Χειρουργική Αντιμετώπιση της Ανεπάρκειας της Μιτροειδούς Βαλβίδας Dr Χρήστος ΑΛΕΞΙΟΥ MD, PhD, FRCS(Glasgow), FRCS(CTh), CCST(UK) Consultant Cardiothoracic Surgeon
Normal Mitral Valve Function
Mitral Regurgitation Severity by Echocardiography Echo Parameter Mild Moderate Severe Vena contracta width (cm) Regurgitant volume (ml/beat) Regurgitant fraction (%) Effective regurgitant orifice area (cm 2 ) <0.3 0.3 0.69 0.7 <30 30 59 60 <30 30 49 50 <0.2 0.2 0.39 0.40
Cardiac events in asymptomatic MR according to the effective regurgitant orifice (ERO). Enriquez-Sarano M, Tajik AJ. Natural history of mitral regurgitation due to flail leaflets. Eur Heart J 1997 May;18(5):705-7.
Functional Classification of MR Normal leaflet motion Increased leaflet motion Decreased leaflet motion (Diastole) Decreased leaflet motion (Systole)
Principles of Mitral Valve Repair 1) Preserve leaflet mobility 2) Restore a large surface of coaptation 3) Remodel the annulus The aim is to restore the FUNCTION of the MV, not necessarily the ANATOMY.
Type I MR : Normal leaflet motion Annular Dilatation Leaflet perforation Vegetations
Type I MR Annular dilatation
Type II MR: Increased leaflet motion (leaflet prolapse) Chordal rupture / elongation Papillary muscle rupture / elongation
Posterior leaflet prolapse (P2) Quandrangular resection and sliding plasty Posterior leaflet quadrangular resection, sliding plasty. A, limits of resection are identified and quadrangular resection is performed and P1 and P3 are also detached to shorten their height; B, sutures are placed in order to vertically plicate the posterior annulus; C, the leaflet segments are re-attached to the annulus; D,, the leaflet edges are re-approximated prior to remodeling annuloplasty.*
Anterior leaflet Prolapse Chordal Transfer Chordal transfer Artificial chordoplasty
A3, P3 and Commissural prolapse Closure of A3, P3 and commissure.
Remodeling the Mitral Valve Annulus Annular remodeling. A, annular dilatation persists after leaflet reconstruction; B, annuloplasty ring selection is based on measurements of the inter-commissural distance, as well as the height of the anterior leaflet; C, sutures are placed around the annulus and passed through the ring; D, final result after remodeling annuloplasty.
Survival after mitral valve repair Comparison of observed and expected survival after mitral valve surgery in patients in NYHA classes I-II (left) and classes III-IV (right). Survival after mitral valve surgery according to preoperative EF
Outcome anterior Vs posterior MV leaflet repair
Infective endocarditis: Valvular dysfunctions and lesions Type I : Vegetation, Leaflet perforation, abscess Type II: Chordal rupture Type III: Leaflet thickening, adhesions, Calcifications
Infective MV endocarditis: Indications for surgery Bacteriological (virulent micro, failure of Rx) Haemodynamic instability Pathological (abscess, large vegetations)
MV repair for active endocarditis: Outcome at Glenfield Hospital, Leicester, UK 36 patients acute IE having MV repair Mortality :2.8% (1 pt) 5-year freedom from >2+ MR :94% 5-year freedom from re-operation :97% 5-year survival :93% Doukas G, Oc M, Alexiou C, Samani N, Spyt T Mitral valve repair for active infective endocarditis Heart. 2006 March; 92(3): 361 363.
Aetiology of functional non-ischaemic MR and IMR
Surgical Options MV repair (Restrictive MV annuloplasty with undersized rings) MV replacement (preservation of subvalvular apparatus) Other (LV restraint devices, papillary muscle slings, ring and papillary muscle stich etc)
Types of annuloplasty rings (1) Carpentier-Edwards classic annuloplasty rings. (2) Carpentier-Edwards physio annuloplasty ring. (3) Cosgrove- Edwards annuloplasty system. (4) Edwards GeoForm annuloplasty ring. (5) Medtronic-Duran flexible annuloplasty ring. (6) St Jude tailor annuloplasty ring and band. (7) Sorin-CarboMedics Flo annuloplasty ring. (8) Genesee Sculptor annuloplasty ring (adjustable). (9) Kalangos Bio-ring. (10) Carpentier-McCarthy-Adams IMR ETlogix. (11) Edwards Myxo ETlogix.
Failed MV annuloplasty (continuous LV remodelling)
Survival After CABG Plus MVAnnuloplasty Versus CABG Alone Unadjusted (A) and propensity-adjusted (B) survival of patients with secondary MR &CHF. Mihaljevic et al. (J Am Coll Cardiol 2007;49:2191 201).
Survival for MVA (dotted line) Versus Medical Therapy in the University of Michigan Cohort Wu et al, J Am Coll Cardiol 2005;45:381-387 (Propensity score matching study)
Repair Vs Replacement for severe Ischaemic MR Acker MA, et al Mitral valve repair vs. replacement for severe ischemic mitral regurgitation. N Engl J Med. 2014; 370:23-32. At 12 months: Recurrence of 2+ MR 32% vs 2% Reduction in LVESI 6% vs 6.2% Mortality 14% vs 17%
Repair vs Replacement for Degenerative MR Advantages of Native valve preservation Reduced operative mortality (variable) Lower rate of PPM requirement Improved long-term survival Less thromboembolism & anticoagulant haemorrhage Less postoperative endocarditis Enriquez-Sarano M, et al. Valve repair improves the outcome of surgery for mitral regurgitation. A multivariate analysis. Circulation 1995;91:1022-8 Gillinov AM, et al. Valve repair versus valve replacement for degenerative mitral valve disease. J Thorac Cardiovasc Surg 2008;135:885-93, 893.e1-2.
MV Repair rates USA : 60% Trends in mitral valve surgery in the United States: results from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg 2009;87:1431-7. UK: 45% of MV procedures Keogh BE, Kinsman R. Fifth National Adult Cardiac Surgical Database Report 2003. Henley-on- Thames: Dendrite; 2004. Europe 50% Iung B, et al. A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease. Eur Heart J 2003;24:1231-43 Repair rate in surgery for asymptomatic MR should be >95% Need for transfer of knowledge and training-education.
Training on MV repair is safe: Glenfield Hospital, Leicester, UK 471 patients (1997-2003) MV repair Consultant 300 pts (64%) Supervised trainees 176 pts (36%) Consultant cases more complex (p<0.0001) Consultant mortality higher (5% vs 0.6%) (p=0.01) Alexiou C, Doukas G, Oc M, OC, B, HadJinikolaou L, Spyt T Effect of training in mitral valve repair surgery on the early and late outcome. The Annals of Thoracic Surgery 2005 Jul;80(1):183-8.
MV repair training: Outcome at Glenfield Hospital, Leicester, UK Reoperation Survival Freedom from reoperation (p = 0.7). = trainees; = consultant. Survival (p = 0.11). (- - - = trainees; = consultant.) Alexiou C, Doukas G, Oc M, OC, B, HadJinikolaou L, Spyt T Effect of training in mitral valve repair surgery on the early and late outcome. The Annals of Thoracic Surgery 2005 Jul;80(1):183-8.
MV repair surgery Team work (Cardiologist, Anaesthetist, Surgeon) Degenerative MR : Repair is simple in most cases excellent results Infective MR: Also, simple & effective Functional CHF MR: Scepticism consider transcatheter techniques (EVEREST II, REALISM), MVR Need for transfer of knowledge training