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
Outcome of Mitral Valve Surgery Valve Ventricle Patient Residual MR Repair vs Replacement Ventricular Function Survival Symptoms Quality of Life What is long-term?
Outcome of Mitral Valve Surgery Survival: Repair versus Replacement Thourani VH et al. Circulation 2003;108:298-304
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
Outcome of Mitral Valve Surgery 20-year Results of MV Repair 100 162 pts operated between 1970 and 1984 80 Freedom from cardiac death 60 40 20 Expected Survival Overall Survival 0 0 5 10 15 20 Braunberger... Carpentier et al. Circulation. 2001;104:8-11
% repaired Timing of Intervention in Mitral Regurgitation STS - MV Repair Rate for Isolated Primary MR Gammie JS et al. Ann Thorac Surg.2009;87:1431-1437
Frequency of Adverse Outcomes Outcome of Mitral Valve Surgery Influence of Hospital Procedural Volume 16 14 12 10 Operative Mortality Reoperation Renal Failure Prolonged vent 8 6 4 Stroke Mortality+ m ajor m orbidity 2 0 1 to 3 5 3 6 to 7 0 7 1 to 1 4 0 140+ Annual Hospital Volume Gammie JS et al. Circulation.2007;115:881-887
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;96:1964-1967.
Mitral Valve Repair in Mitral Regurgitation Influence of Surgeon Experience Bolling S et al. Ann Thorac Surg.2010;90:1904-11
Timing of Intervention in Mitral Regurgitation Mitral Regurgitation Patient-Related Determinants of Postoperative Outcome
Mitral Regurgitation in the Elderly Survival after Mitral Valve Surgery STS database 14604 mitral repair procedures 1991-2007 (age 65 yrs) Badhwar et al. Ann Thor Surg 2012 (online first).
Mitral Regurgitation in the Elderly Survival after Mitral Valve Surgery Detaint, D. et al. Circulation 2006;114:265-272
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
Outcome of Mitral Valve Surgery Impact of Preoperative EF on Survival 100 80 60 40 20 EF 60% EF 50-60% EF <50% 73% 53% 32% 0 0 2 4 6 8 10 Enriquez-Sarano et al. Circulation 1994;90:830-837.
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
Outcome of Mitral Valve Surgery Pulmonary Hypertension Years * 37% in NYHA classes III and IV Le Tourneau et al. Heart 2010;96:1311-1317
Outcome of Mitral Valve Surgery Impact of Preoperative Atrial Fibrillation STS database 14604 mitral repair procedures 1991-2007 Badhwar et al. Ann Thor Surg 2012 (online first).
Mitral Valve Repair Predictors of 5-yr Mortality (age 65 yrs) STS database 11648 procedures 1991-2007 Badhwar et al. Ann Thor Surg 2012 (online first).
Severe but Asymptomatic MR Early Surgery vs Waiting for Symptoms Registry No surgical mortality neither in the OP nor in the CONV group????????????????? + + + 17 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;119:797-804
Asymptomatic Severe Mitral Regurgitation 100 90 80 70 60 50 40 30 20 10 0 Survival Watchful Waiting Strategy All patients Patients with flail leaflet Expected survival P = n.s. 0 1 2 3 4 5 6 7 8 Years 100 90 80 70 60 50 40 30 20 10 0 Event-free Survival 92% 78% 0 1 2 3 4 5 6 7 8 Years 65% 55% Rosenhek et al. Circulation 2006;113:2238-2244.
Percent free of Reoperation Outcome of Mitral Valve Surgery Reoperation for Failure of Valve Repair 100 95 98.7% 96.9% 90 92.9% 85 80 75 0 1 2 3 4 5 6 7 8 9 10 Years after Repair Gillinov, AM. et al. J Thorac Cardiovasc Surg 1997;113:467-473
Mitral Regurgitation in the Elderly Freedom of Re-repair STS database 14604 mitral repair procedures 1991-2007 (age 65 yrs) Badhwar et al. Ann Thor Surg 2012 (online first).
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
Timing of Intervention in Mitral Regurgitation Durability of Mitral Valve Repair Freedom from MR > 2+ 348cpts with degenerative MR Freedom from MR > 2+ 182 pts with Barlow Flameng W et al. J Thorac Cardiovasc Surg 2008;135:274-82 Jouan Jet al. J Thorac Cardiovasc Surg 2012;143:S17-S20
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