY.
WE KNOW TEER VOLUME CONTINUES TO
FWROE AT -- GROW AT A RAPID
PACE AND VOLUMES OUTPACE MVP
REPAIR VOLUMES AMONG MEDICARE
PATIENTS AROUND 2019 WAS THE
INFLEXION POINT BASED ON THE
STUDY ON MEDICARE CLAIMS DATA AT
DARTMOUTH BUT YOU CAN SEE THE
INFLEXION POINT AROUND 2019 AND
ON THE RIGHT HOW THE ANNUALIZED
RATIO OF TEER COMPARED TO MITRAL
VALVE REPAIR CONTINUES TO GROW.
I THINK WE TALKED ABOUT IN MORE
DETAILS PREVIOUSLY OUTCOMES TEER
ARE IMPROVING WITH TIME AND YOU
HAVE TO BE CAREFUL HOW YOU READ
PAPERS.
HERE IT SAYS SUCCESS DEFINED AS
MODERATE AND RATING OF 10 CAN BE
ACHIEVED IN 90% OF PATIENTS WITH
MITRAL VALVE PROLAPSE.
AS WE TALKED ABOUT EARLIER THIS
DEFINITION OF SUCCESS INCLUDES
PATIENTS AND IT'S NOT SUCCESS
CLINICALLY TO HAVE MODERATE MR
AND THE NEXT STUDY THAT WAS
PUBLISHED BY DR. CHIKWE RECENTLY
AND AGAIN LOOKING AT SURGERY AND
TRANS CATHETER INTERVENTIONS FOR
DEGENERATIVE MITRAL
REGURGITATION AMONG MEDICARE
CLAIMS BENEFICIARIES.
THE CONCLUSION WAS THE EARLY
COMPARISON AMONG BENEFICIARIES
SHOWED AN INCREASE WAS
ASSOCIATED WITH WORSE SURVIVAL,
INCREASED READMISSIONS AND MORE
MITRAL INTERVENTIONS.
THERE'S REALLY A NEED FOR
COMPARATIVE EFFECTIVENESS DATA
AND AS A RESULT OF THAT WE HAVE
ONGOING RANDOMIZED TRIALS SUCH
AS PRIMARY AND REPAIR MR THAT
WILL PROVIDE DATA ON THE
COMPARATIVE EFFECTIVENESS OF
TEER VERSUS SURGERY.
WE ALSO KNOW AND AS AN
INVESTIGATOR A LOCAL ADVOCATOR
ENROLLING PATIENTS IN THE
PRIMARY TRIAL WE KNOW THAT
ENROLLMENT IN COMPARATIVE
EFFECTIVENESS TRIALS GOES TO
PATIENT AND PHYSICIAN
PREFERENCES ON TREATMENT
APPROACH AND WE HAVE PATIENTS
TRYING TO CONSENT FOR THE
PRIMARY TRIAL AND HAVE STRONG
PREFERENCES INTERESTINGLY ENOUGH
THEY WANT SURGERY AND SOMETIMES
THAT'S INFLUENCED BY THE
CONVERSATIONS THAT HAVE WITH
THEIR REFERRING CARDIOLOGISTS
AND BASED ON THE CURRENT
EVIDENCE BASE THE PATIENTS LOW
OR INTERMEDIATE RISK SHOULD BE
GETTING MITRAL VALVE REPAIR AND
SOMETIMES THIS HAS BEEN THE
DISCUSSION THAT TAKES PLACE
BETWEEN THE SURGICAL TEAM AND
THE STRUCTURAL CARDIOLOGIST AND
REFERRING CARDIOLOGIST ABOUT
CONSIDERING PATIENTS FOR
ENROMMENT IN THE TRIAL.
THIS IS THE KIND OF PREFERENCES
THAT WILL BROADLY IMPACT THE
IMPLEMENTATION AND DISSEMINATION
OF TRIAL FINDINGS UPON
PUBLICATION.
SO WE KNOW THAT BASED OFTEN THE
PAPER FROM JAMA THE FRACTION OF
DISCOVERY SCIENCES REACHING
PATIENTS IN CLINICAL PRACTICE IS
VERY LOW.
IT TAKES AN AVERAGE OF 17 YEARS
FOR ONLY 14% OF NEW DISCOVERIES
TO ENTER DAY TO DAY CLINICAL
PRACTICED AND ON AVERAGE
AMERICANS RECEIVE HALF.
THE NIH HAS A STRONG INTEREST IN
UNDERSTANDING IMPLEMENTATION AND
DISSEMINATION SCIENCE AND IN THE
CHART FROM A PUBLICATION BY
DR. MENSA FROM THE NIH, YOU CAN
SEE THE PATHWAY OF PARALLELS AND
THE PROGRESSION OF THOUGHTS IN
THE TWO-DAY SYMPOSIUM GOING FROM
BENCH RESEARCH TO BEDSIDE FIRST
IN HUMAN STUDIES AND PHASE II
AND III CLINICAL TRIALS TO
TRIALS TO EFFECTIVENESS RESEARCH
LIKE THE PRIMARY TRIAL.
HOW DO YOU TALK THE
EFFECTIVENESS RESEARCH AND HOW
THE FINDINGS ARE APPLIED IN
BROADER PATIENT POPULATIONS.
I'M A MEMBER OF THE CT SURGERY
NETWORK AND IN THE CT SURGERY
NETWORK YOU HAVE ONE GRANT THAT
I HAVE.
WE BROADLY WITHIN THE NETWORK IN
THE CYCLE PLACED A STRONG
EMPHASIS ON RESEARCH AND
TRAINING AND IMPLEMENTATION
SCIENCE WITHIN A RANDOMIZED
CLINICAL TRIALS.
AND SO THE REASON WHY I FEEL THE
NIH HAD A STRONG INTEREST IN
IMPLEMENTATION SCIENCE RESEARCH
IS THE CRITICAL NEED TO BRIDGE
THE GAP BETWEEN T3 AND T
RESEARCH AND REALLY CLOSE THE
GAP HOW WE TAKE FINDINGS FROM
THIS BENCH TO THE BEDSIDE TO
CLINICAL TRIALS AND REALLY
INCREASE THE AMOUNT OF OR REDUCE
THE TIME IT TAKES TO APPLY THE
SETTINGS MORE BROADLY AND MAKE
SURE THE FINDINGS ARE REALLY
BEING DISSEMINATED CORRECTLY.
AND THERE ARE A LOT OF
CHALLENGES TO THIS.
PRIMARILY THE IMPLEMENTATION
SCIENCE RESEARCH OFTEN LAGS
BEHIND PUBLICATION OF PIVOTAL
TRIALS AND THAT'S WHAT REALLY
LIMITS ITS UTILITY.
AND IF YOU LOOK AT THE SLIDE
WHICH TALKS ABOUT BARRIERS TO
CLINICAL ADOPTION OF RESEARCH
FINDINGS, ONE OF THE BIGGEST
ONES RELATES TO THE TIME LINE
BETWEEN PRACTICE AND DECISION
SUPPORTS.
THE PERFECT EXAMPLE IS WHAT
HAPPENS WHERE YOU'RE SUPPOSED TO
DO SHARED DECISION MAKING WITH
OF IN PATIENTS WITH TAVR THOSE
DECISION AIDS WERE PUBLISHED
AFTER THE PUBLICATION OF THE
PIVOTAL TRIALS AND THE DECISION
BETWEEN THE IN SURGE I HAVE WAS
ALREADY HAPPENING BEFORE THEY
WERE PUBLISHED AND THAT REALLY
LIMITED THE UTILITY AND
PRACTICALITY OF INTEGRATING THEM
BECAUSE THERE WAS A LAG BETWEEN
THE TIME THE DECISION AIDS
BECAME PUBLIC AND THE TIME THEY
COULD BE UTILIZED IN PRACTICE.
SO IMPLEMENTATION SCIENCE IS
TRYING TO UNDERSTAND
SPECIFICALLY HOW TO TAKE THE
FINDINGS FROM TRIALS AND
RESEARCH STUDIES AND UNDERSTAND
HOW THEY CAN BE APPLIED IN
LARGER POPULATIONS AND CLOSE
THAT GAP IN THE TIME AT WHICH
SCIENTIFIC DISCOVERIES ENTER
CLINICAL PRACTICE AND MAKE SURE
IT'S HAPPENING IN AN APPROPRIATE
WAY.
SO, WITH REGARD TO SHARED
DECISION MAKING, IT'S REALLY NOT
SOME SORT OF CONSTRUCT THAT HAS
NO SCIENTIFIC BASIS.
THERE'S BEEN A LOT OF WORK
PARTICULARLY WITH THE GROWTH OF
STRUCTURAL INTERVENTIONS ON THIS
IN CARDIOVASCULAR HEALTH.
THIS SCIENTIFIC STATEMENT FROM
THE AMERICAN HEART ASSOCIATION
WHICH WAS PUBLISHED LAST YEAR
REALLY GOES INTO A LOT OF
DETAILS ABOUT THE IMPORTANCE OF
INTEGRATING SHARED DECISION
MAKING WITHIN MULTI-DISCIPLINARY
HEART TEAM AND THEIR CLOSING
STATEMENT SUMMARIZES IT
PERFECTLY WHICH SAYS JUST AS OUR
THERAPEUTIC ADVANCES HAVE
MARKEDLY IMPROVED CARDIOVASCULAR
OUTCOMES WE NEED TO ENSHURP SURE
THE WAYS OF COMMUNICATING WITH
PATIENTS ARE EVIDENCE BASED AND
ALIGN WITH PATIENTS GOALS AND
NEEDS ARE OPTIMIZED.
YOU SEE ONE EXAMPLE IN THE 2003
GUIDANCE THERE'S SHARED DECISION
MAKING AND SOCIAL DETERMINATES
OF HEALTH TO HELP PATIENTS MAKE
INFORMED DECISIONS IT MEANS
YOU'RE HAVING A FORMAL
DISCUSSION WITH PATIENTS
DISCUSSING WHAT IS THE EVIDENT
BASE AND HELPING THEM MAKE AN
INFORMED DECISION.
AGAIN LIKE THERE'S ISSUES WITH
IMPLEMENTATION SCIENCE AND HOW
DO YOU LOOK AT POLICIES AND
REIMBURSEMENT FOR DOING THIS?
EVERYONE HAS LIMITED TIME BUT
FOR TRANS CATHETER AORTIC VALVE
REPLACEMENT THIS IS SOMETHING
CMS MANDATED TO DO.
YOU NEED IT VALIDATED AND
SUFFICIENT WORK FLOWS WHETHER
INTO AN E.H.R. OR MULTI-DES
DISCIPLINARY MAKING AND ACCESS
TO DECISION AIDS AND PATIENT
ENGAGEMENT.
ONE OF THE MOST IMPORTANT THING
IS EVACUATE
HAVING ACCESS TO DECISION AIDS
BECAUSE WITHOUT THESE
INSTRUMENTS YOU CAN'T EVEN HAVE
A DISCUSSION ABOUT THE UTILITY
OF INTEGRATING THEM INTO
PRACTICE.
AS I MENTIONED EARLIER ONE OF
THE MAJOR CHALLENGES WITH
IMPLEMENTATION SCIENCE AND
DECISION AIDS IS IT HAPPENS AT
THE CONCLUSION OF THE RANDOMIZED
TRIAL AND IT CAN BE DELAYED ONE
YEAR, TWO YEARS AND THAT LIMITS
THE UTILITY OF THE PRACTICE.
SO WHAT WE THINK ABOUT IS THIS
HYBRID EFFECTIVENESS
INFLAMMATION
IMPLEMENTATION MODEL AND TAKES
EFFECTIVENESS AND IMPLEMENTATION
AND THE PATHWAY IS THE
PROVINCIAL MODEL GOING FROM ONE
TO THE OTHER AND DO EACH
INDIVIDUALLY IN SUCCESSION.
WHEN WE THINK OF HYBRID DESIGN
IT'S REALLY PEOPLE SAYING OKAY,
WHY DON'T WE CHANGE THE MODEL?
WHY ARE WE WAITING UNTIL THE END
OF THE TRIAL TO TRY TO FIGURE
OUT HOW TO GET PATIENT AND
PHYSICIAN PREFERENCES WHY DON'T
WE GET IT AS THE TRIAL IS GOING
ALONG?
THAT'S WHAT I'M GOING TO TALK
ABOUT AND WHAT THE CAROL ACT WAS
FOR WAS THIS HYBRID TYPE I
DESIGN TESTING A CLINICAL
INTERVENTION WHILE GATHERING
INFORMATION ON IMPLEMENTATION.
IT'S ACTIVELY ENROLLING IN THE
TRIAL COMPARING TEER TO MITRAL
VALVE THERAPY AND OBSERVED
STRONG PREFERENCES EXIST AMONG
PATIENTS AND PHYSICIANS DESPITE
THAT THE TRIAL IS ENROLLING VERY
WELL BUT THERE'S PATIENTS WE
WANT TO ENROLL IN THE TRIAL AND
WE DON'T.
THESE ARE TE DISCUSSIONS THAT
COME UP.
WE ANTICIPATE OR I ANTICIPATE
UPON COMPLETION A FORMAL SHARED
DECISION MAKING TOOL WILL BE
BENEFICIAL.
THEREFORE WE HAVE THIS UNIQUE
OPPORTUNITY TO ACTIVELY STUDY
PATIENT AND PROVIDER PREFERENCES
WITHIN THE CONTEXT OF AN
ACTIVELY ENROLLING RANDOMIZED
CONTROL TRIAL WHICH WE'VE NOT
DONE BEFORE AND THE CT SURGERY
SURGERY NETWORK.
SO THE TITLE OF MY CAROL ACT
WORK WHICH I THANK THE NIH FOR
AWARDING ME WAS PATIENT CENTERED
APPROACH FOR TREATMENT DECISIONS
IN MITRAL VALVE PROLAPSE AND I'M
THE P.I. WITH JOHN PURTUS AND
DR. CHIKWE AT CEDAR SINAI AND
OTHERS AND WE'VE BEEN ABLE TO
RECRUIT SOME HIGH VOLUME SITES
ENROLLING IN THE PRIMARY TRIAL
LOCATE WILL ACROSS THE
U.S. WHICH WILL ALLOW US TO HAVE
A GEOGRAPHICALLY DIVERSE PATIENT
POPULATION.
THE FIRST AIM WAS TOE -- TO
IDENTIFY PATIENTS CONSIDERING
TEER VERSUS MITRAL VALVE REPAIR
AND WE'VE DONE A QUALITATIVE
FOCUS GROUP ACROSS ALL SITES TO
DEVELOP A CONSOLIDATED FRAMEWORK
OF OUTCOMES PATIENTS VALUE.
YOU SEE SOME OF THE TYPES OF
QUESTIONS WE'VE SATURDAY FOR
THIS AND UNDERSTANDING THE --
WE'VE ASKED ABOUT THIS AND WHAT
THEY ARE UNDERSTAND AND TELL ME
ABOUT WHY YOU ARE DIAGNOSIS AND
THE EXPERIENCE WITH THE HEART
TEAM AND DOCKERS TO TREATING YOU
AND OUTCOMES IMPORTANT TO
PATIENTS AND WHEN YOU THINK
ABOUT THE DIFFERENT OPTIONS FOR
FIXES YOUR HEART VALVE COMIMPORT
TO YOU AND WHAT IS THE DECISION
FOR TREATING YOUR LATER VALVE.
THESE HAVE BEEN DIRECT PATIENT
ENGAGEMENTS THROUGH ZOOM CALLS,
FIVE TO 10 PATIENTS EACH OF THE
SITES AND WITH PATIENTS
SOMETIMES THEY BRING THEIR
RELATIVES ON THE CALL OR FAMILY
MEMB
MEMBERS ON THE CALL AND HAVE HAD
IMPLEMENTATION SCIENTISTS AT MID
AMERICA HEART ANALYZE THE
TRANSCRIPTS FROM THOSE.
WE TOOK THE DATA FROM THE FOCUS
GROUP AND REVIEWED THE
TRANSCRIPTS TO DEVELOP A
QUANTITATIVE SURVEY BECAUSE THAT
WAS QUALITATIVE AND NOW WE
DEVELOPED THE QUANTITATIVE
SURVEY TO SEE HOW PATIENTS
PRIORITIZE OUTCOMES UTILIZING
ALLOCATION TEST FRAMEWORK BASED
ON DATA FROM OUR QUALITATIVE
FOCUS GROUPS.
THIS IS A LONG SURVEY TAKES 15,
MAYBE 20 MINUTES TO DO BUT ARE
REIMBURSED WITH A SMALL GIFT
CARD FOR DOING IT AND THIS IS
ONE SCREEN OF THE SURVEY.
THEY ARE TOLD IMAGINE YOU HAVE
100 SPENDING COINS AND HAVE TO
MOVE THESE SLIDERS TO GET TO 100
AND ASKED INVASIVENESS AND TIME
TO RECOVER AND RISK OF DEATH,
PROCEDURAL COMPLICATIONS, HEALTH
STATUS AND QUALITY OF LIFE,
REPEAT HOSPITALIZATION OR VALVE
PROCEDURE AND CONTINUED VALVE
LEAKINESS THAT DIDN'T EFFECT ANY
OTHER OUTCOMES LISTED AND THE
PATIENTS CAN ADJUST THOSE TO
ALLOCATE HOW THEY PRIORITIZE
EACH OF THESE OUTCOMES AND THEN
WE GO INTO MORE DETAIL ABOUT
EACH OF THESE AND GET
DEMOGRAPHIC DATA FROM THE
PATIENTS AT THE END.
WE SPOKE TO PHYSICIANS AND BASIC
CARDIOLOGISTS AND THOSE TREATING
PATIENTS WITH DEGENERATIVE MR
AND FIVE TO 10 PHYSICIANS PER
GROUP AND LOOKED AT OUTCOMES
IMPORTANT TO THE TEAM WHEN
YOU'RE DECIDING OR REFERRING A
PATIENT FOR TEER VERSUS SURGERY
AND WHAT ARE PATIENT PREFERENCES
AND ABOUT WHAT IS IMPORTANT AND
BA IS YOUR APPROACH TO
INTEGRATING SHARED DECISION
MAKING?
AND LIKE WE DID IN THE FIRST ONE
AND PRIORITIZED OUTCOME AND THE
ALLOCATION TEST FRAMEWORK AND
YOU CAN SEE NOW WE'RE ASKING THE
PHYSICIANS TO RANK THESE ON
SCALE FROM 1 TO 7, PATIENT AGE
AND ANATOMY OF THE MITRAL VALVE
AND SO ON.
WE LOOKED AT SHARED DECISION
MAKING AND WE ASKED QUESTIONS
LOOKED AT THE DECISION IN THE
HEART TEAM.
AND IN THE FINAL TWO SLIDES AND
WE'VE LOOK EDAL -- LOOKED AT TE
GROUPS AND ANALYZED THE
TRANSCRIPTS AND TOOK THE DATA
FROM THE QUALITATIVE SURVEYS AND
THIS IS ENROLLMENT OVER TIME.
WE'VE BEEN ABLE TO ENROLL AND WE
HAVE 80 TO 100 PHYSICIANS THAT
HAVE DONE THE SURVEY AND IT'S A
SIGNIFICANT ACHIEVEMENT WAS IT'S
CHALLENGING TO GET APATIENT TO
SIT DOWN TO DO THIS AND ALL
ACTIVELY SEEN AND A COHORT OF
PATIENTS.
SO IN TERMS OF FUTURE DIRECT
INTERVIEWING OF PATIENTS
CONCURRENT WITH TRIAL ENROLLMENT
AND GETTING THE DATA AS WE DO
THE TRIAL AND NOT ONLY TALKING
DIRECTLY TO PATIENTS BUT
DIRECTLY TO NOT ONLY THE BUT THE
EMPHASIS ON SHARED DECISION
MAKING AND DATA FROM THE STUDY
WILL BE INTEGRAL FOR DEVELOPING
A FORMAL DECISION AID IN
PARALLEL WITH PUBLICATION AT THE
PRIMARY TRIAL AND THINK THAT
WILL BE ABLE TO INCREASE THE
UTILIZATION OF THIS BECAUSE IT
WILL HAPPEN WHEN THE TRIAL IS
PUBLISHED NOT GOING TO HAPPEN A
YEAR OR TWO YEARS AFTERWARDS.
SO BY PROVIDING DATA ON PATIENT
PROVIDER PREFERENCES AND
DECISION MAKING OUR STUDY WILL
ALLOW FOR IMPLEMENTATION AND
DISSEMINATION OF FINDINGS IN THE
BROADER U.S. POPULATION
ULTIMATELY IMPROVING HEALTH.
I THINK THIS IS A GREATER
EXAMPLE OF HOW WE CAN RUN THE
FULL SPECTRUM OF GOING THROUGH
BASIC SCIENCE ALL THE WAY UP TO
PIVOTAL RANDOMIZED TRIAL AS
THERE'S BEEN A PREFERENCE WITHIN
THE NIH LOOKING AT PATIENT ED
OUTCOME RESEARCH WITH AGE EYE TO
UNDERSTANDING THE IMPLEMENTATION
AND DISSEMINATION FROM A
PATIENT-CENTERED APPROACH.
AND I'D LIKE TO CONCLUDE AGAIN
BY THANKING THE NIH AND NHLBI
AND THE CAROL ACT TO CONDUCT THE
RESEARCH AND BENEFIT PATIENTS SO
THANK YOU.
>> THANK YOU.
DOES ANYONE HAVE LAST BRIEF
COMMENTS OR QUESTIONS ON THE
LAST PRESENTATION?
>> I CAN ASK QUICKLY ON THE LAST
PRESENTATION, ALEX, STHCHL --
THANKS FOR DOING THIS BUT HOW DO
YOU DO THE EDUCATION OF THE
PATIENT AND IF I LOOKED AT JOE'S
LAST PAPER IN JTCBS AND THAT A
CANCER PAPER ADJUVANT THERAPY
AND THIS IS IF WE JUST DO
RESECTION, HERE'S YOUR SURVIVAL
AT THREE YEARS.
THERE WOULDN'T BE SURVEYS.
EVERY DOCTOR WOULD SAY THESE ARE
YOUR SURVIVAL CURRENTS AND WHY
WE MAKE THE RECOMMENDATION SO
WHAT DATA IS BEING SHARED WITH A
60-YEAR-OLD THAT COMES TO SEE
YOU TODAY AND SAYS I HAVE A
SIMPLE PROLAPSE CAN I BE
RANDOMIZED AND YOU'VE SEEN THE
PAPER.
HOW DO WE INFORM THE PATIENT
WHAT THE DATA POTENTIALLY MEANS
FOR THEM?
>> THAT'S WHY I WANTED TO DO THE
STUDY.
WHEN WE DO THE FOCUS GROUPS WITH
THE PATIENTS AND THE RED CAP
SURVEY I SHOWED, WE'RE ASKING
THEM WHAT'S IMPORTANT TO THEM
AND ONE OF THOSE THINGS IS
MORTALITY.
>> IS THAT THREE YEARS LATER AND
YOU'RE 60 YEARS OLD?
>> WE DON'T SPECIFY THE TIMING
BUT THE IMPORTANT THING IS WHEN
WE ULTIMATELY FINISH AND PUBLISH
IT, I THINK THE GOAL IS TO
GATHER WHAT'S IMPORTANT TO
PATIENTS AND THEN SUPPLEMENT
THAT AND HAVE DATA JOE PRESENTED
AND WE'LL HAVE MORE FROM PRIMARY
TRIAL AND FROM 42 REPAIR MR, WE
CAN THEN FEED THAT DATA INTO THE
DECISION AID TO SAY TO MAKE LIKE
A CALCULATOR OR MAKE A DIAGRAM
TO SHOW PATIENTS AND SAY LOOK,
IF YOU CHOOSE THIS, THIS IS YOUR
RISK OF DEATH.
IF YOU CHOOSE THIS, THIS IS YOUR
RISK.
NOW KNOWING WHAT THE FACTORS
THAT ARE IMPORTANT TO THEM IS
YEAH, MAYBE FOR SOME PATIENTS
LOW BASE IS IMPORTANT AND WHAT
THEY PLAY THINK BUT IF YOU
CREATE A DECISION AID AND PLAY
BE ONE THING YOU CLICK AS
IMPORTANT BUT IF YOU CLICK
SURVIVAL IS IMPORTANT HERE'S THE
RISK OF MORTALITY WITH TIER
VERSUS MORTALITY AND THAT WILL
THEN THEM UNDERSTAND THIS IS
SURGERY.
WE KNOW FROM THE RANDOMIZED
TRIAL DATA THIS IS GOING TO BE
THE PENALTY IF I CHOOSE TEER.
THAT'S WHAT I WANT TO DO.
I WANT PATIENT TO MAKE DECISIONS
ON REAL TIME AND SOME MAY HAVE
SIGNIFICANT AND RECURRENT MR
WHICH MAY DRIVE THE TRIAL AND
WANT THE SURGERY AND THAT'S OKAY
BECAUSE WE HELPED CREATE THE AID
TO HELP WITH THE DECISION.
>> IT WILL BE INTERESTING TO SEE
WHO ELECTS TO DO THAT AND MY
PREDICTION IS OLDER PATIENTS
WILL BE HAPPY TO BE RANDOMIZED
AND YOUNGER PATIENTS PROBABLY
WON'T BE.
RECOVERY RATES ARE BETTER WITH
THE MINIMALLY INVASIVE TRICKS WE
PRACTICE AND MORTALITY IS A
FAIRLY BIG ONE FOR A CURABLE
DISEASE.
>> YES.
>> OKAY, THANK YOU.
>> THANK YOU FOR YOUR COMMENTS.
>> WE HAVE ONE MORE QUESTION
FROM THE VIDEOCAST.
DAVID, THIS MAY BE FOR YOU.
I HAVE A QUESTION FOR ALL THE
CLINICIANS AND SURGEONS.
I'M GUESSING VALVE SURGERY IS
HIGHLY TECHNICAL.
WHAT ROLE DOES THE SKULL OF THE
SURGEON PLAY IN THE OUTCOME OF
SURGERY?
ARE THERE MECHANISMS IN PLACE
FOR CENTERS AND SURGEONS?
>> IF YOU LOOK AT OUR DATA THAT
WERE PUSH ESTABLISHED AND THE
PAPER WE PUBLISHED IN NEW YORK
STATE CLEARLY THERE'S A
RELATIONSHIP BETWEEN VOLUME AND
EXPERIENCE AND OUTCOMES.
IF YOU HAD A SURGEON IN WERE
HOSPITAL WITH MORE THAN 25 THEN
THE PERFORMANCE WENT UP AMONG
ALL SURGEONS.
THAT'S RELATED TO THE SKILL OF
PE AND PATTERN RECOGNITION AND
INVOLVEMENT AND IMAGINE THAT
AGAINST COMPLEXITY.
I WILL ALSO TELL YOU THE IDEA
YOU ONLY CAN TWO TO CEDARS OR
MOUNT SINAI OR CLEVELAND TO GET
A VALVE REPAIR ISN'T TRUE.
WITH A PROJECT WITH THE MITRAL
FOUNDATION AND AMERICAN HEART
ASSOCIATION WE IDENTIFIED OVER
40 SITES THAT APPLIED AND WENT
THROUGH A RIGOROUS PROFESSION TO
BE IDENTIFIED AS A REFERENCE
CENTER OUR GOAL IS TO FIND
REGIONAL CENTERS ACROSS THE
COUNTRY IF YOU WERE INTERESTED
IN TRYING TO GET A VALVE REPAIR
AND HAD A MORE COMPLEX
MORPHOLOGY YOU COULD GO TO.
BUT IN THE PAPER THE MORTALITY
RATES WERE LOW ACROSS THE BOARD
AND I THINK THE RATES HAVE
STEADILY INCREASED IN THE UNITED
STATES.
FOR MOST SIMPLE PROLAPSE, THE
KIND YOU COULD TREAT WITH TEER
MOST CAN DO A VALVE REPAIR AND
THERE'S SCENARIOS WHERE IT'S
GOING TO MATTER EVEN MORE BUT
CLEARLY THIS IS A TOPIC THAT'S
IMPORTANT AND SOMETHING TO KEEP
EMPHASIZING IS MITRAL VALVE
REPAIR YOU HAVE TO DO ENOUGH OF
IT TO GET THERE AND CUMULATIVELY
IT'S NOT A REASON TO DO ANY
OTHER PROCEDURES INCLUDING VALVE
REPLACEMENT OR REPAIR OR
ANYTHING.
THE VALVE REPAIR SPACE IS MORE
THAN YEARS AGO AND I WAS A
NATIONAL CO-P.I. OF A TRIAL AND
I'LL SAY THIS TO EVERYONE FROM
THAT PERSPECTIVE IS THE MEAN AGE
WERE 78 OR 80 AND YOU'RE RISK
INCREASES.
WHEN YOU GET YOUNGER THEN YOUR
RISK DON'T INCREASE THEN IT'S
JUST ABOUT AVOIDING THREE WEEKS
TO RECOVER FROM SURGERY.
THAT'S WHERE LONG-TERM OUTCOMES
HAVE TO BE OUR PRIMARY FOCUS.
IT'S VERY DIFFERENT AND YOUNG
PEOPLE.
OLDER PEOPLE IT WILL BE
INTERESTING TO SEE WHAT DATA WE
LEARNED.
I IMAGINE IF YOU'RE 80 YOU'RE
THINKING BETTER ABOUT LIVING
BETTER THAN LONGER AND THAT'S
NOT TRUE AT 65 OR 70.
MORTALITY SHOULD BE THE
OVERRIDING THING AND QUALITY OF
REPAIR.
>> JORDAN, YOU MAY HAVE THE LAST
COMMENT.
>> THIS IS RELATED AND BEGS THE
QUESTION SOMETHING LIKE A SYNTAX
SCORE EQUIVALENT FOR MITRAL
VALVE OPERATIONS OF VALUE THAT
CAPTURES THE COMPLEXITY OF THE
PROCEDURE ITSELF BUT NOT
NECESSARILY THE COMORBIDITIES OR
ETCETERA OR AGE OF THE PATIENT
REPAIR DONE AT MANY SITES VERSUS
GUIDANCE TO REPAIR.
IS THAT SOMETHING YOU THINK
WOULD BE OF VALUE?
>> I THINK IT WOULD BE AND I
HOPE OVER THE NEXT SEVERAL YEARS
WE'LL LOOK INTO THE
INDENTATIONS, FREE COMMISSURES
SEGMENTS AND UNDERSTAND THE
COMPLEXITY AND DIRECTIONS
BECAUSE IF WE CAN DO THAT WE'LL
BE IN A BETTER PLACE TO GIVE
PATIENT THE IDEA WHETHER THEY
NEED TO GO TO A MORE ADVANCE D
CENTER TO KEEP THEIR VALVE OR
LET'S PRETEND YOUR 80, AM I A
GOOD TEER CANDIDATE AND I THINK
YOU'RE HITTING AN IMPORTANT
TOPIC.
ONE OF OUR RESPONSIBILITIES THE
NEXT SEVERAL YEARS IS TO
ABSOLUTELY GET THERE.
REALLY DEFINE THE MORPHOLOGY AND
COUNT ON IMAGING TO MAKE IT MORE
REDUCIBLE AND SAY THEY NEED
CONSULTATION AND GIVE US BETTER
TOOLS TO DECIDE WHETHER THEY CAN
STAY HERE OR WHETHER WE SHOULD
REFER THEM AND WHICH PROCEDURE
TO DO.
IT'S AN EXCELLENT POINT TO END
ON.
>> THANK YOU.
ON BEHALF OF THE NHLBI I'D LIKE
TO THANK THE PARTICIPANTS FOR
YOUR ADVICE AND WISDOM OVER THE
LAST TWO DAYS AND WE APPRECIATE
ALL THE TIME AND EFFORT YOU PUT
INTO THE PRESENTATIONS.
IN THE COMING MONTHS YOU'LL BE
HEARING FROM ME AGAIN AS WE
START WORKING ON A PUBLICATION
TO FOLLOW FROM THIS UPDATE.
AGAIN I'D LIKE TO THANK ALL OF
YOU AND THANK THE SUPPORT STAFF
FOR THEIR WORK OVER THE LAST TWO
DAYS AND THIS WORKSHOP IS
ADJOURNED.
THANK YOU AGAIN.