State-of-the-Art SurgicalTechniques to Manage Mitral

Regurgitation

Francesco Maisano, MDSan Raffaele University Hospital

Milano - ITALY

Disclosures

• I disclose the following potential conflicts

– Edwards Lifesciences: consultant, royalties– Micardia: consultant, stock options– Valtech: Consultant– Nycomed: consultant– Medtronic: honoraria– St Jude: honoraria

MV repair is superior to MVR

• Better preservation of LV function• Avoidance of prosthesis related events• Reduced hospital mortality• Reduced morbidity and LOS• Improved long term survival

Thourani et al, Circulation 2003; 108:298-304Zaho et al, JTCVS 2007;1257-1263Shuhaiber J et al, EJCTS 2007; 31:267-275Perrier P et al, Circulation 1984;70:187Akins CW, et al. ATS 1994; 58:668-676

The wedding of the Virgin

Raffaello Sanzio, 1483 - 1520

MV repair: Art or Science?

Milano, Pinacoteca di Brera

Techniques to treat MRfactors involved in the choice

Mechanism of regurgitation functional classification

« Surgeons are not basically concerned with lesions. We care more about function. Therefore one may define the aim of a valve reconstuction as restoring normal leaflet function rather than normal valve anatomy »

A. Carpentier, the French Correction 1984

STRUCTURE AND FUNCTION

structure function

Ethiology

Ethiology

Posterior leaflet prolapse/flail

• Quadrangular resection

• Sliding plasty• Chordal replacement• Haircut technique• Folding plasty• Alfieri / E2E• ….

Quadrangular resection

Sliding plasty

Posterior leaflet chordal repair

• Minimally invasive• when P1 and P3 are

hypoplasic• to obtain wider

surface of coaptation

Chordae Replacement Versus Resection for Repair of Isolated Posterior Mitral Leaflet Prolapse: À Ègalité

Seeburger et al. Ann Thorac Surg 2009;87:1715–20)

Gillinov, JTCVS 2008

Neochordae

Advantages• Anatomical reconstruction• No resection needed

Disadvantages

• Difficult sizing

Adjustable chordae (Valtech Inc)

Anterior and Bileaflet disease

• Chordal replacement• Alfieri / E2E• Chordal transfer• Papillary muscle

repositioning• Triangular resection• …..

The edge-to-edge technique

• First case performed in 1991• Over 1500 published cases

accumulated worldwide• About 15 yrs follow-up• Technically simple and

reproducible• Versatile• Criticized by some surgeons

– Used only as a bailout

Surgical technique

Maisano F et al. EJCTS 1998

Special situations

• Calcified annulus• Endocarditis• Congenital• Rheumatic

Outcomes

• Hospital mortality for isolated first time elective MV repair is 2.5% (males) to 3.9% (females)

• Operative risk is higher in elderly pts, associated CABG, NYHA III-IV, low EF and reoperation

Hospital mortality and repair rate STS National Adult Cardiac Database

Savage EB, et al Ann Thorac Surg 2003;75:820–5

19911993

19951997

19990%

20%

40%

60%

80%

100%

Replacement Repair

Influence Of Hospital Volumeson Repair Prevalence and Risk

Gamie et al. Circulation. 2007;115:881-887

13.614 patients having elective isolated MR surgery between 2000 and 2003 in 575 US centers participating in the STS National Cardiac Database

• Older age is associated toHigher mortality

Higher morbidity

Longer LOS

• 2/3 of pts older than 70 years are denied surgery (Euroheart Survey)

Age and comorbidities

Mehta et al. Ann Thorac Surg 2002;74:1459-67

UNMET CLINICAL NEEDsurgery is often denied in the older patients

Isolated MR

(n=877)

Severe MR

(n=546)

No Severe MR

(n=331)

No Symptoms

(n=144)

Symptoms

(n=396)

No Intervention

(n=193) 49%

Intervention

(n=203) 51%

Mirabel et al, European Heart J 2007;28:1358-1365

2/3 of symptomatic MR patients >70 are

denied surgery

Prevalence of valve disease in the population: MR and AR are epidemic in the elderly

Nkomo et al , Lancet 2006

US population older than 75 years (forecast 2015)

Severe MR 1,419,419

Severe AR 342,944

Severe TR ?

Health Research International Report 2009

LONG-TERM SURVIVAL

Very Long Term Survival for >20 years in 162 pts with Organic MR

Braunberger, et al Circulation. 2001;104[suppl I]:I-8-I-11.

Years

Su

rviv

al (

%)

100

80

20

00 2 4 6 8 10

60

40

72%

EF 60%EF 50-60%

53%

P = 0.0001

EF < 50% 32%

Ejection Fraction

Enriquez-Sarano M et al. Circulation 1994; 90: 830 - 37

Preoperative LV Function Predicts Long Term Postoperative Survival

• If mitral repair is performed before the onset of severe symptoms (congestive heart failure, arrhythmias), life expectancy is restored

Preoperative Symptoms and Long Term Survival

David T et al, J Thorac Cardiovasc Surg 2003;125:1143-52

durability

Durability• Definition

• Freedom from reoperation• Recurrent MR

• Hemolysis

• Other valve disease

• Freedom from recurrent MR

• Methodology

• Single institutions vs Registry

• Visit vs phone calls

• Serial vs instant follow-up

• Internal vs Core lab review

A lesson from the interventional cardiologists….EVEREST trial

• the first clinical trial for treatment of patients with MR to report a prospective, systematic, and integrative approach to the analysis of MR severity at baseline and follow-up that included quantitative parameters.

• CORE LAB

Foster E, et al Am J Cardiol 2007;100:1577–1583

Durability: Freedom from Reoperation1072 patients with degenerative mitral regurgitation

operated upon at CCF between 1985 and 1997

Gillinov et alJ Thorac Cardiovasc Surg 1998;116:734-43

The Bad News….

Flameng W, et al. Circulation. 2003;107:1609-1613

Durability: Freedom from recurrent MR>2+

96%

71%

Linearized rate of recurrent MR>2+: 3.7%pt-year

Flameng W, et al. Circulation. 2003;107:1609-1613

Ethiology: controversial factor

Fornes et alCardiovascular Pathol 1999;8:81-92

Role of pathology on durability• Barlow’s disease may be

associated with shorter durability

Flameng W, et al JTCVS 2008;135:274-82

Durability: ALP vs PLP

Braunberger, et al Circulation. 2001;104[suppl I]:I-8-I-11.Gillinov et al J Thorac Cardiovasc Surg 1998;116:734-43

Techniques for ALP treatment

Chordal shortening Chordal replacement

Smedira NG, et al,J Thorac Cardiovasc Surg 1996;112:287-92)

The influence of surgical technique: ALP treated by E2E vs PLP treated by quadrang. resection

Freedom from reoperation MR grade at echo follow-up

De Bonis et al, J Thorac Cardiovasc Surg 2006;131:364-70

P=N.S.

Annuloplasty• Annuloplasty is routinely performed during MV repair• Annuloplasty reduces stresses on the suture and on the valve

structures and stabilizes annular diameter• Lack of annuloplasty is associated to accelerated failure in the

overall surgical population

- 647- 520 - 394- 267

- 140 - 134+ 113+ 240+ 367+ 493+ 620+ 747+873+100

0

SI (kPa)

Maisano F, et al Eur J Cardiothorac Surg. 1999;15:419-25Gillinov et al J Thorac Cardiovasc Surg 1998;116:734-43

Annuloplasty rings: one fits all?

Fedak, et al. Circulation. 2008;117:963-974

The ring’s rigid titanium design adheres to the classic approach, while the instrumentation redefines the standard.

AnnuloFlo® System

The solution for rheumatic disease

Reinforce the entire native annulus, or only the posterior portion. The choice is yours with the AnnuloFlex Annuloplasty Ring. The true flexibility of the ring means three-dimensional compliance that mirrors natural valve dynamics.

AnnuloFlex™ System

The solution for degenerative disesase

MEMO 3D, the physiologic ring

Mitral repair without annuloplasty Durability in selected patients

Chordal replacement Alfieri repair

Duebener LF, et al EJCTS 2000; 17:206-212Maisano F, et al Eurointervention 2006; 6:181-186

Annular-to leaflet mismatch predicts need for annuloplasty

mid esophageal

120°

mid esophageal

90°

mid esophageal

120°

Maisano F, et al Am J Cardiol 2007;99:1434–1439

SL AL

Coaptation

• Valve competence under variable loading conditions (Coaptation Reserve)

• Reduction of stress on the leaflets, subvalvar apparatus

• Excessive coaptation can be detrimental (SAM)

Assessing coaptation

On Pump

Micardia

Mitral Solutions

ValtechA

djus

tabl

e rin

gs

Off Pump

Valtech adjustable ring

35mm24mm

25mm18 mm

adjustment

Functional mitral regurgitation

• Valve structure is preserved

• Left ventricular function and shape is impaired– Dilated Idiopathic

cardiomyopathy– Ischemic cardiomiopathy– IMR with preserved global LV

function

Mechanism of IMR - Tethering

1. Apical and lateral displacement of the papillary muscles

2. Anterior leaflet Tethering

(Seagull effect)

2. Lowering of the point of coaptation (coaptation depth)

Undersized annuloplasty is the “conventional” method to treat FMR

Coaptation

lenght

Durability using conventional non “disease-specific” rings

25-30% late

recurrence rate

Hung et al. Circulation 2004.

New techniques to improve results• Dedicated rings

– Preshaped• Edwards Ethilogix

– Adjustable• CardiacSolutions• Micardia

• Subvalvar remodeling– Chordal cutting– Papillary muscle cinching

• External devices– Coapsys– Others

GEOFORM, IMR

• Reduction of the SL dimension

• Shortening of the papillary muscle to annulus distance

• Increasing coaptation surface

Physio30 Geoform30

PostPRE

A. Wu, et. Al. JACC 2005, 45 p. 381-387

Survival after undersized MVA

Surgical vs Medical Rx in DCM-MR

CABG alone vs CABG+MVA in IMR

Mihalijevic T et al. J Am Coll Cardiol 2007;49:2191–201

• Comorbidities and operative risk

• Recurrent MR and MS• Lack of reverse

remodeling

• Less invasive therapy• Tailored approach and off

pump adjustments • Early treatment

Reverse remodeling

50/50 chance

Beeri et al. J Am Coll Cardiol 2008;51:476–86De Bonis, et al . Ann Thorac Surg 2008;85:932–9

Duration of CHF is the main factor

De Bonis, et al . Ann Thorac Surg 2008;85:932–9

FMR: Early treatment the key ?

• Experimental model of induced myocardial infarction plus controlled ventriculoarterial shunt simulating MR overload– Induction of MI– Group 1: no MR treatment– Group 2: MR abolished

Beeri R et al. Circulation 2007;116[suppl I]:I-288–I-293.

Early treatment of volume overload is associated with reverse remodeling

Reverse remodeling in MI only, MI +MR and MR repair

Matrix metalloproteinase-2 and MMP inhibitors in MI only, MI +MR and MR repair

conclusions• Mitral repair is a surgical success story

Low operative risk Recovery of life expectancy Low rate of recurrence when appropriate

procedures are performed Minimally invasive techniques are

increasingly performed

• Transcatheter techniques will face the challenge of comparison with these excellent results– Increase the potential candidates for

treatment– Reduce early risk in selected patients– Enable earlier intervention