Stanford CV Surgery

Techniques for ischemic mitral valve disease:

An Update

Grant/ Research Support: NHLBI RO1 HL67025 Consulting Fees/Honoraria:

•Stanford PI – PARTNER Trial, Edwards Lifesciences •Consultant, Abbott Vascular Structural Heart (MitraClip) •Consultant, Medtronic CardioVascular Division •Consultant, St. Jude Medical •Executive Committee, PARTNER U.S. Pivotal Trial , Edwards Lifesciences (non-remunerative)

Major Stock Shareholder/Equity Interest: Royalty Income: Ownership/Founder: Salary: Intellectual Property Rights: Other Financial Benefit:

Conflict of Interest Disclosure

Stanford CV Surgery

FMR and IMR PATHOPHYSIOLOGIC MECHANISMS &

TREATMENT

Levine, RA New Eng J Med 351: 1681,

2004

Stanford CV Surgery

Two mechanisms of leaflet malcoaptation:

Annular dilation with Carpentier type I leaflet motion (IMLC)

PPM

AML

PML

S-L

Stanford CV Surgery

Why do leaflets malcoapt in patients with IMR/FMR?

Two mechanisms of leaflet malcoaptation:

Annular dilation with Carpentier type I leaflet motion (IMLC)

AML

PPM

PML

Most common in FMR

Early and mid systolic leak

Stanford CV Surgery

Why do leaflets malcoapt in patients with IMR/FMR?

Two mechanisms of leaflet malcoaptation:

Papillary muscle displacement with apically restricted systolic leaflet motion (type IIIb)

(apical tethering, tenting) PPM

AML

PML

Stanford CV Surgery

Why do leaflets malcoapt in patients with IMR/FMR?

Two mechanisms of leaflet malcoaptation:

Papillary muscle displacement with apically restricted systolic leaflet motion (type IIIb)

(apical tethering, tenting)

PML AML

PPM

Why do leaflets malcoapt in patients with IMR/FMR?

Most common in IMR

Early systolic leak Stanford CV Surgery

Both mechanisms (type I and type IIIb) of leaflet malcoaptation can coexist in the same patient

Stanford CV Surgery

Why do leaflets malcoapt in patients with IMR/FMR?

Stanford CV Surgery

Advances in Echocardiography

Are Color Doppler and rt 3-D TEE just for amateurs?

But please don’t take away my X-plane and color M-mode

Stanford CV Surgery

Stanford CV Surgery

Stanford CV Surgery

Mechanisms of MR- Color M-mode echo Early systolic (FMR)

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Mechanisms of MR- Color M-mode echo Holosystolic (IMR)

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Mechanisms of MR- Color M-mode echo Late systolic (prolapse)

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IMR/FMR - apical tenting (type IIIb)

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IMR/FMR - apical tenting (type IIIb)

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IMR/FMR - type I s/p Bolling Procedure

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IMR/FMR - type I s/p Bolling Procedure

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Human Mitral “annulus”

From FC Wells and LM Shapiro, 1996

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Hueb AC et al., J Thorac Cardiovasc Surg 2002; 124: 216-24 Stanford CV Surgery

Standard Surgical Approach

Frank Langer, Homburg, Germany Stanford CV Surgery

Mihaljevic, T. et al. J Am Coll Cardiol 2007;49:2191-2201

Surgical treatment of IMR

with ring annuloplasty ± CABG

Stanford CV Surgery

Mihaljevic, T. et al. J Am Coll Cardiol 2007;49:2191-2201

3+ or 4+ residual/recurrent MR

Stanford CV Surgery

Mihaljevic, T. et al. J Am Coll Cardiol 2007;49:2191-2201

Survival After CABG ± Concomitant MV Annuloplasty

Stanford CV Surgery

Stanford CV Surgery

Stanford CV Surgery

Recurrent/residual MR ≥2+ after

ring annuloplasty for IMR

Magne et al. Cardiology 2009;112:244–259 Stanford CV Surgery

Large variety of annuloplasty rings available

a.) Various shapes (flat, saddle, dog bone)

b.) Various configurations (partial, complete)

c.) Various material properties (flexible, semi-flexible, rigid)

Stanford CV Surgery

Stanford CV Surgery

Stanford CV Surgery

IMR-FMR disease-specific ring designs Disproportionate septal-lateral dimension reduction

Bothe W, Swanson J, et al., JTCVS 139:1114-1122, 2010

Stanford CV Surgery

IMR-FMR disease-specific ring designs Disproportionate S-L reduction vs. CE Physio

Bothe W, Swanson J, et al., JTCVS 139:1114-1122, 2010 Stanford CV Surgery

IMR-FMR disease-specific ring designs Disproportionate S-L reduction vs. CE Physio

Bothe W, Swanson J, et al., JTCVS 139:1114-1122, 2010 Stanford CV Surgery

•Coapsys®, SLAC, Hvass PM sling or

PM-suturing, Kron UVA stitch, Homburg

“STRING”, second-order chordal cutting,

CorCap CSD, Fontan stitch, epicardial LV

balloon patch, LV wall polymer injection

Adjunctive surgical subvalvular approaches

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CorCap CSD

Acorn Medical

Stanford CV Surgery JTCVS 2011; 142:569-574

Stanford CV Surgery JTCVS 2011; 142:569-574

Stanford CV Surgery JTCVS 2011; 142:569-574

Ventricular Level Approaches

Hvass Papillary Muscle Sling

U Hvass, et al. Ann Thorac Surg 2003;75:809 –11

Stanford CV Surgery

U Hvass, et al. JTCVS 2010;139:418-423

Hvass Papillary Muscle Sling

Stanford CV Surgery

CIRCULATION 2010; 122 [suppl 1] : S29–S36

Ventricular Level Approaches

Papillary Muscle Imbrication (Univ. of Osaka)

Stanford CV Surgery

Stanford CV Surgery

Stanford CV Surgery

Stanford CV Surgery

MGH thrust #2- 2° order CT cutting to AMVL

Messas, Guerrero, Handschumacher, Conrad, Chow, Sullivan,

Yoganahan, Levine (CIRCULATION 2001; 104:1958-1963) Stanford CV Surgery

J Thorac Cardiovasc Surg 2007;133:1483-92

MR grade Ring + CABG Ring + CT cutting +CABG

Stanford CV Surgery

J Thorac Cardiovasc Surg 2007;133:1483-92

Event-free survival

Defined as freedom from death, recurrent >

moderate MR, reop, TE, hemolysis, major

ACH , or PVE

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IMR/MR

Is the MR the real culprit ?

Stanford CV Surgery

Benefits of MR Reduction in Ischemic MR Patients:

Lessons from RESTOR_MV Trial Open CABG + ring annuloplasty

vs. OpCAB + Coapsys

Eugene A. Grossi, MD

for the RESTOR-MV Study Group

NYU School of Medicine &

NY Harbor Veterans Healthcare System Stanford CV Surgery

RESTOR_MV Trial: FDA Prospective Study

Minimally invasive (no CPB) Ventricular Shape Change Device

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RESTOR_MV: MR Evaluation

CABG+MVRepair vs. CABG+Coapsys

Both effect of time and treatment p=0.0001 Stanford CV Surgery

Intent-To-Treat: All Patient Survival

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Other Approaches

de Varennes CIRC 2009 Langer CIRC 2009 Borger JTCVS 2007

LV systolic function ? X-clamp time ?

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STRING-technique Kron-technique • via atriotomy • final tension in arrested heart

• via horizontal aortotomy • final tension in loaded beating heart under TEE guidance

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IMR (n=60) with severe leaflet tethering (tenting height > 10 mm)

historical matched control group

(n=30)

RING RING+STRING

study group (n=30)

Langer CIRC 2009

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> 10 mm

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> 40 mm

Stanford CV Surgery

0 12 24 36 48 60 72 840

20

40

60

80

100RING+STRING

RING

3030

2626

2024

923

322

subjects at risk 020

014

0 0

p=0.13

Follow-up (months)

Su

rviv

al

(%)

F. Langer CIRC 2009 Stanford CV Surgery

0 12 24 36 48 60 72 840

25

50

75

100RING+STRING

RING

subjects at risk3030

2520

1818

918

317

016

010

0 0

p=0.01

*

Follow-up (months)

Fre

ed

om

fro

m M

R >

II (

%)

F. Langer CIRC 2009 Stanford CV Surgery

Stanford CV Surgery

Stanford CV Surgery AATS 2012

Stanford CV Surgery EJCTS 2011;39:295-303

Goal for CHF and FMR / IMR

Accomplish something below the annulus in

conjunction with disease-specific undersized

annuloplasty ring designs and/or other

adjunctive procedures to restore and maintain

more elliptical LV shape and minimize MR

Which should translate into better reverse

LV remodeling

Stanford CV Surgery

Stanford CV Surgery

Thank you