REPAIR
ISCHEMIC
MITRAL REGURGITATION
KULeuvenKULeuven
Prof. Dr. R. Prof. Dr. R. DionDion
KULeuvenKULeuven
Prof. Dr. R. Prof. Dr. R. DionDion
Genk - Belgium
Edwards Lifesciences -Consultant
Saint Jude Medical-Consultant
Sorin-Consultant
REPAIR
ISCHEMIC
MITRAL REGURGITATION
KULeuvenKULeuven
Prof. Dr. R. Prof. Dr. R. DionDion
KULeuvenKULeuven
Prof. Dr. R. Prof. Dr. R. DionDion
Genk - Belgium
Preop. History
• 78 y old male, 165 cm / 83 kg
• DDD PM for AV block
• DM II / Smoking +++ / Hypertension / Creat. 1.32
• 25/05/2009 : SOB CATH
* post – inf. hypo/akinesia * PAp 55/30 * LVEF 46% * Ao 160/70 * ESV 121 ml * Wp 24 * EDV 223 ml * MR III / IV
- PDA 75% - CX2 80% - LAD 40%
R/ - Amlor 5 mg - Emconcor 5 mg - Coversyl 8 mg + DM / ASA
Preop. History 2
26/07/2009 Pulmonary edema
R/ + Diuretics
09/08/2009 Pulm. edema + bilateral CHF
Creat. Clearance : 35 ml/min COPD → Solumedrol BNP : 800 PAsyst : 70 mm Hg
TEE MR IV , ERO 45 mm² Systolic restriction + dilated annulus Minimal coaptation LVEDD : 63 mm Tric. ann. : 3.5 cm
Systolic restrictive motion
Operation
- CABG → PDA - CX2
- RMA : Physio ring 30 ( 34 )
- Upgrading DDD → BIV PM
TEE MR : 0 Grad. : 3/1 mm Hg ( C.I. 2.2 l/mm²) Coaptation length : 9 mm 31/08/2009 - Cardiac OK - Extubated - Still on dialysis
Film
Follow-up
- 02/2013 → still alive
- NYHA II - Amlor 5 mg
- Emconcor 2.5 mg - Coversyl 8 mg - DM oral - ASA
- Creatinin 2.4
- TEE MR : 0 Grad. : 8/4 mm Hg Coaptation length : 8 mm LVEDD : 55 mm
Restrictive Mitral Annuloplasty
=
Complete (1/2) rigid ring
+
≥ 8mm coaptation length
≥ 8 mm
0%
20%
40%
60%
80%
100%
40 60 80 100LVEDD (mm)
specificity sensitivity
89 %
65
LVEDD and Reverse Remodeling
Bax J et al. Circulation 2004; 110 (suppl II): II-103-II-108
Echo Results: Mitral Regurgitation
BASELINE 3.1 ± 0.5
EARLY 0.5 ± 0.7 INTERMEDIATE (18m) 0.7 ± 0.7 LATE (46m) 0.9 ± 0.8
P < 0.05
Braun J et al. Ann Thorac Surg 2008 Feb;85(2):430-6
Results: Echocardiography
baseline intermediate late
MV gradient 3.6 ± 1.5 3.9 ± 1.7
MV area (cm2)
2.8 ± 0.6 2.6 ± 0.6
Tenting area (cm2)
4.8 ± 1.4
1.4 ± 0.6
Coaptation
Height (mm)
3 ± 1 8 ± 2 8 ± 2
Conclusions
LVEDD 65 mm cut-off = strong outcome predictor
LVEDD > 65 = poor reverse remodeling
For LVEDD ≤ 65 mm: RMA + CABG = CURE
For LVEDD > 65: RMA + CABG is not enough
Braun J et al. Ann Thorac Surg 2008 Feb;85(2):430-6
Kron IL: Surgical relocation of the posterior papillary muscle in chronic
ischemic mitral regurgitation. Ann Thorac Surg 2002;74:600-1
Relocation of the posterior papillary muscle (Kron)
Papillary muscles approximation
+ papillary muscles suspension
Papillary muscles
approximation CV4 for pulling up both PM
Hvass et al. J Thorac Cardiovasc Surg 2010 Feb; 139(2): 418-23 Shingu Y et al. Circ J. 2009 Nov;73(11):2061-7
Langer F et al. J Thorac Cardiovasc Surg 2011 May; 141(5): 1315-6
de Varennes, B. et al. Circulation 2009;119:2837-2843
The bovine pericardial patch extending the medial half of P2 and all of P3
Initial results of posterior leaflet extension for severe type IIIb ischemic mitral regurgitation.
MVR in IMR ?
- Mechanical or bioprosthesis ?
- Which size ?
- What if reverse remodeling and bioprosthesis ?
CorCap™
Braun J. et al. J Thorac Cardiovasc Surg 2011;142:e93-e100
Background—The role of mitral valve repair (MVR) during coronary artery bypass grafting (CABG) in patients with moderate ischemic mitral regurgitation (MR) is uncertain. We conducted a randomized, controlled trial to determine whether repairing the mitral valve during CABG may improve functional capacity and left ventricular reverse remodeling compared with CABG alone. Methods and Results—Seventy-three patients referred for CABG with moderate ischemic MR and an ejection fraction > 30% were randomized to receive CABG plus MVR (34 patients) or CABG only (39 patients). The study was stopped early after review of interim data. At 1 year, there was a greater improvement in the primary end point of peak oxygen consumption in the CABG plus MVR group compared with the CABG group (3.3 mL/kg/min versus 0.8 mL/kg/min; P<0.001). There was also a greater improvement in the secondary end points in the CABG plus MVR group compared with the CABG group: left ventricular end-systolic volume index, MR volume, and plasma B-type natriuretic peptide reduction of 22.2 mL/m², 28.2 mL/beat, and 557.4 pg/mL, respectively versus 4.4 mL/m² (P=0.002), 9.2 mL/beat (P=0.001), and 394.7 pg/mL (P=0.003), respectively. Operation duration, blood transfusion, intubation duration, and hospital stay duration were greater in the CABG plus MVR group. Deaths at 30 days and 1 year were similar in both groups: 3% and 9%, respectively in the CABG plus MVR group, versus 3% (P=1.00) and 5% (P=0.66), respectively in the CABG group. Conclusions—Adding mitral annuloplasty to CABG in patients with moderate ischemic MR may improve functional capacity, left ventricular reverse remodeling, MR severity, and B-type natriuretic peptide levels, compared with CABG alone. The impact of these benefits on longer term clinical outcomes remains to be defined.
Circulation. 2012;126:2502-2510
NOT a reasonable option for functional MR in operable patients
Mitral E-Clip
- Pale copy of the Alfieri stitch
- MR 2 is … a success ! …
- Turbulences (no PISA possible), stenosis ? (2 clips … )
- Anatomical exclusions
- Mitral valve repair after clip ?
- ‘Enthusiastic ‘ interpretations of studies
Q9. How much should one undersize the
annuloplasty device?
a. 2 sizes down.
b. 3 sizes down.
c. The smallest device available.
d. Adapt undersizing to the type of device.
> 30
> 0.2
FMR
RV (ml)
> 60
ERO (cm2)
> 0.4
ORGANIC
ECHO CRITERIA OF SEVERE MR
M. Enriquez-Sarano
A B
A. En-face color 3D image demonstrated an elongated and slightly curved PISA geometry along the entire leaflet coaptation line in patients with functional MR.
B. In patients with MVP, a rounder shaped PISA appeared only in the region where the leaflet prolapsed.
ZOL 02/12
Geometry of the proximal isovelocity surface area in mitral regurgitation by 3-dimensional color Doppler echocardiography: difference between functional mitral regurgitation and prolapse regurgitation.
Yoshiki Matsumura et al. Am Heart J 2008;155:231-8
Results: Mortality per LVEDD
0%
10%
20%
30%
40%
50%
60%
0 1 2 3 4 5 6
100 87 82 60 40 27 11 Patients at risk
Years since surgery
All-cause death
LVEDD >65
LVEDD 65
P-value 0.002 HR 3.4 and 95% CI 1.5-7.4
71 ± 8.5%
49 ± 11%
93 ± 3.0%
80 ± 5.2%
Braun J et al. Ann Thorac Surg 2008 Feb;85(2):430-6
Results: Clinical Outcome
LVEDD ≤ 65 LVEDD > 65 P-value
All mortality 11/72 (15.3%) 14/28 (50.0%) <0.0001
Readmission CHF 6/69 (8.7%) 5/23 (21.7%) <0.0001
Biventricular ICD 0/69 4/23 (17.4%) <0.0001
NYHA 1.6 ± 0.6 1.5 ± 0.5 ns
LVESD ≤ 50 LVESD > 50 P-value
All mortality 9/58 (15.5%) 16/42 (38.1%) 0.018
Readmission CHF 2/56 (3.6%) 9/36 (25.0%) 0.005
Biventricular ICD 0/56 4/36 (11.1%) <0.0001
Braun J et al. Ann Thorac Surg 2008 Feb;85(2):430-6
DISCUSSION The main finding of this study is that severe FMR, defined as RV >30 ml or ERO >0.2 cm2 or VC >0.4 cm, is associated with a twofold increased risk of adverse events after adjustment for LVEF and RMP in patients with HF due to DCM. Accordingly, FMR should not be considered just a mere consequence of ventricular remodelling but a major predictor for the outcome of patients with HF, suggesting that in patients with severe FMR all therapeutic options of pharmacological and non-pharmacological treatment should be considered. … … Finally, the demonstration of a clear and powerful association between FMR and prognosis might only suggest that treatment of FMR may improve outcome. However, particularly for the percutaneous approach to FMR, the effectiveness of these procedures can be demonstrated only by randomised trials. …
Heart 2011;97:1675-1680
ZOL 10/12
Methods and Results—Patients with ejection fraction ≤35% and coronary artery disease amenable to CABG were randomized at 99 sites worldwide to medical therapy with or without CABG. The decision to treat the mitral valve during CABG was left to the surgeon. The primary end point was mortality. Of 1212 randomized patients, 435 (36%) had none/trace MR, 554 (46%) had mild MR, 181 (15%) had moderate MR, and 39 (3%) had severe MR. In the medical arm, 70 deaths (32%) occurred in patients with none/trace MR, 114 (44%) in those with mild MR, and 58 (50%) in those with moderate to severe MR. In patients with moderate to severe MR, there were 29 deaths (53%) among 55 patients randomized to CABG who did not receive mitral surgery (hazard ratio versus medical therapy, 1.20; 95% confidence interval, 0.77–1.87) and 21 deaths (43%) among 49 patients who received mitral surgery (hazard ratio versus medical therapy, 0.62; 95% confidence interval, 0.35–1.08). After adjustment for baseline prognostic variables, the hazard ratio for CABG with mitral surgery versus CABG alone was 0.41 (95% confidence interval, 0.22– 0.77; P=0.006). Conclusion—Although these observational data suggest that adding mitral valve repair to CABG in patients with left ventricular dysfunction and moderate to severe MR may improve survival compared with CABG alone or medical therapy alone, a prospective randomized trial is necessary to confirm the validity of these observations.
Circulation. 2012;125:2639-2648
ZOL 10/12
Conclusions. Undersized ring annuloplasty and revascularization can provide a durable correction of ischemic mitral regurgitation. This technique frequently increases the gradient across the mitral valve, but increasing mitral gradient does not appear to adversely impact survival or heart failure hospitalization.
Ann Thorac Surg 2009;88:1197–201
ZOL 08/12
… Results: At peak exercise (mean 81 ± 12 W), the main cardiac performance indices were significantly improved, including systolic blood pressure (121 ± 5.6 versus 169 ± 14 mmHg, p <0.001), stroke volume (63 ± 15 versus 77 ± 14 ml, p <0.001), left ventricular ejection fraction (43 ± 9% versus 47 ± 9%, p = 0.001), and systolic right ventricular function (pulsed tissue Doppler index peak systolic velocity: 8.6 ± 1.7 versus 11.1 ± 3.2 cm/s, p = 0.004). A mild increase in planimetric mitral valve area was observed at peak exercise (2.12 ± 0.4 versus 2.17 ± 0.3 cm2, p = 0.05). Although the transmitral mean gradient was increased from 3.2 ± 1.2 to 6.3 ± 2.3 mm Hg (p <0.0001), the systolic pulmonary artery pressure did not change significantly (27 ± 2.8 versus 30.1 ± 6.4 mm Hg, p =0.3), thus revealing a preserved cardiac adaptation to exercise. …
The Journal of Heart Valve Disease 2012;21:446-453
ZOL 10/12
Mean gradient <5mmHg (n=14) Mean gradient >5mmHg (n=9) p-value
Resting Exercise p-value Resting Exercise p-value Resting Exercise
LV EF,% 42 ± 16 53 ± 7 0.036
LV EDV, ml 138 ± 55 105 ± 30 0.076
LV ESV, ml 86 ± 49 50 ± 15 0.020
LV EDD, mm 57 ± 8 50 ± 7 0.033
LV ESD, mm 48 ± 10 41 ± 7 0.064
NYHA 1.8 ± 0.7 1.4 ± 0.5 0.225
Maximal workload, Watt 38 ± 14 69 ± 23 <0.001
VO2max, ml/kg/min 12.3 ± 3.4 15.3 ± 2.6 0.035
MV peak gradient, mmHg 9.5 ± 2.7 13.1 ± 4.3 0.004 14.5 ± 2.6 22.6 ± 3.4 0.001 <0.001 <0.001
MV mean gradient, mmHg 3.3 ± 1 5.7 ± 1.6 <0.001 6.2 ± 1 12.0 ± 4.0 0.003 <0.001 <0.001
Syst. PAP, mmHg 43 ± 15 46 ± 26 0.105 43 ± 11 50 ± 20 0.05 0.94 0.71
Cardiac output 3.6 ± 0.8 4.7 ± 1.3 0.01 4.4 ± 0.8 7.3 ± 2.0 0.001 0.03 0.001
Cardiac index 1.9 ± 0.4 2.5 ± 0.7 0.001 2.3 ± 0.4 3.7 ± 0.9 0.001 0.09 0.002
MR VC widt, mm 1.2 ± 1.2 1.2 ± 1.2 NS 1.4 ± 0.7 1.3 ± 1.3 NS NS NS
Exercise stress echocardiography with ergospirometry
Exercise hemodynamics
Method of quantification of ALAbase, ALAtip and PLA. Measurements depicted on
echocardiographic image of mitral valve in apical 4-chamber view in mid-systole.
Am J Cardiol 2010;106:395-401. Ciarka et al
ZOL 08/10
Predictors of mitral regurgitation recurrence in patients with heart failure undergoing mitral valve annuloplasty. Agnieszka Ciarka et al
Am J Cardiol 2010;106:395-401
ZOL 09/10
… Methods. One-hundred and thirty-two patients with severe functional MR and systolic dysfunction (mean ejection fraction 0.32 ± 0.078) underwent mitral surgery in the same time frame. The decision to replace rather than repair the MV was taken when 1 or more echocardiographic predictors of repair failure were identified at the preoperative echocardiogram. Eighty-five patients (64.4%) received MV repair and 47 patients (35.6%) received MV replacement. Preoperative characteristics were comparable between the 2 groups. Only ejection fraction was significantly lower in the MV repair group (0.308 ± 0.077 vs 0.336 ± 0.076, p = 0.04). … Conclusions. In patients with advanced dilated and ischemic cardiomyopathy and severe functional MR, MV replacement is associated with higher in-hospital and late mortality compared with MV repair. Therefore, mitral repair should be preferred whenever possible in this clinical setting.
Ann Thorac Surg 2012;94:44 –51
ZOL 10/12
J Thorac Cardiovasc Surg 2004;128:916-24
Edwin C. McGee et al. J Thorac Cardiovasc Surg 2004;128:916-24
Cardiac support device, restrictive mitral valve annuloplasty, and optimized medical treatment: A multimodality approach to nonischemic cardiomyopathy
Jerry Braun, MD, Agnieszka Ciarka, MD, PhD, Michel I. M. Versteegh, MD, Victoria Delgado, MD, Eric Boersma, MD, PhD, Harriette F. Verwey, MD, PhD, Martin J. Schalij, MD, PhD, Jeroen J. Bax, MD, PhD, Robert A. E. Dion, MD, PhD, Nico R. van de Veire, MD, PhD, and Robert J. M. Klautz, MD, PhD
Methods: Sixty-nine consecutive patients with heart failure (New York Heart Association class III/IV) with functional mitral regurgitation (grade 3+/4+) and left ventricular remodeling (end-diastolic volume 227 ± 73 mL, ejection fraction 26% ± 8%) underwent restrictive mitral annuloplasty (median ring size 26), with (n = 41) or without (n = 28) a cardiac support device and optimal postoperative medical treatment. Patients were clinically and echocardiographically evaluated at up to 3.1 years’ median follow-up. Results: Early mortality was 5.8%. Actuarial survival at 1, 2, and 5 years was 86% ± 4%, 79% ± 5%, and 63% ± 7%. New York Heart Association class improved from 3.1 ± 0.4 to 2.0 ± 0.5 (P<.01). Cardiac support device implantation in addition to mitral valve surgery, applied in patients with more advanced left ventricular remodeling, resulted in similar clinical outcome, greater left ventricular end-diastolic volume decrease (33%vs 18%; P = .007), and in a trend toward less recurrent mitral regurgitation of grade 2+ or more (actuarial freedom at 3 years 89% ± 8% vs 63% ± 11%; P = .067). Conclusions: Favorable survival and improved functional status, low incidence of significant recurrent mitral regurgitation, and sustained left ventricular reverse remodeling. (J Thorac Cardiovasc Surg 2011;142:e93-e100)
ZOL 04/11
ZOL 04/11
Evolution of LVEDV and LVESV at early postoperative follow-up, and at long-term follow-up
CSD + RMA + OMT
Braun et al, J Thorac Cardiovasc Surg 2011;142:e93-e100
