The art of mitral repair oman


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The art of mitral repair oman

  1. 1. 5/31/2009 6:46 AM<br />ISMICS Winter Course, Okinawa, Japan, Nov 08<br />
  2. 2. The Art of Mitral Valve Repair:Improved resultswith introduction of new techniques!!<br />Ahmed M.F El-Watidy, MD, FRCS<br />Consultant Cardiac Surgeon; <br />PSCC; Riyadh, <br />Saudi Arabia<br />
  3. 3. “Swimming Pools”<br />(300 m3 (X 500<br />X16<br />(240 million kg-m)<br />3776 m<br />Mountain<br />Fuji<br />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) <br />Physiology & Pharmacology of the Heart. Brown H, Kozlowski R. Blackwell Science Ltd, 1997.<br />
  4. 4. “Philosophy of Mitral Repair”<br />“Is not only important to learn the basic principles and techniques of MV Repair, <br />But also, more important <br />to know how to produce a long-lasting repair… for life..”<br />
  5. 5. Palliative Repairs: easy, fast, not durable<br />Partial repairs: easy, little time, not durable<br />Reconstructive repairs: complex, needs time and experience<br />A. Carpentier<br />
  6. 6. Strategy<br />Functional Approach<br />Segmental Analysis<br />Pathology ?<br />Operative Assessment<br />Surgical Correction of all underlying factors<br />Postoperative TEE is mandatory .<br />Perfect MV (NO or less than mild MR <br /> & Good MVA) Is only acceptable<br />
  7. 7. Let’s begin by the beginning!!<br />“The Functional Approach to the valve”<br />Functional Classification:<br />Type-I: Normal leaflet motion, Dilated M. Annulus<br />Type-II: Leaflet prolapse <br />Type-III: Restricted Leaflet Motion<br />III-a: Restricted opening in Diastole (Rheumatic)<br />III-b: Restricted closure in systole (Ischemic)<br />
  8. 8. Segmental Analysis:<br /><ul><li>Anterior leaflet: A 1, 2, 3
  9. 9. Posterior leaflet: P1, 2, 3</li></ul>AML<br />PC<br />A3<br />AC<br />A1<br />A2<br />P3<br />P1<br />PML<br />P2<br />
  10. 10. Pathology<br /><ul><li>Rheumatic
  11. 11. Myxomatous
  12. 12. Degenerative,
  13. 13. Fibro-elastic Disorder,
  14. 14. Endocarditis
  15. 15. Mixed Pathology</li></li></ul><li>Questions … ??TO be addressed by the Cardiologist “ECHO”<br />How severe is the regurgitation ?<br />Is the AML prolapsed or restricted ?<br />Is the PML prolapsed or restricted ?<br />Which leaflet segment is involved ?<br />How is the LVF ?<br />“The idea is to develop a common language !!”<br />
  16. 16. TEE “when to do?”<br />TEE is done if one of these questions can not be addressed<br />TEE, Transgastric view 00 Shows very well all segments<br />(THE EYE OF THE SURGEON)<br />Postoperative TEE is Mandatory for all repairs<br />PMC<br />P3<br />A3<br />P2<br />A2<br />P1<br />A1<br />ALC<br />
  17. 17. Result of Analysis <br />Aetiology:<br />Rheumatic, Degenerative, Fibro-elastic Disorder, SBE,..<br />Lesion:<br />Regurge, Stenosis, both<br />Dysfunction:(Mainly concerning leaflet Coaptation)<br />Prolapse, restriction, dilated annulus, … etc<br />
  18. 18. Repair Techniques<br />Correction of ALL underlying factors<br />Remodeling annuloplasty Ring<br />
  19. 19. Different Repair Techniques For MR <br />Ring Annuloplsty <br />Simple Quadrangular resection<br />PL Slideplsty<br />Chordal Transfere <br />Extended or Double Chordal Transfere <br />Selective Chordal Transfere and Reimplantation<br />Triangular Resection<br />AML or PML Augmentation<br />Papillary Ms Slideplasty<br />Chordal Shortening<br />
  20. 20. Posterior Annular Dilatation & Annulus Remodeling concept<br />Surgeon’ View<br />Dilatation<br />AML<br />PC<br />AC<br />PML<br />AP/ IC =2/3<br />Remodeling<br />AP/ IC >0.66<br />
  21. 21. AML Extension<br />Vertical<br />If limitation on the IC Axis<br />Transverse<br />If restriction on the AP axis<br />Autologous pericardium treated with Gluteraldehyde 0.6%<br />Width should be ½ the length of the patch.<br />Continuous suturing has no risk of burse-string effect<br />Smooth surface on the atrial side<br />No risk of SAM <br />
  22. 22. Tips and Tricks (A. Carpentier)<br />Never resect more than 1/10th of AML Circumference (1)<br />In resection of PML (2) (quadrangular excision); it is good to preserve indentations is always good to keep leaflet motion.<br />Repair of PML is advised to be interrupted to avoid the burse – string effect of continuous stitches. <br />(1)<br />Indentations<br />(2)<br />
  23. 23. Extended Chordal Transfer Technique<br />Ahmed El-Watidy, MD, FRCS<br />
  24. 24. A3<br />A1<br />Prolapsing A2<br />A2<br />P1<br />P3<br />P2<br />P2 segment<br />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” <br />
  25. 25. (1-c) Top View<br />(1-b) side View<br />A<br />C<br />B<br />Anterior<br />Posterior<br />1ry chordae<br />(1-b) shows the arrangement of primary, secondary, and tertiary chordae on the resected segment before cutting. <br />(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. <br />2ry chordae<br />3ry chordae<br />A<br />Papillary Muscle<br />C<br />B<br />
  26. 26. (1-d) Extended chordal transfer sutured to the AML <br />Wide prolapsed A2 supported by the Extended chordal transfer from P2<br />AML<br />PML<br />PML before repairing the gap<br />
  27. 27. 1- e<br />A3<br />A1<br />A2<br />P1<br />P3<br />P2<br /> Figure 1-e shows the final appearance of the mitral valve after extended chordal transfer.<br />
  28. 28. Figure-2: Shows the horizontal rotation of transferred chordae<br />Prolapsing A2<br />Prolapsing A2<br />A<br />B<br />B<br />A<br />B<br />A<br />90 degree Rotation around the longitudinal axis of the PML chordae<br />Narrow rectangular segment of P2<br />Posteromedial Papillary Muscle<br />
  29. 29. Figure-3: Shows the vertical rotation of transferred elongated chordae<br />Prolapsing A2<br />Prolapsing A2<br />Prolapsing A2<br />(c)<br />Prolapsing A2 supported by vertically rotated quadrangular segment<br />(b)<br />90 degree Vertical rotation around the inter-commissural axis<br />(a)<br />quadrangular resection from PML with elongated chordae<br />
  30. 30.
  31. 31. SAM “Systolic Anterior Motion”<br />Definition: Discrepancy between the surface of the leaflet “Door” and the size of the annulus “Frame” leading to Excessive movement of AML LVOT Obstruction<br />Causes:<br />Excessive AML Tissue<br />Excessive PML Tissue<br />Too small Ring<br />
  32. 32. Mechanism of SAM<br />AO<br />AML<br />PML<br />LV<br />
  33. 33. How to avoid SAM ?<br />Proper sizing of AML<br />Choosing proper ring size <br />Avoid excessive PML tissue (width of PML should be less than 2.0 cm, average 1.5 cm)<br />< 2 cm<br />
  34. 34. Different Repair Techniques For MS <br />Simple Commissurotomy<br />Papillary Ms. Splitting<br />Chordal splitting and fenestration<br />Chordal resection<br />Decalcification and pealing <br />Leaflet augmentation<br />Restoring Chordal support at commissures<br />
  35. 35. Debridement of all infected tissues<br />Vegetectomy and patching of AML or PML<br />Pericardial Skirting <br />Correction of the underlaying mitral pathology<br />Different Repair Techniques For Endocarditis<br />
  36. 36. Tricuspid Annular Dilatation<br />A<br />P<br />S<br />
  37. 37. New insights Regarding TV Surgery<br />Organic or functional.<br />Dilatation of the TV annulus.<br />How much tissue available.<br />Continued pathology after MVR !<br />
  38. 38. Results of Repair in Rh.H.D - iCirculation. 2001;104:1-14<br />From 1970-1994, 951 patients with rheumatic Mitral valve insufficiency were operated on with reconstructive techniques.<br />Mean age 25.8 years (4-75 year<br />SR in 63 % <br />Functional classification: Type-I (7%), Type-II (33%), Type-III (36%), combined II & III (24%)<br />Surgical techniques:<br />Prosthetic ring in 95 % of patients<br />Chordal shortening, leaflet enlargement, commissurotomy, … <br />
  39. 39. Results of Repair in Rh.H.D - iiCirculation. 2001;104:1-14<br />Hospital mortality 2 %<br />Mean FU 12 years, Max 29 years<br />Actuarial survival 89+19 % at 10 years, 82+18 % at 20 years<br />Rate of thromboembolic events was 0.4 % patients/year (33 events), with 3 deaths<br />Freedom from reoperation 82+19 at 10 years, 55+25 at 20 years.<br />The main cause (83 %) of reoperation was progressive fibrosis of the MV.<br />The actuarial rate of reoperation was 2% patient /year and correlated to the degree of preoperative fibrosis.<br />
  40. 40. Challenges in Rheumatic Patients<br />
  41. 41. (1) Giant left Atria  Recurrence of AF<br /><ul><li>The LA diameter of more than 80 mm was the most important factor in the recurrence of AF after Maze.</li></ul>Isobe F. et al, J. Thorac Cardiovasc Surg 1998:116:220-7<br /><ul><li>Patients with AF were stratified into (Maze-amenable) and (Maze-refractory) based on the LA size.</li></ul>Kawaguchi A.T et al, Eur J Cardiothorac Surg 1996;10:983-9<br /><ul><li>The “functional –anatomical Unit” concept of left atrium and MV</li></ul>Ovidio A.G et al, Ann Thorac Surg 2001;71:1044-5<br />LA ( 8.8x7.8 Cm )<br />
  42. 42. (2) Non compliance with anticoagulation<br />
  43. 43. 3) Extensive Inflammatory Changes in the LA wall<br />2<br />1<br />Normal endocardial layer<br />Thick endocardial layer<br />Focal fibrosis<br />(Masson Trichrome stain)<br />3<br />
  44. 44. New Surgical technique “Modification”<br />MV Repair/ Replacement +TVA<br />Microwave Ablation<br />Resection of LA Appendage<br />+ LA Reduction <br />Atrial <br />Restoration<br />
  45. 45. “The Functional Anatomical unit” concept<br />Of “Left Atrium & Mitral Valve”<br />Atrial Restoration<br />Function<br />(+)<br />Substrate <br />(-)<br />Trigger <br />(-)<br />
  46. 46. Technique of LA Reduction<br />Left Atrium<br />LA Appendage<br />8x9 Cm<br />AML<br />PML<br />LV<br />
  47. 47. Technique<br />Ablation lines<br />L.A.APP<br />LIPV<br />LSPV<br />AML<br />PML<br />RIPV<br />RSPV<br />
  48. 48. “TEE” Pre and Post Atrial Restoration<br />Preoperative<br />LA (8.8x7.8 Cm)<br />Postoperative<br />LA (5.5X5.2 Cm)<br />
  49. 49. AF Ablation Follow up<br />
  50. 50.
  51. 51. 6.8 % increase in SR<br />
  52. 52. Analysis !!Recurrence of AF after Ablation<br />Redo surgery<br /> MR, MS, TR, <br />LA Dimensions <br />AF Ablation tech, <br />LA appendectomy,<br />LA Reduction<br />Histopathology<br />ANP levels<br />Factors analyzed:<br />Age,<br /> sex, <br />wt, ht,<br /> DM, HTN, COPD, <br />SBE, RHD, <br />EF, NYHA, <br />Euroscore,<br />
  53. 53. Predictors of AF ablation Failure in Rheumatic patients<br />SPSS 7.5, Multiple logistic regression analysis, <br />
  54. 54. Tissue Doppler for Lt. Atrial Function<br />
  55. 55. 30 % REDUCTION IN LA SIZE<br />(P<0.05)<br />
  56. 56. Histopathology of LA Appendage (2)<br />Focal LA endocardial Fibrosis<br />
  57. 57. Histopathology of LA Appendage (3)<br />Endocardial fibrosis and thickening<br />N<br />
  58. 58. Physiological Assessment<br />Atrial Natriuretic Peptide “ANP” levels <br />pre and post surgery<br />(mean, pg/ml)<br />N=6<br />
  59. 59. Acute MI<br />Ruptured Papillary Ms.<br /><ul><li>Ischemia or Old MI
  60. 60. Scarring, Dilated LV
  61. 61. PM Dysfunction
  62. 62. Displacement of PM
  63. 63. Dilated Mitral Annulus</li></li></ul><li>Ischemic MR (MECHANISM)<br />Ischemia ->Stunning, Hibernation, Or Infarction<br />Decrease in the closing force due to reduced LVF<br />Increase in PM dysfunction, or displacement<br />So, it is a PM-LV wall disease<br />Functionally classified as<br />Type-I (annular dilatation 2ndry to LV dilatation)<br />Type-III-B (PL restriction especially at P3)<br />
  64. 64. Ruptured Papillary Muscle<br />
  65. 65.
  66. 66.
  67. 67.
  68. 68. What to do??<br />Moderate+, and severe MR should be treated.<br />Mild to moderate still debatable? (Mayo Clinic paper)<br />Isolated , undersized annuloplasty ring is commonly used but it does not address the LV remodeling especially in dilated LV (LVEDD>65mm).<br />Other techniques should be added:<br />PL extension. <br />P3 CHORDAL RESECTION, PTFE CHORDAE<br />LV Remodeling device (echo-guided inflation balloons, or patch devices, or CORCAP…<br />OR REPLACEMENT…<br />
  69. 69. TENTING DISTANCE AND AREA IN ISCHEMIC MR<br />AO<br />AML<br />PML<br />TEE – Guided PLV Wall<br />Remodeling Devices<br />LV<br />
  70. 70. FACTORS AFFECTING LATE SURVIVAL AFTER ISCHEMIC MRGrossi, Gallaway, et al, NY at EACTS/ESTS, 2004<br />AGE <br />EF <30% (dilated LV >65mm LVEDD)<br />COPD<br />Residual MI (MR BEGETS MR)<br />Tenting area size (Carpentier)<br />
  71. 71. QUESTION TO THE AUDIENCE ???(250 cardiac surgeons/25 Countries)<br />Who does believe that MV Replacement in case of ischemic MR can give better result than Repair ??<br />Just five surgeons out of 250 said YES for Replacement<br />
  72. 72. Paris Course; Panel Discussion:Mitral Replacement vs. Repair In Ischemic MR<br />MOHR: Always Repair, and Replacement in dilated LV<br />G. Dreyfus: I follow LV Dimensions<br />>65 mm->Replacement<br />LVF is a major concern<br />Mechanical valve is not a solution<br />A.STARR: Valve replacement is a well taken option especially in dilated LV <br />MESSAS: LVF is better with repair (in favor of repair)<br />Dreyfus & Mohr<br />
  73. 73. CABG – Mild MR (85%)<br />CABG+MV Repair (70%)<br />CABG +MV Replacement (60%)<br />CABG+MV Surgery+ Severe LV Dysfunction (45%)<br />IMR Medically treated (20%)<br />SURVIVAL <br />IHD, Surgical Management, P313<br />
  74. 74.
  75. 75. Start from the Start !<br />
  76. 76.
  77. 77.
  78. 78.
  79. 79. KING FAHD ARMED FORCES HOSPITAL<br />Jeddah – Saudi Arabia<br />
  80. 80. Fibro-elastic Disorder:<br />Collagen-Elastin Degeneration<br />Barlow and Fibro-Elastic Disorder, Both cause leaflet prolapse and severe MR<br />(Q) How would u differentiate between Degenerative & Fibro-elastic Disorder by echo ??<br />(A) Just measure the leaflet thickness at an area which is not prolapsing (e.g. belly of the leaflet)<br />
  81. 81.
  82. 82. Demographic Data<br />
  83. 83.
  84. 84. Operative Data<br />
  85. 85. Early Outcome<br />
  86. 86. Complications<br />Difficulty in coming off CPB 1/32<br />Lt. Cx. Constrain  did well<br />IABP 0/32<br />High Inotropic support 1/32<br />Re-exploration for bleeding 2/32<br />Permanent Pace maker 1/32<br />Uncontrolled INR (warfarin / Amiodaron) 4/32<br /><ul><li>Hospital Mortality 1/32 (SBE, 3 weeks)
  87. 87. Late Mortality 1/32 (?? 14 weeks )</li></li></ul><li>Follow up Data<br />28 patients completed FU (87.5%)<br /> (Min 2, Max 30 Month)<br />Mean FU time /patient (11.89 month/Patient)<br />20 patients completed 1Yr FU<br />26 patients completed 6 m FU<br />
  88. 88. AF Ablation Follow up<br />
  89. 89. Data Analysis<br />Case Selection<br />The full concept and strategy<br />TEE was not routinely used intraoprative <br />Target result <br />
  90. 90. Conclusion:<br />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<br />Mitral valve repair has a low hospital mortality, and acceptable rate of reoperation. <br />The results are excellent regarding the minimal risk of thromboembolic events.<br />