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

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

Degenerative MR is not Functional MR

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

Treatment of MR? Skin cancer Pancreatic cancer

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

Degenerative MR

Mitral Valve Repair Physiology

Which one is the mitral valve?

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

Mitral - LV Power

Mitral Dynamics

Mitral Dynamics

Mitral Valve Active Closure not by pressure!

Roman Arch

Mitral Surgery Operative Mortality

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

Mitral Valve Repair ECHO

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

Mitral Valve Repair - LV

ACC/AHA 2014 Significant MR

Mitral Valve Repair Techniques

Degenerative Mitral Disease FED FED+ Forme Fruste Barlow s Wide Disease Spectrum Adams et al. Eur Heart J 2010;31:1958-1967

Fibroelastic Deficiency

Fibroelastic Deficiency

Fibroelastic Deficiency

Fibroelastic Deficiency

FED Preserve Tissue No Resection, or Limited Resection

Barlow s Disease

Barlow s Disease

Barlow s Remove Tissue Resection, Leaflet Displacement

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

Mitral Valve Repair

Evaluate the valve

Posterior Leaflet Resection

Recreate Posterior Leaflet

Ring

Anterior Leaflet Repair

Smiley face = good line of closure Posterior leaflet disappears

Who s your Daddy, Jason?!

Mitral Valve Repair

It s Math!

Put a ring on it!

Ring Annuloplasty Complete or Incomplete Rigid or Flexible

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

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

Mitral Valve Repair Results

Survival (%) Repair DMR! 100 80 60 68% 40 20 General Population Repair Replacement 52% p = 0.0004 0 5/16/2016 Enriquez Sarano et al. Circulation 1995;91:1022 0 2 4 6 8 10 Time (Years) Cure MR!

Mitral Valve Replacement Results

Mitral Valve Replacement Results

Mitral repair vs. replacement TE events

Mitral repair vs. replacement Survival

Mitral repair vs. replacement

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):609-616.

ACC/AHA 10 Mitral Guidelines - 2014

Survival (percent) Mitral Regurgitation Survival After Mitral Valve Surgery Wait for CHF symptoms? Bad! 100 80 60 40 20 FC I-II 81% n=488 FC III-IV J Thorac Cardiovasc Surg 2003;125:1143-1152 58% p<0.001 0 0 2 4 6 8 10 12 14 1 3 5 7 9 10 11 Time (years) David et al, J Thorac Cardiovasc Surg 2003;126:1143-1152

2016 - Degenerative Mitral Sx or : LVEF < 60 % PAP > 50 mm LVESd > 40 mm AF If > 95% repair and < 1 % mortality

Wait until EF falls, 60 Bad! Enriquez-Sarano et al. Circ 1994:90:830-837

Wait until PAP rises, 50 Bad!

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

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

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!

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

NO! 2-30% were super late the rest mega late referral! Toledano et al. Can J Cardiol 2007; 23 (3): 209-14

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

2016 - Degenerative Mitral Sx or : LVEF < 60 % PAP > 50 LVESd > 40 mm AF If > 95% repair

All Mitral Valve Procedures (Center Repair Rates 2005 2009) If > 95% repair

Individual Surgeon Predictors of Repair Isolated Mitral / yr - 5 (0.3 166) Mean Repair rate - 41% (0 100 %)

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

NOT the country - same in England Anyanwu et al. BMJ Heart 2010;10:1136-40

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

It s the surgeon! LaPar et al. J Thorac Cardiovasc Surg 2014; 148(3):995-1003 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.

For Degenerative Mitral Beware patient surgeon mismatch!

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

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