Ischemic Mitral Valve Disease: Repair, Replace or Ignore?

Transcription

1 Ischemic Mitral Valve Disease: Repair, Replace or Ignore? Fabio B. Jatene Full Professor of Cardiovascular Surgery, Medical School, University of São Paulo, Brazil

2 DISCLOSURE I have no financial relationship to disclose

3 RATIONALE MITRAL REGURGITATION Abnormalities in MV leaflets or SV apparatus Normal MV and ischemic ventricle disorder Organic MR Functional MR Acute IMR IMR may present acutely secondary to papillary muscle infarction and rupture Pts usually present in cardiogenic shock Surgery usually consists of MV replace Organic MR + Incidental CAD Pts with organic MV leaflet pathology (myxomatous, rheumatic, etc) and incidental CAD should not be classified as having chronic IMR Chronic IMR 1 week after MI: LV segmental wall motion abnormalities; CAD in the territory supplying the wall motion abnormality; Leaflets and chordae structurally normal Borger MA et al. Ann Thorac Surg. 2006;81(3):

4 BACKGROUND Operative mortality after surgery for valvular heart disease Guidelines ESC/EACTS. Eur Heart J. 2012;33(19):

5 RATIONALE Ann Thorac Surg. 2006;81(3): Some questions still remain Even 10 years later

6 RATIONALE PubMed ( ) 490 articles retrieved Key words: ischemic mitral valve regurgitation and coronary artery bypass

7 Ischemic Mitral Valve Disease: Repair, Replace or Ignore? Operate or ignore IMR? If operate, repair or replace?

8 Operate or ignore IMR? What the guidelines say?

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10 2012 ESC/EACTS Guidelines. Eur Heart J. 2012;33(19):

11 2014 AHA/ ACC Guidelines. J Am Coll Cardiol. 2014;63(22):

12 Guidelines on myocardial revascularization are nonspecific about ischemic mitral regurgitation approach 2014 ESC/EACTS Guidelines. Eur Heart J. 2014;35(37):

13 301 pts with moderate IMR randomized to CABG alone or CABG plus MV repair CONCLUSIONS: 1. The addition of MV repair to CABG did not result in a higher degree of LV reverse remodeling 2. MV repair was associated with reduced prevalence of moderate or severe mitral regurgitation but an increased number of untoward events 3. Thus, at 1 year, this trial did not show a clinically meaningful advantage of adding MV repair to CABG Smith PK et al. N Engl J Med 2014;371:

14 If operate, repair or replace? What the guidelines and meta-analysis say?

15 Mitral valve repair is prefered over replacement when possible J Am Coll Cardiol. 2014;63(22):

16 Comparison of 30-day survival after MV repair and replacement Shuhaiber J, Anderson RJ. Eur J Cardiothorac Surg. 2007;31(2):

17 Comparison of total survival after MV repair and replacement Shuhaiber J, Anderson RJ. Eur J Cardiothorac Surg. 2007;31(2):

18 Operative Mortality Dayan V et al. Ann Thorac Surg. 2014;97:

19 Global Survival Mitral Regurgitation Dayan V et al. Ann Thorac Surg. 2014;97:

20 251 pts with severe IMR randomized to either mitral-valve repair or chordal-sparing replacement CONCLUSIONS: 1. We observed no significant difference in LV reverse remodeling or survival at 12 months between pts who underwent mitralvalve repair and those who underwent mitral-valve replacement 2. Replacement provided a more durable correction of mitral regurgitation, but there was no significant between group difference in clinical outcomes Acker MA et al. N Engl J Med 2014;370:23-32.

21 Regarding the surgical treatment of IMR, in addition to the initial questions, several other questions could be asked, in this challenging and still controversial situation. Operate or ignore IMR? If operate, repair or replace? If repair, which technique should be used? Repair the valve, reshape the ventricle or both?

22 CONSIDERATIONS Operate or ignore IMR? Previous Guidelines considered IMR as a specific issue but today IMR is in the group of secondary MR MV surgery is indicated or should be considered in pts undergoing CABG with severe IMR and/or symptomatic patients The level of evidence is poor More recently no clinical advantage to add MV surgery to CABG, in moderate IMR

23 CONSIDERATIONS If operate, repair or replace? Current guidelines establish that MV repair is preferred over replacement when possible According to data from the STS, 66% of MV surgeries in pts undergoing CABG used a repair approach More recently no difference in 12 mo. survival between repair or replacement in IMR. Replacement provided a more durable correction, but no difference in clinical outcomes

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32 CONCLUSIONS IMR SURGERY Despite many definitions still remain some controversial points, specially base in recent information and data New

33 CONCLUSIONS A number of surgical techniques have been developed for IMR, but recent studies have questioned the improvement in patient outcomes Operative mortality associated with either procedure has declined in the last years, but the open heart exposure and longer durations of Ao cross-clamping and CPB that are associated with MV repair increase perioperative risk

34 BACKGROUND Borger MA et al. Ann Thorac Surg. 2006;81(3): Beaudoin J et al. Circulation. 2013;128[suppl 1]:S Ischemic Mitral Regurgitation IMR is caused by altered left ventricular geometry and function Chronic IMR is present in 10%-20% of pts with CAD Chronic IMR is associated with a markedly worse prognosis after AMI IMR 2X more heart failure and mortality after AMI Chronic IMR has been called the last frontier in MV repair surgery and one of the few therapeutic opportunities in heart failure pts

35 BACKGROUND Etiology - Heart Institute (InCor-HCFMUSP) % Pomerantzeff PMA et al. Semin Thorac Cardiovasc Surg 2002;4:

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37 Cardiac or Cerebrovascular Event (%) Death (%) Smith PK et al. N Engl J Med 2014;371:

38 Survival curves over 15 years of follow-up Valve repair seems to restore these patients to an adjusted survival that is similar to standard CABG. Mitral valve replacement achieved an average 14% lower riskadjusted survival over 15 years, as compared to valve repair

39 Death (%) Composite Cardiac End Point (%) Acker MA et al. N Engl J Med 2014;370:23-32.