Overview of Surgical Approach to Mitral Valve Disease :

Why Repair ?

Steven F. Bolling, MD Cardiac Surgery

University of Michigan

Degenerative MR is not Functional MR

2o - Functional MR : Ventricular Problem!!

Badhwar, Bolling , chapter in: Advances in Heart Failure, 2004

Skin cancer

Pancreatic cancer

Treatment of MR ?

1o - Degenerative MR :

Everything but the Ventricle Problem!

Carpentier’s Reconstructive Valve Surgery;

Degenerative

MR

Mitral Valve Repair

Physiology

Which one is the mitral valve?

Structures of the Mitral Valve

Annulus

Leaflets

Commissures

Chordae

Papillary Muscle

Left Ventricle

Mitral - LV Power

Mitral Dynamics

Mitral Dynamics

Mitral Valve

Active Closure – not by pressure!

“Roman Arch”

Mitral Surgery – Operative Mortality

Mitral Valve = Left Ventricle

The LV = The MV

Mitral Repair

Mitral Valve Repair

ECHO

Mitral Anatomy Subaortic curtain

Aortic leaflets

AV node position

Coronary Sinus

Circumflex Artery

Preservation of “surrounding” anatomic integrity

essential for successful mitral repair

Mitral Valve Repair - LV

ACC/AHA 2014 – “Significant” MR

Mitral Valve Repair

Techniques

Degenerative Mitral Disease

FED FED+ Forme Fruste Barlow’s

Wide Disease Spectrum

Adams et al. Eur Heart J 2010;31:1958-1967

Fibroelastic Deficiency

Fibroelastic Deficiency

Fibroelastic Deficiency

Fibroelastic Deficiency

FED – Preserve Tissue

No Resection, or Limited Resection

Barlow’s Disease

Barlow’s Disease

Barlow’s – “Remove” Tissue

Resection, Leaflet Displacement

Degenerative Mitral Valve Repair

Ring Annuloplasty alone

with any or all of :

Leaflet excision

Leaflet plication

Leaflet patch

Artificial chordae

Cleft closure

Sliding plasty

Some other stuff

More other stuff

Alfieri stitch

Mitraclip

Mitral Valve Repair

Evaluate the valve

Posterior Leaflet Resection

Recreate Posterior Leaflet

Ring

Anterior Leaflet Repair

“Smiley face” = good line of closure

Posterior leaflet “disappears”

“Who’s your Daddy, Jason ?!

Mitral Valve Repair

It’s Math !

Put a ring on it !

Ring Annuloplasty

Complete or Incomplete

Rigid or Flexible

“It’s not the ring,

it’s the ringer!”

Mitral Valve Repair

• Zone of Coaptation

• Roman Arch

• Chords = Guides

• Ring – obey “Bey” !

Mitral Valve Repair PRINCIPLES

Mitral Valve Repair

Results

5/16/2016

Repair DMR!

0

20

40

60

80

100

0 2 4 6 8 10

General Population

Replacement

Repair

p = 0.0004

Surv

ival (%

)

Time (Years)

68%

52%

Enriquez Sarano et al. Circulation 1995;91:1022

Cure MR!

Mitral Valve Replacement Results

Mitral Valve Replacement Results

Mitral repair vs. replacement – TE events

Mitral repair vs. replacement – Survival

Mitral repair vs. replacement

Early Surgery vs Watchful Waiting Med Rx

Outcomes for MR

JAMA. 2013;310(6):609-616.

Survival After Diagnosis of Mitral Regurgitation Due to Flail Mitral Leaflet According to Initial Treatment StrategyLong-term survival

following early surgery vs initial medical management overall population (A) and in the propensity score–matched cohort (B).

ACC/AHA 10 Mitral Guidelines - 2014

J Thorac Cardiovasc Surg 2003;125:1143-1152

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10 11

Mitral Regurgitation Survival After Mitral Valve Surgery

100

80

60

40

20

0

Surv

ival (p

erc

ent)

0 2 4 6 8 10 14 12

Time (years)

David et al, J Thorac Cardiovasc Surg 2003;126:1143-1152

FC I-II

58%

FC III-IV

81%

n=488

p<0.001

Wait for CHF

symptoms ?

Bad !

Sx or :

LVEF < 60 %

PAP > 50 mm

LVESd > 40 mm

AF

If > 95% repair and < 1 % mortality

2016 - Degenerative Mitral

Enriquez-Sarano et al. Circ 1994:90:830-837

Wait until EF falls , 60 – Bad !

Wait until PAP rises, 50 – Bad !

Enriquez-Sarano et al. Rev Card 2010

Wait until LV dilates, 40 – Bad !

Bando et al. JTCVS 2005

Wait until A Fib – Bad !

Theirry et al. EJCVS 2006

ACC/AHA guidelines: 2014

Mitral valve repair, wait until:

Symptoms …BAD !

if “no” symptoms, wait until:

Fall in EF% < 60

Pul Htn > 50

Increase LV > 40

A Fib

…also BAD and too late !

So are cardiologists even following these lame guidelines ? … they are super late !!

MV surgery referral

Toledano et al. Can J Cardiol 2007; 23 (3): 209-14

NO! 2-30% were super late

the rest …mega late referral!

33% mortality-1yr Failure of Guideline Adherence for Intervention in Patients With Severe Mitral Regurgitation

David S. Bach, et al JACC Vol. 54, No. 9, 2009

USA Mitral late referral rate - 50% !

Sx or :

LVEF < 60 %

PAP > 50

LVESd > 40 mm

AF

If > 95% repair…

2016 - Degenerative Mitral

All Mitral Valve Procedures (Center Repair Rates 2005 – 2009)

“If > 95% repair”…

Individual Surgeon Predictors of Repair

Isolated Mitral / yr - 5 (0.3 – 166)

Mean Repair rate - 41% (0 – 100 %)

MVR Volume effect

Predictors of Mitral Repair

THE SURGEON :The more you do, the better you are !

Anyanwu et al. BMJ Heart 2010;10:1136-40

NOT the country - same in England

Kilic et al. J Thorac Cardiovasc Surg 2012

NOT the hospital

LaPar et al. J Thorac Cardiovasc Surg 2014; 148(3):995-1003

FIGURE 4. Plot of adjusted association between probability of mitral valve repair and the

adjusted restricted cubic spline function for average annual surgeon mitral procedure volume

within (B) a propensity matched patient group. MV, Mitral valve; PROM, Predicted Risk of

Mortality.

It’s the surgeon!

Beware

patient – surgeon mismatch !

For Degenerative Mitral

• Preserved LV function

• No anti-coagulation

• Freedom from re-op

• Low early and late mortality

Mitral Valve Repair

Advantages

Tips for MV Repair 2016

Find a GOOD surgeon, Think EARLY repair …

If your surgeon advises

replacement...

I advise you to replace your

SURGEON !!