Surgical repair techniques for IMR: future percutaneous options?

Transcription

1 Surgical repair techniques for IMR: can this teach us about future percutaneous options? Genk - Belgium Prof. Dr. R. Dion KULeu

2 Disclosure slide Robert A. Dion I disclose the following financial relationships: Consultant Speaker Sorin Biomedica X X Edwards Lifesciences X X St-Jude Medical X Johnson & Johnson X

3 Methods and Results From 1993 to 2002, 61 patients with degenerative MR were treated with an isolated edge-to-edge suture without any annuloplasty. Annuloplasty was omitted in 36 patients because of heavy annular calcification and in 25 for limited annular dilatation. A double-orifice repair was performed in 53 patients and a commissural edge-to-edge in 8. Hospital mortality was 1.6%. Follow-up was 100% complete (mean length, 9.2±4.21 years; median, 9.7; longest, 18.1). Survival at 12 years was 51.3±7.75%. At the last echocardiographic examination, MR 3+ was demonstrated in 33 patients (55%). At 12 years, freedom from reoperation was 57.8±7.21% and freedom from recurrence of MR 3+ was 43±7.6%. Residual MR >1+ at hospital discharge was identified as a risk factor for recurrence of MR 3+ (hazard ratio, 3.8; 95% confidence interval, ; P=0.001). In patients with residual MR 1+ immediately after surgery, freedom from MR 3+ at 5 and 10 years was 80±6% and 64±7.58%, respectively. Conclusions In degenerative MR, the overall long-term results of the surgical edge-to-edge technique without annuloplasty are not satisfactory. Early optimal competence (residual MR 1+) was associated with higher freedom from recurrent severe regurgitation. Circulation. 2014;130[suppl 1]:S19-S24

4 Long-term results ( 18 years) of the edge-to-edge mitral valve repair without annuloplasty in degenerative mitral regurgitation. Implications for the percutaneous approach. De Bonis et al. Circulation. 2014;130[suppl 1]:S19-S24

5 DO, double orifice; EE, edge-to-edge De Bonis et al. Circulation. 2014;130[suppl 1]:S19-S24

6 The American Journal of Pathology, Vol. 171, n 5, nov Amber C. Liu et al. ZOL 10/13

7 These findings suggest that VICs respond to local tissue stress by altering cellular stiffness (through SMA content) and collagen biosynthesis. This functional VIC stress-dependent biosynthetic relation may be crucial in maintaining valvular tissue homeostasis and also prove useful in understanding valvular pathologies. Am J Physiol Heart Circ Physiol 290: H224-H231, 2006 ZOL 10/13

8 We demonstrated a long time ago the strong correlation between flow turbulence and valve calcification Circulation 2010;121: ZOL 10/13

9 Surgery Edge to Edge «Mitral Smile» «Mitral Grimace»

10 Degenerative mitral valve regurgitation: best practice revolution. David Adams et al. European Heart Journal (2010) 31,

11 Relocation of the papillary muscles Kron IL: Ann Thorac Surg 2002;74:600-1 Fattouch K: Semin Thoracic Surg 2012; 24:

12 RING plus STRING: Papillary muscle repositioning as an adjunctive repair technique for ischemic mitral regurgitation Langer F. JTCS 2007;133:247-9

13 Baseline patient characteristics by patient outcomes ZOL 06/14 Characteristic No Recurrence or Death (N=40) Recurrence and/or Death (N=76) P-value No Recurrence (N=44) Recurrence (N=66) P-value Age (y) 65.7 ± ± ± ± BMI (kg/m 2 ) 28.1 ± ± ± ± Male 28 (70.0) 42 (55.3) (68.2) 37 (56.1) White 36 (90.0) 59 (77.6) (90.9) 50 (75.8) EROA (cm 2 ) 0.4 ± ± ± ± Basal Dyskinesia/Aneurysm * 8 (20.0) 44 (57.9) < (20.5) 41 (62.1) <0.001 NYHA Class I+II 10 (25.0) 40 (52.6) 13 (29.5) 34 (51.5) NYHA Class III+IV 30 (75.0) 36 (47.4) 31 (70.5) 32 (48.5) History of CABG 4 (10.0) 15 (19.7) (9.1) 13 (19.7) History of PCI 13 (32.5) 34 (44.7) (34.1) 30 (45.5) History of Ventricular Arrhythmia 8 (20.0) 6 (7.9) (22.7) 3 (4.5) J. Thorac Cardiovasc Surg in press. Kron et al * 50 pts

14 preop ZOL 06/14

15 MJ, male, 1953 CASE description Result pumprun #1 - restrictive annuloplasty PM reloc : Posterior leaflet mobility??

16 MJ, male, 1953 CASE description Result pumprun #2 - restrictive annuloplasty PM relocation +++ (! PL prolapse on watertest) Acceptable result

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18 ZOL 06/14 postop postop

19 CorCap Braun J. et al. J Thorac Cardiovasc Surg 2011;142:e93-e100

20 ZOL 04/11 CSD + RMA + OMT Evolution of LVEDV and LVESV at early postoperative follow-up, and at long-term follow-up Braun et al, J Thorac Cardiovasc Surg 2011;142:e93-e100

21 Suggestions for future percutaneous options - Annuloplasty! - Preserve leaflets motion phenotype - Subvalvular approaches - from inside - from outside

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23 Aim of our study was to compare the results of combined approach papillary muscles relocation (PPMr) + mitral annuloplasty (MA) vs only restrictive annuloplasty (RA) in ischemic mitral regurgitation, guided by 3-dimensional (3D) echocardiography. Sixty-nine patients with severe ischemic mitral regurgitation who had PPMr + MA and coronary artery bypass grafting were matched 1:1 with patients who underwent isolated RA and coronary artery bypass grafting. A comprehensive pre- and postoperatory 2-dimensional and 3D transesophageal echocardiographic examination followed by a 3D offline assessment of the mitral valve apparatus was performed. Five-year freedom from cardiac-related event in the PPMr + MA group and isolated RA group was 83% ± 2.1% and 65.4% ± 1.2%, respectively (P < 0.001). Recurrent mitral regurgitation equal to or greater than moderate occurred in 2 (2.8%) and 8 (11.5%) in PPMr + MA group and RA group, respectively (P < 0.02). The PPMr promoted a significant reversal in left ventricle remodeling compared with the isolated RA. PPMr + MA reduce the tenting area and the coaptation depth with respect to RA, with less incidence of recurrent mitral regurgitation. Semin Thoracic Surg 2012; 24: ZOL 11/13