What is the Role of Surgical Repair in 2012

Transcription

1 What is the Role of Surgical Repair in 2012 The Long-Term Results of Surgery Raphael Rosenhek Department of Cardiology Medical University of Vienna European Society of Cardiology 2012 Munich, August 27th 2012

2 Outcome of Mitral Valve Surgery Valve Ventricle Patient Residual MR Repair vs Replacement Ventricular Function Survival Symptoms Quality of Life What is long-term?

3 Outcome of Mitral Valve Surgery Survival: Repair versus Replacement Thourani VH et al. Circulation 2003;108:

4 Outcome of Mitral Valve Surgery Survival after MV surgery N=1411 pts undergoing MV surgery because of leaflet prolapse Suri RM et al. Ann Thorac Surg. 2006;82:819-27

5 Outcome of Mitral Valve Surgery 20-year Results of MV Repair pts operated between 1970 and Freedom from cardiac death Expected Survival Overall Survival Braunberger... Carpentier et al. Circulation. 2001;104:8-11

6 % repaired Timing of Intervention in Mitral Regurgitation STS - MV Repair Rate for Isolated Primary MR Gammie JS et al. Ann Thorac Surg.2009;87:

7 Frequency of Adverse Outcomes Outcome of Mitral Valve Surgery Influence of Hospital Procedural Volume Operative Mortality Reoperation Renal Failure Prolonged vent Stroke Mortality+ m ajor m orbidity to to to Annual Hospital Volume Gammie JS et al. Circulation.2007;115:

8 Center-Related Variability of Outcome The Lottery of Mitral Valve Surgery National repair rate of 51% Variability of 20% to 90% among different hospitals Variations in rates of mitral valve repair for degenerative disease among 46 heart centres in the UK Anyanwu AC, Bridgewater B and Adams D. Heart 2010;96:

9 Mitral Valve Repair in Mitral Regurgitation Influence of Surgeon Experience Bolling S et al. Ann Thorac Surg.2010;90:

10 Timing of Intervention in Mitral Regurgitation Mitral Regurgitation Patient-Related Determinants of Postoperative Outcome

11 Mitral Regurgitation in the Elderly Survival after Mitral Valve Surgery STS database mitral repair procedures (age 65 yrs) Badhwar et al. Ann Thor Surg 2012 (online first).

12 Mitral Regurgitation in the Elderly Survival after Mitral Valve Surgery Detaint, D. et al. Circulation 2006;114:

13 Outcome of Mitral Valve Surgery Impact of Preoperative Symptoms on Survival NYHA I-II NYHA III-IV Years Tribouilloy C et al. Circulation 1999;99:400

14 Outcome of Mitral Valve Surgery Impact of Preoperative EF on Survival EF 60% EF 50-60% EF <50% 73% 53% 32% Enriquez-Sarano et al. Circulation 1994;90:

15 Outcome of Mitral Valve Surgery Left Ventricular Endsystolic Diameter Adjusted Post-Operative Overall Survival according to LVESD Tribouilloy, C. et al. J Am Coll Cardiol 2009;54:1961-8

16 Outcome of Mitral Valve Surgery Pulmonary Hypertension Years * 37% in NYHA classes III and IV Le Tourneau et al. Heart 2010;96:

17 Outcome of Mitral Valve Surgery Impact of Preoperative Atrial Fibrillation STS database mitral repair procedures Badhwar et al. Ann Thor Surg 2012 (online first).

18 Mitral Valve Repair Predictors of 5-yr Mortality (age 65 yrs) STS database procedures Badhwar et al. Ann Thor Surg 2012 (online first).

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20 Severe but Asymptomatic MR Early Surgery vs Waiting for Symptoms Registry No surgical mortality neither in the OP nor in the CONV group????????????????? pts lost to follow-up apparently all in the OP group 3 unaccounted Noncardiac deaths in the surgical group 2 strokes, 1 infection considered No conclusive benefit of either strategy demonstrated Events in the conventional group: 22 heart failure (trigger for surgery) 5 congestive heart failure deaths in pts refusing surgery 1 sudden death in a patient who became symptomatic Kang, D.-H. et al. Circulation 2009;119:

21 Asymptomatic Severe Mitral Regurgitation Survival Watchful Waiting Strategy All patients Patients with flail leaflet Expected survival P = n.s Years Event-free Survival 92% 78% Years 65% 55% Rosenhek et al. Circulation 2006;113:

22 Percent free of Reoperation Outcome of Mitral Valve Surgery Reoperation for Failure of Valve Repair % 96.9% % Years after Repair Gillinov, AM. et al. J Thorac Cardiovasc Surg 1997;113:

23 Mitral Regurgitation in the Elderly Freedom of Re-repair STS database mitral repair procedures (age 65 yrs) Badhwar et al. Ann Thor Surg 2012 (online first).

24 Rate per year (%) Outcome of Mitral Valve Surgery Rates of Reoperation N=1411 pts undergoing MV surgery because of leaflet prolapse 1,8 1,6 1,4 1,2 1 0,8 0,6 0,4 0,2 0 PL BL AL Mechanical Repair Replacement Suri RM et al. Ann Thorac Surg. 2006;82:819-27

25 Timing of Intervention in Mitral Regurgitation Durability of Mitral Valve Repair Freedom from MR > cpts with degenerative MR Freedom from MR > pts with Barlow Flameng W et al. J Thorac Cardiovasc Surg 2008;135: Jouan Jet al. J Thorac Cardiovasc Surg 2012;143:S17-S20

26 Outcome of Mitral Valve Surgery Conclusion Mitral valve repair is associated with an excellent outcome Little long-term data are available beyond a follow-up of 10 years The immediate procedural success, which has repercussions on the longterm outcome is determined by hospital volume and surgeon experience Rates of reoperation are in the range of 6% to 10% Recurrence rates of (> moderate) mitral regurgitation are centerdependent with reported rates between 10% to 35% Long-term postoperative survival is affected by preoperative patient characteristics such as symptoms, left ventricular size and function, pulmonary arterial pressure Surgery should not be delayed in symptomatic patients and atrial fibrillation These criteria are considered in the current recommendations for surgery

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