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Maisano Edge To Edge Tor Vergata

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guiding the procedure is key.

guiding the procedure is key.

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  • 1. Francesco Maisano San Raffaele Scientific Institute and University Hospital Milano
  • 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.
    • 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%)
    Alfieri O et al. JTCVS 2001
  • 4. Alfieri O et al. JTCVS 2001; Maisano F et al. EJCTS 1998 Freedom from reoperation Recurrence of MR / MS 5 yrs follow-up of 82 pts with severe Barlow’s disease and bileaflet prolapse Overall Etiology subgroups
  • 5. Debonis et al. JTCVS 2005 ALP: 96,6 ± 1 ,74% E2E offers the same results as conventional techniques PLP: 96.2 ± 2.0% n.s. Mayo Cleveland
  • 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. Maisano F et al. EJCTS 1998
  • 8.
    • Stenosis / Gradients
    • Suture dehiscence
    • Role of annuloplasty
  • 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 cm 2 Maisano F et al. EJCTS 1999
  • 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.
    • 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)
    Alfieri et al. JTCVS 2001, Maisano et al JTCVS 2003, Nielsen et al Circulation 2005 - 647 - 520 - 394 - 267 - 140 - 134 + 113 + 240 + 367 + 493 + 620 + 747 +873 +1000 SI (kPa)
  • 12. Maisano F et al. Eurointervention 2006
  • 13.  
  • 14. Guide Steerable sleeve Clip delivery handle Stabilizer Atrial Septum
  • 15. 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
  • 16.  
  • 17.  
  • 18. 79 pts
  • 19. 71% Repaired 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
  • 20.
    • Applicable only to central MR originating from A2-P2
    • Not applicable in case of wide prolapse
    • Not applicable in case of annular dilatation
    Maisano F, et al Am J Cardiol 2007;99:1434–1439 SL AL <10% of current surgical candidates mid esophageal 120° mid esophageal 90° mid esophageal 120°
  • 21.
    • 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
  • 22.
    • 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. 1
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