1. 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

2. 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

3. 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

4. J Am Coll Cardiol 2014;63:e57–185

6. 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

7. 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): doi: /jama

8. 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

9. 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.

10. 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)

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

12. 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.

13. 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.

14. 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.

16. CT post-alcohol ablation