THE FOLDING LEAFLET. Rafael García Fuster. Cardiac Surgery Department University General Hospital of Valencia

THE FOLDING LEAFLET Rafael García Fuster Cardiac Surgery Department University General Hospital of Valencia School of Medicine Catholic University of Valencia San Vicente Mártir SPAIN

Carpentier s principles of a reconstructive valve operation 1.Preserve or restore FULL LEAFLET MOTION 2. LARGE SURFACE OF COAPTATION 3. Remodel-stabilize THE ENTIRE ANNULUS

1.FULL LEAFLET MOTION Respect rather than resect --NO neochordal shortening (the key-point: neochordal height adjustment) 2. REMODEL THE LEAFLET -large surface of coaptation -avoid SAM in case of excess of tissue 3. REMODEL THE ENTIRE ANNULUS

FULL LEAFLET MOTION with leaflet restrictive techniques? Posterior leaflet restriction Bileaflet restriction

Patrick Perier s new paradigm but without neochordal shortening in order to avoid posterior leaflet restriction RESPECT BOTH, *LEAFLET TISSUE AND *LEAFLET MOBILITY

1. FULL LEAFLET MOTION Remodel the leaflet avoiding neochordal shortening FROZEN POSTERIOR LEAFLET MOBILE POSTERIOR LEAFLET 2. REMODEL THE LEAFLET

Remodel the leaflet fixing the neochordae along the rough zone Hockey-stick effect - > SURFACE OF COAPTATION

fixing the neochordae along the rough zone

Ventricular view of anterior leaflet

Coaptation line

Coaptation line Smooth zone Rough zone

Hockey-stick effect on the leaflets

(Rough zone)

Remodel the leaflet to avoid SAM in case of excess of tissue Atrial surface Atrial surface

Avoid SAM Global bileaflet atrial surface Prosthetic ring internal área tailoring the Global Bileaflet Atrial Surface to the ring Prosthetic ring internal área 1. Remodel the leaflet 2. Height of posterior leaflet 15mm 3. Physio II

ATRIAL SURFACE Approaching the excess of tissue with neochordae AVOIDING SAM

REMODEL THE LEAFLETS WITH NEOCHORDAE <<<< ATRIAL SURFACE >>>> SURFACE OF COAPTATION

>>>> internal oriffice area Annuloplasty ring <<<< ATRIAL SURFACE >>>> SURFACE OF COAPTATION

Avoid excessive anterior displacement of the coaptation line (2/3 1/3 proportion) 2/3 Avoid excessive remodeling 1/3 Height 15mm

the key-point: neochordal height adjustment FOLDING LEAFLET

Put the knot at the level of the annulus MARGINAL = BASAL PAPILLARY MUSCLE while the leaflet is completely folded

POSTERIOR AND ANTERIOR LEAFLET NEOCHORDAL RECONSTRUCTION

Papillary muscle variability --- Loop technique? Carpentier s Classification

Loop technique --- papillary muscle variability Carpentier s Classification x x

A1 A2 (A) A2 (P) A3 AC PC A2 (P) A3 PC P1 P2 (P) P3 P3 P2 (A) P2 (P) Neochordal arrangement

1. Annuloplasty sutures for a good exposure 2. Exploration: isolation of the prolapsing área (5/0 prolene suture) 3. Identify the coaptation line --- between rough and smooth zone 4. Folding sutures from the coaptation line to the annulus ( folding ) 5. Neochordae fixation across the corresponding papillary muscle 6. Neochordae fixation across the rough zone of the leaflet (remodeling) 7. Neochordal height adjustment ( knot at the level of the annulus ) 8. Unfolding and testing 9. Ring implantation 10. Final testing. SYSTEMATIC APPROACH FOR NEOCHORDAL REPAIR

VIDEO 3 DISTINTOS PROLAPSOS

TOTAL NEOCHORDAL RECONSTRUCTION A1 A2 A3 P1 P3 P2

COMPLETE MV RECONSTRUCTION Wetlab on human heart

THE FOLDING LEAFLET TECHNIQUE MIDTERM OUTCOMES

MIDTERM OUTCOMES 100 patients 10 years follow-up ONLY one surgeon ONLY MV repair ONLY one technique --- neochordal repair MAINLY degenerative MR

Variable Preoperative characteristics n=104 patients Study period: Feb 2009 June 2018 One surgeon Folding leaflet technique n (%) / x±sd Age (y) 64±11 (26-83) Female sex 36 (34.6) NYHA class -I 9 (8.7) -II 59 (56.7) -III 32 (30.8) -IV 4 (3.8) Hypertension 62 (59.6) Diabetes 22 (21.2) CRF 3 (2.9) COPD 22 (21.2) Stroke 4 (3.8) AF 36 (34.6) EuroSCORE II 5.2±2.5 (2-14)

Preoperative characteristics 60 53 patients MR Etiology *Rheumatic: 4 50 40 38 patients *Endocarditis: 6 *Ischemic: 1 *Congenital: 1 30 *Trauma: 1 20 13 patients 10 0 FED Barlow Other

Pattern of lesions BARLOW A2 P3 FED P2 P2

Posterior leaflet prolapse -- n=58 patients Multiscalloped prolapse n=30 patients Annulus calcification n= 8 patients

n=21 pat *Barlow: 8 *FED: 10 *endocard: 3 P2 P3 n=14 pat *Barlow: 6 *FED: 8 P2 P1 P2 P3 n=7 pat *Barlow: 4 *FED: 2 *Rheum: 1

P3 n=5 pat *FED: 5 P1 n=2 pat *FED: 2 P1 P2 n=9 pat *Barlow: 4 *FED: 4 *Endocard: 1

Anterior leaflet prolapse -- n=27 patients Multisegment prolapse n=17 patients Annulus calcification n= 1 patient

A2 n=8 pat *FED: 5 *Rheumat: 1 *Trauma: 1 *Congenit: 1 A2 A3 n=9 pat *Barlow: 4 *FED: 5 A1 A2 A3 n=8 pat *Barlow: 2 *FED: 5 *Rheumat: 1

A3 n=2 pat *FED: 1 *Ischemic: 1 (PM elongat)

Bileaflet prolapse n=19 patients Anterior Commissural prolapse n=8 patients Posterior Commissural prolapse n=15 patients Annulus calcification n= 4 patients

A2 n=4 pat *Barlow: 1 *FED: 1 *Endocard: 2 P2 A2 A3 P3 n=4 pat *Barlow: 2 *FED: 2 P2 A2 P2 P3 n=1 pat *Barlow: 1

A2 A3 n=1 pat *Barlow: 1 P2 A1 A2 A3 n=1 pat *FED: 1 P2 P1 A1 A3 A2 P3 n=5 pat *Barlow: 5 P2

A3 P3 n=1 pat *FED: 1 P1 A1 A2 n=2 pat *FED: 1 *Rheumat: 1

Intraoperative variables Variable n (%) / x±sd Median sternotomy 100% PTFE neochordae 100% Annuloplasty ring 100% -CE Physio 63 (60.6) size (mm) 28±6 (26-30) -CE Physio II 41 (39.4) size (mm) 30±4 (28-34) Indentation closure 14 (13.5) (posterior flail leaflet) Maze procedure 24 (23.1) Atrial appendage closure 12 (11.5) CPB time 143±34 (90-192) Cross-Clamp time 115±29 (52-135)

Outcomes In-hospital mortality: 2 / 104 patients (1.9%) Causes of death: distress (1) sepsis (1) Late mortality: 4 / 102 patients (3.9%) Causes of death: Pneumonia (1) ARF (1) Tumoral disease (1) Unknown (1)

Survival Study period: Feb 2009 June 2018 (2 months 9 years 6 months) 91±0.4% 109.3±2.2 months (104.8 113.7) Patients at risk: 102 82 70 44 24 7

Reoperation: 3 patients *Non-valve related: -postcardiotomy síndrome: 1 --- after 1 month *Valve related: -Mitral stenosis: 1 --- after 3 years (rheumatic disease) -Endocarditis: 1 --- after 12 months

Reoperation: 3 patients 97±0.01% Patients at risk: 102 82 69 44 26 8

Qx 1st month 6th month 1st year Annually Systematic Echo follow-up

Recurrence of MR > 2+ 4+ MR: 2 patients Causes: -AL chordal ruptura (endocarditis) -P3 retraction by annulus calcification 3+ MR: 5 patients Causes: -PL restriction + moderate MS (rheum) -PL restriction (annulus calcification) -traumatic elongation of anterior PM -excessive remodeling of AL -commissural jet (large previous AL prolapse).

Grade of MR at latest Echo follow-up 70 60 Excluded: MV REDO (2) + Dead patients (6) n=57 (59.4%) 50 40 30 20 10 0 n=25 (26%) n=9 (9.4%) n=4 (4.2%) n=1 (1%) 0 MR 1+ MR 2+ MR 3+ MR 4+ MR

Recurrence of MR > 2+ 89±0.3% Patients at risk: 102 83 71 43 26 9

Echo parameters at follow-up 70 60 50 40 30 20 10 0 p<0.0001 preop 6 month 1 year late LVEF EDLVD PSP ESLVD

Echo parameters at follow-up 70 60 50 40 55±6 49±5 47±4 46±5 EDLVD (mm) 30 20 10 0 34±6 31±5 30±5 29±5 p<0.0001 preop 6 month 1 year late ESLVD (mm)

Echo parameters at follow-up 70 60 50 40 56±5 59±6 61±5 62±7 p<0.0001 LVEF (%) 30 20 10 0 preop 6 month 1 year late

Echo parameters at follow-up 70 60 50 46±1 40 30 20 10 0 32±6 31±7 31±9 p<0.0001 preop 6 month 1 year late PSP (mmhg)

EDLVD (mm) One-way ANOVA with repeated measures p<0.001 70 60 50 40 55±6 55±5 48±4 49±5 2+ MR 48±5 50±5 47±4 46±5 30 20 0-1+ MR 10 0 preop 6 month 1 year late

ESLVD (mm) One-way ANOVA with repeated measures p=0.24 70 60 50 40 30 34±9 2+ MR 31±6 32±6 31±6 20 10 0 33±5 32±5 29±5 29±5 0-1+ MR preop 6 month 1 year late

PSP (mmhg) One-way ANOVA with repeated measures p<0.0001 70 60 50 40 48±1 33±5 36±7 2+ MR 41±9 30 20 46±1 32±7 29±5 29±8 10 0-1+ MR 0 preop 6 month 1 year late

70 60 LVEF (%) 56±5 One-way ANOVA with repeated measures p=0.17 0-1+ MR 60±5 62±5 63±6 50 40 30 54±8 58±8 58±7 58±9 2+ MR 20 10 0 preop 6 month 1 year late

CONCLUSIONS -1. Neochordal repair with the Folding Leaflet Technique has achieved excellent results. -2. This technique is suitable for complex repairs: a great variety of complex lesions can be managed. -3. Excellent results at follow-up ( 10 years), especially in degenerative MR: *a large percentage of patients with absent MR and preservation of bileaflet mobility *good regression of LV diametres and PSP *improvement to normal values of LVEF.

THE FOLDING LEAFLET Rafael García Fuster Cardiac Surgery Department University General Hospital of Valencia School of Medicine Catholic University of Valencia San Vicente Mártir SPAIN