Denti Paolo Hybrid Surgeon
Cardio-thoracic and Vascular Surgery Dept.
San Raffaele Hospital, Milan
Italy
Esperienza condivise: L’opinione del Cardiochirurgo
MV repair is superior to MVR
• Better preservation of LV function
• Avoidance of prosthesis related events
• Reduced hospital mortality
• Reduced morbidity and LOS
• Improved long term survival
Thourani et al, Circulation 2003; 108:298-304
Zaho et al, JTCVS 2007;1257-1263
Shuhaiber J et al, EJCTS 2007; 31:267-275
Perrier P et al, Circulation 1984;70:187
Akins CW, et al. ATS 1994; 58:668-676
The role of Annuloplasty • Annuloplasty has been routinely added to the Alfieri procedure
• Absence of annuloplasty is associated with increased stresses on the suture and on the valve structures
• Absence of annuloplasty may be associated with accelerated failure (but not in multivariate analysis)
- 647
- 520
- 394
- 267
- 140
- 134
+ 113
+ 240
+ 367
+ 493
+ 620
+ 747
+873
+100
0
SI (kPa)
Alfieri et al. JTCVS 2001, Maisano et al JTCVS 2003, Nielsen et al Circulation 2005
OSR MitraClip in octogenarians
AJC 2015
OSR MitraClip in octogenarians
MitraClip in the elderly
Impact of 2+ residual MR 2+ is APC!!!
Degenerative MR
Mitraclip Second Choice • In high volume center,
degenerative MR is treated with optimal results and low risk but: – 50% of patients are denied to
surgery because of age (Euro Heart Survey) (Mirabel EHJ 2007)
– Age and comorbidity change
risk profile(STS database, 2010)
– QoL is not improved in old
operated patients (Maisano et al EJCTS 2009)
Durability using conventional non “disease-specific” rings
25-30% late
recurrence
rate
Hung et al. Circulation 2004.
Reverse remodeling
Beeri et al. J Am Coll Cardiol 2008;51:476–86
De Bonis, et al . Ann Thorac Surg 2008;85:932–9
Mitraclip
Good Option for Functional MR
• Surgical Treatment is
associated:
– High Mortality
– High recurrence
– Prolonged LOS
– Prognostic Benefit ?
Surgery vs Mitraclip
Chance of correcting MR with Mitraclip
Ris
k
of
su
rgery
L
ow
H
igh
Low High
Risk of
Mitraclip
procedure
•Risk of Mitraclip
procedure •Preservation of
surgical option •Long term results of
Mitraclip
OSR MitraClip in octogenarians
OSR Experience: Re-hospitalization for CHF
Reduction of re-hospitalization for CHF
205
87
7 7
12 months pre-OP
12 months post-OP
12 months pre-OP
12 months post-OP
# Patient # CHF Hosp
Cost effective??
Cost- effectiveness
Armeni et al, Int J Card 2016
Mitraclip Procedure
Mitraclip Procedure
Post TPMVP Pre
Suitable Patient N = 351
Total Patients Evaluated in OSR N = 758
Not Suitable Patient N = 407
Treated Mitraclip Therapy N = 287
Surgery N = 189
MR≤2+ N = 75
Not Treated N = 35
Treated in other centers N = 29
Patient Selection
Unfavourable Anatomy N = 143
• 46% asymmetric apposition • 36% coaptation absence • 18% both
Heart Team and
Hybrid Operator
Individualize the therapy
• Anatomy and function
• Comorbidities, Life expectancy
• Compare risk and probability of success
• Preservation of surgical option
• Improving Devices and Imaging
• Surgeons will do procedures
Heart
Team