Mitral valve repair in rheumatic patients

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ESCTS 2012

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Mitral valve repair in rheumatic patients

  1. 1. Prof. Walaa Ahmed Saber MD
  2. 2. ADVANTAGES OF MITRAL REPAIR OVERREPLACEMENT:* Lower operative mortality* Better LV function* Lower incidence of thromboembolism* Lower incidence of bleeding* Lower incidence of infective endocarditis* Increased long term survival
  3. 3. Controversial problems of mitral valve Repair In General:-Predictability of results.-Reproducibility of techniques-Selection of patients.
  4. 4. - In 1970’s: Carpentier used to say that:- All mitral valves are repairable until proved otherwise. Is that a true statement??
  5. 5. 1. Leaflets2. Chordae tendineae3. Annulus4. Papillary muscles5. Left ventricle6. Left atriumThe function of the mitral valve is wonderfullycomplex and involves precisely timed interactionsamong all the six components of the mitral valveto function properly.
  6. 6. Type DescriptionType 1 *normal leaflet motion -annular dilatation -leaflet perforationType 2 *leaflet prolapse -chordal rupture -chordal elongation -papillary muscle rupture -papillary muscle elongationType 3 *restricted leaflet motion -commissural fusion, leaflet thickening -chordal fusion/ thickening
  7. 7. - Continuous inflammatory process.- Aggressive pathological changes.- Decreased repair durability.
  8. 8. Degenerative Rheumatic-Generous leaflet tissue -Reduced leaflet tissue-Thin leaflet -Thickened leaflet-Elongated thin chordae -Shortened thick chordae-Free MR -Mainly stenotic
  9. 9. Mitral valve repair in the setting of rheumatic changescan be technically difficult to perform and the late resultsare adversely affected by new episodes of acute rheumaticinflammation.
  10. 10. Up to 95% of degenerative mitral valves can be repairedwith current techniques. But only 75% of the patientswith rheumatic mitral valves disease are amenable toreparative procedures.
  11. 11. - Mitral valve repair is more challenging and controversialin rheumatic patients.- There is a higher probability of valve replacementcompared to valve repair.- The durability of mitral valve repair is also limited in therheumatic pathology due to its progressive nature
  12. 12. Mitral valve repair in rheumatic disease showedsatisfactory early results. Long-term results were poor because of high mortalityand a high number of valve-related reoperations. Of the 144 Patients who survived the operation, 63(41.2%) required reoperation because of valvedysfunction.
  13. 13. 55 publications reviewed29 publications were included (10,000 cases)Divided into 4 etiologies:i.Degenerativeii.Ischemiciii.Rheumaticiv.Mixed
  14. 14. In rheumatic lesions, patients undergoing mitralreplacement had the following increased risks ,compared to mitral repair:I.Almost 3 times the risk of early mortality.II.More than twice the risk of thromboembolism.III.More than twice the risk of dying in the long term. Shuhaiber&Anderson, 2007
  15. 15. In a young Saudi population <20 yearsIsolated MR of rheumatic etiologyActuarial survival was around: 98% at 6.5 years for repair 75% at 4 years for replacement Gometza et al. J Heart Valve Disease, 1996
  16. 16. Reoperation rate at 10 years: 18-28%.Mean delay to reoperation: 9.3 years.Mortality of reoperation: 0-6.5%Yau et al.
  17. 17. Nice study with follow up data for 36 years:The rheumatic patients who survive more than 20 yearsafter repair require reoperation (more than 90%)
  18. 18. In conclusion, it is quite obvious that, even in rheumaticpathology, mitral valve repair is still worthwhile and thatthe percentage of valves repaired increases with theexperience and the will of the surgeon to preserve the valve.In my view, mitral valve replacement is only justified whena good repair is not feasible, but the experience of thesurgeon is absolutely vital. This can only be obtained byexposure to an adequate number of patients, which isusually made difficult by the political and economicalsituation in our country.
  19. 19. Rheumatic mitral regurgitation in the youngpopulation group is amenable to repair, although theresults are less favorable than those observed withother types of mitral valve disease, especially in olderpopulations. However, a better knowledge of thepathology and evolution of the techniques of repairhave led to improved results. The latter includeavoidance of resection of anterior leaflet, use of PTFEchordae versus shortening of the chordae and use ofpre-shaped rigid rings.
  20. 20. Intra-operative transoesophageal echocardiographyhas proven most valuable. On the other hand,continued prophylaxis of rheumatic fever remains avery important component of the treatment ofthese patients.

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