THE FOLDING LEAFLET. Rafael García Fuster. Cardiac Surgery Department University General Hospital of Valencia
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1 THE FOLDING LEAFLET Rafael García Fuster Cardiac Surgery Department University General Hospital of Valencia School of Medicine Catholic University of Valencia San Vicente Mártir SPAIN
2 Carpentier s principles of a reconstructive valve operation 1.Preserve or restore FULL LEAFLET MOTION 2. LARGE SURFACE OF COAPTATION 3. Remodel-stabilize THE ENTIRE ANNULUS
3 1.FULL LEAFLET MOTION Respect rather than resect --NO neochordal shortening (the key-point: neochordal height adjustment) 2. REMODEL THE LEAFLET -large surface of coaptation -avoid SAM in case of excess of tissue 3. REMODEL THE ENTIRE ANNULUS
4 FULL LEAFLET MOTION with leaflet restrictive techniques? Posterior leaflet restriction Bileaflet restriction
5 Patrick Perier s new paradigm but without neochordal shortening in order to avoid posterior leaflet restriction RESPECT BOTH, *LEAFLET TISSUE AND *LEAFLET MOBILITY
6 1. FULL LEAFLET MOTION Remodel the leaflet avoiding neochordal shortening FROZEN POSTERIOR LEAFLET MOBILE POSTERIOR LEAFLET 2. REMODEL THE LEAFLET
7 Remodel the leaflet fixing the neochordae along the rough zone Hockey-stick effect - > SURFACE OF COAPTATION
8 fixing the neochordae along the rough zone
9 Ventricular view of anterior leaflet
10 Ventricular view of anterior leaflet
11 Ventricular view of anterior leaflet
12 Coaptation line
13 Coaptation line
14
15 Coaptation line Smooth zone Rough zone
16 Coaptation line Smooth zone Rough zone
17 Hockey-stick effect on the leaflets
18 (Rough zone)
19 Remodel the leaflet to avoid SAM in case of excess of tissue Atrial surface Atrial surface
20 Avoid SAM Global bileaflet atrial surface Prosthetic ring internal área tailoring the Global Bileaflet Atrial Surface to the ring Prosthetic ring internal área 1. Remodel the leaflet 2. Height of posterior leaflet 15mm 3. Physio II
21 ATRIAL SURFACE Approaching the excess of tissue with neochordae AVOIDING SAM
22 REMODEL THE LEAFLETS WITH NEOCHORDAE <<<< ATRIAL SURFACE >>>> SURFACE OF COAPTATION
23 >>>> internal oriffice area Annuloplasty ring <<<< ATRIAL SURFACE >>>> SURFACE OF COAPTATION
24 Avoid excessive anterior displacement of the coaptation line (2/3 1/3 proportion) 2/3 Avoid excessive remodeling 1/3 Height 15mm
25 the key-point: neochordal height adjustment FOLDING LEAFLET
26 Put the knot at the level of the annulus MARGINAL = BASAL PAPILLARY MUSCLE while the leaflet is completely folded
27 POSTERIOR AND ANTERIOR LEAFLET NEOCHORDAL RECONSTRUCTION
28
29 Papillary muscle variability --- Loop technique? Carpentier s Classification
30 Loop technique --- papillary muscle variability Carpentier s Classification x x
31 A1 A2 (A) A2 (P) A3 AC PC A2 (P) A3 PC P1 P2 (P) P3 P3 P2 (A) P2 (P) Neochordal arrangement
32 A1 A2 (A) A2 (P) A3 AC PC A2 (P) A3 PC P1 P2 (P) P3 P3 P2 (A) P2 (P) Neochordal arrangement
33 1. Annuloplasty sutures for a good exposure 2. Exploration: isolation of the prolapsing área (5/0 prolene suture) 3. Identify the coaptation line --- between rough and smooth zone 4. Folding sutures from the coaptation line to the annulus ( folding ) 5. Neochordae fixation across the corresponding papillary muscle 6. Neochordae fixation across the rough zone of the leaflet (remodeling) 7. Neochordal height adjustment ( knot at the level of the annulus ) 8. Unfolding and testing 9. Ring implantation 10. Final testing. SYSTEMATIC APPROACH FOR NEOCHORDAL REPAIR
34 VIDEO 3 DISTINTOS PROLAPSOS
35 TOTAL NEOCHORDAL RECONSTRUCTION A1 A2 A3 P1 P3 P2
36 COMPLETE MV RECONSTRUCTION Wetlab on human heart
37 THE FOLDING LEAFLET TECHNIQUE MIDTERM OUTCOMES
38 MIDTERM OUTCOMES 100 patients 10 years follow-up ONLY one surgeon ONLY MV repair ONLY one technique --- neochordal repair MAINLY degenerative MR
39 Variable Preoperative characteristics n=104 patients Study period: Feb 2009 June 2018 One surgeon Folding leaflet technique n (%) / x±sd Age (y) 64±11 (26-83) Female sex 36 (34.6) NYHA class -I 9 (8.7) -II 59 (56.7) -III 32 (30.8) -IV 4 (3.8) Hypertension 62 (59.6) Diabetes 22 (21.2) CRF 3 (2.9) COPD 22 (21.2) Stroke 4 (3.8) AF 36 (34.6) EuroSCORE II 5.2±2.5 (2-14)
40 Preoperative characteristics patients MR Etiology *Rheumatic: patients *Endocarditis: 6 *Ischemic: 1 *Congenital: 1 30 *Trauma: patients 10 0 FED Barlow Other
41 Pattern of lesions BARLOW A2 P3 FED P2 P2
42 Posterior leaflet prolapse -- n=58 patients Multiscalloped prolapse n=30 patients Annulus calcification n= 8 patients
43 n=21 pat *Barlow: 8 *FED: 10 *endocard: 3 P2 P3 n=14 pat *Barlow: 6 *FED: 8 P2 P1 P2 P3 n=7 pat *Barlow: 4 *FED: 2 *Rheum: 1
44 P3 n=5 pat *FED: 5 P1 n=2 pat *FED: 2 P1 P2 n=9 pat *Barlow: 4 *FED: 4 *Endocard: 1
45 Anterior leaflet prolapse -- n=27 patients Multisegment prolapse n=17 patients Annulus calcification n= 1 patient
46 A2 n=8 pat *FED: 5 *Rheumat: 1 *Trauma: 1 *Congenit: 1 A2 A3 n=9 pat *Barlow: 4 *FED: 5 A1 A2 A3 n=8 pat *Barlow: 2 *FED: 5 *Rheumat: 1
47 A3 n=2 pat *FED: 1 *Ischemic: 1 (PM elongat)
48 Bileaflet prolapse n=19 patients Anterior Commissural prolapse n=8 patients Posterior Commissural prolapse n=15 patients Annulus calcification n= 4 patients
49 A2 n=4 pat *Barlow: 1 *FED: 1 *Endocard: 2 P2 A2 A3 P3 n=4 pat *Barlow: 2 *FED: 2 P2 A2 P2 P3 n=1 pat *Barlow: 1
50 A2 A3 n=1 pat *Barlow: 1 P2 A1 A2 A3 n=1 pat *FED: 1 P2 P1 A1 A3 A2 P3 n=5 pat *Barlow: 5 P2
51 A3 P3 n=1 pat *FED: 1 P1 A1 A2 n=2 pat *FED: 1 *Rheumat: 1
52 Intraoperative variables Variable n (%) / x±sd Median sternotomy 100% PTFE neochordae 100% Annuloplasty ring 100% -CE Physio 63 (60.6) size (mm) 28±6 (26-30) -CE Physio II 41 (39.4) size (mm) 30±4 (28-34) Indentation closure 14 (13.5) (posterior flail leaflet) Maze procedure 24 (23.1) Atrial appendage closure 12 (11.5) CPB time 143±34 (90-192) Cross-Clamp time 115±29 (52-135)
53 Outcomes In-hospital mortality: 2 / 104 patients (1.9%) Causes of death: distress (1) sepsis (1) Late mortality: 4 / 102 patients (3.9%) Causes of death: Pneumonia (1) ARF (1) Tumoral disease (1) Unknown (1)
54 Survival Study period: Feb 2009 June 2018 (2 months 9 years 6 months) 91±0.4% 109.3±2.2 months ( ) Patients at risk:
55 Reoperation: 3 patients *Non-valve related: -postcardiotomy síndrome: after 1 month *Valve related: -Mitral stenosis: after 3 years (rheumatic disease) -Endocarditis: after 12 months
56 Reoperation: 3 patients 97±0.01% Patients at risk:
57 Qx 1st month 6th month 1st year Annually Systematic Echo follow-up
58 Recurrence of MR > MR: 2 patients Causes: -AL chordal ruptura (endocarditis) -P3 retraction by annulus calcification 3+ MR: 5 patients Causes: -PL restriction + moderate MS (rheum) -PL restriction (annulus calcification) -traumatic elongation of anterior PM -excessive remodeling of AL -commissural jet (large previous AL prolapse).
59 Grade of MR at latest Echo follow-up Excluded: MV REDO (2) + Dead patients (6) n=57 (59.4%) n=25 (26%) n=9 (9.4%) n=4 (4.2%) n=1 (1%) 0 MR 1+ MR 2+ MR 3+ MR 4+ MR
60 Recurrence of MR > 2+ 89±0.3% Patients at risk:
61 Echo parameters at follow-up p< preop 6 month 1 year late LVEF EDLVD PSP ESLVD
62 Echo parameters at follow-up ±6 49±5 47±4 46±5 EDLVD (mm) ±6 31±5 30±5 29±5 p< preop 6 month 1 year late ESLVD (mm)
63 Echo parameters at follow-up ±5 59±6 61±5 62±7 p< LVEF (%) preop 6 month 1 year late
64 Echo parameters at follow-up ± ±6 31±7 31±9 p< preop 6 month 1 year late PSP (mmhg)
65 EDLVD (mm) One-way ANOVA with repeated measures p< ±6 55±5 48±4 49±5 2+ MR 48±5 50±5 47±4 46± MR 10 0 preop 6 month 1 year late
66 ESLVD (mm) One-way ANOVA with repeated measures p= ±9 2+ MR 31±6 32±6 31± ±5 32±5 29±5 29± MR preop 6 month 1 year late
67 PSP (mmhg) One-way ANOVA with repeated measures p< ±1 33±5 36±7 2+ MR 41± ±1 32±7 29±5 29± MR 0 preop 6 month 1 year late
68 70 60 LVEF (%) 56±5 One-way ANOVA with repeated measures p= MR 60±5 62±5 63± ±8 58±8 58±7 58±9 2+ MR preop 6 month 1 year late
69 CONCLUSIONS -1. Neochordal repair with the Folding Leaflet Technique has achieved excellent results. -2. This technique is suitable for complex repairs: a great variety of complex lesions can be managed. -3. Excellent results at follow-up ( 10 years), especially in degenerative MR: *a large percentage of patients with absent MR and preservation of bileaflet mobility *good regression of LV diametres and PSP *improvement to normal values of LVEF.
70 THE FOLDING LEAFLET Rafael García Fuster Cardiac Surgery Department University General Hospital of Valencia School of Medicine Catholic University of Valencia San Vicente Mártir SPAIN
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