Download repair ischemic mitral regurgitation

REPAIR
ISCHEMIC
MITRAL REGURGITATION
Edwards Lifesciences -Consultant
Saint Jude Medical-Consultant
Sorin-Consultant
Prof. Dr. R. Dion
Genk - Belgium
KULeuven
REPAIR
ISCHEMIC
MITRAL REGURGITATION
Prof. Dr. R. Dion
Genk - Belgium
KULeuven
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
* LVEF 46%
* ESV
121 ml
* EDV
223 ml
* PAp 55/30
* Ao
160/70
* Wp 24
* 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
31/08/2009
MR : 0
Grad. : 3/1 mm Hg ( C.I. 2.2 l/mm²)
Coaptation length : 9 mm
- 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
LVEDD and Reverse Remodeling
89 %
100%
specificity
sensitivity
80%
60%
40%
20%
65
0%
40
60
80
100
LVEDD (mm)
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
0.9 ± 0.8
(46m)
Braun J et al. Ann Thorac Surg 2008 Feb;85(2):430-6
P < 0.05
Results: Echocardiography
baseline
intermediate
late
MV gradient
3.6 ± 1.5
3.9 ± 1.7
MV area
2.8 ± 0.6
2.6 ± 0.6
(cm2)
Tenting area
4.8 ± 1.4
1.4 ± 0.6
(cm2)
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
Relocation of the posterior papillary muscle (Kron)
Kron IL: Surgical relocation of the posterior papillary muscle in chronic
ischemic mitral regurgitation. Ann Thorac Surg 2002;74:600-1
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
The bovine pericardial patch extending the medial half of P2 and all of P3
de Varennes, B. et al. Circulation 2009;119:2837-2843
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 endsystolic 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
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
NOT a reasonable option for functional MR
in operable patients
Q9. How much should one undersize the
annuloplasty device?
a.
b.
c.
d.
2 sizes down.
3 sizes down.
The smallest device available.
Adapt undersizing to the type of device.
ECHO CRITERIA OF SEVERE MR
ERO (cm2)
RV (ml)
ORGANIC
> 0.4
> 60
FMR
> 0.2
> 30
M. Enriquez-Sarano
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
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
Results: Mortality per LVEDD
All-cause death
60%
P-value 0.002
HR 3.4 and 95% CI 1.5-7.4
50%
49 ± 11%
LVEDD >65
40%
71 ± 8.5%
30%
80 ± 5.2%
20%
LVEDD 65
93 ± 3.0%
10%
0%
0
1
2
3
4
5
6
40
27
11
Years since surgery
Patients at risk
100
87
82
60
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
Heart 2011;97:1675-1680
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.
…
ZOL 10/12
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 08/12
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 10/12
…
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
Exercise stress echocardiography with ergospirometry
Exercise hemodynamics
Mean gradient <5mmHg (n=14)
Mean gradient >5mmHg (n=9)
Resting
Resting
Exercise
p-value
Exercise
p-value
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
ZOL 08/10
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 09/10
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 10/12
Ann Thorac Surg 2012;94:44 –51
…
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.
J Thorac Cardiovasc Surg 2004;128:916-24
Edwin C. McGee et al.
J Thorac Cardiovasc Surg 2004;128:916-24
ZOL 04/11
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
CSD + RMA + OMT
Evolution of LVEDV and LVESV at early postoperative follow-up,
and at long-term follow-up
Braun et al, J Thorac Cardiovasc Surg 2011;142:e93-e100