Gregory P. Fontana, M.D., FACC, FACS

National Medical Director for Cardiovascular Research And Innovation

Hospital Corporation of America

Medical Director for Cardiovascular Research

Sarah Cannon Research Institute

Director and Chairman

Cardiovascular Institute of Los Robles Hospital and Medical Center

Functional Mitral Regurgitation Requires Botha Mitral and a Ventricular Solution

Func tio na l MR is a VENTRIC ULAR Dise a se !

In No nisc he m ic a nd isc he m ic c a rd io m yo p a th ie s, g e o m e tric p e rturb a tio ns in the

le ft ve ntric le (LV) re sult in d ysfunc tio n o f the Mitra l Va lve a nd se c o nd a ry

(func tio na l) m itra l re g urg ita tio n (FMR).

An inc re a se in the in te rp a p illa ry d ista nc e , a nnula r d ila tio n, a nd e nha nc e d le a fle t

te the ring c o ntrib ute to se c o nd a ry MR.

THE VALVE ARC HITEC TURE IS NO RMAL

Surgery for FMR

Mitral Valve Replacement or Repair (annuloplasty)

56 years of experience

Whic h Ring is b e tte r (Be st)? ? Do e s size m a tte r, d o e s Sha p e ?

Surg ic a l The ra p y a nd Func tio na l Im p ro ve m e nt

C o sg ro ve 2000

Im p ro ve d NYHA fro m 2.8 to 1.2

Re d uc e d Re a d m issio ns fo r He a rt Fa ilure

Pa tie nts to le ra te d hig he r d o se s o f Me d ic a l The ra p y

Ba d w a r a nd Bo lling 2002

4+ MR a nd Lo w EF (m e a n 14%)

NYHA 3.9 to 2.0

Ro m a no a nd Bo lling 2004

O ve r 200 p a tie nts

Im p ro ve d NYHA C la ss fro m 3.2 to 1.8

De Bo nis, Alfie ri 2005

Im p ro ve d NYHA 3.4 to 1.4

Ac ke r (Ac o rn Tria l) 2006

Be tte r Func tio na l C la ss, MLHF, Sho rt-fo rm 36, 6 m inu te w a lk

Date of download: 2/10/2016 Copyright © The American College of Cardiology. All rights reserved.

What is the Impact of mitral valve annuloplasty on mortality risk in patientswith mitral regurgitation and left ventricular systolic dysfunction?

Wu, Bolling, et al, J Am Coll Cardiol. 2005;45(3):381-387. doi:10.1016/j.jacc.2004.09.073

Event-free survival for non-mitral-valve annuloplasty (MVA) group (solid line)and MVA group (dotted line).

Lack of Survival Benefit!

N=419

Date of download: 2/10/2016 Copyright © The American College of Cardiology. All rights reserved.

What is the impact of mitral valve annuloplasty on mortality risk in patients withmitral regurgitation and left ventricular systolic dysfunction?

Wu, Bolling, et al, J Am Coll Cardiol. 2005;45(3):381-387. doi:10.1016/j.jacc.2004.09.073

Event-free survival for patients without coronary artery disease in non-mitral-valve

annuloplasty (MVA) group (solid line) and MVA group (dotted line).

Double-orifice technique: A simple solution for complex problems

Ottavio Alfieri, MD, Francesco Maisano, MD, Michele De Bonis, MD, Pier Luigi Stefano, MD, Lucia Torracca, MD, Michele Oppizzi, MD, Giovanni LaCanna, MD

The Journal of Thoracic and Cardiovascular SurgeryVolume 122, Issue 4, Pages 674-681 (October 2001)

Fre e d o m fro m re c urre nc e o f MR o f g ra d e 3 to 4+ in the e d g e -to -e d g e a nd in thering -o nly g ro up s.

Michele De Bonis et al. Circulation. 2005;112:I-402-I-408

Is the Mitra C lip d iffe re n t tha n the Alfie ri Stitc h?

Copyright © The American College of Cardiology. All rights reserved.

From: Randomized Comparison of Percutaneous Repair and Surgery for MitralRegurgitation: 5-Year Results of EVEREST II

J Am Coll Cardiol. 2015;66(25):2844-2854. doi:10.1016/j.jacc.2015.10.018

12

Original Article

Two-Year Outcomes of Surgical Treatment of SevereIschemic Mitral Regurgitation(MV Repair vs Replacement)

Daniel Goldstein, M.D., Alan J. Moskowitz, M.D., Annetine C. Gelijns, Ph.D., GoravAilawadi, M.D., Michael K. Parides, Ph.D., Louis P. Perrault, M.D., Judy W. Hung, M.D.,

Pierre Voisine, M.D., Francois Dagenais, M.D., A. Marc Gillinov, M.D., VinodThourani, M.D., Michael Argenziano, M.D., James S. Gammie, M.D., Michael Mack, M.D.,Philippe Demers, M.D., Pavan Atluri, M.D., Eric A. Rose, M.D., Karen O’Sullivan, M.P.H.,

Deborah L. Williams, B.S.N., M.P.H., Emilia Bagiella, Ph.D., Robert E. Michler, M.D.,Richard D. Weisel, M.D., Marissa A. Miller, D.V.M., Nancy L. Geller, Ph.D., Wendy C.

Taddei-Peters, Ph.D., Peter K. Smith, M.D., Ellen Moquete, R.N., Jessica R.Overbey, M.S., Irving L. Kron, M.D., Patrick T. O’Gara, M.D., Michael A. Acker, M.D., for

the CTSN

N Engl J MedVolume 374(4):344-353

January 28, 2016

Tim e -to -Eve nt C urve s fo r De a th .

Goldstein D et al. N Engl J Med 2016;374:344-353

Time-to-Event Curves for Major Adverse Cardiac or Cerebrovascular Events (MACCE).

Goldstein D et al. N Engl J Med 2016;374:344-353

Quality-of-Life Scores.

Goldstein D et al. N Engl J Med 2016;374:344-353

C um ula tive Fa ilure o f Mitra l-Va lve Re p a ir o r Re p la c e m e nt.

Goldstein D et al. N Engl J Med 2016;374:344-353

No ve l De vic e Stra te g ie s… .o u tsid e the b o xMitra l Brid g e TM C o nc e p t

Tra n sva lvu la r Brid g e in SL d im e n sio n with

c e n te re d in fra a n n u la r c u rva tu re

Dire c t n o n p la n a r re d u c tio n in SL

d ia m e te r

Pre se rve s th e le a fle t c u rva tu re

sh o rte n s th e p a p illa ry m u sc le to le a fle t

d ista n c e

Le a fle t Re stra in t b e lo w th e a n n u la r

p la n e

C u rre n t d e vic e is a d a p ta b le fo r

tra n sc a th e te r d e live ry via 16 Fr C a th e te r

Anchoring Pad

Silicon-nitinol

Bridge

Ho w a b o ut p MVR p lus LV Re d uc tio n o r Sta b iliza tio n?

Proven Survival Benefit Benefit

Ho w a b o ut p MVR a nd LV Assist?

Tho se Unfa m ilia r with Histo ry a re d o o m e d to Re p e a t it?

In FMR

Pathophysiology: Ventricular Disease

Surgical Mitral Valve Repair or Replacement improveQuality of life NOT Quantity of Life!!

Replacement better than repair!

(Except Coapsys Device)

Improved survival will require a ventricular solution!