Degenerative Mitral Valve disease: Approach to Mitral valve repair through imaging Thilo Noack Working Group Structural Heart Disease, Dept. of Cardiac Surgery, Heart Centre Leipzig University, Leipzig, Germany AATS Annual Meeting Integrating Advanced Imaging In Planning Interventions: A Case-Based Interactive Expert Panel Review Monday, 28 April, 2015
Conflict of Interest Disclousure Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship Company Honoraria for lectures Siemens Healthcare 2
Recommendations Background Questions to MV Imaging Grading MR severity Surgical planning / decision-making Interventional planning / decision-making Doppler Color flow jet area PW/CW Pulmonary vein flow Quantification VC width R Vol RF ERO Structural LA LV Mitral leaflets Quantification Inter trigone distance Anterior leaflet length Anterior leaflet area Intercommissural distance Annular diameter Qualitative characteristics Pathoanatomy Pathophysiology Functional classification MV Dynamic Quantification Coaptation length Coaptation depth Gap flail leaflet Width of flail leaflet area Mitral valve opening area Leaflet thickness Qualitative characteristics Pathoanatomy Pathophysiology Functional classification MV Dynamic No recommendations 2D-TTE/TEE MRI 2D-TTE/TEE RT-3D-TEE MRI 2D-TEE RT-3D-TEE MRI 3
Case 1: Surgical Mitral Valve Repair Case History 60yro male Progressive dyspnea NYHA II-III Servere systolic murmur HTN No other co-morbidities 4
Case 1: Surgical Mitral Valve Repair Grading MR Severity by 2D TTE Severe excentric MR grade 3+ VC width 7.3 mm LVEF 65% (overestimated) 5
Case 1: Surgical Mitral Valve Repair Grading MR Severity by 2D TEE 6
Case 1: Surgical Mitral Valve Repair Surgical Planning PML prolapse Flail leaflet + chordea rupture Carpentier Typ II 7
Case 1: Mitral Valve Surgery Image-based Surgical Planning with esie Valves Quantitative Parameters AML length: 24.7 mm IT distance: 30.8 mm IC diameter: 39.6 mm AP-Diameter 37.8 46.3 mm Qualitative Criteria Servere P2 prolapse Highly dynamic and dilated annulus Noack et al, Interact CardioVasc Thorac Surg. 2015 8
Case 1: Mitral Valve Surgery Annuloplasty rings Maissano et al., Multimedia Manual of Cardiothoracic Surgery, 2008 9
Case 1: Mitral Valve Repair Carpentier-Edwards Physio Annuloplasty Ring (32 mm) Natural 3:4 ratio Anatomical shape to provide optimal orifice area Anterior saddle shape!! Semi-rigid Posterior flexibility allows for physiologic contractility of the MV annulus during systole 10
Case 1: Mitral Valve Surgery Virtual Sizing Quantitative Parameters: S-L-Diameter: C-C Diameter: N-N Diameter: 24.7 mm 39.6 mm 30.8 mm Size 34 11
Case 1: Mitral Valve Surgery Image-based Surgical Planning with esie Valves Minimally invasive MV repair via right-lateral mini-thoracotomy Ring: Carpentier-Edwards Physio ring (size 34 mm) Neochord on P2 12
Case 1: Mitral Valve Repair Post-operative 2D-TEE 13
Case 1: Mitral Valve Repair Carpentier-Edwards Physio Annuloplasty Ring (32 mm) 14
Case 2: Percutaneous Mitral Valve Repair Case History 75 yro male NYHA III-IV Hospitalization due to decompesation Servere systolic murmur Co-morbidities CABG + mechanical AVR 2011 AFIB AV-Block w PM 2012 PH HT Hyperlipidemia CKD 15
Case 2: Percutaneous Mitral Valve Repair TEE X-Plane Servere MR AML prolapse (flail leaflet) PML restrictive Carpentier Typ II (+III) 16
Case 2: Percutaneous Mitral Valve Repair 3D-TEE with Color Flow Key problem: several jets and regurgitation width 17
Case 2: Percutaneous Mitral Valve Repair 3D TEE Location of the lesion: servere A2 prolapse (posteriomedial) 18
Case 2: Percutaneous Mitral Valve Repair EVEREST Criteria DMR FMR < 10 mm < 15 mm < 15 mm > 2 mm 19
Case 2: Percutaneous Mitral Valve Repair RT-3D-TEE MV Model Noack et al, Interact CardioVasc Thorac Surg. 2015 20
Case 2: Percutaneous Mitral Valve Repair 4D Quantification Anatomical MV Orifice Area (AMVOA) MV Leaflet Gap max AMVOA max = 8.87 cm 2 FLAIL GAP max = 8.6 mm AROA max = 0.98 cm 2 Percutaneous edge-to-edge MV repair possible 21
Case 2: Percutaneous Mitral Valve Repair Advanced Image-based Planning Percutaneous edge-to-edge MV repair Strategy: 1-clip Position: middle of AML prolapse (posteriomedial of A2/P2 and not in the max of color flow) 22
Case 2: Percutaneous Mitral Valve Repair Post-procedural 2D TEE 23
Case 2: Percutaneous Mitral Valve Repair 3D TEE 24
Case 2: Percutaneous Mitral Valve Repair Post-interventional Measurement Pre Post Annulus diameter AP/ALPL 33.3 / 40.6 mm 29.4 / 39.5 mm Annulus Area 11.2 cm 2 9.9 cm 2 Annulus Perimeter 12.6 cm 2 11.1 cm2 Regurgitant Orifice Area 0.9 cm 2 0.0 cm 2 Orifice Area 5.8 cm 2 2.6 cm 2 25
Conclusion Summary 1. Structural and functional imaging is the fundament of every surgical/interventional planning 2. 2D-TEE and RT-3D-TEE are the recommended modalities for surgical / interventional decision-making of HVD 3. RT-3D-TEE-based heart valves models improve the surgical/interventional decision-making 4. Understand and treat the pathology 26
thilo.noack@medizin.uni-leipzig.de 27
Case 1: Mitral Valve Surgery Image-based Surgical Planning with esie Valves Visualization Measurements LAX SAX Noack et al, Interact CardioVasc Thorac Surg. 2015 28