What Is a Mitral Center of Excellence? Ted Feldman, M.D., MSCAI FACC FESC Evanston Hospital CRT Valve – Mitral (6:30 AM – 2:30 PM) CRT 2017 Track: CRT Valve & Structural CRT Valve - Mitral Session: The Essentials on Mitral Clip: Treating Mitral Regurgitation, Addressing Patient Selection and Therapy in Complex Valvular Heart Disease (1:00 PM – 1:50 PM) Sunday, February 19, 2017 1:00 PM – 1:10 PM Room: Blue Room What Is a Mitral Center of Excellence? Your role: Presenter The Essentials on Mitral Clip: Treating Mitral Regurgitation, Addressing Patient Selection and Therapy in Complex Valvular Heart Disease 1:00 PM - 1:50 PM 1:00 PM Session ModeratorsModerator: Ted Feldman, MD, MSCAI Digital Moderator: James B. Hermiller, MD, FACC, FSCAI What Is a Mitral Center of Excellence?Presenter: Ted Feldman, MD, MSCAI 1:10 PM Mitral Clip for Functional MR: Pitfalls and PearlsPresenter: Scott Lim, MD 1:20 PM Impact of Cardiac Imaging in Mitral Clip for Patients With Functional Mitral RegurgitationSpeaker: Brijeshwar S. Maini, MD 1:30 PM MitraClip for Acute and Subacute MR With ShockPresenter: Michael J. Rinaldi, MD 1:40 PM Afternoon Break CRT Cardiovascular Research Technologies Washington D.C. February 18-21st, 2017

Ted Feldman MD, MSCAI FACC FESC Disclosure Information The following relationships exist: Grant support: Abbott, BSC, Cardiokinetics, Corvia, Edwards, WL Gore Consultant: Abbott, BSC, Edwards, WL Gore Stock Options: Mitralign Off label use of products and investigational devices will be discussed in this presentation

Heart Valve Centers of Excellence are composed of experienced healthcare providers with expertise from multiple disciplines offer all available options for diagnosis and management, including complex valve repair, aortic surgery, and transcatheter therapies participate in regional or national outcome registries demonstrate adherence to national guidelines participate in continued evaluation and quality improvement processes to enhance patient outcomes publicly report their available mortality and success rates some Heart Valve Centers of Excellence may have expertise in select valve problems J Am Coll Cardiol 2014;63:e57–185

J Am Coll Cardiol 2014;63:e57–185

MV repair is reasonable in asymptomatic patients with chronic severe primary MR (stage C1) with preserved LV function (LVEF >60% and LVESD <40 mm) in whom the likelihood of a successful and durable repair without residual MR is >95% with an expected mortality rate of <1% when performed at a Heart Valve Center of Excellence

Early Surgery vs Watchful Waiting for MR Due to Flail Mitral Leaflets Replacement Mean age 62 years LVEF 69% LVESD 33.5mm A-Fib 12.4% Repair GUIDELINE GOAL: Successful & durable repair without residual MR >95% n=446 surgery Suri RM JAMA. 2013;310(6):609-616. doi:10.1001/jama.2013.8643

Predictors of Mitral Valve Repair: Clinical and Surgeon Factors Steven F. Bolling, MD, Shuang Li, MS, Sean M. O’Brien, PhD, J. Matthew Brennan, Richard L. Prager, and James S. Gammie, MD Section of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan; Duke Clinical Research Institute, Durham, North Carolina; and Division of Cardiac Surgery, University of Maryland, Baltimore, Maryland Background. Mitral valve repair is acknowledged as desirable and superior to replacement for virtually all mitral pathology. Utilizing The Society of Thoracic Sur- geons (STS) Adult Cardiac Surgery Database (ACSD), a multivariable model was created that included patient clinical characteristics and surgeon-specific mitral vol- ume to predict the likelihood of mitral valve repair. Methods. Between January 2005 and December 2007, 28,507 patients undergoing isolated mitral valve surgery (with or without tricuspid valve surgery, with or without atrial fibrillation surgery) by 1,088 surgeons at 639 hos- pitals in the STS ACSD were identified. Patient charac- teristics independently associated with mitral valve re- pair were identified using a generalized estimating equations logistic regression model. Observed mitral valve repair rates were plotted against surgeon-specific annual mitral volume, and predicted probabilities of mitral repair by surgeon volume were calculated after adjusting for patient baseline covariates. Results. On average, patients undergoing mitral valve surgery were 62 years old, with 51% female and 82% Caucasian. Among surgeons performing mitral proce- dures, the mean rate of mitral valve repair was 41% (range, 0% to 100%) and the median number of mitral valve operations per year was 5 (range, 1 to 166). Several patient characteristics were independently associated with a decreased odds of mitral repair (versus replace- ment), including mitral stenosis (odds ratio 0.09; 95% confidence interval: 0.08 to 0.11) and active endocarditis (odds ratio 0.21; 95% confidence interval: 0.17 to 0.25). While substantial variability in repair rates was observed among low-volume surgeons, increased surgeon-level mitral volume was independently associated with an increased probability of mitral repair. Conclusions. This analysis demonstrates marked vari- ability in the frequency of mitral valve repair, and the influence of both patient- and surgeon-level factors on the likelihood of mitral valve repair. Increasing surgeon- specific annual mitral valve volume is associated with a higher probability of mitral repair. Identification of these predictors of mitral valve repair creates substantial op- portunity for quality improvement in patient outcomes in mitral valve surgery, potentially through education, adoption of best practices, and improved mitral repair enabling technology. Observed mitral repair rates by surgeon-specific annual mitral valve repair volume Surgeon-specific mitral valve repair volume without mitral stenosis cases Ann Thorac Surg 2010;90:1904–12

Gladwell "10,000-Hour Rule" The key to achieving world class expertise in any skill is, to a large extent, a matter of practicing the correct way, for a total of around 10,000 hours.

SCAI/AATS/ACC/STS Operator and Institutional Requirements for Transcatheter Valve Repair and Replacement. Part II. Mitral Valve Catheterization and Cardiovascular Interventions 84:567–580 (2014)

Variables Associated With Residual MR Sorajja,P: J Am Coll Cardiol 2016;67:1129–40

Enrollment March 2005-April 2007 SYNTAX Enrollment March 2005-April 2007 Selection and Randomization of Patients A local interventional cardiologist and cardiac surgeon at each site prospectively evaluated eligible patients with previously untreated three-vessel coronary disease or left main coronary artery disease. Patients in whom it was determined that equivalent anatomical revascularization could be achieved with either CABG or PCI involving paclitaxel-eluting stents were randomly assigned to undergo one of the two treatment options. Patients for whom only one treatment option was suitable were entered into a parallel, nested registry: the PCI registry for CABG-ineligible patients and the CABG registry for PCI-ineligible patients.

Enrollment September 2005-November 2008 EVEREST II Enrollment September 2005-November 2008 Selection and Randomization of Patients Eligible patients were candidates for mitral-valve repair or replacement surgery and met echocardiographic criteria.

Selection and Randomization of Patients PARTNER IB May 11, 2007-March 16, 2009 Selection and Randomization of Patients Patients were divided into two cohorts: those who were considered to be candidates for surgery despite the fact that they were at high surgical risk, as defined by STS risk >10% or with coexisting conditions, and those who were not considered to be suitable candidates for surgery with predicted probability of 50% or more of either death by 30 days after surgery or a serious irreversible condition. At least two surgeon investigators had to agree that the patient was not a suitable candidate for surgery. All patients were evaluated on a conference call by a case review committee.

CT post-alcohol ablation