ACUTE AND LATE RESULTS AFTER SURGICAL REPAIR/REPLACEMENT OF DEGENERATIVE MITRAL REGURGITATION Thierry MESANA, MD, PhD President and CEO Professor Cardiac Surgery Valve Surgery Research Chair University of Ottawa Heart Institute Ottawa, Ontario, Canada

I have no relevant financial relationships

Important questions Immediate results : Operative Risk in mitral valve surgery and Variations in repair rates : Variations depending on Volumes and Expertise Long-term results : Durability of MV repair for MV Prolapse Recurrence of MR, Functional MS due to small rings

EARLY MORTALITY/OPERATIVE RISK Mitral Repair Mitral Replacement 0.9% (Castillo JTCVS 2012) 1.2% (Coutinho EJCTS 2016) Expert centers usually below 0.5 % 1.8% (Coutinho EJCTS 2016) 3.3% (Bourguignon JTCVS 2014) 7.2% (McClure Ann Thorac Surg 2010) CRT 2017

Mitral Valve Replacement Perioperative deaths after MV operations may be overestimated by contemporary risk models Presented at STS meeting January, 2014., Annals of TS July 2014 Mitral Valve Surgery N = 1154 Mitral Valve Repair N = 851 Mitral Valve Replacement N = 303 Follow up and also this is not clear Study Dates: 2001-2011

Observed & EuroSCORE II Predicted Mortality Isolated Mitral Surgery Ottawa Heart Institute series 2002-2013 (Annals TS, July 2014) EuroSCORE II Quartile N Observed Mortality Predicted Mortality Lower Limit (%) Upper Limit (%) 1 141 0 (0%) 0.5 0.7 2 143 1.0 3 142 2 (1.4%) 1.8 4 144 25.2 Patients were also grouped into quartiles according to their EuroSCORE II. Again, Overall O:E ratio 0.3

Observed & EuroSCORE II Predicted Mortality All procedures including Mitral valve Surgery Ottawa Heart Institute series 2001-2011 (Annals TS, July 2014) EuroSCORE II Quartile N Observed Mortality Predicted Mortality Lower Limit (%) Upper Limit (%) 1 285 1 (0.4%) 0.5 0.9 2 291 2 (0.7%) 1.7 3 288 3 (1.1%) 1.8 3.9 4 290 5 (1.7%) 31.1 Patients were also grouped into quartiles according to their EuroSCORE II. Again, Overall O:E ratio 0.3

Low Surgeon volume + low hospital volume : 5.6 % The effect of hospital volume on outcomes in MV surgery is also driven by individual surgeon within this hospital 30-day Mortality Low Surgeon volume + low hospital volume : 5.6 % Low surgeon volume + high Hospital Volume : 3.3% High surgeon volume + low Hospital volume : 2.3% High surgeon volume + high hospital volume : 2.0% Kilic et al . JTCVS 2013:146:638-46 (J Hopkins, Baltimore)

REPAIR RATE Depends on surgeon and on anatomy for a given surgeon Nationwide Isolated MV surgery 2003-2008, including 25,427 MV repairs (50.7%) Median volumes was 61 for hospitals and 12 for surgeons.( Kilic et al JTCVS 2013:146:638-46). Repair rates from 30 to 60% for all etiologies. Expert centers between 95 and 100% for MV Prolapse repair Only 3 surgeons >100 MV/year, majority less than 25/year Only 4 hospitals >200 MV /year, majority below 100/year A given surgeon may have an overall repair rate of 90%, a repair rate of 90-95% for fibroelastic deficiency with single segment posterior leaflet prolapse due to chordal rupture, but a lower success rate for bileaflet Barlow’s disease (<90%) Patients referred for MV repair should be considered on an individual basis, i-e for each case probability of repair by the surgeon > institution.

VARIATION IN SURGEON MITRAL REPAIR RATES J Thorac Cardiovasc Surg 2014;148:995-1004

LONG-TERM DURABILTY OF MITRAL VALVE REPAIR Excellent , not perfect

Chordal replacement with PTFE 25-year experience (T David Chordal replacement with PTFE 25-year experience (T David. JTCVS 2013;145:1563-9) 1986-2004 ; 606 consecutive pts AL 18%, PL 30%, BL 52%, 13 annular reconstructions (3%), 2 to 38 neochords per patient (mean 13), resection if PL height >20mm 90 % freedom from reoperation at 18 years 90% freedom from severe MR 67% freedom from mod/severe MR Anterior Leaflet Prolapse predictive for reoperation, as well as older age, HBP and low EF (<40%) Total of 35 reoperations. 32 replacement, 3 re-repairs (1 week to 22 y)

David T. E. et al.; J Thorac Cardiovasc Surg 2005;130:1242-1249 Freedom from recurrent moderate or severe mitral regurgitation (MR) in patients with posterior (PL), anterior (AL), and bileaflet (BL) prolapse David T. E. et al.; J Thorac Cardiovasc Surg 2005;130:1242-1249

Long-Term Durability Edge-to Edge for Anterior Leaflet Prolapse M Long-Term Durability Edge-to Edge for Anterior Leaflet Prolapse M.DeBonis (Alfieri’s Group)- JTCVS, 2014:Vol 148, 2027-32 1991-2004:139 pts, mean age 54 years, mean LVEF 56% Isolated AL prolapse/flail. A2 in 105 pts (75%), A1 or A3 (25%) E-to-E technique plus annuloplasty 11 years mean duration of follow-up 11 years, up to 21 years Moderate MR at discharge : 9pts (6,4%) 72% actuarial survival, 89% freedom from reoperation 82% freedom from severe MR (Grade 3 or 4) Predictors of severe MR : more than mild MR at discharge and pericardial ring annuloplasty instead of Prosthetic

Very Late outcomes after MV replacement with CE pericardial bioprosthesis Bourguignon et al, J Thorac Cardiovasc Surg 2014;148:2004-11 450 Isolated MV Replacement (404 pts). CE Perimount in 404 pts 1984-2011; Mean age 68; 53% female; Mean follow-up 7.2 years, up to 20 years Pts <65 y-o, freedom from SVD was 47% (15 years) and 19 % (20 years) and freedom from reoperation was 50% (15 years ) and 25% ( 20 years) Pts >65 y-o, freedom from SVD 62.5% at 15 y and 30% at 20 y , and freedom from reoperation 75% at 15 years

HOW DOES MITRAL VALVE REPAIR FAIL IN PATIENTS WITH PROLAPSE HOW DOES MITRAL VALVE REPAIR FAIL IN PATIENTS WITH PROLAPSE? – INSIGHTS FROM LONGITUDINAL ECHOCARDIOGRAPHIC FOLLOW-UP Vincent Chan, MD, MPH; Elsayed Elmistekawy, MD; Marc Ruel, MD, MPH; Marc Hynes, MD; Thierry G. Mesana, MD PhD PRESENTED at Society of Thoracic Surgeons Annual Meeting January 2016 Published: The Annals of Thoracic Surgery Volume 102, Issue 5, November 2016, Pages 1459–1465

Mitral Valve Repair of Myxomatous Degeneration N = 855 Study Dates: 2001-2015 Mitral Valve Repair of Myxomatous Degeneration N = 855 Patients assessed regularly in a dedicated clinic with serial echocardiographic assessments 1, 3-6 months, & 12-months Clinical & Echocardiographic assessments Annually thereafter Follow up and also this is not clear Clinical Follow-up 4.3 ± 3.5 years

MITRAL VALVE PATHOLOGY Moderate-Severe MAC 83/855 = .09707602 Prolapse ≥2 Anterior Leaflet Scallops 33(4%) Prolapse ≥2 Posterior Leaflet Scallops 100(12%) Mitral Annular Calcification 109 (13%)

REPAIR TECHNIQUES Annuloplasty Size 30.4 ± 5.8 mm Sliding plasty 263 (31%) Chordal Transfer 170 (20%) Artificial Neochordae 241 (28%) Edge-to-Edge 170 (20%) Conversion to replacement: 25 (2.8%) 30-day mortality : 0.4 % 35% combined procedures

Fig 1. Freedom from New York Heart Association (NYHA) III/IV symptoms, recurrent mitral regurgitation (MR) of 2+ or higher, and mitral valve reoperation, and survival are described for 855 patients with a follow-up of 4.3 ± 3.5 years. A total of 2,754 postoper... Vincent Chan, Elsayed Elmistekawy, Marc Ruel, Mark Hynes, Thierry G. Mesana How Does Mitral Valve Repair Fail in Patients With Prolapse?—Insights From Longitudinal Echocardiographic Follow-Up The Annals of Thoracic Surgery, Volume 102, Issue 5, 2016, 1459–1465 http://dx.doi.org/10.1016/j.athoracsur.2016.08.088

POSTOPERATIVE MR Proportion of Total (%) Mean Echocardiographic Follow-up 3.8 ± 3.2 years

FREEDOM FROM MV REOPERATION 100% 75% 96.9 ± 0.6% @ 5-years 50% 93.8 ± 1.2% @ 10-years 25% 0% 1 2 3 4 5 6 7 8 9 10 11 12 13 Patients at risk Reoperation 855 670 510 455 403 354 267 201 150 101 65

PREDICTORS FOR MITRAL REOPERATION Recurrent MR after 1-year Recurrent MR after 2-years Recurrent MR after 3-years afteroneyear | 5.201912 2.8908 2.97 0.003 1.750388 15.45937 After 2 years | 3.22807 2.399721 1.58 0.115 .7519113 13.8586 After 3 years | 1.893182 1.939934 0.62 0.533 .2540799 14.106345.45937 1 5 10 15 Incident Rate Ratio

ASSESSING FUNCTIONAL MITRAL STENOSIS AFTER “SUCCESSFUL”MITRAL VALVE REPAIR CRT 2017

RESULTS Functional MS after MV repair for Degenerative MR Impact of Annuloplasty type . Bands vs, full rings J Thorac Cardiovasc Surg 2013 Dec;146(6):1418-23 Mesana at al, University of Ottawa Heart Institute The higher gradients observed in patients with rings at rest, were also observed at peak exercise. In fact, the mean mitral gradient at peak stress was higher in the ring group as compared to the band group for all annuloplasty sizes. 3 reoperations for severe MS post full Ring ring less than 30 mm size

SUMMARY Severe MR after repair is rare, although some may have recurrent moderate MR (4-5%) Patients who require subsequent mitral valve reoperation were most likely to have recurrent MR ≥2+ within the first year after surgery suggesting that valve surveillance beyond a year may not be needed in asymptomatic patients Look for FUNCTIONAL MS in patients with FULL RINGS BELOW 30-32 mm In this series … Although there was …

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MI mitral valve surgery is associated with adverse events Nationwide STS Database LESS INVASIVE VERSUS CONVENTIONAL Stroke risk x2 (x3 if fibrillating heart) Gammie et al. Ann Thorac Surg 2010;90:1401-1410 EQUAL ONLY IN EXPERT/HIGH VOLUMES MIS CENTERS

Interval From Repair (years) RECURRENT MR ≥2+ Mode of Failure N (%) Interval From Repair (years) Prolapse Recurrent Other site 6 2 4 2.7 ± 2.1 3.9 ± 3.0 2.8 ± 2.8 No Prolapse Central jet Eccentric jet 43 14 24 3.2 ± 2.9 4.0 ± 3.6 3.1 ± 2.6 Group 1 | 3.920773 3.05445 1.760951 6.080595 Group 2 | 2.807381 2.789991 .1052361 5.677618 Group 3 | 3.95386 3.62323 .3607118 10.17 Group 4 | 3.082 2.551206 .0778576 8.300479