Current Surgical Standards for Mitral Leaflet and Chordal Repair: Patient Selection,Techniques and Clinical Outcomes CRT February 2011 Niv Ad, MD Chief,

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Presentation transcript:

Current Surgical Standards for Mitral Leaflet and Chordal Repair: Patient Selection,Techniques and Clinical Outcomes CRT February 2011 Niv Ad, MD Chief, Cardiac Surgery Professor of Surgery, VCU Inova Heart and Vascular Institute Washington DC Metropolitan Area

Disclosures Medtronic Speaker Trainer Estech Consultant SJD Medical Advisory Board

Mitral Valve Anatomy Segments of mitral valve leaflets: anterior, posterior Annulus contacts and relaxes (dynamic) Relationship to aortic valve ‘Bean’ shape 3

Degenerative MR Adams et al. Ann ThoracSurg 2006;82:2096-2101 4

Mitral Valve Repair Triangular Resection Less tension on posterior annulus than quadrangular resection Applied for a large unsupported, prolapsing posterior leaflet Use two layers of continuous 4-0 Prolene suture For a large unsupported prolapsing posterior leaflet, Dr Carpentier described his technique of triangular resection of posterior leaflet in his paper. 5

Mitral Valve Repair Quadrangular Resection 6

Mitral Valve Repair Gortex Chord Reconstruction 7

Current Annuloplasty Choices Complete Ring Complete Flexible Ring Flexible Band Rigid Bands Composite/Variations of the above 8

Minimally Invasive Valve Surgery Same Indications Myxomatous or Degenerative Disease Ischemic Rheumatic Same Techniques Leaflet Resection Gortex Cord Reconstruction Annuloplasty Band Flexible or Rigid

Minimally Invasive Valve Surgery Same Operation as with Sternotomy Same durability Same results Different Technologies Thoracoscopic Robotic Direct Vision Same Operation Different Tools

Evolution of Technology 2001-2010 The Evolution of minimally Invasive Mitral Valve Repair: From Heartport Through da Vinci to Fibrillation without Crossclamping

An intraoperative picture which reveals femoral venous and arterial canulas, the 4cm long 4th intercostal space thoracotomy and the video camera system.

Robotic Mitral Valve Surgery 15

Patients Should Have a Minimally Invasive Valve Surgery Unless… All valve patients are potential candidates Relative contra-indications Other cardiac pathology e.g. CAD Advanced age

Patients Should Have a Minimally Invasive Valve Surgery Unless… All valve patients are potential candidates Relative contra-indications Other cardiac pathology e.g. CAD Advanced age Peripheral vascular disease Body habitus Extreme obesity Severe pectus excavatum Previous thoracic surgery Projected volume for 2011 – 200 cases

Benefits of Minimally Invasive Surgery Less Trauma = Less Pain Shorter Length of Stay Quicker Overall Recovery Dramatically Improved Patient Satisfaction

Why do Few Surgeons Perform Minimally Invasive Surgery? Steep Learning Curve It’s Harder Takes Longer Low Valve Volumes at Most Institutions – Little Room for Innovation

Early and Late Results Robotic N=35 Direct Approach P value Cardioplegia N=51 No Cardioplegia N=93 Perioperative MI - Mediastinitis Permanent Stroke TIA Prolonged Ventilator 2(2%) 0.27 Atrial Fibrillation 1(3%) 3(6%) 4(4%) 0.09 Renal Failure Renal Failure, Dialysis Tamponade 1(2%) 0.28 Reoperation Bleeding 0.11 Operative Death Readmit <30 Days 9(18%)* 1(1%) 0.001 Reoperation Mitral Valve 0.52 *This group is significantly different

Summary Surgical repair of the MV Less resection NeoChordes Edge to Edge not common Larger Rings Excellent immediate outcome Predicted durability

Thank You