The future of mitral surgery: revolution versus involution Ottavio Alfieri S. Raffaele University Hospital, Milano
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
Predicting
Bulk of Population Growth The Economist, May 14 th 2011
Nkomo, Lancet 2006
Surgical Risk vs. Benefit Optimum Value Limited? Value Surgical Risk Poor value: Patient Purchaser Physician Clinical Benefit Increasing age, comorbidities,lv dysf.
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;28:1358-1365
THE EVOLVING APPROACH TO MITRAL VALVE INTERVENTIONS (REPAIR OR REPLACEMENT) Sternotomy Minimally Invasive Robotic Percutaneous
THE EVOLVING APPROACH TO MITRAL VALVE INTERVENTIONS (REPAIR OR REPLACEMENT) Sternotomy Minimally Invasive Robotic Percutaneous
Minimally Invasive Approach
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 455-462 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;34:760-765. Ryan WH, Dewey TM, Mack MJ, et al. Mitral valve surgery using the classical heartport technique J Heart Valve Dis 2005;14:709-714 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;17:325-328 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;5:132-135 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;2:212-215
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;90:1471-1478. Division of Cardiothoracic Surgery Columbia University, New York NO DIFFERENCE
Robot Assisted
THE EVOLVING APPROACH TO MITRAL VALVE INTERVENTIONS (REPAIR OR REPLACEMENT) Sternotomy Minimally Invasive Robotic Percutaneous
THE EVOLVING APPROACH TO MITRAL VALVE INTERVENTIONS (REPAIR OR REPLACEMENT) Sternotomy Minimally Invasive Robotic Percutaneous
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
CRITICAL DECISIONS REPAIR vs REPLACEMENT OPTIMAL TIMING SURGICAL vs PERCUTANEOUS
The best solution (whenever possible) Durable mitral repair in the early stage (with negligible procedural risk)
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; 108:298-304 Zaho et al, JTCVS 2007;1257-1263 Shuhaiber J et al, EJCTS 2007; 31:267-275 Perrier P et al, Circulation 1984;70:187 Akins CW, et al. ATS 1994; 58:668-676
SURVIVAL Chronic Mitral Regurgitation Survival after valve repair vs replacement P.Perier, Circulation 1984;70:187 Enriquez-Sarano et al., Circulation 1995;91:1022
The Mitral Valve Complex Anulus Leaflet Chordae Papillary muscle Left ventricle
VORTICES AND FLUID DYNAMICS
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;114:265-272
Surgical techniques Quadrangular resection Triangular resection Sliding plasty Chordal replacement Haircut technique Folding plasty Butterfly resection Edge to edge.
Rate of Repair
Mitra Clip
Neochord Inc.
Vicious Circle Dysfunction of the LV HF Anular-Ventricular dilatation Muscle damage/loss Volume overload Increased load/stress
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
Am J Cardiol. 2005;96[suppl]:11G-17G.
Cohn, J. N. Nat.Rev. Cardiol. 11, 69 70 (2014)
UNDERSIZED ANNULOPLASTY COMPLETE, RIGID, SHAPED RING
% ml/m2 160 120 140 EDVI 100 ESVI 120 100 p=0.0001 80 p=0.0001 60 80 40 60 40 Pre-op Early post-op Mid post-op Late post-op Pre-op Early post-op Mid post-op Late post-op 20 55 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
Mitra Clip
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
Valtech Cardioband The band is adjustable to minimize residual MR under echo feedback
The involution Replacement when a durable repair is possible Intervention at a late stage Inappropriate choice of the modality of treatment
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