Selection of repair technique for Ischemic Mitral Regurgitation

Transcription

1 Selection of repair technique for Ischemic Mitral Regurgitation Genk - Belgium Prof. Dr. R. Dion KULeuven

2 Systolic restrictive motion

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4 J Thorac Cardiovasc Surg 2004;128:916-24

5 Edwin C. McGee et al. J Thorac Cardiovasc Surg 2004;128:916-24

6 ECHO CRITERIA OF SEVERE MR ERO (cm 2 ) RV (ml) ORGANIC > 0.4 > 60 FMR > 0.2 > 30 M. Enriquez-Sarano

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8 Restrictive Mitral Annuloplasty = Complete (1/2) rigid ring + 8mm coaptation length

9 8 mm

10 LVEDD and Reverse Remodeling 100% 89 % 80% specificity sensitivity 60% 40% 20% 0% LVEDD (mm) EACTS 15/09/04

11 Results: Mortality per LVEDD All-cause death 60% 50% P-value HR 3.4 and 95% CI ± 11% LVEDD >65 40% 30% 20% 10% 71 ± 8.5% 93 ± 3.0% 80 ± 5.2% LVEDD 65 0% Years since surgery Patients at risk STS 01/30/2007

12 Results: Clinical Outcome LVEDD 65 LVEDD > 65 P-value All mortality 11/72 (15.3%) 14/28 (50.0%) < Readmission CHF 6/69 (8.7%) 5/23 (21.7%) < Biventricular ICD 0/69 4/23 (17.4%) < NYHA 1.6 ± ± 0.5 ns LVESD 50 LVESD > 50 P-value All mortality 9/58 (15.5%) 16/42 (38.1%) Readmission CHF 2/56 (3.6%) 9/36 (25.0%) Biventricular ICD 0/56 4/36 (11.1%) < STS 01/30/2007

13 Echo Results: Mitral Regurgitation BASELINE 3.1 ± 0.5 EARLY 0.5 ± 0.7 INTERMEDIATE (18m) 0.7 ± 0.7 P < 0.05 LATE (46m) 0.9 ± 0.8 STS 01/30/2007

14 Results: Echocardiography baseline intermediate late MV gradient 3.6 ± ± 1.7 MV area (cm2) Tenting area (cm2) Coaptation 2.8 ± ± ± ± ± 1 8 ± 2 8 ± 2 Height (mm)

15 Resultaten ZOL Follow-up 6 weken (klepherstel-groep) Coaptatielengte in groep IIIb 8,5 ± 1,4 mm

16 LVESD (mm) Regression of LVESD * * all LVEDD 65 mm LVEDD > 65 LVEDD > 65: only 25 % reverse remodeling All late deaths had no SYSTOLIC reverse remodeling at intermediate FU *

17 preoperative images Parasternal long axis. Moderate LV function. Restrictive MV motion. MMode: LV diameter end-diastolic: 6,5 cm.

18 preoperative images Apical two chamber view. Note the restrictive closure of the mitral valve. Apical four chamber view, color-doppler encoded. Note the severe regurgitation.

19 postoperative images Parasternal short axis 3 years after repair. Note the improved systolic function. MMode: LV diameter end-diastolic: 4,6 cm. LVIDd showed 1,9 cm regression to normal value.

20 Conclusions LVEDD 65 mm cut-off = strong outcome predictor LVEDD > 65 = poor reverse remodeling For LVEDD 65 mm: RMA + CABG = CURE For LVEDD > 65: RMA + CABG is not enough STS 01/30/2007

21 Am J Cardiol 2010;106: Ciarka et al

22 Method of quantification of ALA base, ALA tip and PLA. Measurements depicted on echocardiographic image of mitral valve in apical 4-chamber view in mid-systole. Am J Cardiol 2010;106: Ciarka et al

23 Am J Cardiol 2010;106: Predictors of mitral regurgitation recurrence in patients with heart failure undergoing mitral valve annuloplasty. Ciarka et al

24 Am J Cardiol 2010;106: Predictors of mitral regurgitation recurrence in patients with heart failure undergoing mitral valve annuloplasty. Ciarka et al

25 CorCap NVT 08/10/04

26 LV reconstruction Technical Aspects Reducing LV size exclusion of infarct area Reshaping LV Precise determination of LV size Exclusion septal infarcts Reverse Remodeling

27 Relocation of the posterior papillary muscle (Kron) Kron IL: Surgical relocation of the posterior papillary muscle in chronic ischemic mitral regurgitation. Ann Thorac Surg 2002;74:600-1

28 Papillary Muscles Approximation a=b b a b a a>b PM sling failure PM approximation

29 papillary muscles approximation +papillary muscles suspension (n=20) Papillary muscles approximation CV4 for pulling up both PM

30 Papillary muscle approximation (plication) for treating mitral valve tethering Tethering to lateral site Tethering to posterior site --volume reduction of posterior wall anterior displacement of posterior wall preop postop

31 Anterior leaflet augumentation for IMR Kincaid EH, Riley RD, Hines MH, Hammon JW, Kon ND. Anterior leaflet augumentation for ischemic mitral regurgitation. Ann Thora Surg 2004;78:564-8

32 Aantal ingrepen Resultaten ZOL > Mitralisklep Totaal (n=148) MvP (n=121) % 100% % % I II IIIa IIIb Carpentier-classificatie

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39 MRI Assessment of Reverse Left Ventricular Remodeling Late After Restrictive Mitral Annuloplasty in Dilated Cardiomyopathy J Braun, JJM Westenberg, NR van de Veire, RJM Klautz, MIM Versteegh, SD Roes, RJ van der Geest, A de Roos, EE van der Wall, JHC Reiber, JJ Bax, RAE Dion Departments of Cardio-Thoracic Surgery, Radiology and Cardiology Leids Universitair Medisch Centrum, Leiden, The Netherlands

40 Patient characteristics 22 selected patients (MRI) Mild-moderate heart failure NYHA 2.2 ± 0.4 Severe MR mean grade 3.6 ± 0.5 Non-ischemic dilated cardiomyopathy LVEF 37 ± 5 LVEDV 215 ± 34 ml 40 AATS 05/08/2007

41 Study protocol TTE + TEE + MRI preoperatively TEE in OR directly after surgery TTE + MRI late FU Outpatient clinic mean 43 ± 8 months 41 AATS 05/08/2007

42 Clinical outcome No peri-operative mortality Late mortality n = 2 (CHF) 1 redo MV repair 18 pts late FU NYHA 2.2 ± ± 0.4 (p <0.01) AATS 05/08/

43 Imaging outcome pre-surgery follow-up p MR grade 3.6 ± ± 0.5 <0.01 Coaptation (mm) 3 ± 1 8 ± 3 <0.01 LAESV/BSA (ml/m 2 ) 84 ± ± 12 <0.01 LAEDV/BSA (ml/m 2 ) 48 ± ± LVESV/BSA (ml/m 2 ) 42 ± ± 12 <0.01 LVEDV/BSA (ml/m 2 ) 110 ± ± 17 <0.01 LV Mass/BSA (g/m2) 76 ± ± LVEF (%) 37 ± 5 55 ± 10 <

44 Imaging outcome pre-surgery follow-up p MR grade 3.6 ± ± 0.5 <0.01 Coaptation (mm) 3 ± 1 8 ± 3 <0.01 LAESV/BSA (ml/m 2 ) 84 ± ± 12 <0.01 LAEDV/BSA (ml/m 2 ) 48 ± ± LVESV/BSA (ml/m 2 ) 42 ± ± 12 <0.01 LVEDV/BSA (ml/m 2 ) 110 ± ± 17 <0.01 LV Mass/BSA (g/m2) 76 ± ± LVEF (%) 37 ± 5 55 ± 10 <

45 Imaging outcome pre-surgery follow-up p MR grade 3.6 ± ± 0.5 <0.01 Coaptation (mm) 3 ± 1 8 ± 3 <0.01 LAESV/BSA (ml/m 2 ) 84 ± ± 12 <0.01 LAEDV/BSA (ml/m 2 ) 48 ± ± LVESV/BSA (ml/m 2 ) 42 ± ± 12 <0.01 LVEDV/BSA (ml/m 2 ) 110 ± ± 17 <0.01 LV Mass/BSA (g/m2) 76 ± ± LVEF (%) 37 ± 5 55 ± 10 <

46 Imaging outcome pre-surgery follow-up p MR grade 3.6 ± ± 0.5 <0.01 Coaptation (mm) 3 ± 1 8 ± 3 <0.01 LAESV/BSA (ml/m 2 ) 84 ± ± 12 <0.01 LAEDV/BSA (ml/m 2 ) 48 ± ± LVESV/BSA (ml/m 2 ) 42 ± ± 12 <0.01 LVEDV/BSA (ml/m 2 ) 110 ± ± 17 <0.01 LV Mass/BSA (g/m2) 76 ± ± LVEF (%) 37 ± 5 55 ± 10 <

47 MRI images AATS 05/08/2007 PRE POST 47

48 Conclusion MRI confirms that in early stages non-ischemic DCM, stringent RMA alone resolves functional MR and induces reverse remodeling in the long term 48 AATS 05/08/2007