A Bridge too good

Valve disease Clinical case

Heart Failure With Severe Mitral Regurgitation

Author: Saleh Altaf, Owais Dar 
Affiliated institution: Harefield Hospital, Guy’s and St Thomas’ NHS Foundation Trust 
Conflict of interest: None

A Bridge too good
Saleh Altaf
Saleh Altaf
Fellow
United Kingdom
Dar Owais
Dar Owais
Cardiologist
United Kingdom
Case presentation

    A male in his mid-30s, with BMI of 19.5 kg/m2, and three heart failure hospitalisations in last six months, presented with one month history of gradually worsening shortness of breath on exertion and bilateral leg oedema.

    His past medical history included: 

    • Ischaemic heart disease – 1 year ago
      • Occluded LAD with no viability on cardiac MRI
      • PCI to proximal LCx
    • Heart failure with reduced ejection fraction of 30%
    • Primary prevention ICD
    • Severe ischaemic secondary mitral regurgitation 
    • Hyperlipidaemia

    Social:

    • Occasional ex-smoker
    • Socially drank alcohol in past, now abstinent

    Weight:

    • 57.1 Kg

    Height:

    • 171 cm

    Medications: 

    Our patient was taking following medications prior to admission:

    • Aspirin 75 mg OD
    • Atorvastatin 80 mg OD
    • Bisoprolol 2.5 mg OD
    • Dapagliflozin 10 mg OD
    • Eplerenone 25 mg OD
    • Sacubitril/Valsartan 24/26 mg BD
    • Furosemide 40 mg BD

    He had no known drug allergies 

    On examination patient’s blood pressure was 92/60 mm Hg, heart rate was 88 beats per minute, chest was clear with no crepitations, jugular venous pressure of 14 cm, normal heart sounds with a pan-systolic murmur and bilateral leg oedema till just below knees. He did not have hepatomegaly or ascites. 

    Investigations on admission:

    Haemoglobin: 133 g/L
    White blood cell count: 7.1 x 109/L
    Platelets: 204 x 109/L
    Creatinine: 83 µmole/L
    Alanine aminotransferase: 137 U/L
    Alkaline phosphatase: 188  U/L
    Total bilirubin: 17 µmole/L
    NT-ProBNP: 5274 ng/L
    ECG: Sinus rhythm at 87 beats/min, P-mitrale, narrow QRS with right bundle branch block morphology, with Q waves in I, aVL, V6.
    Chest X-Ray: Clear well inflated lungs.

    Based on presentation, patient was diagnosed with acute decompensation of advanced heart failure NYHA (New York heart association) class IV and treatment with intravenous furosemide 80 mg BD was started.

    Transthoracic echocardiogram (TTE) on admission:

    • Severely dilated LV with EF: 17%
    • Dilated RV
    • Severe MR, moderate TR
    • PSAP: 71 mm Hg

    Repeat TTE 10 days after admission: 

    • Severely dilated LV, LVEF: 29%, LVOT VTI: 6.5 cm, LVIDd I:  4.52 cm/m2, LVIDs I 3.89 cm/m2,  LVEDV I: 135.1 ml/m2 
    • Severely dilated LA
    • Dilated RV. TAPSE:  1.49 cm
    • Severely dilated RA
    • Severe MR, EROA: 0.38cm2
    • Moderate TR. 
    Right heart catheterisation result
     Baseline10-minutes after starting milrinone infusion at 5 mcg/kg/min
    BP (non-invasive, mm Hg)80/51 MAP: 6195/58 MAP: 71
    RA pressure (mm Hg)116
    RV pressure (mm Hg)56/9 EDP: 1034/4 EDP: 8
    PA pressure (mm Hg)57/33 Mean: 4232/19 Mean: 24
    PCWP (mm Hg)2714
    TPG (mm Hg)1510
    Cardiac output Fick's (L/min)2.845.01
    Cardiac index (L/min/m2)1.861.99
    PVR (Wood units)5.281.99
    SVR (dynes/sec/cm5)14081021
    Cardiopulmonary exercise test
    Peak VO218.6 ml/Kg/min (39% of predicted)
    VE/VCO2 slope35
    RER:1.19 
    Anaerobic threshold12.9 ml/Kg/min
     

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Discussion

    Our patient was diagnosed with advanced heart failure as he met following criteria from ESC guidelines for the diagnosis of advanced heart failure1:

    • NYHA class IV
    • Left ventricular ejection fraction (LVEF) <30%, High NT-ProBNP
    • Requiring high doses of IV diuretics
    • pVO2 <50% predicted

    He also had following markers of poor prognosis from ‘I NEED HELP’ criteria2, in addition to above mentioned advanced heart failure criteria, with an estimated 1-year all-cause mortality of 46.5%3:

    • New York Heart Association (NYHA) classes III and IV or persistently high natriuretic peptide levels
    • Left ventricular ejection fraction (LVEF) below 20%
    • >1 heart failure hospitalisation in the last year
    • Persisting fluid overload (oedema) or increasing diuretic requirement (escalating diuretics)
    • Consistently low blood pressure (systolic blood pressure, <90–100 mm Hg)
    • Inability to up-titrate or need to reduce/discontinue prognostic medications

    In view of advanced heart failure with severe mitral regurgitation, patient was discussed in heart team comprised of advanced heart failure and transplant physicians, interventional cardiologists, cardiac imaging physician and cardio-thoracic surgeons.

    Outcome of the meeting was to proceed with mitral transcatheter edge-to-edge repair (TEER) with bridge-to-decision (BTD) intention i.e to improve haemodynamic profile and re-assess for cardiac transplant. 

    Patient underwent mitral-transcatheter edge-to-edge repair procedure:

    Primary access was gained through right femoral vein.

    One PASCAL 10 mm clip (Edwards lifesciences LTD) was deployed at A3-P3 and two PASCAL ACE clips (Edwards lifesciences LTD) were deployed at A2-P2.

    No major post-procedural complications occurred in our patient and he was started on clopidogrel 75 mg OD, in addition to his usual aspirin, for 3 months.

    Figure 2: TOE bicommissural view pre-TERR (A) and  post TEER (B). Mitral clips can be seen in (B) on the left side. Decrease in size of MR colour jet can be appreciated in (B) compared to (A). 

    Figure 3: Three mitral clips can be seen on fluoroscopic image
    Right heart catheterisation result
     Pre-TEER14 day Post TEER
    BP (non-invasive, mm Hg)80/51 MAP: 6183/54 MAP: 63
    RA pressure (mm Hg)1118
    RV pressure (mm Hg)56/9 EDP: 1039/9 EDP: 21
    PA pressure (mm Hg)57/33 Mean: 4241/24 Mean: 31
    PCWP (mm Hg)2720
    TPG (mm Hg)1511
    Cardiac output
    Fick's (L/min)    		2.843.58
    Cardiac index
    (L/min/m2)    		1.862.24
    PVR (Wood units)5.283.07
    SVR (dynes/sec/cm5)14081005
    Echocardiography results
     Baseline pre-TEER7-day Post TEER
    MR severitySevereModerate+
    MR ERO (cm2)0.380.3
    LV EF (%)2925-30
    LVOT VTI (cm)6.58.4

     

    Cardiopulmonary exercise test result
     Baseline pre-TEER16-day Post TEER
    Peak VO2 (mL/Kg/Min)18.627.4
    VE/VCO2 slope3523.72

    Our patient was discharged 15 days after TEER procedure.

    Patient profile on 3-month follow-up:

    Clinical picture

    • Able to walk 12,000 steps/day
    • Able to lie flat
    • Minimal leg oedema
    • NYHA I-II
    • No heart failure admission since discharge

    Blood results

    • NT-Pro BNP: 515 ng/L

    GDMT

    Tolerating following regimen:

    • Bisoprolol 2.5 mg OD
    • Sacubitril/valsartan 97/103 mg BD
    • Eplerenone 50 mg OD
    • Dapagliflozin 10 mg OD
Learning points
    1. Recognition of advanced heart failure according to ESC guidelines1.
    2. ‘I NEED HELP’ is a useful mnemonic to identify markers of advanced heart failure and refer the patient to advanced heart failure team2.
    3. Patients with advanced heart failure and secondary severe mitral regurgitation who fulfill COAPT criteria should be considered for TEER. TEER can help delay the need for advanced heart failure therapies (LVAD or transplant) in 22.5% of patients.6
    4. COAPT criteria includes: 
      • Secondary MR with severity 3+ or 4+
      • NYHA II, III, IV-a 
      • LV EF ≥20% and ≤50%
      • LVIDs ≤70 mm
    5. Heartmate 3 LVAD therapy is associated with an improved survival and quality of life in advanced heart failure with a median survival beyond 5 years.8
    6. Heart transplant is not a panacea for advanced heart failure. Heart transplant patients have a median survival of approximately 12 years9. Due to limited donor availability all patients eligible for heart transplant should be refractory to medical therapy. 
    To diagnose advanced heart failure according to ESC guidelines, all the following criteria must be present despite GDMT:
    1. Severe and persistent symptoms of heart failure (NYHA ≥ 3)

    2. Severe cardiac dysfunction defined by at least one of the following: 

    • LVEF ≤ 30% 
    • Isolated RV failure 
    • Non-operable severe valve abnormality 
    • Non-operable severe congenital abnormality 
    • Persistently high (or increasing) BNP or NT-ProBNP values and severe LV diastolic dysfunction (according to the definition of HFpEF)
    3. Episodes of pulmonary or systemic congestion requiring high-dose IV diuretics or episodes of low cardiac output requiring inotropes/vasopressors or malignant arrhythmia causing > 1 unplanned hospitalisation in last 12 months
    4. Severely impaired exercise capacity or 6-minute walk test distance <300 m or pVO2 < 12mL/kg/min or <50% predicted value, estimated to be of cardiac origin

    Summary

     TEERSurgical mitral valve replacementDurable LVADCardiac transplant
    Benefits. Minimally invasive 
    . 89.5% procedural success6 
    . Bailout with surgical replacement possible    		 . Can delay transplant 
    . Survival rate of 58.4% at 5 years8    		. Option of last resort
    Risks. May not be beneficial if in-appropriately selected patients10. Invasive procedure 
    . TEER non-inferior to surgical mitral valve repair/replacement7 
    . Peri-procedural morbidity/mortality can be calculated using STS score    		. 2.1% device thrombosis8 
    . 10.7% stroke8 
    . 45.8% bleeding risk8 
    . 22.7% drive line infection8    		. Median survival of 12 years9
    AvailabilityNo waiting timeNo waiting timeNo waiting timeWaiting list


     

References
Acronyms and abbreviations

Disclaimer

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