Download The future of mitral valve repair The future of mitral valve repair

The future of mitral valve repair
The future of mitral valve repair Dr. Ali Aburumman
QAHI KHMC Al Riyadh ‐ 2011
Lancet 1957
The future of Mitral valve repair
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Mitral valve diseased either
Mitral
valve diseased either
Stenosis
Regurgitation
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Combine pathology
Mitral Stenosis
Mitral Stenosis
• Etiology
– Rheumatic – Degenerative (calcification)
Degenerative (calcification)
– Congenital (parachute MV)
– post‐inflammatory, t i fl
t
– metabolic syndromes – Others
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3-D Echo of Mitral Stenosis
LA view
LV view
3-D measurement of Mitral valve area
LA view
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MVA= 0.914 cm2
LV view
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Real Time TTE of MS
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LA
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T t
Treatment of mitral Stenosis
t f it l St
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1. Close mitral valvotomy (CMV)… not used.
2.Open mitral valvotomy (OMV) rarely used.
3.Percutaneous Balloon mitral valvotomy (PBMV) commonly used .
4. Mitral valve replacement more frequent surgical option Indications for percutaneous valvuloplasty of MS
• Class I
Class I
– Symptomatic patients (NYHA II, III, or IV), moderate or severe MS (MVA ≤ 1 5) and valve
moderate or severe MS (MVA ≤ 1.5) and valve morphology favorable for percutaneous balloon valvotomy in the absence of left atrial thrombus or moderate to severe MR
• Class IIa
Class IIa
– Asymptomatic patients with moderate or severe MS and valve morphology favorable for percutaneous balloon valvotomy who have pulmonary hypertension (PAP > 50 at rest or 60 with exercise) in the absence of LA thrombus or moderate to severe MR
– Patients with NYHA III‐IV symptoms, moderate or severe MS and a nonpliable calcified valve who are at high risk for surgery in the absence of LA thrombus or mod/sev MR
i th b
f LA th
b
d/
MR
• Class IIb
Class IIb
– Asymptomatic patients, moderate or severe MS and valve morphology favorable for percutaneous
and valve morphology favorable for percutaneous balloon valvotomy who have new onset of AF in the absence of left atrial thrombus or mod/sev MR.
– Patients in NYHA III‐IV, mod or sev MS, and a nonpliable calcified valve who are low‐risk candidates for surgery
• Relative contraindications
Relative contraindications
– Left atrial thrombus
• TEE
TEE frequently performed prior to the procedure to frequently performed prior to the procedure to
rule out thrombus
• According to Palacios and Vahanian, no consensus regarding thrombus localized in L atrial appendage.
– Limit to patients with contraindications to surgery or those with urgent need for intervetion
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– Significant MR (3+ to 4+)
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Last month I face with 78 year old patient
Last
month I face with 78 year old patient
Present with calcific mitral Stenosis 1.8cm
With LAD lesion ih
l i
Is their any contraindication to try BMV +Stent to LAD Immediate outcomes of percutaneous valvuloplasty of MV
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The immediate results of percutaneous mitral valvotomy are similar to those of surgical mitral commissurotomy – Mean MVA doubles (from 1.0 cm2 to 2.0 cm2) – 50% to 60% reduction in transmitral gradient. – Overall, 80% to 95% procedural success (MVA >1.5 cm2 and a decrease in LA pressure to <18 mm Hg). Most common acute complications
Most common acute complications – severe MR 2% to 10% – residual ASD
• Large ASD (>1.5:1 L‐>R shunt) in <12% with the double balloon technique and <5% with the Inoue q
balloon technique. • Smaller ASD detected by TEE in larger numbers of patients. Less frequent complications – perforation of LV (0.5% ‐ 4.0%)
– embolic events (0.5% ‐ 3%)
– MI (0.3% ‐ 0.5%). Mortality – 1% to 2% – < 1% with increasing experience in selected patients.
Long‐term results of percutaneous valvuloplasty of MS
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Survival rate 60 % ‐ 90 % over 3‐7 yrs
Restenosis rate 40% after 7 yrs.
Randomized trials comparing percutaneous approach with both closed and open surgical commissurotomy consisted mainly of younger patients p
g
y
y y
g p
with favorable morphology.
– No significant difference in acute hemodynamic results or complication rate.
– No difference in clinical improvement or exercise time in early follow‐up
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– More favorable hemodynamics and symptomatic results with percutaneous approach than closed commissurotomy and equivalent results with open commissurotomy.
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MR stable or decreaswes slightly.
ASD likely to close later in majority of cases.
• Percutaneous BMV is the procedure of
choice in patients who have
symptomatic, hemodynamically severe
stenosis with an echocardiographic
score of 8 or less and without left
atrial thrombus
• if the score > 8 the durability well be
low and in favor of replacement
Treatment of mitral stenosis
Treatment of mitral stenosis
• All
All of us agree BMV is treatment of choice of us agree BMV is treatment of choice
• It replace CMV & OMV in favorable cases
• All the time we said repair is better for the ll h i
id
i i b
f h
patient especially female at child bearing age, &
& we avoid warfarine
id
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• But the durability of OMV was query if it not suitable for BMV >>>> replacement • What about mitral regurgitation
What about mitral regurgitation
Carpentier Classification of Mitral Regurgitation
• Type Leaflet , Mobility & Cause
• I Normal Annular dilatation Leaflet perforation
• II Excessive Chordal elongation or rupture Papillary muscle elongation or rupture
elongation or rupture
• III Restricted • a. Restricted opening;
• Commissural fusion, leaflet and chordal thickening
C
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lf i
l fl
d h d l hi k i
• b. Restricted closure; Excess tension on chordae during systole
Modified Carpentier Classification of Mitral Regurgitation
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Leaflet Motion Description
Ia Normal Annular dilatation
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l dil
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Ib Leaflet perforation
IIa Increased Chordal elongation
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IIb Chordal rupture
IIc Papillary muscle infarction or scarring
IId Papillary muscle rupture
IId Papillary muscle rupture
IIIa Restricted Commissural or chordal fusion and
shortening
IIIb L fl
IIIb Leaflet tethering by dyskinetic or
h i b d ki i
aneurysmal LV segments
IV Variable Dynamic papillary muscle dysfunction
Treatment of Mitral Regurgitation
Treatment of Mitral Regurgitation
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Ia Normal Annular dilatation Ib L fl t
Ib Leaflet perforation
f ti
IIa Increased Chordal elongation
IIb Chordal rupture
IIc Papillary muscle infarction or p
y
scarring
IId Papillary muscle rupture
IIIa Restricted Commissural or chordal fusion and
shortening
IIIb Leaflet tethering by dyskinetic or aneurysmal LV segments
IV Variable Dynamic papillary muscle
IV Variable Dynamic papillary muscle dysfunction
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Ia commisroplasty // ring Ib l
Ib closure of Leaflet perforation
f L fl t
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IIa excision,alfieri,artificial chordee
IIb excision, artificial chordee
IIc excision, artificial chordee, graft
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IId excision, artificial chordee, graft
IIIa excision, artificial chordee, graft , OMV , excision of basal chordee
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IIIb excision, artificial chordee, graft , OMV , excision of basal chordee repair aneurysmal LV segments
IV Variable treatment
IV Variable treatment
If fail replacement of the valve with tissue or mechanical prosthesis
The future of Mitral valve repair
Surgical weapons
Surgical weapons 1.
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Commisserotomy ±splitting of chordee and muscle Annulus ring, annuloplasty
g,
p y
Excision and plication± sliding
Closure of perforation
Excision of 2ndary chordee
Alfieri stitch
Artificial chordee
Grafting pericardial, tricuspid..etc
Remodeling of the ventricle
Remodeling of the ventricle The future of Mitral valve repair
If repair failed due to If
repair failed due to
complex anatomy or
combine lesions or not durable or cost
not durable or cost
presence of another indication for blood thinner we shift to replacement
we shift to replacement • “ Most often the entire valve appears
normal;… There is little to fix, yet the
valve leaks… the valve is structurallyy
normal; it need not be replaced, but
currently we do not know how to fix it…”
• - L. Henry
y Edmunds Jr. 1997
(Cardiac Surgery in the Adult)
Severe Mitral Regurgitation
R
Repair
i vs. R
Replacement
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t:
Better
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tt LV function
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Improved Survival
• ((A) Posterior leaflet )
endocarditis with P2 segment prolapse. (B) P2 segment is resected (C)
segment is resected. (C) Compression sutures are placed along the posterior annulus. (D) Sliding plasty ( )
of segments P1 and P3 is p
performed. • Leaflet Leaflet
perforation (anterior leaflet) treated by autologous pericardial i di l
patch
Coronary Revasc
Revasc. & IMR
Gold Standard
– Ischemic MR grade 3-4
– Carpentier type IIIb dysfunction
– Reduction annuloplasty
Adams et al. Ann ThoracSurg 2006;;82::2096‐2101
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Fig 1. (a) Placement of one or more simple Gore‐
p p
y
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Tex sutures in the papillary muscle head is easy to perform after posterior leaflet resection because of enhanced exposure. (b) Typical appearance of a myxomatous mitral valve after posterior leaflet quadrangular resection and sliding valvuloplasty. Poor leaflet apposition is present in all leaflet segments and segmental
present in all leaflet segments, and segmental anterior leaflet prolapse can be localized only by height comparison with the normal reference point (usually P1). (c) After ring annuloplasty symmetric leaflet apposition limits valve incompetence to the prolapsing anterior leaflet segment (d) After annuloplasty both arms of
segment. (d) After annuloplasty both arms of the Gore‐Tex suture are passed through the margin of the prolapsing segment. Optimal artificial chord height is determined by intermittently testing valve competency by injecting saline into the ventricle. (e) Completed repair with artificial chord in place. A symmetric f
line of apposition results in valve competence. Intervention mitral valve repair
Intervention mitral valve repair
• percutaneous
• Mitral Repair
• Approaches
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Coronary sinus annuloplasty
• Edwards Monarc
• Edwards Monarc
• Cardiac Dimensions Carillon
• Viacor Shape Changing Rods
• St. Jude Annulus Reshaping
Direct annuloplasty
Direct annuloplasty
• Mitralign Suture‐Based Plication
• Guided Delivery Anchor‐Cinch Plication
• QuantumCor RF Annulus Remodeling
• MiCardia variable size ring
• MiCardia variable size ring
Leaflet repair
• EValve Mitraclip
• Edwards Mobius stitch
Chamber + annular remodeling
Chamber + annular remodeling
• Myocor iCoapsys
• Ample PS3
Figure 3. Coronary sinus annuloplasty devices.
Masson J , Webb J G Circ Cardiovasc Interv 2009;2:140146
Copyright © American Heart Association
Figure 1. A, Mitraclip device in its open position.
Masson J , Webb J G Circ Cardiovasc Interv 2009;2:140146
Copyright © American Heart Association
Figure 4. Schematic representation of a coronary annuloplasty procedure with the MONARC
device.
Masson J , Webb J G Circ Cardiovasc Interv 2009;2:140146
Copyright © American Heart Association
Figure 6. Direct annular plication concept.
Masson J , Webb J G Circ Cardiovasc Interv 2009;2:140146
Copyright © American Heart Association
Figure 5. Schematic representation of the atrial remodeling PS3 device (A) and the left
ventricular remodeling iCoapsys device (B).
Masson J , Webb J G Circ Cardiovasc Interv 2009;2:140146
Copyright © American Heart Association
Figure 7. Direct annular plication in an ovine model using the Accucinch device.
Masson J , Webb J G Circ Cardiovasc Interv 2009;2:140146
Copyright © American Heart Association
The future of mitral valve surgery
The future of mitral valve surgery
• Even
Even Para leaking Para leaking
prosthetic valve device was available EEven percutaneous Trans catheter t
T
th t
mitral valve implantation p
Figure 8. Transcatheter mitral valve implantation.
Masson J , Webb J G Circ Cardiovasc Interv 2009;2:140146
Copyright © American Heart Association
Mitral valve repair in Jordan
Mitral valve repair in Jordan
• During
During the period between 1980 and 1990 an the period between 1980 and 1990 an
3000 case of open heart surgery was done in Jordan 30% was valvular heart surgery 70% of them CMV or OMV
• During the period between 1990 and 2000 an 15000 case of open heart surgery was done in Jordan10% was valvular heart surgery but less than 1% was OMV, why we started BMV h 1%
OMV h
d BMV
Mitral valve repair in Jordan
Mitral valve repair in Jordan
• During
During the period between 2000 and 2010 an the period between 2000 and 2010 an
30000 case of open heart surgery was done in Jordan10% was valvular heart surgery but
Jordan10% was valvular heart surgery but repair procedure more than 40% of mitral valve surgery
valve surgery Mitral valve repair in Jordan
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Most common annular ring … IMR
Most
common annular ring IMR
Posterior leaflet remolding.
Artificial chordee
ifi i l h d
Alfieri stitch
Excision of 2ndary chordee
These cover 95% of repair process
These cover 95% of repair process The future of mitral valve surgery
The future of mitral valve surgery
• Our old enemies became new friends
Our old enemies became new friends
• Infection and adhesions • Infective endocarditis if medical treat failed may need surgical interference • And of course redo surgery g y
The future of mitral valve surgery
The future of mitral valve surgery
• So I think we had to review our classification of repairable mitral valve and non repairable taken in mind the following points
• 1.durabilty of repair.
1 durabilty of repair
• 2. the need of blood thinner .
• 3. Combine pathology
p
gy
• 4. Age ,sex, patient IQ …..etc • 5.possibility of percutaneous repair.
• 6. cost.
• 7. trained surgeon
The future of mitral valve surgery
The future of mitral valve surgery
• For
For example example
• Central ischemic mitral regurge with CABG grade II III IV
grade II –III‐‐
• Revascularization alone may improve MR b l II
below II+ and if failed percutaneous ring
d if f il d
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The future of mitral valve surgery
The future of mitral valve surgery
• The
The durability of repair with rheumatic mitral durability of repair with rheumatic mitral
valve is low • So percutaneous procedure may bridge the So percutaneous procedure may bridge the
patient for few years until resolve the reason for MVR
for MVR The future of mitral valve surgery
The future of mitral valve surgery
• The
The usage of new generation of Bioprosthetic usage of new generation of Bioprosthetic
valves with long life and no need for blood thinner omit the need of the low durable
thinner omit the need of the low durable repair
• St.
St. Jude Medical
Jude Medical'ss new new
pericardial aortic stented tissue valve, the Trifecta, has been granted CE Mark of approval by the l b th
European authorities SJM'ss Aortic Trifecta Valve
SJM
Aortic Trifecta Valve
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The next‐generation tissue valve has a tri leaflet stented pericardial design
a tri‐leaflet stented pericardial design which offers excellent hemodynamic performance, or nearly unobstructed blood flow, in order to mimic as y p
closely as possible the flow of a natural, healthy heart. The unique valve design includes leaflets manufactured from pericardial tissue attached to the exterior of the valve stent which open more fully and
stent which open more fully and efficiently to perform like a natural heart valve. •
The valve's titanium stent, which provides a fatigue resistant frame to
provides a fatigue resistant frame to support the valve within a patient's heart, is covered with pericardial tissue to allow tissue‐to‐tissue p
contact when the leaflets open and close, which reduces the amount of wear and deterioration. Additional attributes contributing to the Trifecta valve's durability include proprietary tissue fixation and St Jude Medical'ss tissue fixation and St. Jude Medical
patented Linx(TM) AC Technology, an anticalcification treatment designed to reduce tissue mineralization (
(hardening).
g)
The future of mitral valve surgery
The future of mitral valve surgery
• May conclusion of primary lectures was May conclusion of primary lectures was
• Mitral valve repair was done by senior surgeon for fit patient under optimal conditions as TEE testing with acceptance of near normal results keeping the geometry of the heart as normal • while in replacement a junior surgeon do the surgery for non healthy valve under non optimal conditions as no need TEE testing and ignorance of the geometry of the heart by cutting
testing and ignorance of the geometry of the heart by cutting all of the chordee conclusion
• We
We had to review the timing &the best method of had to review the timing &the best method of
repair taking in consideration the durability of repair, the need of blood thinner, the pathology, Age ,sex, patient IQ, possibility of percutaneous repair & the cost.
• We had to focus the new generation of trained surgeon certain repair method
• And filling the other in especial medical video library d f ll
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l
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for the history