Surgical Mitral Valve Repair: What is the Gold Standard?

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Presentation transcript:

Surgical Mitral Valve Repair: What is the Gold Standard? Donald D. Glower, M.D. Duke University Medical Center lit review robot video CRT 2017 10 min

Disclosure Statement of Financial Interest 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 Grant/Research Support Consulting Fees/Honoraria Major Stock Shareholder/Equity Royalty Income Ownership/Founder Intellectual Property Rights Other Financial Benefit Company Names

Gold Standard Therapy Best available outcome Documentation Reliable, reproducible results

DMR: Carpentier Repair Techniques

DMR: 20-Year Reoperation Braunberger, Carpentier Circ 104,I-8, 2001

DMR: 12-Year Recurrent MR David JTCVS 130:1242, 2005

FMR Repair 2017 COMPLETE, UNDERSIZED / FLATTENED, RIGID RING

FMR: Recurrent MR CTSN TRIAL - 2 years Goldstein D NEJM Nov 9, 2015 REPAIR REPLACE P >=2+MR 59% 4% <0.001 Reoperation 3% 1% NS EF 43±12 38±12 LVESVI 53±28 61±39 0.19 Ring size 28, 25% no CABG, 12% subvalvular repair procedures Goldstein D NEJM Nov 9, 2015

FMR: Recurrent MR EVEREST II randomized trial 5 year results Presented at EuroPCR 2014 S Kar et al. MitraClip not FDA approved for FMR COAPT Trial ongoing

Surgical Mitral Repair Rates Posterior prolapse 90-95% Anterior prolapse 90% Bileaflet prolapse 90% IMR 90% (70%) FMR-nonischemic 90% (60%) Rheumatic 15% Acute endocarditis 30% Prior repair 30%

Surgical Mitral Repair Rate Gammie JF ATS 87;1431,2009

Surgical Repair Rate v Volume Bolling SF ATS 90;1904,2010

100% Mitral Repair? NORMAL MITRAL END STAGE MITRAL

Surgical DMR Early Outcomes Mortality 1% Stroke 1% Wound infection 0.3% Atrial fibrillation 20% Transfusion 0-2U LOS 5 days

Surgical Mitral Repair Unknowns New Gold Standards? - Need late results Nonresectional repairs Minimally invasive, Robotic approaches Different Gold Standards for Different Patients? DMR repair vs FMR replacement Pressures of Nonsurgical Therapies - Percutaneous More minimally invasive surgery?

Surgical Mitral Repair Gold Standard Median Sternotomy On pump Carpentier resectional techniques (DMR) Low but real morbidity/mortality 20 year results (DMR) 10-15% reoperation 10 year results (DMR) 10-30% >=3+MR 20-60% >=2+MR