Download Primary degenerative MR is a disease of the valve and

FMR: Surgical Approaches
Michael J. Reardon, M.D.
Professor of Cardiothoracic Surgery
Allison Family Distinguish Chair of Cardiovascular Research
Houston Methodist DeBakey Heart & Vascular Center
Michael J. Reardon, M.D.
I have no relevant financial relationships
Primary degenerative MR is a disease of the
valve and we strive to fix this before the
ventricle deteriorates
Secondary or functional MR is a disease of
the ventricle and it is already too late to
prevent deterioration
But in FMR we operate on the valve
There is substantial evidence that
correcting degenerative MR improves
QoL and extends survival
There is little evidence that correcting
FMR improves Qol or extends survival
Chronic severe secondary MR adds volume
overload to a decompensated left ventricle and
worsens prognosis. However, there is only sparse
data to indicate that correcting MR prolongs life
or even improves symptoms over an extended
time. The benefits of performing mitral valve
repair over MVR are also unclear in this subset of
patients. Percutaneous mitral valve repair
provides a less invasive alternative to surgery but
is not approved for clinical use in the United
States.
MV surgery is reasonable for patients
with chronic severe MR (stages C and
D) who are undergoing CABG or AVR.
MV surgery may be considered for
severely symptomatic patients (NYHA
class III/IV) with chronic severe
secondary
MV repair may be considered for
patients with chronic moderate
secondary MR (Stage B) who are
undergoing other cardiac surgery
IIa
C
IIb
B
IIa
C
FMR is very dynamic which can be
related to loading conditions,
ischemia or both
So what should we do for
FMR?
Our Goals
Improve symptoms and QoL
Reduce HF admissions
Improve survival
Therapy should be directed at the
underlying failing ventricle
GDMT
Resynchronization
Revascularization
MR correction
Other interventions
VAD
Transplant
MV repair or replacement
Percutaneous options
Higher up front mortality for MVR
More heart failure and
readmissions in repair group but;
For those that worked better LV
remodeling
How about moderate
FMR and CAB?
Operative Mortality
RCT
CAB+MV repair
CAB
Survival
CAB+MV repair
CAB
NYHA 2 or more
CAB+MV repair
CAB
There is neither increased operative
mortality or increased survival by
adding MV repair
Symptomatic relief is equivocal
The main benefit is reduced MR
Can we improve on our repairs?
Dimensions better with PMA but not better
survival and patients felt no better
We conclude that an adjunctive subvalvular repair
performed at the time of mitral annuloplasty for
secondary MR can be safely performed, improves
the durability of valve repair and enhances left
ventricular reverse remodeling.
Cardioband
Therapy for MR
Degenerative
Functional
Low Surgical
Risk
Surgical Mitral
Repair
Surgery ??
Repair??
Replace??
High Surgical
Risk
Commercial
MitraClip
Surgery??COAPT
??
TMVR??
CONCLUSIONS
Surgical options leave much to be desired
I believe it is unlikely that future surgical
techniques aimed at the valve itself will have
better success
Where will transcatheter approached fit in
this scheme?
Thank You