Techniques for ischemic mitral valve disease: An Update. Stanford CV Surgery
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1 Techniques for ischemic mitral valve disease: An Update
2 Conflict of Interest Disclosure Grant/ Research Support: NHLBI RO1 HL67025 Consulting Fees/Honoraria: Stanford PI PARTNER Trial, Edwards Lifesciences Consultant, Abbott Vascular Structural Heart (MitraClip) Consultant, Medtronic CardioVascular Division Consultant, St. Jude Medical Executive Committee, PARTNER U.S. Pivotal Trial, Edwards Lifesciences (non-remunerative) Major Stock Shareholder/Equity Interest: Royalty Income: Ownership/Founder: Salary: Intellectual Property Rights: Other Financial Benefit:
3 FMR and IMR PATHOPHYSIOLOGIC MECHANISMS & TREATMENT Levine, RA New Eng J Med 351: 1681, 2004
4 Why do leaflets malcoapt in patients with IMR/FMR? Two mechanisms of leaflet malcoaptation: Annular dilation with Carpentier type I leaflet motion (IMLC) AML S-L PML PPM
5 Why do leaflets malcoapt in patients with IMR/FMR? Two mechanisms of leaflet malcoaptation: Annular dilation with Carpentier type I leaflet motion (IMLC) Most common in FMR Early and mid systolic leak AML PML PPM
6 Why do leaflets malcoapt in patients with IMR/FMR? Two mechanisms of leaflet malcoaptation: Papillary muscle displacement with apically restricted systolic leaflet motion (type IIIb) (apical tethering, tenting) AML PPM PML
7 Why do leaflets malcoapt in patients with IMR/FMR? Two mechanisms of leaflet malcoaptation: Papillary muscle displacement with apically restricted systolic leaflet motion (type IIIb) (apical tethering, tenting) AML PPM PML Most common in IMR Early systolic leak
8 Why do leaflets malcoapt in patients with IMR/FMR? Both mechanisms (type I and type IIIb) of leaflet malcoaptation can coexist in the same patient
9 Advances in Echocardiography Are Color Doppler and rt 3-D TEE just for amateurs? But please don t take away my X-plane and color M-mode
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12 Mechanisms of MR- Color M-mode echo Early systolic (FMR)
13 Mechanisms of MR- Color M-mode echo Holosystolic (IMR)
14 Mechanisms of MR- Color M-mode echo Late systolic (prolapse)
15 IMR/FMR - apical tenting (type IIIb)
16 IMR/FMR - apical tenting (type IIIb)
17 IMR/FMR - type I s/p Bolling Procedure
18 IMR/FMR - type I s/p Bolling Procedure
19 Human Mitral annulus From FC Wells and LM Shapiro, 1996
20 Hueb AC et al., J Thorac Cardiovasc Surg 2002; Stanford 124: CV Surgery
21 Standard Surgical Approach Frank Langer, Homburg, Germany
22 Surgical treatment of IMR with ring annuloplasty ± CABG Mihaljevic, T. et al. J Am Coll Cardiol 2007;49:
23 3+ or 4+ residual/recurrent MR Mihaljevic, T. et al. J Am Coll Cardiol 2007;49:
24 Survival After CABG ± Concomitant MV Annuloplasty Mihaljevic, T. et al. J Am Coll Cardiol 2007;49:
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27 Recurrent/residual MR 2+ after ring annuloplasty for IMR Magne et al. Cardiology 2009;112:
28 Large variety of annuloplasty rings available a.) Various shapes (flat, saddle, dog bone) b.) Various configurations (partial, complete) c.) Various material properties (flexible, semi-flexible, rigid)
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31 IMR-FMR disease-specific ring designs Disproportionate septal-lateral dimension reduction Bothe W, Swanson J, et al., JTCVS 139: , 2010
32 IMR-FMR disease-specific ring designs Disproportionate S-L reduction vs. CE Physio Bothe W, Swanson J, et al., JTCVS 139: , Stanford 2010 CV Surgery
33 IMR-FMR disease-specific ring designs Disproportionate S-L reduction vs. CE Physio Bothe W, Swanson J, et al., JTCVS 139: , Stanford 2010 CV Surgery
34 Adjunctive surgical subvalvular approaches Coapsys, SLAC, Hvass PM sling or PM-suturing, Kron UVA stitch, Homburg STRING, second-order chordal cutting, CorCap CSD, Fontan stitch, epicardial LV balloon patch, LV wall polymer injection
35 CorCap CSD Acorn Medical
36 JTCVS 2011; 142:
37 JTCVS 2011; 142:
38 JTCVS 2011; 142:
39 Ventricular Level Approaches Hvass Papillary Muscle Sling U Hvass, et al. Ann Thorac Surg 2003;75:809 11
40 Hvass Papillary Muscle Sling U Hvass, et al. JTCVS 2010;139:
41 Ventricular Level Approaches Papillary Muscle Imbrication (Univ. of Osaka) CIRCULATION 2010; 122 [suppl 1] : S29 S36
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45 MGH thrust #2-2 order CT cutting to AMVL Messas, Guerrero, Handschumacher, Conrad, Chow, Sullivan, Yoganahan, Levine (CIRCULATION 2001; 104: )
46 Ring + CABG MR grade Ring + CT cutting +CABG J Thorac Cardiovasc Surg 2007;133:
47 Event-free survival Defined as freedom from death, recurrent > moderate MR, reop, TE, hemolysis, major ACH, or PVE J Thorac Cardiovasc Surg 2007;133:
48 IMR/MR Is the MR the real culprit?
49 Benefits of MR Reduction in Ischemic MR Patients: Lessons from RESTOR_MV Trial Open CABG + ring annuloplasty vs. OpCAB + Coapsys Eugene A. Grossi, MD for the RESTOR-MV Study Group NYU School of Medicine & NY Harbor Veterans Healthcare System
50 RESTOR_MV Trial: FDA Prospective Study Minimally invasive (no CPB) Ventricular Shape Change Device
51 RESTOR_MV: MR Evaluation CABG+MVRepair vs. CABG+Coapsys Both effect of time and treatment p=0.0001
52 Intent-To-Treat: All Patient Survival
53 Other Approaches LV systolic function? X-clamp time? Borger JTCVS 2007 de Varennes CIRC 2009 Langer CIRC 2009
54 Kron-technique via atriotomy final tension in arrested heart STRING-technique via horizontal aortotomy final tension in loaded beating heart under TEE guidance
55 IMR (n=60) with severe leaflet tethering (tenting height > 10 mm) RING historical matched control group (n=30) RING+STRING study group (n=30) Langer CIRC 2009
56 > 10 mm
57 > 40 mm
58 Survival (%) RING+STRING RING p= Follow-up (months) subjects at risk F. Langer CIRC 2009
59 Freedom from MR >II (%) * RING+STRING RING p= Follow-up (months) subjects at risk F. Langer CIRC 2009
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62 AATS 2012
63 EJCTS 2011;39:
64 Goal for CHF and FMR / IMR Accomplish something below the annulus in conjunction with disease-specific undersized annuloplasty ring designs and/or other adjunctive procedures to restore and maintain more elliptical LV shape and minimize MR Which should translate into better reverse LV remodeling
65 Thank you
Steven F Bolling Professor of Cardiac Surgery University of Michigan
Optimal Treatment of Functional MR Steven F Bolling Professor of Cardiac Surgery University of Michigan Functional MR Functional MR in Ischemia Badhwar, Bolling, chapter in: Advances in Heart Failure,
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Index. B B-type natriuretic peptide (BNP), 76
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