Overview of Surgical Approach to Mitral Valve Disease : Why Repair? Steven F. Bolling, MD Cardiac Surgery University of Michigan

Transcription

1 Overview of Surgical Approach to Mitral Valve Disease : Why Repair? Steven F. Bolling, MD Cardiac Surgery University of Michigan

2 Degenerative MR is not Functional MR

3 2o - Functional MR : Ventricular Problem!! Badhwar, Bolling, chapter in: Advances in Heart Failure, 2004

4 Treatment of MR? Skin cancer Pancreatic cancer

5 1o - Degenerative MR : Everything but the Ventricle Problem! Carpentier s Reconstructive Valve Surgery;

6 Degenerative MR

7 Mitral Valve Repair Physiology

8 Which one is the mitral valve?

9 Structures of the Mitral Valve Annulus Leaflets Commissures Chordae Papillary Muscle Left Ventricle

10 Mitral - LV Power

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13 Mitral Dynamics

14 Mitral Dynamics

15 Mitral Valve Active Closure not by pressure!

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17 Roman Arch

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19 Mitral Surgery Operative Mortality

20 Mitral Repair Mitral Valve = Left Ventricle The LV = The MV

21 Mitral Valve Repair ECHO

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24 Mitral Anatomy Subaortic curtain Aortic leaflets AV node position Coronary Sinus Circumflex Artery Preservation of surrounding anatomic integrity essential for successful mitral repair

25 Mitral Valve Repair - LV

26 ACC/AHA 2014 Significant MR

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29 Mitral Valve Repair Techniques

30 Degenerative Mitral Disease FED FED+ Forme Fruste Barlow s Wide Disease Spectrum Adams et al. Eur Heart J 2010;31:

31 Fibroelastic Deficiency

32 Fibroelastic Deficiency

33 Fibroelastic Deficiency

34 Fibroelastic Deficiency

35 FED Preserve Tissue No Resection, or Limited Resection

36 Barlow s Disease

37 Barlow s Disease

38 Barlow s Remove Tissue Resection, Leaflet Displacement

39 Degenerative Mitral Valve Repair Ring Annuloplasty alone with any or all of : Leaflet excision Leaflet plication Leaflet patch Artificial chordae Cleft closure Sliding plasty Some other stuff More other stuff Alfieri stitch Mitraclip

40 Mitral Valve Repair

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42 Evaluate the valve

43 Posterior Leaflet Resection

44 Recreate Posterior Leaflet

45 Ring

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47 Anterior Leaflet Repair

48 Smiley face = good line of closure Posterior leaflet disappears

49 Who s your Daddy, Jason?!

50 Mitral Valve Repair

51 It s Math!

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54 Put a ring on it!

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56 Ring Annuloplasty Complete or Incomplete Rigid or Flexible

57 Mitral Valve Repair It s not the ring, it s the ringer!

58 Mitral Valve Repair PRINCIPLES Zone of Coaptation Roman Arch Chords = Guides Ring obey Bey!

59 Mitral Valve Repair Results

60 Survival (%) Repair DMR! % General Population Repair Replacement 52% p = /16/2016 Enriquez Sarano et al. Circulation 1995;91: Time (Years) Cure MR!

61 Mitral Valve Replacement Results

62 Mitral Valve Replacement Results

63 Mitral repair vs. replacement TE events

64 Mitral repair vs. replacement Survival

65 Mitral repair vs. replacement

66 Early Surgery vs Watchful Waiting Med Rx Outcomes for MR Survival After Diagnosis of Mitral Regurgitation Due to Flail Mitral Leaflet According to Initial Treatment StrategyLong-term survival following early surgery vs initial medical management overall population (A) and in the propensity score matched cohort (B). JAMA. 2013;310(6):

67 ACC/AHA 10 Mitral Guidelines

68 Survival (percent) Mitral Regurgitation Survival After Mitral Valve Surgery Wait for CHF symptoms? Bad! FC I-II 81% n=488 FC III-IV J Thorac Cardiovasc Surg 2003;125: % p< Time (years) David et al, J Thorac Cardiovasc Surg 2003;126:

69 Degenerative Mitral Sx or : LVEF < 60 % PAP > 50 mm LVESd > 40 mm AF If > 95% repair and < 1 % mortality

70 Wait until EF falls, 60 Bad! Enriquez-Sarano et al. Circ 1994:90:

71 Wait until PAP rises, 50 Bad!

72 Wait until LV dilates, 40 Bad! Enriquez-Sarano et al. Rev Card 2010

73 ait until A Fib Bad! Bando et al. JTCVS 2005 Theirry et al. EJCVS 2006

74 ACC/AHA guidelines: 2014 Mitral valve repair, wait until: Symptoms BAD! if no symptoms, wait until: Fall in EF% < 60 Pul Htn > 50 Increase LV > 40 A Fib also BAD and too late!

75 MV surgery referral So are cardiologists even following these lame guidelines? they are super late!!

76 NO! 2-30% were super late the rest mega late referral! Toledano et al. Can J Cardiol 2007; 23 (3):

77 USA Mitral late referral rate - 50%! 33% mortality-1yr Failure of Guideline Adherence for Intervention in Patients With Severe Mitral Regurgitation David S. Bach, et al JACC Vol. 54, No. 9, 2009

78 Degenerative Mitral Sx or : LVEF < 60 % PAP > 50 LVESd > 40 mm AF If > 95% repair

79 All Mitral Valve Procedures (Center Repair Rates ) If > 95% repair

80 Individual Surgeon Predictors of Repair Isolated Mitral / yr - 5 ( ) Mean Repair rate - 41% (0 100 %)

81 Predictors of Mitral Repair MVR Volume effect THE SURGEON :The more you do, the better you are!

82 NOT the country - same in England Anyanwu et al. BMJ Heart 2010;10:

83 NOT the hospital Kilic et al. J Thorac Cardiovasc Surg 2012

84 It s the surgeon! LaPar et al. J Thorac Cardiovasc Surg 2014; 148(3): FIGURE 4. Plot of adjusted association between probability of mitral valve repair and the adjusted restricted cubic spline function for average annual surgeon mitral procedure volume within (B) a propensity matched patient group. MV, Mitral valve; PROM, Predicted Risk of Mortality.

85 For Degenerative Mitral Beware patient surgeon mismatch!

86 Mitral Valve Repair Advantages Preserved LV function No anti-coagulation Freedom from re-op Low early and late mortality

87 Tips for MV Repair 2016 Find a GOOD surgeon, Think EARLY repair If your surgeon advises replacement... I advise you to replace your SURGEON!!