Surgical Treatment of Ischemic Mitral Regurgitation

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• “ Most often the entire valve appears normal;… There is little to fix, yet the valve leaks… the valve is structurally normal; it need not be replaced, but currently we do not know how to fix it…”

• - L. Henry Edmunds Jr. 1997 (Cardiac Surgery in the Adult)

Ischemic Mitral Regurgitation(IMR)

• Life-threatening ; ventricular ds, not valvular

• Limits functional capability & life expectancy - if CHF (+), 52% 1 yr mortality with medication

• Suboptimal long-term results (50% in 5 YSR)

• Tremendous consumption of health care sources

- D. Craig Miller, JTCS ‘01

Lamas et al., Circulation, 1997.

P=0.0022

No MR (n=586)

MR (n=141)

Significance of IMR after AMI (SAVE trial -substudy)

CADILLAC trial (PCI, 2000 pts), JACC 2004,

IMR after PCI

for acute MI

Subdivision of IMR

• Ruptured PM

• Infarcted PM w/o rupture

• Functional regurgitation

- normal PM, chordae, & leaflets

but, fail to coapt (type I & IIIb)

Definition of Functional IMR

• MR caused by CAD

• Previous MI >30 days before CABG

• r/o rheumatic, infectious, or degenerative (myxomatous) mitral disease

• r/o PM rupture or elongation

• Lam, Guillinov, et al, CCF, ATS ’05

Definition of FIMR (2)

• Normal-appearing valve leaflets, chordae, & PMs• MR caused MI

- at least one previous MI from :

1) review of clinical information,

2) echo,

3) direct surgical inspection

Gillinov et al., CCF, ATS ‘05

Definition of Moderate IMR

• Significant sx (+) multivessel CAD, w/ or w/o documented prior MI

• Gr 3+ MR ( 0 ~ 4+) - documented on preop echo or VG while not actively ischemic - regurgitant jet to LA w/o reversal or blunting of PV flow - no MS• Type I or IIIb

• Aklog et al., Harvard Medical School, Circ ‘01

Causes of FIMR

• Annular dilatation (type I)

• Leaflet tethering (type IIIb)

• both

Coronary Revasc. & IMR

Background

• Mitral Insufficiency and CABG– DilemmaDilemma

– Mortality and morbidityMortality and morbidity– Neglected Neglected long-term mortalitylong-term mortality– Lack of consensus on… Lack of consensus on…

““When to operate?”When to operate?”

Coronary Revasc. & IMR

Gold Standard

– Ischemic MR grade 3-4

– Carpentier type IIIb dysfunction

– Reduction annuloplasty

Coronary Revasc. & IMR

Moderate Ischemic MR (2+)

– No gold standard

– Remodeling annuloplasty optional• ProsPros• ConsCons

CABG alone (1)

Revascularization alone suffices with advanced ischemic cardiomyopathy & mild-to-mod IMR

“Revascularization alone suffices in patients with advancehy and mild-to-moderatTolis GA, Yale Univ (ATS 2002)

Clinical + echographic outcomeClinical + echographic outcome

- - 49 patients 49 patients

- 1-3+ MR- 1-3+ MR- LVEF < 30%- LVEF < 30%

- MR 1+: 18 - MR 1+: 18 (38%)(38%) pts pts 2+: 26 2+: 26 (52%)(52%) pts pts 3+: 5 (10%) pts3+: 5 (10%) pts

Op. mort.:Op. mort.: 2%2%LVEF: LVEF: 31% (22%)31% (22%)MR: MR: 1.73 1.73 0.54 (p<0.05) 0.54 (p<0.05)Survival:Survival: 50% (5 years)50% (5 years)

Conclusion:Conclusion:- - Advanced ischemic cardiomypathyAdvanced ischemic cardiomypathy-- Mild to moderate MR Mild to moderate MR- - Isolated CABGIsolated CABG- Reasonable option- Reasonable option

CABG alone (2)

““The importance of gr. 2+ IMR in CABG””

Ryden T (Eur J Cardiothorac 2001)

Grade 2+ IMR- - Case-control study - MR vs. no MR (n=89)- Matched: Age, gender, LVEF

MR patients:MR patients:

- Older (68 vs. 65yrs)- Older (68 vs. 65yrs)- Lower LVEF ( 42 vs. 58%)- Lower LVEF ( 42 vs. 58%)

Kaplan-Meier: Kaplan-Meier: MR vs. noneMR vs. none

- - 30 days mort.: 30 days mort.: 4.5% vs. 4.5%4.5% vs. 4.5%

- - 1 year surviv.: 1 year surviv.: 91 vs. 93%91 vs. 93%

- - 3 year surviv.: 3 year surviv.: 84 vs. 88%84 vs. 88%

NYHA: similar improvementNYHA: similar improvementMR pts:MR pts: - - 62% reduced MR62% reduced MR

- 36% unchanged- 36% unchanged- 2% inccreased- 2% inccreased

Conclusion:Conclusion:- - Similar morbiditySimilar morbidity

- Similar survival- Similar survival- MR reduced or unchanged- MR reduced or unchanged- Support conservative treatment- Support conservative treatment

CABG alone (3)

“ MV repair vs. revascularization alone in the treatment of IMR “

- Whether adjunctive MV repair with CABG

is beneficial ?

Kang DH, Asan Medical Center, Circ ’06

107 pts with mod or severe IMR

-50 (with repair) vs 57 CABG only - higher Af & severe MR in repair gp

repair only CABG Op. mort.: 12 % 2 %5 YSR : 88 % 87 %Improving MR : all 67 % in severe MR

75 % 67 % in mod. MR

Conclusion:- CABG alone may be preferable option in moderate IMR & high risk factors such as old age or Af

with MV repair (1)

““Does CABG alone correct moderate IMR?”

Aklog L, Brigham & women’s hospital (Circ ‘01)

Optimal Tx of moderate Optimal Tx of moderate 3+ MR3+ MR- 136 patients - 136 patients - 70 years- 70 years- NYHA: 2.7- NYHA: 2.7- LVEF: 38% - LVEF: 38%

Op. mort.:Op. mort.: 2.9% 2.9%Residual MR: Residual MR: 40% 40% 3+4+ 3+4+

51% 51% 2+ 2+ 9% 9% 0+ 0+

Conclusion:Conclusion:- - WithWith CABG alone CABG alone

- Significant residual MR- Significant residual MR

- - Not optimalNot optimal

with MV repair (2)

Patient Survival characteristics after

routine MV repair for IMR

- whether IMR remains an independent predictor of outcome after valve repair

Donald D. Glower, Duke Univ Medical center (JTCS ‘05),

535 pts undergoing MV repair ( primarily rigid ring annuloplasty)

- 1993 to 2002 - IMR 141 pts vs. non-ischemic 394 pts

IMR pts had ; - - older age, higher comorbidity, lower EF, higher NYHA & reop rate (all p<0.001) - higher 30-day mortality (4.3% vs 1.3%, p=.01)

- higher unadjusted 5-yr mortality (44% vs. 16%)

In multivariable models ; - only No. of preop. comorbidities &advanced age were independent factors of survival (p < 0.0001)

Conclusion- with routine application of rigid ring annuloplasty,

long-term survival is more influenced by

baseline pt characteristics & comorbidity than

by ischemic cause of MR per se.

OPCAB and IMR

What should we do? – Moderate-severe ischemic MR and

CAD should be fixed– Moderate ischemic MR is still a

difficult problem to treat

Conventional CABG and IMR

Conventional CPB Surgery

• If MR is not fixed– Not necessarily problematic– IABP and inotrops may be neededIABP and inotrops may be needed– The patient could get by… on short-termThe patient could get by… on short-term

““What about OPCAB?”What about OPCAB?”

OPCAB and IMR

OPCAB surgery

• If ischemic MR ignored– Could be problematic– Manipulation and ischemia exacerbates MR– Cause severe hemodynamic instability– Conversion to CPB needed

OPCAB and IMR

““ Perioperative and long-term outcomes

after isolated OPCAB with

mild to moderate IMR ””

Cartier R, Montreal Heart Institute

- - 67 pts (6.7%) with mild or moderate IMR among 1000 consecutive OPCAB

- To evaluate the perioperative and

long-term outcomes (survival & MACE-free)

OPCAB pts with mild-to-moderate IMR

–Had prevalence of preoperative risk factors

–Comparable perioperative mortality and morbidity

long-term survival compare to no-IMR pts

OPCAB pts with mild-to-moderate IMR

–IMR itself was not found a significant risk for

the long-term mortality

Repair vs. MVR for IMR

• Guillinov AM et al, CCF, JTCS ’01• IMR ; n=482 (’85~’97, 397 repair vs. 85 MVR)• Functional IMR in 65 %• Central MR jet (type I) in 58%• Complex jet (type IIIb) in 15%• Repair pts very different from MVR

(NYHA I-II, FIMR, ITA graft, non-emergent)

Repair vs. MVR for IMR

• Operative 30 day mortality - 13%• Risk fc for death :

older age, higher NYHA, LV dysfunction,

renal dysfunction, Af, and MVR• Mortality risk fc after repair :

complex MR jet, lateral LV dysfunction,

pericardial annuloplasty (no ring),

no ITA graft

Repair vs. MVR for IMR

• Medium-term survival is still poor

• Most pts benefit from repair

• But, survival similar btw repair & MVR

in the sickest pts

• Durability of repair ; 91% at 5 yrs

MGH thrust #1 -

“ Guerrero procedure”

• Design of a New Surgical approach for ventricular remodeling to relieve IMR : insight from 3-D echo

Guerrero JL et al, MGH, Circ 2000

MGH thrust #2 -

2o chordae cutting to AMVL

• Chordal cutting :

A New therapeutic approach for IMR

Messas, Gerrero, MGH, Circ 2001

MGH thrust #3 -

External balloon-inflated patch “reverse remodeling”

• Reverse ventricular remodeling reduces IMR : echo-guided device application in the beating heart

Hung J, Guerrero, et al, MGH, Circ ‘02

Grossi, RESTOR-MV, ATS ‘05

Coapsys

Percutaneous approach to FIMR

• Leaflet (“edge-to-edge”) approach

• CS annuloplasty approach (cinch)

• Direct annular plication approach

- percutaneous septal sinus shortening (PS system)

13771377 년 청주 흥덕사에서 년 청주 흥덕사에서 금속활자로 찍음금속활자로 찍음

구텐베르트의 금속활자에구텐베르트의 금속활자에비해 비해 7070 여년이 앞섬여년이 앞섬

감사합니다 !

with MV repair (3)

Flexible vs. Non-flexible MV rings for CHF

- with ischemia & dilated cardiomyopathy

differential durability of repair

Steven F. Bolling, Univ of Michigan, (Circ ‘06)

289 CHF pts with EF < 30%

- 1992 to 2004 - undersized complete mitral rings - 170 flexible vs 119 non-flexible

Repeat procedure for recurrent MR

- Flexible ring ; 16 pts (9.4%) - Non-flexible ; 3 pts (2.5%, p = 0.012)

Average time to reoperation - Flexible ring ; 2,4 yrs - Non-flexible ; 4.0 yrs (p = 0.012)* No defference in age, ring size, EF, MR grade

Conclusion- Non-flexible ring annuloplasty

- reduce repeat procedure

than flexible complete ring

?

Is Mitral Annuloplasty durable?

“Late results of isolate mitral annuloplasty for functional ischemic mitral insufficiency”

Grossi EA, NYU, (J Card Surg 2001)

174 patients ischemic MR174 patients ischemic MR- - 1980 to 19991980 to 1999

- 87% CABG- 87% CABG

Op. mort.:Op. mort.: 17% 17%Residual MR: 0.84 Residual MR: 0.84 0.86 0.86

Long-Term Long-Term (5 years):(5 years):

- 7.7% reoperation MVR- 7.7% reoperation MVR

- 90% NYHA I-II- 90% NYHA I-II- 83% mild MR- 83% mild MR

ConclusionConclusion- - Ring annuloplastyRing annuloplasty

- Durable results- Durable results- Significant mortality- Significant mortality

Assessment & management of IMR in TEE

• Downgrading of MR d/t unloading effect of anesthesia (same as in intrinsic valve ds or LV dysfunction,

but not in flail leaflets)

• Provocative testing : - preload challenge ; PCWP 15~18 mmHg - afterload challenge (phenylephrine) ; mean AP > 100 mmHg - if positive, inspection & repair of MV

Byrne et al, Brigham & Women’s Hospital, The Lancet ’00

Surgical Treatment of Ischemic Mitral Regurgitation

충북대학교 의과대학

흉부외과 홍 종 면

감사합니다 !