0
Francesco Maisano, MD
San Raffaele University Hospital
        Milano - ITALY
Disclosures
• I disclose the following potential conflicts

  – Edwards Lifesciences: consultant, royalties
  – Micardia: ...
MV repair is superior to MVR
•   Better preservation of LV function
•   Avoidance of prosthesis related events
•   Reduced...
MV repair: Art or Science?

            The wedding of the
            Virgin

            Raffaello Sanzio,
            1...
Techniques to treat MR
   factors involved in the choice




Anatomy     Function      Ethiology
Mechanism of regurgitation
         functional classification




« Surgeons are not basically concerned withlesions. We c...
structure   function
Ethiology
      Organic                  Functional
• Degenerative           • Ischemic
 • Barlow’s
                      ...
Ethiology
      Organic                  Functional
• Degenerative           • Ischemic
 • Barlow’s
                      ...
Posterior leaflet prolapse/flail
• Quadrangular
  resection
• Sliding plasty
• Chordal replacement
• Haircut technique
• F...
Quadrangular
resection


Sliding plasty
Posterior leaflet chordal repair


• Minimally invasive
• when P1 and P3 are
  hypoplasic
• to obtain wider
  surface of
 ...
ChordaeReplacement Versus
ResectionforRepairofIsolatedPosteriorMitralLeafletProlapse:
                         ÀÈgalité


...
Neochordae
Disadvantages
• Difficult sizing

Advantages
• Anatomical reconstruction
• No resection needed




            ...
Adjustable chordae (Valtech Inc)
Anterior and Bileaflet disease

• Chordal replacement
• Alfieri / E2E
• Chordal transfer
• Papillary muscle
  repositionin...
The edge-to-edge technique
• First case performed in 1991
• Over 1500 published cases
  accumulated worldwide
• About 15 y...
Surgical technique




         Maisano F et al. EJCTS 1998
Special situations
•   Calcified annulus
•   Endocarditis
•   Congenital
•   Rheumatic
Hospital mortality and repair rate
             STS National Adult Cardiac Database

• Hospital mortality for
  isolated f...
Influence Of Hospital Volumes
    on Repair Prevalence and Risk




13.614 patients having elective isolated MR surgery be...
Age and comorbidities
• Older age is associated to
   Higher mortality
   Higher morbidity
   Longer LOS
• 2/3 of pts o...
UNMET CLINICAL NEED
      surgeryisoftendenied in the olderpatients

             Isolated MR
               (n=877)
2/3 o...
Prevalenceof valve disease in the population: MR and
           AR are epidemicin the elderly
                       US po...
LONG-TERM SURVIVAL
Very Long Term Survival for
>20 years in 162 pts with Organic MR




     Braunberger, et al Circulation. 2001;104[suppl I...
Preoperative LV Function Predicts Long Term Postoperative
                         Survival

        100                  ...
Preoperative Symptoms and
            Long Term Survival




•   If mitral repair is performed before the onset of
    sev...
durability
Durability
• Definition
   • Freedom from reoperation
       • Recurrent MR
       • Hemolysis
       • Other valve diseas...
A lesson from the interventional
  cardiologists….EVEREST trial
                • the first clinical trial for
           ...
Durability: Freedom from Reoperation
1072 patients with degenerative mitral regurgitation
  operated upon at CCF between 1...
The Bad News….




 Flameng W, et al. Circulation. 2003;107:1609-1613
Durability: Freedom from recurrent MR>2+

                                                  96%
                       Val...
Ethiology: controversial factor
         Fibroelastic Deficiency
         •   Elderly pt, recent onset MR
         •   No ...
Role of pathology on durability
              • Barlow’s disease may be
                associated with shorter
          ...
Durability: ALP vs PLP




           Braunberger, et al Circulation. 2001;104[suppl I]:I-8-I-11.
           Gillinov et a...
Techniques for ALP treatment
Chordal shortening                 Chordal replacement




                     Smedira NG, e...
The influence of surgical technique:
ALP treated by E2E vs PLP treated by quadrang. resection

    Freedom from reoperatio...
Annuloplasty
• Annuloplasty is routinely performed during MV repair
• Annuloplasty reduces stresses on the suture and on t...
Annuloplasty rings: one fits all?




               Fedak, et al. Circulation. 2008;117:963-974
The solution for rheumatic disease
AnnuloFlo® System
                    The ring’srigidtitanium design
                  ...
The solution for degenerative disesase
 AnnuloFlex™ System
                      Reinforce the entire native annulus, or
 ...
MEMO 3D, the physiologic ring
Mitral repair without annuloplasty
  Durability in selected patients

Chordal replacement                   Alfieri repair...
Annular-to leaflet mismatch predicts need
             for annuloplasty
                       mid esophageal   mid esopha...
Coaptation
• Valve competence under variable loading
  conditions (Coaptation Reserve)
• Reduction of stress on the
  leaf...
Assessing coaptation

On Pump       Off Pump                       Mitral Solutions




                          Adjustab...
Valtech adjustable ring
24mm           35mm




       adjustment




                25mm
   18 mm
Functional mitral regurgitation

• Valve structure is
  preserved
• Left ventricular function
  and shape is impaired
  – ...
Mechanism of IMR - Tethering
2. Anterior leaflet
    Tethering
 (Seagull effect)


     1. Apical and lateral
     displac...
Undersized annuloplasty is the
“conventional” method to treat FMR




Coaptation
  lenght
Durability using conventional
 non “disease-specific” rings



  25-30% late
  recurrence
     rate

                   Hu...
New techniques to improve results
• Dedicated rings
   – Preshaped
      • Edwards Ethilogix
   – Adjustable
      • Cardi...
GEOFORM, IMR
                          Physio30   Geoform30



• Reduction of the SL
  dimension
• Shortening of the
  pap...
Survival after undersized MVA
Surgical vs Medical Rx in DCM-          CABG alone vs CABG+MVA in
MR                        ...
Reverse remodeling




              Beeri et al. J Am Coll Cardiol 2008;51:476–86
          De Bonis, et al . Ann Thorac ...
Duration of CHF is the main factor




                  De Bonis, et al . Ann Thorac Surg 2008;85:932–9
FMR: Early treatment the key ?

                            • Experimental model
                              of induced ...
Early treatment of volume overload is
    associated with reverse remodeling
Reverse remodeling in MI only, MI +MR   Matri...
conclusions
• Mitral repair is a surgical success story
    Low operative risk
    Recovery of life expectancy
    Low ...
State of the art mitral valve repair
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State of the art mitral valve repair

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Invited Lecture at the Hanshin Heart Valve Symposium on the State of the art mitral valve repair techniques (Osaka, 2009)

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  • * DISEASES THAT AFFECT the mitral valve include mitral regurgitation, mitral stenosis, rheumatic heart disease, and cardiomyopahy.

    * THE RESULTS OF DIAGNOSTIC procedures are used to identify and confirm mitral valve disease, evaluate the patient's anatomy, and determine the severity of the disease.

    * AFTER THE PATIENT IN PREPARED for surgery, the surgeon performs an intraoperative trans-esophageal echocardiogram and the patient is placed on cardiopulmonary bypass.

    * A REPAIR PROCEDURE (eg, annuloplasty, slidingplasty, chordal repair/transfer/replacement, valve replacement) is performed depending on the patient's specific anatomic abnormalities. please click here:http://heart-consult.com/articles/what-mitral-valve-repair
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  • * DISEASES THAT AFFECT the mitral valve include mitral regurgitation, mitral stenosis, rheumatic heart disease, and cardiomyopahy.

    * THE RESULTS OF DIAGNOSTIC procedures are used to identify and confirm mitral valve disease, evaluate the patient's anatomy, and determine the severity of the disease.

    * AFTER THE PATIENT IN PREPARED for surgery, the surgeon performs an intraoperative trans-esophageal echocardiogram and the patient is placed on cardiopulmonary bypass.

    * A REPAIR PROCEDURE (eg, annuloplasty, slidingplasty, chordal repair/transfer/replacement, valve replacement) is performed depending on the patient's specific anatomical abnormalities. please click here:http://heart-consult.com/articles/what-mitral-valve-repair
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
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Transcript of "State of the art mitral valve repair"

  1. 1. Francesco Maisano, MD San Raffaele University Hospital Milano - ITALY
  2. 2. Disclosures • I disclose the following potential conflicts – Edwards Lifesciences: consultant, royalties – Micardia: consultant, stock options – Valtech: Consultant – Nycomed: consultant – Medtronic: honoraria – St Jude: honoraria
  3. 3. MV repair is superior to MVR • Better preservation of LV function • Avoidance of prosthesis related events • Reduced hospital mortality • Reduced morbidity and LOS • Improved long term survival Thourani et al, Circulation 2003; 108:298-304 Zaho et al, JTCVS 2007;1257-1263 Shuhaiber J et al, EJCTS 2007; 31:267-275 Perrier P et al, Circulation 1984;70:187 Akins CW, et al. ATS 1994; 58:668-676
  4. 4. MV repair: Art or Science? The wedding of the Virgin Raffaello Sanzio, 1483 - 1520 Milano, PinacotecadiBrera
  5. 5. Techniques to treat MR factors involved in the choice Anatomy Function Ethiology
  6. 6. Mechanism of regurgitation functional classification « Surgeons are not basically concerned withlesions. We care more about function. Therefore one may define the aim of a valve reconstuction as restoring normal leaflet function rather than normal valve anatomy » A. Carpentier, the French Correction 1984
  7. 7. structure function
  8. 8. Ethiology Organic Functional • Degenerative • Ischemic • Barlow’s • DCM • Dystrophic • Marfan’s • Secondary to AS • Other • Endocarditis • Rheumatic • Post-traumatic
  9. 9. Ethiology Organic Functional • Degenerative • Ischemic • Barlow’s • DCM • Dystrophic • Marfan’s • Secondary to AS • Other • Endocarditis • Rheumatic • Post-traumatic
  10. 10. Posterior leaflet prolapse/flail • Quadrangular resection • Sliding plasty • Chordal replacement • Haircut technique • Folding plasty • Alfieri / E2E • ….
  11. 11. Quadrangular resection Sliding plasty
  12. 12. Posterior leaflet chordal repair • Minimally invasive • when P1 and P3 are hypoplasic • to obtain wider surface of coaptation
  13. 13. ChordaeReplacement Versus ResectionforRepairofIsolatedPosteriorMitralLeafletProlapse: ÀÈgalité Seeburgeret al. AnnThoracSurg 2009;87:1715–20)
  14. 14. Neochordae Disadvantages • Difficult sizing Advantages • Anatomical reconstruction • No resection needed Gillinov, JTCVS 2008
  15. 15. Adjustable chordae (Valtech Inc)
  16. 16. Anterior and Bileaflet disease • Chordal replacement • Alfieri / E2E • Chordal transfer • Papillary muscle repositioning • Triangular resection • …..
  17. 17. The edge-to-edge technique • 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 – Used only as a bailout
  18. 18. Surgical technique Maisano F et al. EJCTS 1998
  19. 19. Special situations • Calcified annulus • Endocarditis • Congenital • Rheumatic
  20. 20. Hospital mortality and repair rate STS National Adult Cardiac Database • Hospital mortality for isolated first time 100% elective MV repair is 80% 2.5% (males) to 3.9% 60% (females) 40% 20% • Operative risk is higher 0% in elderly 1991 1993 1995 1997 1999 pts, associated Replacement Repair CABG, NYHA III-IV, low EF and reoperation Savage EB, et al Ann Thorac Surg 2003;75:820–5
  21. 21. Influence Of Hospital Volumes on Repair Prevalence and Risk 13.614 patients having elective isolated MR surgery between 2000 and 2003 in 575 US centers participating in the STS National Cardiac Database Gamie et al. Circulation. 2007;115:881-887
  22. 22. Age and comorbidities • Older age is associated to  Higher mortality  Higher morbidity  Longer LOS • 2/3 of pts older than 70 years are denied surgery (Euroheart Survey) Mehta et al. Ann Thorac Surg 2002;74:1459-67
  23. 23. UNMET CLINICAL NEED surgeryisoftendenied in the olderpatients Isolated MR (n=877) 2/3 of symptomatic No Severe MR Severe MR MR patients >70 are (n=331) (n=546) denied surgery No Symptoms Symptoms (n=144) (n=396) No Intervention Intervention (n=193) 49% (n=203) 51% Mirabel et al, European Heart J 2007;28:1358-1365
  24. 24. Prevalenceof valve disease in the population: MR and AR are epidemicin the elderly US population older than 75 years (forecast 2015) Severe MR 1,419,419 Severe AR 342,944 Severe TR ? Health Research International Report 2009 Nkomo et al , Lancet 2006
  25. 25. LONG-TERM SURVIVAL
  26. 26. Very Long Term Survival for >20 years in 162 pts with Organic MR Braunberger, et al Circulation. 2001;104[suppl I]:I-8-I-11.
  27. 27. Preoperative LV Function Predicts Long Term Postoperative Survival 100 Ejection Fraction 80 72% Survival (%) 60 53% EF  60% 40 EF 50-60% EF < 50% 32% 20 P = 0.0001 0 0 2 4 6 8 10Years Enriquez-Sarano M et al. Circulation 1994; 90: 830 - 37
  28. 28. Preoperative Symptoms and Long Term Survival • If mitral repair is performed before the onset of severe symptoms (congestive heart failure, arrhythmias), life expectancy is restored David T et al, J Thorac Cardiovasc Surg 2003;125:1143-52
  29. 29. durability
  30. 30. Durability • Definition • Freedom from reoperation • Recurrent MR • Hemolysis • Other valve disease • Freedom from recurrent MR • Methodology • Single institutions vs Registry • Visit vs phone calls • Serial vs instant follow-up • Internal vs Core lab review
  31. 31. A lesson from the interventional cardiologists….EVEREST trial • the first clinical trial for treatment of patients with MR to report a prospective, systematic, a nd integrative approach to the analysis of MR severity at baseline and follow-up that included quantitative parameters. • CORE LAB Foster E, et al Am J Cardiol 2007;100:1577–1583
  32. 32. Durability: Freedom from Reoperation 1072 patients with degenerative mitral regurgitation operated upon at CCF between 1985 and 1997 Gillinov et alJ Thorac Cardiovasc Surg 1998;116:734-43
  33. 33. The Bad News…. Flameng W, et al. Circulation. 2003;107:1609-1613
  34. 34. Durability: Freedom from recurrent MR>2+ 96% Valve anatomy 71% Linearized rate of recurrent MR>2+: 3.7%pt-year Surgical Ethiology expertise Flameng W, et al. Circulation. 2003;107:1609-1613
  35. 35. Ethiology: controversial factor Fibroelastic Deficiency • Elderly pt, recent onset MR • No excess tissue • Thickening of prolapsing area, remaining valve thinner and transparent • Mild annular dilatation • Chordae thinner • Segmental lesions Myxomatous degeneration • Middle aged pt, long-lasting history of MR • Excess tissue • Myxoid appearance • Annular dilatation • Chordae thickened • Diffuse type II lesions Fornes et alCardiovascular Pathol 1999;8:81-92
  36. 36. Role of pathology on durability • Barlow’s disease may be associated with shorter durability Flameng W, et al JTCVS 2008;135:274-82
  37. 37. Durability: ALP vs PLP Braunberger, et al Circulation. 2001;104[suppl I]:I-8-I-11. Gillinov et al J Thorac Cardiovasc Surg 1998;116:734-43
  38. 38. Techniques for ALP treatment Chordal shortening Chordal replacement Smedira NG, et al,J Thorac Cardiovasc Surg 1996;112:287-92)
  39. 39. The influence of surgical technique: ALP treated by E2E vs PLP treated by quadrang. resection Freedom from reoperation MR grade at echo follow-up P=N.S. De Bonis et al, J Thorac Cardiovasc Surg 2006;131:364-70
  40. 40. Annuloplasty • Annuloplasty is routinely performed during MV repair • Annuloplasty reduces stresses on the suture and on the valve structures and stabilizes annular diameter • Lack of annuloplasty is associated to accelerated failure in the overall surgical population SI (kPa) - 647 - 520 - 394 - 267 - 140 - 134 + 113 + 240 + 367 + 493 + 620 + 747 +873 +100 0 Maisano F, et al Eur J Cardiothorac Surg. 1999;15:419-25 Gillinov et al J Thorac Cardiovasc Surg 1998;116:734-43
  41. 41. Annuloplasty rings: one fits all? Fedak, et al. Circulation. 2008;117:963-974
  42. 42. The solution for rheumatic disease AnnuloFlo® System The ring’srigidtitanium design adheresto the classicapproach, while the instrumentationredefines the standard.
  43. 43. The solution for degenerative disesase AnnuloFlex™ System Reinforce the entire native annulus, or only the posteriorportion. The choiceisyourswith the AnnuloFlex Annuloplasty Ring. The trueflexibilityof the ring meansthree- dimensionalcompliancethatmirrorsnatura l valve dynamics.
  44. 44. MEMO 3D, the physiologic ring
  45. 45. Mitral repair without annuloplasty Durability in selected patients Chordal replacement Alfieri repair Duebener LF, et al EJCTS 2000; 17:206-212 Maisano F, et al Eurointervention 2006; 6:181-186
  46. 46. Annular-to leaflet mismatch predicts need for annuloplasty mid esophageal mid esophageal mid esophageal 120° 90° 120° Annuloplasty can be avoided if SL/AL<1.4 SL AL 10% of current surgical population Maisano F, et al Am J Cardiol 2007;99:1434–1439
  47. 47. Coaptation • Valve competence under variable loading conditions (Coaptation Reserve) • Reduction of stress on the leaflets, subvalvar apparatus • Excessive coaptation can be detrimental (SAM)
  48. 48. Assessing coaptation On Pump Off Pump Mitral Solutions Adjustable rings Micardia Valtech
  49. 49. Valtech adjustable ring 24mm 35mm adjustment 25mm 18 mm
  50. 50. Functional mitral regurgitation • Valve structure is preserved • Left ventricular function and shape is impaired – Dilated Idiopathic cardiomyopathy – Ischemic cardiomiopathy – IMR with preserved global LV function
  51. 51. Mechanism of IMR - Tethering 2. Anterior leaflet Tethering (Seagull effect) 1. Apical and lateral displacement of the papillary muscles 2. Loweringof the pointofcoaptation (coaptationdepth)
  52. 52. Undersized annuloplasty is the “conventional” method to treat FMR Coaptation lenght
  53. 53. Durability using conventional non “disease-specific” rings 25-30% late recurrence rate Hung et al. Circulation 2004.
  54. 54. New techniques to improve results • Dedicated rings – Preshaped • Edwards Ethilogix – Adjustable • CardiacSolutions • Micardia • Subvalvar remodeling – Chordal cutting – Papillary muscle cinching • External devices – Coapsys – Others
  55. 55. GEOFORM, IMR Physio30 Geoform30 • Reduction of the SL dimension • Shortening of the papillary muscle to annulus distance • Increasing coaptation surface PRE Post
  56. 56. Survival after undersized MVA Surgical vs Medical Rx in DCM- CABG alone vs CABG+MVA in MR IMR A. Wu, et. Al. JACC 2005, 45 p. 381-387 Mihalijevic T et al. J Am Coll Cardiol 2007;49:2191–201
  57. 57. Reverse remodeling Beeri et al. J Am Coll Cardiol 2008;51:476–86 De Bonis, et al . Ann Thorac Surg 2008;85:932–9
  58. 58. Duration of CHF is the main factor De Bonis, et al . Ann Thorac Surg 2008;85:932–9
  59. 59. FMR: Early treatment the key ? • Experimental model of induced myocardial infarction plus controlled ventriculoarterial shunt simulating MR overload – Induction of MI – Group 1: no MR treatment – Group 2: MR abolished Beeri R et al. Circulation 2007;116[suppl I]:I-288–I-293.
  60. 60. Early treatment of volume overload is associated with reverse remodeling Reverse remodeling in MI only, MI +MR Matrix metalloproteinase-2 and MMP and MR repair inhibitors in MI only, MI +MR and MR repair
  61. 61. conclusions • Mitral repair is a surgical success story  Low operative risk  Recovery of life expectancy  Low rate of recurrence when appropriate procedures are performed  Minimally invasive techniques are increasingly performed • Transcatheter techniques will face the challenge of comparison with these excellent results – Increase the potential candidates for treatment – Reduce early risk in selected patients – Enable earlier intervention
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