Ottavio Alfieri S. Raffaele University Hospital, Milano
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1 The future of mitral surgery: revolution versus involution Ottavio Alfieri S. Raffaele University Hospital, Milano
2 Future The trouble with the future is that it s so much less knowable than the past. John Lewis Gaddis, The Landscape of History 2
3 Predicting
4 Bulk of Population Growth The Economist, May 14 th 2011
5 Nkomo, Lancet 2006
6 Surgical Risk vs. Benefit Optimum Value Limited? Value Surgical Risk Poor value: Patient Purchaser Physician Clinical Benefit Increasing age, comorbidities,lv dysf.
7 Euro Heart Survey: 50% symptomatic patients with severe MR are denied surgery Isolated MR (n=877) No Severe MR (n=331) Severe MR (n=546) No Symptoms (n=144) Symptoms (n=396) No Intervention (n=193) 49% Intervention (n=203) 51% Mirabel et al, European Heart J 2007;28:
8 THE EVOLVING APPROACH TO MITRAL VALVE INTERVENTIONS (REPAIR OR REPLACEMENT) Sternotomy Minimally Invasive Robotic Percutaneous
9 THE EVOLVING APPROACH TO MITRAL VALVE INTERVENTIONS (REPAIR OR REPLACEMENT) Sternotomy Minimally Invasive Robotic Percutaneous
10 Minimally Invasive Approach
11 Minimally Invasive Approach MORTALITY No significant difference between minimally - invasive and conventional approaches Jan D. Schmitto, Suyog A. Mokashi, Lawrence H. Cohn. Minimally-Invasive Valve Surgery JACC vol 56, 6: (2010) pp Seeburger J, Borger MA, Falk V, et al. Minimal invasive mitral valve repair for mitral regurgitation: results of 1339 consecutive patients Eur J Cardiothoracic Surg 2008;34: Ryan WH, Dewey TM, Mack MJ, et al. Mitral valve surgery using the classical heartport technique J Heart Valve Dis 2005;14: Gaudiani VA, Grunkemeier GL, Castro LJ, et al. Mitral valve operations through standard and smaller incisions Heart Surg Forum 2004;7:E337-E342 de Vaumas C, Philip I, Daccache G, et al. Comparison of minithoracotomy and conventional sternotomy approaches for valve surgery J Cardiothorac Vasc Anesth 2003;17: Onnasch JF, Schneider F, Falk V, et al. Five years of less invasive mitral valve surgery: from experimental to routine approach Heart Surg Forum 2002;5: Grossi EA, Galloway AC, Ribakove GH, et al. Minimally invasive port-access surgery reduces operative morbidity for valve replacement in the elderly Heart Surg Forum 1999;2:
12 Minimally Invasive Approach MORBIDITY Minimally Invasive Versus Sternotomy Approach for Mitral Valve Surgery: A Propensity Analysis (n=764) Alexander Iribarne, MD et all Ann Thorac Surg 2010;90: Division of Cardiothoracic Surgery Columbia University, New York NO DIFFERENCE
13 Robot Assisted
14
15 THE EVOLVING APPROACH TO MITRAL VALVE INTERVENTIONS (REPAIR OR REPLACEMENT) Sternotomy Minimally Invasive Robotic Percutaneous
16 THE EVOLVING APPROACH TO MITRAL VALVE INTERVENTIONS (REPAIR OR REPLACEMENT) Sternotomy Minimally Invasive Robotic Percutaneous
17 Percutaneous Devices Landscape 2010/2014 Edge-to-Edge MitraClip* Edwards Mobius Coronary sinus annuloplasty Cardiac Dimensions Carillon* Edwards Monarc Viacor PTMA* Cerclage annuloplasty Indirect annuloplasty Ample PS3 St. Jude AAR Mycor i-coapsys Direct annuloplasty Mitralign* QuantumCor MiCardia ebcor Accucinch* ReCor (US)* Quantum Cor (RF) Valtech Cardioband Micardia encor Mitral valve replacement EndoValve CardiAQ Valtech Cardiovalve ValveXchange Chordal shortening and other Cardiosolutions Mitra-Spacer* NeoChord Valtech VChordal *in humans
18 CRITICAL DECISIONS REPAIR vs REPLACEMENT OPTIMAL TIMING SURGICAL vs PERCUTANEOUS
19 The best solution (whenever possible) Durable mitral repair in the early stage (with negligible procedural risk)
20 MV repair is superior to MVRepl Better preservation of LV function Avoidance of prosthesis related events Reduced hospital mortality Reduced morbidity and LOS Improved long term survival Thourani et al, Circulation 2003; 108: Zaho et al, JTCVS 2007; Shuhaiber J et al, EJCTS 2007; 31: Perrier P et al, Circulation 1984;70:187 Akins CW, et al. ATS 1994; 58:
21 SURVIVAL Chronic Mitral Regurgitation Survival after valve repair vs replacement P.Perier, Circulation 1984;70:187 Enriquez-Sarano et al., Circulation 1995;91:1022
22 The Mitral Valve Complex Anulus Leaflet Chordae Papillary muscle Left ventricle
23 VORTICES AND FLUID DYNAMICS
24 DMR If a good and durable repair is carried out before symptoms LV dysfunction and AF,, normal life expectancy and quality of life is expected at any age Detaint, et al. Circulation. 2006;114:
25 Surgical techniques Quadrangular resection Triangular resection Sliding plasty Chordal replacement Haircut technique Folding plasty Butterfly resection Edge to edge.
26 Rate of Repair
27 Mitra Clip
28 Neochord Inc.
29
30 Vicious Circle Dysfunction of the LV HF Anular-Ventricular dilatation Muscle damage/loss Volume overload Increased load/stress
31 Ischemic MR Kaplan-Meier curves of cardiovascular survival in patients with (n=141) and without (n=586) MR (multivariate P=.0022). Lamas et al, Circulation 1996 Survival (±SE) after diagnosis according to degree of MR as graded by RVol >30 ml/beat or <30 ml/beat. Numbers at bottom indicate patients at risk for each interval. Grigioni et al, Circulation 2001
32 Am J Cardiol. 2005;96[suppl]:11G-17G.
33 Cohn, J. N. Nat.Rev. Cardiol. 11, (2014)
34 UNDERSIZED ANNULOPLASTY COMPLETE, RIGID, SHAPED RING
35 % ml/m EDVI 100 ESVI p= p= Pre-op Early post-op Mid post-op Late post-op Pre-op Early post-op Mid post-op Late post-op EF p=0.0001,82 Sphericity index,78 45,74 p=0.0001,70 35,66 25,62,58 15 Pre-op Early post-op Mid post-op Late post-op,54 Pre-op Early post-op Mid post-op Late post-op
36 Mitra Clip
37 Freedom from reintervention in successfully treated patients with secondary mitral regurgitation, differentiated by the severity of mitral regurgitation (MR) at discharge. Volker Rudolph et al. European Journal of Heart Failure Advance Access published February 20, 2013
38 Valtech Cardioband The band is adjustable to minimize residual MR under echo feedback
39 The involution Replacement when a durable repair is possible Intervention at a late stage Inappropriate choice of the modality of treatment
40 Conclusions The availability of a large stectrum of treatment modalities as a result of advancements in technology represents the revolution Deviation from scientific evidences, established knowledge and common sense is the involution
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