1. Mitral Valve Surgery For Heart Failure
Dr. J Brink
University of the Free State

2. Introduction 5,000,000 Americans suffer from HF
500,000 newly Dx each year
Cost to society of > $30 Billion in 2005
50% 3 year mortality (Bolling)
Natural history of CIMR (1y mortality)
- CAD & No IMR: 6%
- Mild: 10%
- Moderate: 17%
- Severe: 40%

3. SAVE Trail ( Survival and Ventricular Enlargement study)
LAMAS Circ 1997

4. Definitions No uniform definition Acute IMR : °2 to PM infarction
Cardiogenic shock
Chronic IMR: > 1 week post MI
1/ > ventricle wall motion abn
CAD in abn wall distribution
Structural normal MV leaflets

5. Pathophysiology
Normal MV function requires coordinated dynamics of all components
Annulus
Leaflets
Chordae
Papillary muscle
Ventricle

7. Saddle Shape of Normal Systole
Frater

8. Diagnosis Symptoms of HF & murmur TEE Echo - Carpentier classification
- Grading
- Effective regurgitant orifice
- Regurgitant Volume
- Coaptation depth
- LVEDD, LVESD
- LVESVI

9. Carpentier Classification (type I)
Central Jet
Annuloplasty - Dilatation (McCarthy Never Say Never)

10. Carpentier Classification (type III b)
Restrictive Systolic Leaflet Motion
Complex Jet ( Mayo)
Treatment more complex

11. Color Doppler

12. Grading Grade RV (ml) ERO (mm²) I <30 <20 II 30 - 44 20-29 III
45 – 59
30-39 IV
>60
>40
Maurice Serrano

13. Effective Regurgitant Orifice
5y Survival
- < 20 mm² : 47%
- > 20 mm² : 29%

14. Regurgitant Volume
5 y survival
- < 30 ml : 44%
- > 30 ml : 35%

15. Coaptation Depth

16. “Seagull Sign”

17. LVEDD (Dion) LVEDD < 6.5 cm LVESD < 5.1 cm
- LV reverse remodelling

18. LVESVI > 30 ml/m² - impaired LVF post-op
40-50 ml/m² - referral for surgery
>60 ml/m² very poor surgical outcome
Borow

19. Isolated CABG vs MV surgery & CABG
3/4 IMR CABG & MV surgery
1/2 IMR Balance risk of long term IMR & HF with a 2 fold peri-op risk of add. MV surgery (Mallidi)
% progress to 3/4 IMR in 16 months
- 1/2 IMR & ↑ co-morbidities & < 5y life exp.
CABG alone
- 1/2 IMR & low risk
CABG & MV surgery

20. Surgical Options

21. MV Replacement Reliable Acute IMR CIMR & co-morbidities Complex jets
Severe tethering
Coaptation > 10 mm (Calafiori)

22. MV Replacement
Retention of subvalvular apparatus
(Lillihei 1964)

23. MV Replacement
Cohn

24. MV Repair
Repair vs replace equally effective immediately post-op but repair ass. with ↓ peri-op mortality (Gillinov & Grossi)
High risk pt with most severe IMR do possibly better with replacement
General consensus is to repair whenever possible due to lower peri-op mortality

25. Undersized Mitral Annuloplasty
Type of ring – complete and rigid
Recurrent MR in 28% 6 months post-op
Lead to examine alternative therapies

26. Tailor Ring 25: Fluid Test
Frater

27. GeoForm Ring (Bolling)
Titanium & silicon ring
Saddle shape
Elevate ventricle
Restore position of PM toward MV
↑ coaptation & ↓ regurgitation
Restore geometry

28. A Finite Element Study (Bolling 2007)

29. Second-Order Chordal Cutting
↓ leaflet tethering
Divide all °2 chords from effected PM
Lead to a debate on ? LV Dimensions and ? decreased LV function

30. Cutting Load Bearing Second 2° Chordae
Frater

31. Alfieri Edge-Edge Repair
Quick & easy
Stitch center of anterior and posterior leaflets creating a double orifice & ring
Recurrent MR in 30% pt 1y post-op (Bhudia & McCarthy)

32. Papillary Muscle Sling (Hvass)
Correction of abn PM displacement
Intra-ventricular Gore-Tex-sling
Device implanted in via LA & MV and encircle trabecular base of papillary muscle + ring
↓ distance between papillary muscles
Double ring
? Long term result 32

34. Surgical Relocation of Posterior PM
Kron
suture to connect posterior papillary muscle to mitral annulus adjacent to R trigone + ring
↓ tethering & ↑ coaptation
No MR 8/52 post-op 34

35. Posterior MV Restoration
Fundaro
Ameliorate post leaflet tethering
Incision in base of posterior leaflet
Cut basal chordae
Annular plication
Close defect in posterior leaflet
Reinforce annulus with Gore-Tex strip 35

36. Infarct Plication (Guerroro procedure)
↓ myocardial bulging
PM move toward annulus
Mattress sutures in infarcted area
More data needed

37. Dacron Patch Inflatable Balloon
Animals
Non invasive
Inflated in infarcted myocardium
Displace PM toward the annulus
↓ MR

38. Acorn Cardiac Support Device
LVEDD > 6.5 cm & LVESD > 5,1 cm (Dion)
Polyester mesh fabric
↓ WT & ↓ LV volume
External support & prevent further dilatation
No constrictive physiology

39. Experimental Therapies for MR
Percutaneous Alfieri repair
- Double-arm clip device via femoral a.
- ? Results
- Recurrent MR ? Because of no ring

40. Experimental Therapies
Percutaneous annuloplasty
- Device put in coronary sinus
- Risk

41. Experimental Therapies
Myocor Coapsys
- Restore septoannular geometry
- 2 epicardial pads
- Expanded subvalvular chord
- Posterior pad shape of the ventricle
- Anterior pad
- Tightened under echo guidance
- Optimize law of La Place

42. Myocor Coapsys

43. Conclusion Heart failure with MR is a common clinical entity
Several surgical therapies have rapidly evolved but with disappointing results
Recent clinical, theoretical and experimental studies have shed new light on this problem
MV surgery in HF should remain an active area of research to optimize surgical treatment strategies