Disclosure David H. Adams, MD - American...
Transcript of Disclosure David H. Adams, MD - American...
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Inventor with Royalty Agreements with Edwards
Lifesciences and Medtronic:
Physio II Mitral Annuloplasty Ring
IMR ETlogix Mitral Annuloplasty Ring
TriAd Tricuspid Annuloplasty Ring
National Co-PI: Core Valve-Medtronic US Pivotal Trial
Disclosure
David H. Adams, MD
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David H. Adams, MD Marie-Josée & Henry R. Kravis
Professor & Chairman
Department of Cardiothoracic Surgery
The Mount Sinai Medical Center
New York, NY
Mitral Valve Repair: Which Technique
is Best for Which Lesion
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Annulus, Leaflets, Commissures, Chordae,
Papillary Muscles and the left Ventricle
Structures Involved in Mitral Function
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Adams et al In Hurst’s the Heart 2011;Vol 2:1721-37
Structures Involved in Mitral Function
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The Pathophysiological Triad
Carpentier et al. J Thorac Cardiovasc Surg 1983;86
Etiology
Lesions
Dysfunction
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Mitral Repair Surgical Strategy
Etiology
Lesions
Repair
Strategy
Anyanwu AC and Adams DH ; J Thorac Cardiovasc Surg 2008;36
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Mitral Valve Repair
Optimize Valve
Exposure
Surgical Tips
Place Annuloplasty
Sutures First
Valve / Lesion
Analysis
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Optimize Valve Exposure
• Develop Sondergaard’s Groove
• Curvilinear Left Atrial Incision
• Specialized Mitral Retractor
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Mitral Valve Repair
Optimize Valve
Exposure
Surgical Tips
Place Annuloplasty
Sutures First
Valve / Lesion
Analysis
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Valve and Lesion Analysis
• Assess All Structural Components
• Identify All Lesions (consider MR jets)
• Plan Surgical Strategy
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Mitral Valve Repair
Optimize Valve
Exposure
Surgical Tips
Place Annuloplasty
Sutures First
Valve / Lesion
Analysis
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Place Annuloplasty Sutures First
• Backhand on the Horizontal
• Forehand on the Vertical
• Interlocking Sutures are Fine
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Mitral Valve Repair
Consider Leaflet
Indentations
Surgical Tips
Magic Suture to Correct
Commissural Lesions
Neochord Adjustment
after Ring
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Consider Leaflet Clefts
• Distinguish Clefts and Indentations
• Close Clefts to Create Single Segments
• Target Clefts in Leaflet Resections
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Mitral Valve Repair
Consider Leaflet
Indentations
Surgical Tips
Magic Suture to Correct
Commissural Lesions
Neochord Adjustment
after Ring
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Magic Suture at Commissure
• Advances the Commissure and Coaptation
• Corrects Commissural Prolapse
• Corrects Commissural Restriction
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Mitral Valve Repair
Consider Leaflet
Indentations
Surgical Tips
Magic Suture to Correct
Commissural Lesions
Neochord Adjustment
after Ring
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Neochord Adjustment after Ring
• Allows Discrimination of Prolapsing Segments
• “Functional” Assessment of Chordal Height
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Adams et al In Hurst’s the Heart 2011;Vol 2:1721-37
Carpentier’s Functional Classification
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Assessment of Leaflet Integrity and Annular Dilatation
Leaflet Perforation Annular Dilatation
Surgical Strategy - Type I
Patch Augmentation Annuloplasty
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Patch Augmentation
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Assessment of Leaflet Integrity and Annular Dilatation
Leaflet Perforation Annular Dilatation
Surgical Strategy - Type I
Patch Augmentation Annuloplasty
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Annuloplasty
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Type II - Prolapse
Adams et al. Eur Heart J 2010;31:1958-1967
+ ++ +++ ++++
FED FED+ Forme Fruste Barlow’s
Leaflet Tissue
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Minimal Leaflet Tissue
Chordal
Transfer
PTFE
Neochordoplasty
Triangular
Resection
Surgical Strategy - Type II
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Chordal Transfer
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Minimal Leaflet Tissue
Chordal
Transfer
PTFE
Neochordoplasty
Triangular
Resection
Surgical Strategy - Type II
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PTFE Neochordoplasty
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Minimal Leaflet Tissue
Chordal
Transfer
PTFE
Neochordoplasty
Triangular
Resection
Surgical Strategy - Type II
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Triangular Resection
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FED – Bileaflet Prolapse
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FED – Bileaflet Prolapse
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Minimal Leaflet Tissue: Annular Plication
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Excess Leaflet Tissue
Targeted
Resection(s)
Leaflet Sliding
Plasty
Leaflet
Displacement
Surgical Strategy - Type II
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Leaflet Displacement
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Excess Leaflet Tissue
Targeted
Resection(s)
Leaflet Sliding
Plasty
Leaflet
Displacement
Surgical Strategy - Type II
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Targeted Resection
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Excess Leaflet Tissue
Leaflet
Displacement
Leaflet Sliding
Plasty
Targeted
Resection(s)
Surgical Strategy - Type II
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Leaflet Sliding Plasty
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Barlow’s Disease – Bileaflet Prolapse
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Barlow’s Disease – Bileaflet Prolapse
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Assessment of Lesions and Tissue Availability
Surgical Strategy - Type IIIa
Commissural Fusion Leaflet Retraction Chordal Restriction
Glutaraldehyde Fixed
Pericardium Techniques Commissurotomy
& “Magic Suture”
Chordal Fenestration
Chordal Replacement
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Commissurotomy
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Assessment of Lesions and Tissue Availability
Surgical Strategy - Type IIIa
Commissural Fusion Leaflet Retraction Chordal Restriction
Glutaraldehyde Fixed
Pericardium Techniques Commissurotomy
& “Magic Suture”
Chordal Fenestration
Chordal Replacement
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Leaflet Enlargement
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Assessment of Lesions and Tissue Availability
Surgical Strategy - Type IIIa
Commissural Fusion Leaflet Retraction Chordal Restriction
Glutaraldehyde Fixed
Pericardium Techniques Commissurotomy
& “Magic Suture”
Chordal Fenestration
Chordal Replacement
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Chordal Cutting and Fenestration
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Assessment of Leaflet Tethering
Surgical Strategy - Type IIIb
Less Severe More Severe
Downsized Rigid
Annuloplasty
+ Adjunctive
Techniques
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Downsized Annuloplasty
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Assessment of Leaflet Tethering
Surgical Strategy - Type IIIb
Less Severe More Severe
Downsized Rigid
Annuloplasty
+ Adjunctive
Techniques
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Chordal Cutting in IMR
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MAC with Adequate Leaflet Tissue
Surgical Strategy: MAC
Less Severe More Severe
Oversized
Annuloplasty
Unconventional
Annuloplasty
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Oversized Annuloplasty - Respect
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Oversized Annuloplasty - Respect
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Oversized Annuloplasty - Respect
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Oversized Annuloplasty - Respect
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Oversized Annuloplasty - Respect
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MAC with Adequate Leaflet Tissue
Surgical Strategy: MAC
Less Severe More Severe
Oversized
Annuloplasty
Unconventional
Annuloplasty
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Unconventional Annuloplasty
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Unconventional Annuloplasty
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Unconventional Annuloplasty
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Calcification with Inadequate
Leaflet Tissue
Targeted Debridement -
Patch Augmentation En bloc Resection -
Patch Augmentation
Surgical Strategy - MAC
Less Severe More Severe
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Targeted Debridement – Patch Augmentation
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Targeted Debridement – Patch Augmentation
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Targeted Debridement – Patch Augmentation
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Calcification with Inadequate
Leaflet Tissue
Targeted Debridement -
Patch Augmentation En bloc Resection -
Patch Augmentation
Surgical Strategy - MAC
Less Severe More Severe
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En bloc Debridement – Patch Augmentation
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En bloc Debridement – Patch Augmentation
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En bloc Debridement – Patch Augmentation
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Castillo et al. J Thorac Cardiovasc Surg 2012;144:308-12
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Castillo et al. J Thorac Cardiovasc Surg 2012;144:308-12
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Castillo et al. J Thorac Cardiovasc Surg 2012;144:308-12
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Castillo et al. J Thorac Cardiovasc Surg 2012;144:308-12
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Castillo et al. J Thorac Cardiovasc Surg 2012;144:308-12
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Castillo et al. J Thorac Cardiovasc Surg 2012;144:308-12
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Blending Strategies is the Key to
Successful Mitral Valve Repair