Mitral regurgitation :Mitral regurgitation :Surgical OptionsSurgical Options
Steven F. Bolling, M.D.Steven F. Bolling, M.D.Section of Cardiac SurgerySection of Cardiac Surgery
University of MichiganUniversity of Michigan
REPAIR !REPAIR !
Mitral RegurgitationMitral Regurgitation
Mitral replacement in the Mitral replacement in the repair era: Indications ?repair era: Indications ?
Steven F. Bolling, M.D.Steven F. Bolling, M.D.Section of Cardiac SurgerySection of Cardiac Surgery
University of MichiganUniversity of Michigan
NONE !NONE !
Mitral ReplacementMitral Replacement
Mitral Valve = Left VentricleMitral Valve = Left Ventricle
The LV = The MVThe LV = The MV
Mitral RepairMitral Repair
11/9/2011
Mitral Repair vs. ReplacementMitral Repair vs. Replacement
0
20
40
60
80
100
0 2 4 6 8 10
General PopulationGeneral Population
ReplacementReplacementRepairRepair
p = 0.0004p = 0.0004
Sur
viva
l (%
)S
urvi
val (
%)
Time (Years)Time (Years)
68%68%
52%52%
Enriquez Sarano et al. Circulation 1995;91:1022
Mitral Valve RepairMitral Valve Repair
•• Simple AnnuloplastySimple Annuloplasty•• Quadrangular ExcisionQuadrangular Excision•• Leaflet Leaflet PlicationPlication•• Ring AnnuloplastyRing Annuloplasty•• Artificial ChordaeArtificial Chordae•• Combination RepairsCombination Repairs
•• Correct annular dilatation of the Correct annular dilatation of the posterior mitral leafletposterior mitral leaflet
•• Increase leaflet coaptationIncrease leaflet coaptation
•• Reinforce the annular suturesReinforce the annular sutures
•• Prevent future annular dilatationPrevent future annular dilatation-- rere--operationoperation
Ring AnnuloplastyRing Annuloplasty
““ItIt’’s not the ring,s not the ring,itit’’s the ringer!s the ringer!””
Mitral Valve RepairMitral Valve Repair
Mitral Valve ReplacementMitral Valve Replacement
BAD BAD RheumaticRheumatic
““HeavyHeavy”” calcificationcalcification
Mitral Valve ReplacementMitral Valve Replacement
IschemiaIschemia……but only but only --ruptured Pap muscleruptured Pap muscle
Mitral Valve ReplacementMitral Valve Replacement
Mitral Valve Replacement Mitral Valve Replacement -- ResultsResults
State of the Art State of the Art -- 19791979
What you want to drive What you want to drive –– 2011 !2011 !
Current Valves
• Gen 4 - Tissue valves : better– Improved hemodynamics– Improved durability
• Proven 20 years of data• Addition of anti-Ca
– Improved ease of implant
Mechanical Valves– 2% to 4% per yr risk of hemorrhage or TE
(Akins, Ann Thorac Surg 1995)
– Incidence of reop (mech): 25% at 12 years (Hammermeister, et al. J Am Coll Cardiol 2000)
– Mortality of reop (mech): 3 to 4 x tissue (Jones, et al. J Thorac Cardiovasc Surg 2001)
What are the risks of reoperation?
Potter, et al. Ann Thorac Surg 2004
UM = 3.8%400 redoJTCVS 2006 !
MVR Operative Mortality Mayo Clinic
1997 2001 2005 20100%
20%
40%
60%
80%
100%
Perc
ent o
f Tot
al V
alve
s Tissue
Mechanical
U.S.
0%
20%
40%
60%
80%
100%
Tissue
Mechanical
Perc
ent o
f Tot
al V
alve
s
Rest of World
1997 2001 2005 20101997 2001 2005 20100%
20%
40%
60%
80%
100%
Perc
ent o
f Tot
al V
alve
s Tissue
Mechanical
U.S.
1997 2001 2005 20100%
20%
40%
60%
80%
100%
Perc
ent o
f Tot
al V
alve
s Tissue
Mechanical
U.S.
0%
20%
40%
60%
80%
100%
Tissue
Mechanical
Perc
ent o
f Tot
al V
alve
s
Rest of World
1997 2001 2005 20100%
20%
40%
60%
80%
100%
Tissue
Mechanical
Perc
ent o
f Tot
al V
alve
s
Rest of World
1997 2001 2005 2010
Shift in Valve Prostheses :Mechanical Tissue
Mitral replacement: Mitral replacement: Indications ?Indications ?
Prior MV replacement !Prior MV replacement !Bad rheumaticBad rheumatic
Heavy calcificationHeavy calcificationRuptured ischemic pap muscleRuptured ischemic pap muscle
CarcinoidCarcinoidEndocarditisEndocarditis -- rarerare
Mitral repair : Indications ?Mitral repair : Indications ?
DegenerativeDegenerativeIschemicIschemic
FunctionalFunctional
90 % of MR 90 % of MR –– REPAIR !!REPAIR !!
Mitral RegurgitationMitral Regurgitation
If your surgeon advises If your surgeon advises replacementreplacement……..
I advise you to replace your I advise you to replace your SURGEON !!SURGEON !!