Download Ischemic Mitral Valve Disease: Repair, Replace or Ignore?

Ischemic Mitral Valve Disease:
Repair, Replace or Ignore?
Fabio B. Jatene
Full Professor of Cardiovascular Surgery, Medical School,
University of São Paulo, Brazil
DISCLOSURE
I have no financial relationship
to disclose
RATIONALE
MITRAL REGURGITATION
Abnormalities in MV leaflets or SV apparatus
Organic MR
Normal MV and ischemic ventricle disorder
Functional MR
Acute IMR
• IMR may present
acutely secondary to
papillary muscle
infarction and rupture
• Pts usually present in
cardiogenic shock
• Surgery usually
consists of MV replace
Organic MR +
Incidental CAD
• Pts with organic MV
leaflet pathology
(myxomatous,
rheumatic, etc) and
incidental CAD
should not be
classified as having
chronic IMR
Chronic IMR
• 1 week after MI:
• LV segmental wall
motion abnormalities;
• CAD in the territory
supplying the wall
motion abnormality;
• Leaflets and chordae
structurally normal
Borger MA et al. Ann Thorac Surg. 2006;81(3):1153-61.
BACKGROUND
Operative mortality after surgery for
valvular heart disease
Guidelines ESC/EACTS. Eur Heart J. 2012;33(19):2451-96.
RATIONALE
Ann Thorac Surg. 2006;81(3):1153-61.
Some questions still remain
Even 10 years later
RATIONALE
PubMed (1974-2015)
490 articles retrieved
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1971 -1975 1976-1980 1981-1985 1986-1990 1991-1995 1996-2000 2001-2005 2006-2010 2011-2015
Key words: ischemic mitral valve regurgitation and coronary artery bypass
Ischemic Mitral Valve Disease:
Repair, Replace or Ignore?
Operate or ignore
IMR?
If operate, repair or
replace?
Operate or ignore IMR?
What the guidelines say?
2012 ESC/EACTS Guidelines. Eur Heart J. 2012;33(19):2451-96.
2014 AHA/ ACC Guidelines. J Am Coll Cardiol. 2014;63(22):2438-88.
Guidelines on
myocardial
revascularization are
nonspecific about
ischemic mitral
regurgitation approach
2014 ESC/EACTS Guidelines. Eur Heart J. 2014;35(37):2541-619.
• 301 pts with moderate IMR randomized to CABG alone or CABG
plus MV repair
• CONCLUSIONS:
1. The addition of MV repair to CABG did not result in a higher
degree of LV reverse remodeling
2. MV repair was associated with reduced prevalence of moderate
or severe mitral regurgitation but an increased number of
untoward events
3. Thus, at 1 year, this trial did not show a clinically meaningful
advantage of adding MV repair to CABG
Smith PK et al. N Engl J Med 2014;371:2178-88.
If operate, repair or
replace?
What the guidelines and
meta-analysis say?
Mitral valve repair is
prefered over
replacement when
possible
J Am Coll Cardiol. 2014;63(22):2438-88.
Comparison of 30-day survival after MV repair and replacement
Shuhaiber J, Anderson RJ. Eur J Cardiothorac Surg. 2007;31(2):267-75.
Comparison of total survival after MV repair and replacement
Shuhaiber J, Anderson RJ. Eur J Cardiothorac Surg. 2007;31(2):267-75.
Operative Mortality
Dayan V et al. Ann Thorac Surg. 2014;97:758-66.
Global Survival
Mitral Regurgitation
Dayan V et al. Ann Thorac Surg. 2014;97:758-66.
• 251 pts with severe IMR randomized to either mitral-valve repair or
chordal-sparing replacement
• CONCLUSIONS:
1.
We observed no significant difference in LV reverse remodeling or
survival at 12 months between pts who underwent mitralvalve repair and those who underwent mitral-valve replacement
2.
Replacement provided a more durable correction of mitral
regurgitation, but there was no significant between group difference
in clinical outcomes
Acker MA et al. N Engl J Med 2014;370:23-32.
Regarding the surgical treatment of IMR, in addition to the
initial questions, several other questions could be asked, in
this challenging and still controversial situation.
Operate or ignore
IMR?
If operate, repair or
replace?
If repair, which
technique should be
used?
…
Repair the valve, reshape
the ventricle or both?
CONSIDERATIONS
Operate or ignore IMR?
• Previous Guidelines considered IMR as a specific issue
but today IMR is in the group of secondary MR
• MV surgery is indicated or should be considered in pts
undergoing CABG with severe IMR and/or symptomatic
patients
• The level of evidence is poor
• More recently no clinical advantage to add MV surgery
to CABG, in moderate IMR
CONSIDERATIONS
If operate, repair or replace?
• Current guidelines establish that MV repair is preferred
over replacement when possible
• According to 2008–2012 data from the STS, 66% of MV
surgeries in pts undergoing CABG used a repair approach
• More recently no difference in 12 mo. survival between
repair or replacement in IMR. Replacement provided a
more durable correction, but no difference in clinical
outcomes
Thank you
CONCLUSIONS
IMR SURGERY
• Despite many definitions still remain some controversial
points, specially base in recent information and data
•
• New
CONCLUSIONS
• A number of surgical techniques have been developed for
IMR, but recent studies have questioned the
improvement in patient outcomes
• Operative mortality associated with either procedure has
declined in the last years, but the open heart exposure
and longer durations of Ao cross-clamping and CPB that
are associated with MV repair increase perioperative risk
BACKGROUND
Ischemic Mitral Regurgitation
• IMR is caused by altered left ventricular geometry and function
• Chronic IMR is present in 10%-20% of pts with CAD
• Chronic IMR is associated with a markedly worse prognosis
after AMI
• IMR 2X more heart failure and mortality after AMI
• Chronic IMR has been called the “last frontier” in MV repair
surgery and one of the few therapeutic opportunities in heart
failure pts
Borger MA et al. Ann Thorac Surg. 2006;81(3):1153-61.
Beaudoin J et al. Circulation. 2013;128[suppl 1]:S248-52
BACKGROUND
Etiology - Heart Institute (InCor-HCFMUSP)
350
300
250
200
150
100
7.1%
50
0
Pomerantzeff PMA et al. Semin Thorac Cardiovasc Surg 2002;4: 324-7.
Cardiac or Cerebrovascular Event (%)
Death (%)
Smith PK et al. N Engl J Med 2014;371:2178-88.
Survival curves over 15 years of follow-up
• Valve repair seems to restore these patients to an adjusted
survival that is similar to standard CABG.
• Mitral valve replacement achieved an average 14% lower riskadjusted survival over 15 years, as compared to valve repair
Death (%)
Composite Cardiac End Point (%)
Acker MA et al. N Engl J Med 2014;370:23-32.