How to Do A Mitral Valve Repair for Rheumatic Valve Disease

Taweesak Chotivatanapong, MD. AATS 2015: Adult Cardiac Skills Course

25th April 2015 Seattle, USA.

Department of CVT Surgery, Central Chest Institute of Thailand Nonthaburi, Thailand.

• Goals of MV Repair• To restore normal mitral dynamics BOTH

Diastole and Systole.

• Focus :• Rheumatic : MS MR : MS

Severe MS with Large LA Clot

Severe MS with very severe Subvalvular Fibrosis

Severe Calcified MS

MS MR Post PBMV

Long Term Fate of Autologous Pericardium

• Rheumatic Mitral Valve Repair : Current Approaches and Results at Central Chest Institute of Thailand

• Taweesak Chotivatanapong, MD.

Between March 2003 – June 2014

420♦ patients : RHD MV repair

MR : 157 , MS MR : 178 , MS : 85 ♦

F : 271 M : 149 , AV age : 46.05 y ♦

• Follow up :• Range : 11 Y 3 m – 1 m• Lost FU: 22 patients• Mean : Overall : 35.65 m• MR : 43.93 m• MS MR : 18.40 m• MS : 20.10 m

Pre-op. Post-opLVEDD 52.93 47.99

LVESD 36.22 33.75

EF 58.95 57.97

MR 2.47 0.19 MVA

1.78 2.33

NYHA FC 2.35 1.15

Technique 5.45

P.O Mean gradient 4.96 Max gradient 9.11

Overall

Pre-op. Post-opLVEDD 59.32 49.76

LVESD 39.27 35.94

EF 60.86 55.37

MR 2.81 0.23

MVA 3.31 2.28

NYHA FC 2.44 1.17

Technique 4.13

PO . Mean gradient 4 Max. gradient 7.08

MR

Pre-op. Post-opLVEDD 50.75 47.08

LVESD 35.38 32.51

EF 57.83 58.27

MR 2.19 0.18

MVA 1.31 2.62

NYHA FC 2.27 1.12

Technique 6.21

PO. Mean gradient 5.24 Max. gradient 9.32

MS MR

Pre-op. Post-opLVEDD 46.36 45.27

LVESD 32.61 30.55

EF 57.57 61.31

MR 1.21 0.2 MVA

1.02 1.78

NYHA FC 2.34 1.18

Technique 6.29

PO. Mean gradient 5.67 Max. gradient 10.42

MS

Operations :MV repair = 137

MV repair + TV repair = 95

MV repair + MAZE = 67

MV repair + TV repair + MAZE = 62

MV repair + AVR + TV repair = 22

MV repair + AVR = 20

MV repair+ CABG = 7

MV repair+ TV repair + ASD = 2

MV repair + Other = 8

• Results :• Hospital mortality = 8 (1.9% )• Late death : 6 ; 3 cardiac, 3 non-cardiac• Readmission• - Pericardial effusion 19 • - CHF 18• - Coumadin overdose 8• - Severe MR 3• - Transient CVA 1

• Reoperation :

- Redo MVR 4 - Redo MV re-repair 2

Current MV Repair Strategy• Restore sinus rhythm • Restore mobility : - Type I - 3 dimensional movements -Up& down, transverse , billowing• Tissue repair - Good quality and adequate tissue.• Coaptation surface• Remodelling of annulus

Decision Making• We should try our best to repair rheumatic

MV especially in :• Young patients• Need for pregnancy• Poor compliance for medication• Inappropriate health care system• For those elderly with complex pathology,

high co-morbidity, MVR with bioprosthesis should be proceeded.

Conclusion• Rheumatic inflammation affects every part of

MV complex.• Fibrotic with calcified mitral valve is a complex

pathology that impairs mitral dynamics BOTH diastole and systole.

• Rheumatic MS is often associated with severe tissue retraction and subvalvular problem that needs both tissue and chordal repair.

• Autologous pericardium and PTFE chordal replacement are useful and reliable tools.