Francesco Maisano
San Raffaele Scientific Institute
and University Hospital
Milano
 First case performed in
1991
 Over 1500 published cases
accumulated worldwide
 About 15 yrs follow-up
 Technically si...
Alfieri O et al. JTCVS 2001
 Performed in diverse
clinical settings:
 High risk patients
 Complex anatomy
 Functional ...
Alfieri O et al. JTCVS 2001; Maisano F et al. EJCTS 1998
Freedomfrom
reoperation
Recurrence
ofMR/MS
5 yrs follow-up of 82
...
Debonis et al. JTCVS 2005
years
14121086420
Freedomfromreoperation
1,00
,90
,80
,70
,60
,50
,40
,30
,20
,10
ALP: 96,6 ± 1,...
 The suture must incorporate the
diseased segment(s) completely
 Respect symmetry
 Suture lenght should be kept to the
...
Maisano F et al. EJCTS 1998
Stenosis / Gradients
Suture dehiscence
Role of annuloplasty
 Hemodynamics
are not influenced
by a two orifice
configuration of
the valve
 Pressure
gradients are
related to the sum
...
 Stresses on the
suture are
maximum at
diastole
 Stresses depend
on annular size
Redaelli et al. J. Biomechanics 2001
- ...
 Annuloplasty has been routinely added to the Alfieri procedure
 Absence of annuloplasty is associated with increased st...
Maisano F et al. Eurointervention 2006
Guide
Steerable sleeve
Clip delivery handle
Stabilizer
Atrial
Septum
Enrollment Population n
EVEREST I
Feasibility (completed)
Registry patients 55
EVEREST II
Randomized n=244
Roll-in
Randomi...
79 pts
SURGERY FREE
76/104
Surgery After Clip Implanted (n = 20)
• 15 (75%) Repairs (0 - 562 days)
• 5 (25%) Replacements
Surgery...
 Applicable only to
central MR
originating from
A2-P2
 Not applicable in
case of wide
prolapse
 Not applicable in
case ...
 When performed according to surgical principles,
the E2E technique provides results at least non
inferior to other surgi...
66 aa, maschio, 64 Kg, 164 cm, BSA 1.7 m2, BMI 24
IM 4+, FE 15-20%, PAPs 75 mmHg, disfunzione VDx, IT 3+
1994 IMA anterior...
Maisano Edge To Edge Tor Vergata
Maisano Edge To Edge Tor Vergata
Maisano Edge To Edge Tor Vergata
Maisano Edge To Edge Tor Vergata
Maisano Edge To Edge Tor Vergata
Maisano Edge To Edge Tor Vergata
Maisano Edge To Edge Tor Vergata
Maisano Edge To Edge Tor Vergata
Maisano Edge To Edge Tor Vergata
Maisano Edge To Edge Tor Vergata
Maisano Edge To Edge Tor Vergata
Maisano Edge To Edge Tor Vergata
Maisano Edge To Edge Tor Vergata
Maisano Edge To Edge Tor Vergata
Maisano Edge To Edge Tor Vergata
Maisano Edge To Edge Tor Vergata
Maisano Edge To Edge Tor Vergata
Maisano Edge To Edge Tor Vergata
Maisano Edge To Edge Tor Vergata
Maisano Edge To Edge Tor Vergata
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Maisano Edge To Edge Tor Vergata

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Maisano Edge To Edge Tor Vergata

  1. 1. Francesco Maisano San Raffaele Scientific Institute and University Hospital Milano
  2. 2.  First case performed in 1991  Over 1500 published cases accumulated worldwide  About 15 yrs follow-up  Technically simple and reproducible  Versatile  Criticized by some surgeons  Did not apply correctly  Used only as a bailout
  3. 3. Alfieri O et al. JTCVS 2001  Performed in diverse clinical settings:  High risk patients  Complex anatomy  Functional MR  Used to correct anterior and posterior lesions  Annuloplasty has been added whenever possible (90%)
  4. 4. Alfieri O et al. JTCVS 2001; Maisano F et al. EJCTS 1998 Freedomfrom reoperation Recurrence ofMR/MS 5 yrs follow-up of 82 pts with severe Barlow’s disease and bileaflet prolapse Overall Etiology subgroups
  5. 5. Debonis et al. JTCVS 2005 years 14121086420 Freedomfromreoperation 1,00 ,90 ,80 ,70 ,60 ,50 ,40 ,30 ,20 ,10 ALP: 96,6 ± 1,74% PLP: 96.2 ± 2.0% E2E offers the same results as conventional techniques n.s. MayoMayo ClevelandCleveland
  6. 6.  The suture must incorporate the diseased segment(s) completely  Respect symmetry  Suture lenght should be kept to the minimum effective to correct MR in order to avoid stenosis  Depth of suture bites is variable according to the nature of the MR
  7. 7. Maisano F et al. EJCTS 1998
  8. 8. Stenosis / Gradients Suture dehiscence Role of annuloplasty
  9. 9.  Hemodynamics are not influenced by a two orifice configuration of the valve  Pressure gradients are related to the sum of the two orifices area 0 2 4 6 8 (mmHg) Double (1:1) Double (1:2)Single Q = 11 l/min Area = 2.25 cm2 Maisano F et al. EJCTS 1999
  10. 10.  Stresses on the suture are maximum at diastole  Stresses depend on annular size Redaelli et al. J. Biomechanics 2001 - 647 - 520 - 394 - 267 - 140 - 134 + 113 + 240 + 367 + 493 + 620 + 747 +873 +1000 SI (kPa)
  11. 11.  Annuloplasty has been routinely added to the Alfieri procedure  Absence of annuloplasty is associated with increased stresses on the suture and on the valve structures  Absence of annuloplasty may be associated with accelerated failure (but not in multivariate analysis) - 647 - 520 - 394 - 267 - 140 - 134 + 113 + 240 + 367 + 493 + 620 + 747 +873 +100 0 SI (kPa) Alfieri et al. JTCVS 2001, Maisano et al JTCVS 2003, Nielsen et al Circulation 2005
  12. 12. Maisano F et al. Eurointervention 2006
  13. 13. Guide Steerable sleeve Clip delivery handle Stabilizer Atrial Septum
  14. 14. Enrollment Population n EVEREST I Feasibility (completed) Registry patients 55 EVEREST II Randomized n=244 Roll-in Randomized Clip Randomized Surgery 60 172 88 EVEREST II High Risk Registry 78 Total enrolled 453
  15. 15. 79 pts
  16. 16. SURGERY FREE 76/104 Surgery After Clip Implanted (n = 20) • 15 (75%) Repairs (0 - 562 days) • 5 (25%) Replacements Surgery After No Clip (n = 8) • 5 (63%) Repairs • 3 (37%) Replacements 71% Repaired
  17. 17.  Applicable only to central MR originating from A2-P2  Not applicable in case of wide prolapse  Not applicable in case of annular dilatation mid esophageal 120° mid esophageal 90° mid esophageal 120° Maisano F, et al Am J Cardiol 2007;99:1434–1439 SL AL <10% of current surgical candidates
  18. 18.  When performed according to surgical principles, the E2E technique provides results at least non inferior to other surgical techniques  Precision of the repair is mandatory for efficacy and durability  Pt selection + include all diseased segments + respect symmetry  Patients with normal annular function may undergo ringless repair, although lower durability may be expected  Percutaneous approach is feasible also in FMR  Addition of annuloplasty should be an option also for percutaneous patients
  19. 19. 66 aa, maschio, 64 Kg, 164 cm, BSA 1.7 m2, BMI 24 IM 4+, FE 15-20%, PAPs 75 mmHg, disfunzione VDx, IT 3+ 1994 IMA anteriore; 2001 PTCA e successivo CABG (LIMA—LAD); successive plurime PTCA con stents medicati 2005 AlloTx di midollo per AML, inizia CsA 2006 stenting a. carotide comune e interna destra 1/2008: recidiva di IMA per trombosi intrastent  POBA su LAD 4/2008 EPA  PM-ICD biv AAA sottorenale; CCS II, NYHA II, labile compenso emodinamico Anamnesi-1 Paziente n. 1Paziente n. 1
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