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Presentation transcript:

Washington Hospital Center The Outcome of Patients Undergoing Isolated Mitral Valve Surgery as a Potential Comparator for Patients Undergoing Percutaneous Mitral Valve Repair Sa’ar Minha, Xiumei Sun, Paul Corso, Louis T. Kanda, Bafi S. Ammar, Israel M. Barbash, Danny Dvir, Itsik Ben-Dor, Salem Badr, Joshua P. Loh, Lakshmana K Pendyala, Hironori Kitabata, Rebecca Torguson, Fang Chen, William O. Suddath, Lowell F. Satler, Kenneth M. Kent, Augusto D. Pichard, Ron Waksman Washington Hospital Center

I have no real or apparent conflicts of interest to report. Sa'ar Minha, MD I have no real or apparent conflicts of interest to report.

Mitral Regurgitation Malcoaptation of mitral valve leaflets. Incidence of 7-9% of the population ≥75 years of age. Leading cause for valve surgery in Europe. Classification: Primary (degenerative) Secondary (functional) Bonow ; JACC 2008;52:e1-e142

Edge to Edge Mitral Valve Repair MitraClip, Abbot Vascular, Santa Clara, CA, USA Alfieri. J Card Surgery. 2010

Everest II Prospective randomized trial

Results Efficacy Primary Efficacy Endpoint Freedom from Death/Surgery for MV dysfunction/MR +3/+4 73% (surgery) vs. 55% (MitraClip);p=0.007) Cross over of MitaClip to surgery-21% The exact population of patients to benefit from percutaneous mitral valve repair (PMVR) is unknown.

Aim To study the contemporary operative risk for patients undergoing isolated mitral valve surgery to serve as reference to future PMVR trials.

Methods Retrospective analysis of WHC’s Cardiac Surgery Division data including patient who had an isolated MV replacement/repair between 2003-2010 d/t severe MR. Exclusion criteria Endocarditis, Prior CABG/Valve surgery. Comparison Between 3 risk strata according to STS score (STS<3;3≤STS<6;STS ≥ 6).

End-Points Incidence of major clinical outcome indices at 30 days: Operative mortality Reoperation for failed mitral valve surgery Stroke Renal failure Prolonged ventilation >48 hours New-onset atrial fibrillation, Blood product transfusion Re-admission.

Results A total of 422 patient met the inclusion/exclusion criteria. Repair vs. Replacement MV Repair 73% MV replacement 27%.

Baseline Characteristics STS Score<3 (n=350) STS Score3 to <6 (n=36) STS Score≥6 P Age 54.7±12.2 66.3±16.3 70.9±10.5 <0.01 Female gender 140 (40%) 23 (63.9%) 26 (72%) <0.001 Diabetes 26 (7.4%) 12 (33.3%) Hypertension 180 (51.4%) 28 (77.8%) 32 (88.9%) Dyslipidemia 124 (35.4%) 18 (50%) 19 (52.8%) 0.034 Renal failure-dialysis 1 (0.3%) 3 (8.3%) 8 (22.2%) Peripheral Vascular Disease 9 (2.6%) 1 (2.8%) 5 (13.9%) 0.0003 Preoperative stroke 11 (3.1%) 2 (5.6%) 4 (11.1%) 0.015 Preoperative myocardial infarction 16 (4.6%) 7 (19.4%) 9 (25%) Heart failure 82 (23.4%) 27 (75%) 29 (80.6%) Ejection Fraction 52.1±9.9 48±12.3 44.2±13 0.005 New York Heart Association class III-IV 93 (26.6%) 24 (66.8%) Carcinogenic shock 2 (0.6%) Preoperative ventricular fibrillation 4 (1.1%) 0.579 Preoperative atrial fibrillation 35 (10%) 14 (38.9%) Society of Thoracic Surgeons score 0.8±0.7 4±0.8 11.9±6.7

Surgical Data STS<3 (n=350) STS Score3 to <6 (n=36) STS≥6 (n=36) STS<3 (n=350) STS Score3 to <6 (n=36) STS≥6 (n=36) P Mitral Valve Relacement 69 (19.7%) 21 (58.3% 24 (66.7%) <0.001 Elective Surgery 297 (84.5%) 20 (55.6%) 6 (16.7%) Perfusion time (min) 97.5±37.7 94±16.3 82.9±31.8 0.074 Cross-clamp time (min) 75.4±30.2 69.4±34.2 59.4±20.5 0.008 Intraoperative IABP 2 (0.6%) 3 (8.3%) 2 (5.6%)

%

% P=0.652

Discussion Concordance generally existed between the predicted STS outcome model and the actual results from out cohort. Sub-analysis of EVEREST II 78 high risk pts. (STS 14.2) who underwent PMVR Mortality rate of 7.7% @30d In the present analysis in the high STS group, mortality rate was 13.4% @30d (!) Tamburino; Eur Heart J 2010;31:1382-1389

Limitations Relatively small cohort. No differentiation between replacement and repair of MV. No differentiation between functional and degenerative MR.

Conclusions Isolated Mitral valve surgeries are generally performed in patients with low STS scores. Patients with a STS score >6 are at high risk for mortality and should be subjected to a PMVR. The STS score should be used as a comparator tool to evaluate the performance of PMVR for patients with severe MR.