When is less more minimally invasive surgery in low ef

1. When Is Less More?
Minimally Invasive Surgery in Low EF
Michael Mack, M.D.
Baylor Scott& White Health
Dallas, TX

2. Conflict of Interest Disclosure
• Member of Executive Committee of the
PARTNER Trial of Edwards Lifesciences
• Co-PI of the COAPT Trial of Abbott Vascular
• Travel expenses paid by sponsors for trial
Steering Committee meetings

3. I am Presuming…
• Secondary MR and not primary MR
3

4. Options to Treat Secondary MR
GDMT
Resynchronization

5. How are Patients with Isolated FMR Treated?
Duke Databank: 1,538 pts with echocardiographic 3+ - 4+ FMR
and LVEF ≥20% between 2000 and 2010 not undergoing CABG
11.4% 5.9% 8.4% 11.8% 18.4%
0%
25%
50%
75%
100%
All pts 20%-30% 30%-40% 40%-50% 50%-60%
Conservative management Isolated MV surgery
LVEF
N=1538 N=440 N=298 N=313 N=479
8 other pts had LVEF >60%; none underwent MV surgery c/o Mitch Krucoff

7. Chronic Severe Secondary Mitral
Regurgitation: Intervention
Recommendations COR LOE
MV surgery is reasonable for patients with chronic
severe secondary MR (stages C and D) who are
undergoing CABG or AVR
IIa C
MV surgery may be considered for severely
symptomatic patients (NYHA class III-IV) with
chronic severe secondary MR (stage D)
IIb B
MV repair may be considered for patients with
chronic moderate secondary MR (stage B) who are
undergoing other cardiac surgery
IIb C

8. When Would You Consider MI Surgery
in Low EF?
•Redo
–Hostile reentry
–Grafts in jeopardy
•Elderly
•Frailty
8

9. When Would You NOT Consider MI
Surgery in Low EF?
• Patient needs SURGICAL revascularization
• Concerns about myocardial protection
• Ascending aorta > 4 cm
• Right chest adhesions
• Elevated right hemi-diaphragm
• Extreme morbid obesity
9

10. How to treat this 69-year old male ?
• Mitral regurgitation III-IV, EF 35 %, AFib, NYHA class III-IV
• Medical history:
– s/p anterior myocardial infarction 1988
– s/p posterior myocardial infarction in 1991
– 2-CABG 1993
– biventricular ICD 2005
• Concomitant diseases:
– COPD
– renal insufficiency III°
– hyperlipidaemia
– arterial hypertension

11. EF 29 %, LVEDD: 61 mm
MV: annulus 47 mm
restrictive AML, MI III°, Type IIIB
LA: 47 mm
Echocardiography

12. Secondary MR

13. 1. Lateral position of the right chest around
30°
2. Abduction of the right arm
3. Bend the region of the groin back slightly
Mini MV repair

14. Right anterolateral
minimally invasive incision

15. Minimally invasive
Mitral Valve Surgery
Left atrial retractor Cannulation
femoral artery and vein
Chitwood clamp
Camera Atrial vent
Cardioplegia/ Aortic Vent
Soft tissue retractor

16. Secondary MR- Fibrillating Heart

17. Secondary MR- Fibrillating Heart

18. Secondary MR- Fibrillating Heart

19. Postoperative result

20. Postoperative echo result
No residual MI
Orifice area: 3.3 cm2
Mean gradient: 2 mmHg

21. sternotomy
1569
24%
MIS
4887
76%
Mitral valve surgery, isolated
and combined with tricuspid valve procedures
1996 - 2013
sternotomy vs. MIS
Mitral valve surgery, isolated and combined with tricuspid valve
procedures – sternotomy vs. MIS
at Heart Centre Leipzig (1996-2013) n = 6456

22. Isolated MV repair in cardiomyopathy
(EF<35%) baseline characteristics
N 161
ICM/DCM 70.1 vs. 29.9 %
Age 61 ± 10 y
EF 25 ± 8 %
LVEDD 69 ± 11 mm
MI ≥ III° 93.2 %
NYHA ≥ III° 97.5 %

23. preoperative early postop long term evaluation
0
1
2
3
4
mitral regurgitation
p < 0.001
Isolated MV repair in cardiomyopathy (EF<35%)
echocardiographic MV function

24. NYHA-Median
P < 0.001
0
0,5
1
1,5
2
2,5
3
3,5
preoperative early postop long term evaluation
Isolated MV repair in cardiomyopathy
(EF<35%) NYHA class

25. MV repair
MV replacement
years after operation
survival
Isolated MV surgery in cardiomyopathy (EF<35%)
Survival MV repair vs. replacement
actuarialsurvival(%)
follow-up (y)
Log rank p=0.032

26. DCM
ICM
years after operation
actuarialsurvival(%)
follow-up (y)
Isolated MV surgery in cardiomyopathy (EF<35%)
Survival related to MVR etiology
Log rank p=0.132

27. 0 12 24 36 48 60 72
Postoperative months
0
20
40
60
80
100
NYHA class
Inotr. IV III < III
Survival (%)
Isolated MV surgery in cardiomyopathy (EF<35%)
Survival related to baseline NYHA class

28. When Should We Be Performing MV
Replacement for IMR?
• Ruptured papillary muscle (acute IMR)
• Patients in cardiogenic shock
• Severe apical tenting (>11mm)
• During second CPB run
• Complex MR leaks?
• Surgeons who do not do many repairs?
Valve of choice – bioprosthesis

29. Critical Appraisal / Conclusion
 Residual MR up to 30% following
surgical MV repair  poor survival
 New developments are not superior to MV
surgery
 FMR is and will remain a ventricular
disease!