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The art of mitral repair oman The art of mitral repair oman Presentation Transcript

  • 5/31/2009 6:46 AM
    ISMICS Winter Course, Okinawa, Japan, Nov 08
  • The Art of Mitral Valve Repair:Improved resultswith introduction of new techniques!!
    Ahmed M.F El-Watidy, MD, FRCS
    Consultant Cardiac Surgeon;
    PSCC; Riyadh,
    Saudi Arabia
  • “Swimming Pools”
    (300 m3 (X 500
    X16
    (240 million kg-m)
    3776 m
    Mountain
    Fuji
    The work accomplished by the heart during human lifetime is comparable to that of raising 16 elephant the height of mount Fuji and the amount of blood pumped is the equivalent of emptying 500 swimming pools. (courtesy of Dr. M.Kameyama)
    Physiology & Pharmacology of the Heart. Brown H, Kozlowski R. Blackwell Science Ltd, 1997.
  • “Philosophy of Mitral Repair”
    “Is not only important to learn the basic principles and techniques of MV Repair,
    But also, more important
    to know how to produce a long-lasting repair… for life..”
  • Palliative Repairs: easy, fast, not durable
    Partial repairs: easy, little time, not durable
    Reconstructive repairs: complex, needs time and experience
    A. Carpentier
  • Strategy
    Functional Approach
    Segmental Analysis
    Pathology ?
    Operative Assessment
    Surgical Correction of all underlying factors
    Postoperative TEE is mandatory .
    Perfect MV (NO or less than mild MR
    & Good MVA) Is only acceptable
  • Let’s begin by the beginning!!
    “The Functional Approach to the valve”
    Functional Classification:
    Type-I: Normal leaflet motion, Dilated M. Annulus
    Type-II: Leaflet prolapse
    Type-III: Restricted Leaflet Motion
    III-a: Restricted opening in Diastole (Rheumatic)
    III-b: Restricted closure in systole (Ischemic)
  • Segmental Analysis:
    • Anterior leaflet: A 1, 2, 3
    • Posterior leaflet: P1, 2, 3
    AML
    PC
    A3
    AC
    A1
    A2
    P3
    P1
    PML
    P2
  • Pathology
    • Rheumatic
    • Myxomatous
    • Degenerative,
    • Fibro-elastic Disorder,
    • Endocarditis
    • Mixed Pathology
  • Questions … ??TO be addressed by the Cardiologist “ECHO”
    How severe is the regurgitation ?
    Is the AML prolapsed or restricted ?
    Is the PML prolapsed or restricted ?
    Which leaflet segment is involved ?
    How is the LVF ?
    “The idea is to develop a common language !!”
  • TEE “when to do?”
    TEE is done if one of these questions can not be addressed
    TEE, Transgastric view 00 Shows very well all segments
    (THE EYE OF THE SURGEON)
    Postoperative TEE is Mandatory for all repairs
    PMC
    P3
    A3
    P2
    A2
    P1
    A1
    ALC
  • Result of Analysis
    Aetiology:
    Rheumatic, Degenerative, Fibro-elastic Disorder, SBE,..
    Lesion:
    Regurge, Stenosis, both
    Dysfunction:(Mainly concerning leaflet Coaptation)
    Prolapse, restriction, dilated annulus, … etc
  • Repair Techniques
    Correction of ALL underlying factors
    Remodeling annuloplasty Ring
  • Different Repair Techniques For MR
    Ring Annuloplsty
    Simple Quadrangular resection
    PL Slideplsty
    Chordal Transfere
    Extended or Double Chordal Transfere
    Selective Chordal Transfere and Reimplantation
    Triangular Resection
    AML or PML Augmentation
    Papillary Ms Slideplasty
    Chordal Shortening
  • Posterior Annular Dilatation & Annulus Remodeling concept
    Surgeon’ View
    Dilatation
    AML
    PC
    AC
    PML
    AP/ IC =2/3
    Remodeling
    AP/ IC >0.66
  • AML Extension
    Vertical
    If limitation on the IC Axis
    Transverse
    If restriction on the AP axis
    Autologous pericardium treated with Gluteraldehyde 0.6%
    Width should be ½ the length of the patch.
    Continuous suturing has no risk of burse-string effect
    Smooth surface on the atrial side
    No risk of SAM
  • Tips and Tricks (A. Carpentier)
    Never resect more than 1/10th of AML Circumference (1)
    In resection of PML (2) (quadrangular excision); it is good to preserve indentations is always good to keep leaflet motion.
    Repair of PML is advised to be interrupted to avoid the burse – string effect of continuous stitches.
    (1)
    Indentations
    (2)
  • Extended Chordal Transfer Technique
    Ahmed El-Watidy, MD, FRCS
  • A3
    A1
    Prolapsing A2
    A2
    P1
    P3
    P2
    P2 segment
    Figure (1-a) In this diagram, the A2 segment is prolapsing.The dotted lines represent the segment to be resected, extended posteriorly as indicated by the arrow, and transferred to a wider A2 “double the width”
  • (1-c) Top View
    (1-b) side View
    A
    C
    B
    Anterior
    Posterior
    1ry chordae
    (1-b) shows the arrangement of primary, secondary, and tertiary chordae on the resected segment before cutting.
    (1-c) The rectangular segment is cut, starting from the middle of the posterior margin along the posterior two third of the transferred segment. The two cut segments are stretched bilaterally and sutured to the AML. All chordae are transferred into primary.
    2ry chordae
    3ry chordae
    A
    Papillary Muscle
    C
    B
  • (1-d) Extended chordal transfer sutured to the AML
    Wide prolapsed A2 supported by the Extended chordal transfer from P2
    AML
    PML
    PML before repairing the gap
  • 1- e
    A3
    A1
    A2
    P1
    P3
    P2
    Figure 1-e shows the final appearance of the mitral valve after extended chordal transfer.
  • Figure-2: Shows the horizontal rotation of transferred chordae
    Prolapsing A2
    Prolapsing A2
    A
    B
    B
    A
    B
    A
    90 degree Rotation around the longitudinal axis of the PML chordae
    Narrow rectangular segment of P2
    Posteromedial Papillary Muscle
  • Figure-3: Shows the vertical rotation of transferred elongated chordae
    Prolapsing A2
    Prolapsing A2
    Prolapsing A2
    (c)
    Prolapsing A2 supported by vertically rotated quadrangular segment
    (b)
    90 degree Vertical rotation around the inter-commissural axis
    (a)
    quadrangular resection from PML with elongated chordae
  • SAM “Systolic Anterior Motion”
    Definition: Discrepancy between the surface of the leaflet “Door” and the size of the annulus “Frame” leading to Excessive movement of AML LVOT Obstruction
    Causes:
    Excessive AML Tissue
    Excessive PML Tissue
    Too small Ring
  • Mechanism of SAM
    AO
    AML
    PML
    LV
  • How to avoid SAM ?
    Proper sizing of AML
    Choosing proper ring size
    Avoid excessive PML tissue (width of PML should be less than 2.0 cm, average 1.5 cm)
    < 2 cm
  • Different Repair Techniques For MS
    Simple Commissurotomy
    Papillary Ms. Splitting
    Chordal splitting and fenestration
    Chordal resection
    Decalcification and pealing
    Leaflet augmentation
    Restoring Chordal support at commissures
  • Debridement of all infected tissues
    Vegetectomy and patching of AML or PML
    Pericardial Skirting
    Correction of the underlaying mitral pathology
    Different Repair Techniques For Endocarditis
  • Tricuspid Annular Dilatation
    A
    P
    S
  • New insights Regarding TV Surgery
    Organic or functional.
    Dilatation of the TV annulus.
    How much tissue available.
    Continued pathology after MVR !
  • Results of Repair in Rh.H.D - iCirculation. 2001;104:1-14
    From 1970-1994, 951 patients with rheumatic Mitral valve insufficiency were operated on with reconstructive techniques.
    Mean age 25.8 years (4-75 year
    SR in 63 %
    Functional classification: Type-I (7%), Type-II (33%), Type-III (36%), combined II & III (24%)
    Surgical techniques:
    Prosthetic ring in 95 % of patients
    Chordal shortening, leaflet enlargement, commissurotomy, …
  • Results of Repair in Rh.H.D - iiCirculation. 2001;104:1-14
    Hospital mortality 2 %
    Mean FU 12 years, Max 29 years
    Actuarial survival 89+19 % at 10 years, 82+18 % at 20 years
    Rate of thromboembolic events was 0.4 % patients/year (33 events), with 3 deaths
    Freedom from reoperation 82+19 at 10 years, 55+25 at 20 years.
    The main cause (83 %) of reoperation was progressive fibrosis of the MV.
    The actuarial rate of reoperation was 2% patient /year and correlated to the degree of preoperative fibrosis.
  • Challenges in Rheumatic Patients
  • (1) Giant left Atria  Recurrence of AF
    • The LA diameter of more than 80 mm was the most important factor in the recurrence of AF after Maze.
    Isobe F. et al, J. Thorac Cardiovasc Surg 1998:116:220-7
    • Patients with AF were stratified into (Maze-amenable) and (Maze-refractory) based on the LA size.
    Kawaguchi A.T et al, Eur J Cardiothorac Surg 1996;10:983-9
    • The “functional –anatomical Unit” concept of left atrium and MV
    Ovidio A.G et al, Ann Thorac Surg 2001;71:1044-5
    LA ( 8.8x7.8 Cm )
  • (2) Non compliance with anticoagulation
  • 3) Extensive Inflammatory Changes in the LA wall
    2
    1
    Normal endocardial layer
    Thick endocardial layer
    Focal fibrosis
    (Masson Trichrome stain)
    3
  • New Surgical technique “Modification”
    MV Repair/ Replacement +TVA
    Microwave Ablation
    Resection of LA Appendage
    + LA Reduction
    Atrial
    Restoration
  • “The Functional Anatomical unit” concept
    Of “Left Atrium & Mitral Valve”
    Atrial Restoration
    Function
    (+)
    Substrate
    (-)
    Trigger
    (-)
  • Technique of LA Reduction
    Left Atrium
    LA Appendage
    8x9 Cm
    AML
    PML
    LV
  • Technique
    Ablation lines
    L.A.APP
    LIPV
    LSPV
    AML
    PML
    RIPV
    RSPV
  • “TEE” Pre and Post Atrial Restoration
    Preoperative
    LA (8.8x7.8 Cm)
    Postoperative
    LA (5.5X5.2 Cm)
  • AF Ablation Follow up
  • 6.8 % increase in SR
  • Analysis !!Recurrence of AF after Ablation
    Redo surgery
    MR, MS, TR,
    LA Dimensions
    AF Ablation tech,
    LA appendectomy,
    LA Reduction
    Histopathology
    ANP levels
    Factors analyzed:
    Age,
    sex,
    wt, ht,
    DM, HTN, COPD,
    SBE, RHD,
    EF, NYHA,
    Euroscore,
  • Predictors of AF ablation Failure in Rheumatic patients
    SPSS 7.5, Multiple logistic regression analysis,
  • Tissue Doppler for Lt. Atrial Function
  • 30 % REDUCTION IN LA SIZE
    (P<0.05)
  • Histopathology of LA Appendage (2)
    Focal LA endocardial Fibrosis
  • Histopathology of LA Appendage (3)
    Endocardial fibrosis and thickening
    N
  • Physiological Assessment
    Atrial Natriuretic Peptide “ANP” levels
    pre and post surgery
    (mean, pg/ml)
    N=6
  • Acute MI
    Ruptured Papillary Ms.
    • Ischemia or Old MI
    • Scarring, Dilated LV
    • PM Dysfunction
    • Displacement of PM
    • Dilated Mitral Annulus
  • Ischemic MR (MECHANISM)
    Ischemia ->Stunning, Hibernation, Or Infarction
    Decrease in the closing force due to reduced LVF
    Increase in PM dysfunction, or displacement
    So, it is a PM-LV wall disease
    Functionally classified as
    Type-I (annular dilatation 2ndry to LV dilatation)
    Type-III-B (PL restriction especially at P3)
  • Ruptured Papillary Muscle
  • What to do??
    Moderate+, and severe MR should be treated.
    Mild to moderate still debatable? (Mayo Clinic paper)
    Isolated , undersized annuloplasty ring is commonly used but it does not address the LV remodeling especially in dilated LV (LVEDD>65mm).
    Other techniques should be added:
    PL extension.
    P3 CHORDAL RESECTION, PTFE CHORDAE
    LV Remodeling device (echo-guided inflation balloons, or patch devices, or CORCAP…
    OR REPLACEMENT…
  • TENTING DISTANCE AND AREA IN ISCHEMIC MR
    AO
    AML
    PML
    TEE – Guided PLV Wall
    Remodeling Devices
    LV
  • FACTORS AFFECTING LATE SURVIVAL AFTER ISCHEMIC MRGrossi, Gallaway, et al, NY at EACTS/ESTS, 2004
    AGE
    EF <30% (dilated LV >65mm LVEDD)
    COPD
    Residual MI (MR BEGETS MR)
    Tenting area size (Carpentier)
  • QUESTION TO THE AUDIENCE ???(250 cardiac surgeons/25 Countries)
    Who does believe that MV Replacement in case of ischemic MR can give better result than Repair ??
    Just five surgeons out of 250 said YES for Replacement
  • Paris Course; Panel Discussion:Mitral Replacement vs. Repair In Ischemic MR
    MOHR: Always Repair, and Replacement in dilated LV
    G. Dreyfus: I follow LV Dimensions
    >65 mm->Replacement
    LVF is a major concern
    Mechanical valve is not a solution
    A.STARR: Valve replacement is a well taken option especially in dilated LV
    MESSAS: LVF is better with repair (in favor of repair)
    Dreyfus & Mohr
  • CABG – Mild MR (85%)
    CABG+MV Repair (70%)
    CABG +MV Replacement (60%)
    CABG+MV Surgery+ Severe LV Dysfunction (45%)
    IMR Medically treated (20%)
    SURVIVAL
    IHD, Surgical Management, P313
  • Start from the Start !
  • KING FAHD ARMED FORCES HOSPITAL
    Jeddah – Saudi Arabia
  • Fibro-elastic Disorder:
    Collagen-Elastin Degeneration
    Barlow and Fibro-Elastic Disorder, Both cause leaflet prolapse and severe MR
    (Q) How would u differentiate between Degenerative & Fibro-elastic Disorder by echo ??
    (A) Just measure the leaflet thickness at an area which is not prolapsing (e.g. belly of the leaflet)
  • Demographic Data
  • Operative Data
  • Early Outcome
  • Complications
    Difficulty in coming off CPB 1/32
    Lt. Cx. Constrain  did well
    IABP 0/32
    High Inotropic support 1/32
    Re-exploration for bleeding 2/32
    Permanent Pace maker 1/32
    Uncontrolled INR (warfarin / Amiodaron) 4/32
    • Hospital Mortality 1/32 (SBE, 3 weeks)
    • Late Mortality 1/32 (?? 14 weeks )
  • Follow up Data
    28 patients completed FU (87.5%)
    (Min 2, Max 30 Month)
    Mean FU time /patient (11.89 month/Patient)
    20 patients completed 1Yr FU
    26 patients completed 6 m FU
  • AF Ablation Follow up
  • Data Analysis
    Case Selection
    The full concept and strategy
    TEE was not routinely used intraoprative
    Target result
  • Conclusion:
    Reconstructive surgery of mitral valve insufficiency has to follow principles and rules that will result in a comprehensive strategy for valve repair and therefore improve the outcome
    Mitral valve repair has a low hospital mortality, and acceptable rate of reoperation.
    The results are excellent regarding the minimal risk of thromboembolic events.