Can mitral repair still be simplified ?

Pr Fabien DOGUET

Department of Cardiovascular and Thoracic SurgeryCHU Charles Nicolle, Rouen University Hospital

Rouen, France

Disclosure Statement of Financial Interest

I currently have, or have had over the last two years, an affiliation or financial interests or interests of any order with a company or I receive compensation or fees or research grants with a commercial company :

Speaker's name: Fabien, Doguet, Rouen

☑ I have the following potential conflicts of interest to report:

Consultant: Edwards, LivaNova, Abott

Why should we simplify mitral repair ?

The first step to standardize mitral repair

Techniques pioneered by Carpentier

• Quadrangular resection with annular plication

• Transfer of native chordae

• Papillary muscle shortening or plasty

Transposition chordae

But some techniques are not easy to use in minimal invasive surgery

Evolving techniques to treat leaflet prolaps

« Respect rather than resect »

Perier’s technique with the use of artificialneochordae

Emerging techniques

• Minimally-invasive techniques in MV repair: mini-thoracotomy video-assisted/robotic

• Perfect view on papillary muscle and leaflet prolaps

• Easier to use artificial chordae

• Difficulty to adjust length and securely fixing the chordae

What are the challenges using neochordae?

• How to determine the exact length of artificial chordae?

• How easily and securely fixing the chordae?

• How can we obtain a satisfactory long term result?

Remaining problems with AC: optimal length of chordae

• Too short: neochordae exert high tension on the valve

leaflet and papillary muscle (rupture, impair proper leaflet

motion)

• Too long: fail to repair the prolaps and increase the risk of

SAM

But it is not always easy to define the good length of artificialchordae…

… for the posterior leaflet

… for the anterior leaflet

3 simple techniques

to adjust the good lenght of AC

Techniques for the repair of posterior or both mitral leaflets

AATS Mitral Conclave 2013 Courtesy of Dr G Touati

« The Braids »

- Preoperative mesure with TEE

- 2*4/0 Gore Tex

- Length fixed with knots

Stages of Gortex custom-made standardized anterior and posteriormitral loops. (A) 15-mm self-made loop for the posterior valve.(B) 25-mm self-made loop for the anterior valve. (C) First stage of the 15-mm self-made loop. (D) First stage of the 25-mm self-made loop. (E) Several loops can be made with one Gortex suture as 15-mm loopsalone, 15/25-mm loops, or 25-mm loops according to the lesions of the mitral valve.

Preoperative planification

TOE (ex):

Large P2 prolaps

Small P2 prolaps (FED)

A2 Prolaps

2*15mm PTFE loops

1*15mm PTFE loop

2*25mm PTFE loops

During cardioplegia

Robotic cases

• Treat leaflet prolaps

• Anterior and/or posterior leaflet prolaps

• Only one technique to adjust the good length of artificial

chordae

• The aim is to adjust the length to the annulus plan

• Fixe the chordae easily and securely

• Real interest in MICS

Memo3D ReChordHow does it work ?

Memo3D ReChordhow does it work?

Anterior leaflet prolaps Posterior leaflet prolaps

The most complex case…but with the simplest treatment !

Simple repair approach for mitral regurgitation in Barlow disease

Simple repair approach for mitral regurgitation in Bar low disease

Sagit Ben Zekry, MD,a,c Dan Spiegelstein, MD,b,c Leonid Sternik, MD,b,c Innon Lev, MD,b,c

Alexander Kogan, MD,b,c Rafael Kuperstein, MD,a,c and Ehud Raanani, MDb,c

ABSTRACT

Objective: Mitral valve repair for myxomatous Barlow disease is a challenging

procedure requiring complex surgery with less than optimal results. The use of

ring-only repair has been previously reported but never analyzed or followed-

up. Weinvestigated thissimplevalverepair approach for patientswith Barlow dis-

ease and multisegment involvement causing mainly central jet.

Methods: Of 572 patients who underwent mitral valve repair for mitral regurgi-

tation at our medical center, 24 with Barlow disease (aged 47 14 years; 46%

male) underwent ring-only repair. Patients were characterized by severely

enlarged mitral valve annulus, multisegment prolapse involving both leaflets,

and demonstrated mainly a central wide regurgitant jet. Surgical technique

included only the implantation of a large mitral annuloplasty ring. Early and

lateoutcome resultswerecompared with thoseof the remaining patientswho un-

derwent conventional mitral valve repair for degenerative disease (controls).

Results: All ring-only patients presented with moderate-severe/severe mitral

regurgitation (vena contracta, 0.6 0.1 cm; regurgitation volume,

52 17 mL), with mainly a central jet and almost preserved ejection fraction

(59% 6%). Cardiopulmonary bypass and crossclamp times were significantly

shorter compared with controls (P < .0001). At follow-up (ring-only,

38 36 months and controls, 36 29 months), there were no late deaths in

the ring-only group compared with 19 (4%) in the controls. Late follow-up re-

vealed New York Heart Association functional class I or II in 95% of ring-only

patients, compared with 90% of controls. Freedom from recurrent moderate or

severe mitral regurgitation was 100% and 89% in the ring-only and control

groups, respectively.

Conclusions: Mitral annuloplasty for Barlow disease patientswith multisegment

involvement and mainly central regurgitant jet is both simple and reproducible

with excellent late outcomes. (J Thorac Cardiovasc Surg 2015;150:1071-7)

Transesophageal echocardiography. A-D, Before

valve repair. Eand F, After valve repair.

Central Message

A simple valve repair technique limited to

mitral annuloplasty for patients with Barlow

disease and multisegment involvement.

Perspective Statement

Mitral valve repair for myxomatous Barlow

disease is a challenging procedure. We present

a simple valve repair technique limited to

mitral annuloplasty. Thistechniquewasapplied

on 24 patients with Barlow disease and multi-

segment involvement causing mainly central

jet. Thetechniquewasfound to bereproducible

with excellent late outcomes.

See Editorial Commentary page 1078.

Supplemental material is available online.

Degenerativemitral regurgitation (MR) isthemost frequent

etiology for severe MR, accounting for most mitral valve

(MV) repair surgery. Based on surgical technique advance-

ment and improved surgical outcomes, the American

College of Cardiology/American Heart Association guide-

lines for valvular heart disease recommend MV repair

rather than replacement, specifying a class IIa indication

for high probabil ity of repair.1 Barlow disease, which ac-

counts for up to 30% of patients who undergo MV repair

surgery,2 is actually a spectrum of phenotypes with its

extreme form manifesting typically in young patients. It is

characterized by massiveannular dilation, excessthickened

leaflet tissue, with amultisegment prolapse, aswell aselon-

gated and weak chordae that may often cause flail leaflet.2

Repairing this complex form of Barlow pathology is

From the aNon-Invasive Cardiology Unit and bCardiac Surgery Department, Leviev

Heart Center, Sheba Medical Center, Tel Hashomer, Israel; and cSackler School

of Medicine, Tel Aviv University, Tel Aviv, Israel.

S.B.Z. and D.S. contributed equally to this work.

Received for publication May 30, 2015; revisionsreceivedJuly 27, 2015; accepted for

publication Aug 9, 2015; available ahead of print Sept 15, 2015.

Address for reprints: Ehud Raanani , MD, Cardiac Surgery Department, Leviev Heart

Institute, Sheba Medical Center, Tel Hashomer, Israel 52621 (E-mail : Ehud.

Raanani@sheba.health.gov.il).

0022-5223/$36.00

Copyright Ó 2015 by The American Association for Thoracic Surgery

http://dx.doi.org/10.1016/j.jtcvs.2015.08.023

The Journal of Thoracic and Cardiovascular Surgery c Volume 150, Number 5 1071

ACQUIRED CARDIOVASCULAR DISEASE: MITRAL VALVE

AC

D

Figure 3

Schematic presentation of the mitral ring-only repair. Myxomatous disease is characterized by an enlarged annulus and excess leaflet tissue that has prolapsed (upper row). A triangle with an enlarged base can be draw between the mitral annulus and left ventricle apex (lower row). Placement of a ring and reducing annular size reduces the triangular base and thus mitral leaflets are pushed down toward the left ventricle to coapt at the left ventricle level. Note that leaflet dynamicity is preserved at the left ventricle level.

Symmetrical bileaflet prolaps

No chordal rupture

Significant annular dilatation

Wide central regurgitation jet

In conclusion

New simple techniques of mitral repair are required:

- To obtain 100% of mitral repair when repair is feasible

- With the development of minimal invasive mitral surgery

With the respect of principles of mitral repair:

- To restore a good surface of coaptation

- To correct abnormal valve motion

- To reshape and stabilize the mitral annulus