Why Repair · Badhwar, Bolling , chapter in: Advances in Heart Failure, 2004 . Skin cancer...
Transcript of Why Repair · Badhwar, Bolling , chapter in: Advances in Heart Failure, 2004 . Skin cancer...
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Overview of Surgical Approach to Mitral Valve Disease :
Why Repair ?
Steven F. Bolling, MD Cardiac Surgery
University of Michigan
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Degenerative MR is not Functional MR
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2o - Functional MR : Ventricular Problem!!
Badhwar, Bolling , chapter in: Advances in Heart Failure, 2004
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Skin cancer
Pancreatic cancer
Treatment of MR ?
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1o - Degenerative MR :
Everything but the Ventricle Problem!
Carpentier’s Reconstructive Valve Surgery;
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Degenerative
MR
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Mitral Valve Repair
Physiology
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Which one is the mitral valve?
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Structures of the Mitral Valve
Annulus
Leaflets
Commissures
Chordae
Papillary Muscle
Left Ventricle
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Mitral - LV Power
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Mitral Dynamics
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Mitral Dynamics
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Mitral Valve
Active Closure – not by pressure!
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“Roman Arch”
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Mitral Surgery – Operative Mortality
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Mitral Valve = Left Ventricle
The LV = The MV
Mitral Repair
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Mitral Valve Repair
ECHO
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Mitral Anatomy Subaortic curtain
Aortic leaflets
AV node position
Coronary Sinus
Circumflex Artery
Preservation of “surrounding” anatomic integrity
essential for successful mitral repair
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Mitral Valve Repair - LV
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ACC/AHA 2014 – “Significant” MR
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Mitral Valve Repair
Techniques
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Degenerative Mitral Disease
FED FED+ Forme Fruste Barlow’s
Wide Disease Spectrum
Adams et al. Eur Heart J 2010;31:1958-1967
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Fibroelastic Deficiency
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Fibroelastic Deficiency
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Fibroelastic Deficiency
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Fibroelastic Deficiency
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FED – Preserve Tissue
No Resection, or Limited Resection
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Barlow’s Disease
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Barlow’s Disease
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Barlow’s – “Remove” Tissue
Resection, Leaflet Displacement
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Degenerative Mitral Valve Repair
Ring Annuloplasty alone
with any or all of :
Leaflet excision
Leaflet plication
Leaflet patch
Artificial chordae
Cleft closure
Sliding plasty
Some other stuff
More other stuff
Alfieri stitch
Mitraclip
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Mitral Valve Repair
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Evaluate the valve
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Posterior Leaflet Resection
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Recreate Posterior Leaflet
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Ring
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Anterior Leaflet Repair
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“Smiley face” = good line of closure
Posterior leaflet “disappears”
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“Who’s your Daddy, Jason ?!
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Mitral Valve Repair
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It’s Math !
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Put a ring on it !
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Ring Annuloplasty
Complete or Incomplete
Rigid or Flexible
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“It’s not the ring,
it’s the ringer!”
Mitral Valve Repair
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• Zone of Coaptation
• Roman Arch
• Chords = Guides
• Ring – obey “Bey” !
Mitral Valve Repair PRINCIPLES
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Mitral Valve Repair
Results
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5/16/2016
Repair DMR!
0
20
40
60
80
100
0 2 4 6 8 10
General Population
Replacement
Repair
p = 0.0004
Surv
ival (%
)
Time (Years)
68%
52%
Enriquez Sarano et al. Circulation 1995;91:1022
Cure MR!
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Mitral Valve Replacement Results
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Mitral Valve Replacement Results
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Mitral repair vs. replacement – TE events
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Mitral repair vs. replacement – Survival
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Mitral repair vs. replacement
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Early Surgery vs Watchful Waiting Med Rx
Outcomes for MR
JAMA. 2013;310(6):609-616.
Survival After Diagnosis of Mitral Regurgitation Due to Flail Mitral Leaflet According to Initial Treatment StrategyLong-term survival
following early surgery vs initial medical management overall population (A) and in the propensity score–matched cohort (B).
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ACC/AHA 10 Mitral Guidelines - 2014
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J Thorac Cardiovasc Surg 2003;125:1143-1152
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10 11
Mitral Regurgitation Survival After Mitral Valve Surgery
100
80
60
40
20
0
Surv
ival (p
erc
ent)
0 2 4 6 8 10 14 12
Time (years)
David et al, J Thorac Cardiovasc Surg 2003;126:1143-1152
FC I-II
58%
FC III-IV
81%
n=488
p<0.001
Wait for CHF
symptoms ?
Bad !
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Sx or :
LVEF < 60 %
PAP > 50 mm
LVESd > 40 mm
AF
If > 95% repair and < 1 % mortality
2016 - Degenerative Mitral
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Enriquez-Sarano et al. Circ 1994:90:830-837
Wait until EF falls , 60 – Bad !
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Wait until PAP rises, 50 – Bad !
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Enriquez-Sarano et al. Rev Card 2010
Wait until LV dilates, 40 – Bad !
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Bando et al. JTCVS 2005
Wait until A Fib – Bad !
Theirry et al. EJCVS 2006
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ACC/AHA guidelines: 2014
Mitral valve repair, wait until:
Symptoms …BAD !
if “no” symptoms, wait until:
Fall in EF% < 60
Pul Htn > 50
Increase LV > 40
A Fib
…also BAD and too late !
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So are cardiologists even following these lame guidelines ? … they are super late !!
MV surgery referral
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Toledano et al. Can J Cardiol 2007; 23 (3): 209-14
NO! 2-30% were super late
the rest …mega late referral!
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33% mortality-1yr Failure of Guideline Adherence for Intervention in Patients With Severe Mitral Regurgitation
David S. Bach, et al JACC Vol. 54, No. 9, 2009
USA Mitral late referral rate - 50% !
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Sx or :
LVEF < 60 %
PAP > 50
LVESd > 40 mm
AF
If > 95% repair…
2016 - Degenerative Mitral
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All Mitral Valve Procedures (Center Repair Rates 2005 – 2009)
“If > 95% repair”…
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Individual Surgeon Predictors of Repair
Isolated Mitral / yr - 5 (0.3 – 166)
Mean Repair rate - 41% (0 – 100 %)
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MVR Volume effect
Predictors of Mitral Repair
THE SURGEON :The more you do, the better you are !
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Anyanwu et al. BMJ Heart 2010;10:1136-40
NOT the country - same in England
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Kilic et al. J Thorac Cardiovasc Surg 2012
NOT the hospital
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LaPar et al. J Thorac Cardiovasc Surg 2014; 148(3):995-1003
FIGURE 4. Plot of adjusted association between probability of mitral valve repair and the
adjusted restricted cubic spline function for average annual surgeon mitral procedure volume
within (B) a propensity matched patient group. MV, Mitral valve; PROM, Predicted Risk of
Mortality.
It’s the surgeon!
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Beware
patient – surgeon mismatch !
For Degenerative Mitral
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• Preserved LV function
• No anti-coagulation
• Freedom from re-op
• Low early and late mortality
Mitral Valve Repair
Advantages
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Tips for MV Repair 2016
Find a GOOD surgeon, Think EARLY repair …
If your surgeon advises
replacement...
I advise you to replace your
SURGEON !!