When is less more minimally invasive surgery in low ef
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Transcript of When is less more minimally invasive surgery in low ef
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When Is Less More?
Minimally Invasive Surgery in Low EF
Michael Mack, M.D.
Baylor Scott& White Health
Dallas, TX
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Conflict of Interest Disclosure
• Member of Executive Committee of the
PARTNER Trial of Edwards Lifesciences
• Co-PI of the COAPT Trial of Abbott Vascular
• Travel expenses paid by sponsors for trial
Steering Committee meetings
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I am Presuming…
• Secondary MR and not primary MR
3
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Options to Treat Secondary MR
GDMT
Resynchronization
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How are Patients with Isolated FMR Treated? Duke Databank: 1,538 pts with echocardiographic 3+ - 4+ FMR
and LVEF ≥20% between 2000 and 2010 not undergoing CABG
11.4% 5.9% 8.4% 11.8% 18.4%
0%
25%
50%
75%
100%
All pts 20%-30% 30%-40% 40%-50% 50%-60%
Conservative management Isolated MV surgery
LVEF
N=1538 N=440 N=298 N=313 N=479
8 other pts had LVEF >60%; none underwent MV surgery c/o Mitch Krucoff
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Chronic Severe Secondary Mitral
Regurgitation: Intervention
Recommendations COR LOE
MV surgery is reasonable for patients with chronic
severe secondary MR (stages C and D) who are
undergoing CABG or AVR
IIa C
MV surgery may be considered for severely
symptomatic patients (NYHA class III-IV) with
chronic severe secondary MR (stage D)
IIb B
MV repair may be considered for patients with
chronic moderate secondary MR (stage B) who are
undergoing other cardiac surgery
IIb C
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When Would You Consider MI Surgery
in Low EF?
•Redo
–Hostile reentry
–Grafts in jeopardy
•Elderly
•Frailty
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When Would You NOT Consider MI
Surgery in Low EF?
• Patient needs SURGICAL revascularization
• Concerns about myocardial protection
• Ascending aorta > 4 cm
• Right chest adhesions
• Elevated right hemi-diaphragm
• Extreme morbid obesity
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How to treat this 69-year old male ?
• Mitral regurgitation III-IV, EF 35 %, AFib, NYHA class III-IV
• Medical history:
– s/p anterior myocardial infarction 1988 – s/p posterior myocardial infarction in 1991 – 2-CABG 1993 – biventricular ICD 2005
• Concomitant diseases: – COPD – renal insufficiency III° – hyperlipidaemia – arterial hypertension
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EF 29 %, LVEDD: 61 mm
MV: annulus 47 mm
restrictive AML, MI III°, Type IIIB
LA: 47 mm
Echocardiography
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Secondary MR
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1. Lateral position of the right chest around
30°
2. Abduction of the right arm
3. Bend the region of the groin back slightly
Mini MV repair
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Right anterolateral
minimally invasive incision
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Minimally invasive
Mitral Valve Surgery
Left atrial retractor Cannulation
femoral artery and vein
Chitwood clamp
Camera Atrial vent
Cardioplegia/ Aortic Vent
Soft tissue retractor
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Secondary MR- Fibrillating Heart
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Secondary MR- Fibrillating Heart
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Secondary MR- Fibrillating Heart
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Postoperative result
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Postoperative echo result
No residual MI
Orifice area: 3.3 cm2
Mean gradient: 2 mmHg
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sternotomy156924%
MIS488776%
Mitral valve surgery, isolated and combined with tricuspid valve procedures
1996 - 2013sternotomy vs. MIS
Mitral valve surgery, isolated and combined with tricuspid valve
procedures – sternotomy vs. MIS
at Heart Centre Leipzig (1996-2013) n = 6456
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Isolated MV repair in cardiomyopathy
(EF<35%) baseline characteristics
N 161
ICM/DCM 70.1 vs. 29.9 %
Age 61 ± 10 y
EF 25 ± 8 %
LVEDD 69 ± 11 mm
MI ≥ III° 93.2 %
NYHA ≥ III° 97.5 %
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preoperative early postop long term evaluation 0
1
2
3
4 mitral regurgitation
p < 0.001
Isolated MV repair in cardiomyopathy (EF<35%)
echocardiographic MV function
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NY
HA
- M
edia
n P < 0.001
0
0,5
1
1,5
2
2,5
3
3,5
preoperative early postop long term evaluation
Isolated MV repair in cardiomyopathy
(EF<35%) NYHA class
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MV repair
MV replacement
years after operation
su
rviv
al
Isolated MV surgery in cardiomyopathy (EF<35%)
Survival MV repair vs. replacement a
ctu
arial surv
ival (%
)
follow-up (y)
Log rank p=0.032
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DCM
ICM
years after operation
actu
arial surv
ival (%
)
follow-up (y)
Isolated MV surgery in cardiomyopathy (EF<35%)
Survival related to MVR etiology
Log rank p=0.132
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0 12 24 36 48 60 72
Postoperative months
0
20
40
60
80
100
NYHA class
Inotr. IV III < III
Survival (%)
Isolated MV surgery in cardiomyopathy (EF<35%)
Survival related to baseline NYHA class
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When Should We Be Performing MV
Replacement for IMR?
• Ruptured papillary muscle (acute IMR)
• Patients in cardiogenic shock
• Severe apical tenting (>11mm)
• During second CPB run
• Complex MR leaks?
• Surgeons who do not do many repairs?
Valve of choice – bioprosthesis
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Critical Appraisal / Conclusion
Residual MR up to 30% following
surgical MV repair poor survival
New developments are not superior to MV
surgery
FMR is and will remain a ventricular
disease!