When Is Less More?

Minimally Invasive Surgery in Low EF

Michael Mack, M.D.

Baylor Scott& White Health

Dallas, TX

Conflict of Interest Disclosure

• Member of Executive Committee of the

PARTNER Trial of Edwards Lifesciences

• Co-PI of the COAPT Trial of Abbott Vascular

• Travel expenses paid by sponsors for trial

Steering Committee meetings

I am Presuming…

• Secondary MR and not primary MR

3

Options to Treat Secondary MR

GDMT

Resynchronization

How are Patients with Isolated FMR Treated? Duke Databank: 1,538 pts with echocardiographic 3+ - 4+ FMR

and LVEF ≥20% between 2000 and 2010 not undergoing CABG

11.4% 5.9% 8.4% 11.8% 18.4%

0%

25%

50%

75%

100%

All pts 20%-30% 30%-40% 40%-50% 50%-60%

Conservative management Isolated MV surgery

LVEF

N=1538 N=440 N=298 N=313 N=479

8 other pts had LVEF >60%; none underwent MV surgery c/o Mitch Krucoff

Chronic Severe Secondary Mitral

Regurgitation: Intervention

Recommendations COR LOE

MV surgery is reasonable for patients with chronic

severe secondary MR (stages C and D) who are

undergoing CABG or AVR

IIa C

MV surgery may be considered for severely

symptomatic patients (NYHA class III-IV) with

chronic severe secondary MR (stage D)

IIb B

MV repair may be considered for patients with

chronic moderate secondary MR (stage B) who are

undergoing other cardiac surgery

IIb C

When Would You Consider MI Surgery

in Low EF?

•Redo

–Hostile reentry

–Grafts in jeopardy

•Elderly

•Frailty

8

When Would You NOT Consider MI

Surgery in Low EF?

• Patient needs SURGICAL revascularization

• Concerns about myocardial protection

• Ascending aorta > 4 cm

• Right chest adhesions

• Elevated right hemi-diaphragm

• Extreme morbid obesity

9

How to treat this 69-year old male ?

• Mitral regurgitation III-IV, EF 35 %, AFib, NYHA class III-IV

• Medical history:

– s/p anterior myocardial infarction 1988 – s/p posterior myocardial infarction in 1991 – 2-CABG 1993 – biventricular ICD 2005

• Concomitant diseases: – COPD – renal insufficiency III° – hyperlipidaemia – arterial hypertension

EF 29 %, LVEDD: 61 mm

MV: annulus 47 mm

restrictive AML, MI III°, Type IIIB

LA: 47 mm

Echocardiography

Secondary MR

1. Lateral position of the right chest around

30°

2. Abduction of the right arm

3. Bend the region of the groin back slightly

Mini MV repair

Right anterolateral

minimally invasive incision

Minimally invasive

Mitral Valve Surgery

Left atrial retractor Cannulation

femoral artery and vein

Chitwood clamp

Camera Atrial vent

Cardioplegia/ Aortic Vent

Soft tissue retractor

Secondary MR- Fibrillating Heart

Secondary MR- Fibrillating Heart

Secondary MR- Fibrillating Heart

Postoperative result

Postoperative echo result

No residual MI

Orifice area: 3.3 cm2

Mean gradient: 2 mmHg

sternotomy156924%

MIS488776%

Mitral valve surgery, isolated and combined with tricuspid valve procedures

1996 - 2013sternotomy vs. MIS

Mitral valve surgery, isolated and combined with tricuspid valve

procedures – sternotomy vs. MIS

at Heart Centre Leipzig (1996-2013) n = 6456

Isolated MV repair in cardiomyopathy

(EF<35%) baseline characteristics

N 161

ICM/DCM 70.1 vs. 29.9 %

Age 61 ± 10 y

EF 25 ± 8 %

LVEDD 69 ± 11 mm

MI ≥ III° 93.2 %

NYHA ≥ III° 97.5 %

preoperative early postop long term evaluation 0

1

2

3

4 mitral regurgitation

p < 0.001

Isolated MV repair in cardiomyopathy (EF<35%)

echocardiographic MV function

NY

HA

- M

edia

n P < 0.001

0

0,5

1

1,5

2

2,5

3

3,5

preoperative early postop long term evaluation

Isolated MV repair in cardiomyopathy

(EF<35%) NYHA class

MV repair

MV replacement

years after operation

su

rviv

al

Isolated MV surgery in cardiomyopathy (EF<35%)

Survival MV repair vs. replacement a

ctu

arial surv

ival (%

)

follow-up (y)

Log rank p=0.032

DCM

ICM

years after operation

actu

arial surv

ival (%

)

follow-up (y)

Isolated MV surgery in cardiomyopathy (EF<35%)

Survival related to MVR etiology

Log rank p=0.132

0 12 24 36 48 60 72

Postoperative months

0

20

40

60

80

100

NYHA class

Inotr. IV III < III

Survival (%)

Isolated MV surgery in cardiomyopathy (EF<35%)

Survival related to baseline NYHA class

When Should We Be Performing MV

Replacement for IMR?

• Ruptured papillary muscle (acute IMR)

• Patients in cardiogenic shock

• Severe apical tenting (>11mm)

• During second CPB run

• Complex MR leaks?

• Surgeons who do not do many repairs?

Valve of choice – bioprosthesis

Critical Appraisal / Conclusion

Residual MR up to 30% following

surgical MV repair poor survival

New developments are not superior to MV

surgery

FMR is and will remain a ventricular

disease!