VALVE SURGERY / HEART FAILURE Dr. F. Wellens O.-L.-Vrouwziekenhuis Aalst AORTIC VALVE MITRAL VALVE TRICUSPID VALVE

AORTIC VALVE SURGERY

Aortic valve surgery Aortic valve stenosis Heart failure systemic arterial valvular left ventricular compliance stenosis function

AVR is efficient in heart failure patients With: Preserved systolic function Reduced ejection fraction and high after load Low ejection fraction, low gradient and inotropic reserve

AVR is not efficient in patients With: Low ejection fraction, low gradient and no inotropic reserve Low ejection fraction, low flow and pseudo aortic stenosis

Epidemiology studies of patients with AS: demonstrate that an important cohort will not undergo AVR although the conservative management showes a dismal prognosis Euro Heart Surgery: 32% Loma Linda experience: 39%

Predictors of reduced survival: Advanced age Low ejection fraction Heart failure Renal failure

Annals of Thoracic Surgery 2006, vol. 82, p 2111 - 2115

Annals of Thoracic Surgery 2006 vol. 82, p 2111 - 2115

How do we indentify high risk or unoperable patients? STS risk algorithm Euroscore (additive and logistic)

These algorithms Are based upon operated patients Factors like stroke, discharge disposition and quality of life are not included Many risk variables are not included: - chest irradiation - redo with open grafts - porcelain aorta - cirrhosis - neurocognitive disorders - frailness or debility

In the “unoperable” group we need to identify these patients who are candidates for transcatheter AVR Highest tenth percentile of predicted risk by the STS risk algorithm Other candidates independant of risk algorithms: - porcelain aorta - chest irradiation - multiple sternotomies - with open grafts - CRF

Surgery for AVR and heart failure: Short ECC and Ao cc Meticulous haemostasis Optimal myocardial protection (Buckberg blood cardioplegia) Avoidance of prosthesis – patient mismatch

Prosthesis mismatch after AVR Ruel et all, Journal of Thoracic and Cardiovascular Surgery 2006, vol. 131, p 1039

Survival (x 2) Freedom from heart failure (x 5) Left ventricle mass regression

Percutaneous Transcatheter Transapical

How to discriminate the individual patients who still will benefit from AVR?

Evaluation of aortic stenosis in Heart Failure patients Value of Dobutamine stress echo BNP

BNP  550 ug/ml: poor outcome in: true aortic stenosis Bergher – Klein et al, Circulation 2007, vol. 115, p. 2484 - 2855 BNP  550 ug/ml: poor outcome in: true aortic stenosis pseudo aortic stenosis

CONCLUSION Absolute need for development of other algorithms in clinical practice. increase of age new technology economics

MITRAL VALVE SURGERY

Mitral valve surgery – Heart failure Organic M.R Functional - Rheumatic - Ischaemic CMD - Degenerative - Dilated CMD Highly successfull A failed innovation?

Functional Mitral valve regurgitation – Heart failure Normal anatomy of the mitral valve Left ventricular dysfunction When physiology is disrupted, attempts at restoring anatomy are futile.

The ischaemic Heart failure patient: Mitral valve regurgitation Left ventricular volume Asynergic areas Remote myocardium Coronary disease QRS

JACC 2005, vol. 45, p 388 - 390

Expansion of surgeon familiarity with basic and complex valvuloplasty techniques

All Mitral Valve Surgery 1991-2006 (n = 3122 )

Endoscopic Mitral Valve surgery, 1997 – 2006 (+/- tricuspid surgery) (Total = 1140, MVP = 842, MVR = 298)

Patients with impaired left ventricular function and even a mild degree of M.R will have a decreased five year survival B.H. Trichon et al; American Journal of Cardiology; 2003; vol. 91

No convincing data for: Surgical expertise Natural history MVP as treatment for end stage heart failure No convincing data for: Increased longevity Improval of symptoms Reduction in ventricular size

Mitral valve anatomy Ventricular dysfunction creates: Annular dilatation Increase of interpapillary muscle distance Amplified leaflet thetering Decreased closing forces

Knowledge of: Presence of leaflet malcoaptation Malapposition Annulus diameter Interpapillary distance Chordal length is critical for the mode of repair

Additional techniques External devices (CorCap, …) Section of secondary chordae Repositioning papillary muscles Remodeling infero – posterior infarct zone Leaflet extension Edge to edge technique + Treatment of atrial fibrillation (Minimaze) + CRT (left ventricular epicardial lead)

Mitral valve replacement In case of: Complex multiple jets No annular dilatation Large tenting area Coaptation depth > 15 mm

Results of repair operations for functional MR in Heart Failure patients are mostly analyzed with an overwhelming bias that mitral intervention in heart failure must be beneficial. Efficacy of mitral surgery in heart failure: LV remodeling (ventricular size and function) symptoms (need for medication – hospitalisation) survival

Survival Medical treatment: 1990 – 2000 : ± 50% Cleveland clinic experience for ischaemic M.R: survival at 5 years, ± 50 % MV repair is better than MVR Journal of Thoracic and Cardiovascular Surgery 2001, vol. 122, p 1125 - 1141

Combined MVR + CABG No survival benefit from MVP 5 year survival: 50% or less Harris et al; The Annals of Thoracic Surgery ; 2002, vol. 74, p 1468 – 1475 Diodato et al; The Annals of Thoracic Surgery; 2004, vol. 78, p 794 – 799

No clearly demonstrable mortality benefit. Michigan experience 1995 – 2002 No clearly demonstrable mortality benefit. Irrespective of heart failure etiology. Earlier patients MVP rings: complete rigid smaller Wu et al, JACC 2005, vol. 45, p 381 - 387

Exceedingly limited information Braun et al. (Leiden): In 87 patients: Effect on remodeling Exceedingly limited information Braun et al. (Leiden): In 87 patients: meticulous F.U small but significant reduction in moderately dilated hearts but: - no control group - 75% combined CABG

Braun et al. , European Journal of Cardiothoracic Surgery, 2005, vol Braun et al., European Journal of Cardiothoracic Surgery, 2005, vol. 27, p. 847 - 853

The Leiden protocol LVEDD < 65 mm: MV repair: downsizing 2 sizes coaptation depth: 8 mm LVEDD > 65 mm: MV repair + ACORN device LVEDD > 80 mm: - orthotopic HTX - destination therapy / mechanical assist - (Batista?) Tricuspid valve repair when A – P diameter exceeds 40 mm

Two year surgical benefit of MVP CorCap cardiac support device Very limited differences compared to medical controll group Acker, Bolling et al, J. Thoracic and Cardiovascular Surgery 2006, vol. 132, p 368 – 577

Effect on symptoms Extensive empiric clinical experience is the basis of widespread belief that MV surgery has a beneficial effect on symptomatic heart failure. Unfortunately: Only improvement in NYHA class No quantitative data on - exercice tolerance - reduction hospitalization/medication

Why is MV-surgery for functional MR less convincing? Is the current repair technique not durable? Most studies: high recurrence of MR > 2+ Braun et al: a very small (24-26) use of semirigid complete rings may result in improved durability. Stimulus of remodeling is severe in ischaemic pathology FMR is dependant on loading conditions and activity levels

Has minimal access surgery an impact on the results of MV-surgery for Heart Failure? No studies available Empiric results: favorable minimal access with decreased mortality and morbidity (more pronounced in redo settings)

Future role of percutaneous mitral valve remodeling? Probably very limited in Heart failure patients with: LVEDD > 60 mm LVESD > 50 mm

Randomized study is urgently needed Conclusion: Functional MR in heart failure patients is a poor prognostic sign. MVR data retrospective: survival benefit? remodeling: limited symptoms: limited How to indentify the patient groups that derive significant benefit? Randomized study is urgently needed

THE TRICUSPID VALVE

The tricuspid valve Tricuspid regurgitation will never dissappear after correction of left-sided lesions. Progressive evolution towards TR post mitral and/or aortic valve surgery The Annals of Thoracic Surgery 2005, vol. 79, p 127 - 132

More agressive approach to tricuspid valve surgery Tricuspid valve regurgitation Fysiology Diuretics Vasodilators

Pre- or perioperative echography or surgical measurement of tricuspid valve diameter will indicate the surgical indication and not the presence or absence of tricuspid valve regurgitation

CONCLUSION There is a most intimate interdependence of physiology, pathology and surgery. Without progress in physiology and pathology, surgery could advance but little, and surgery has paid its debt by contributing much to the knowledge of the pathologist and physiologist, never more than at the present. William Stewart Halsted, 1852 - 1922