1. The Spectrum of Evolving Mitral Repair Techniques
Thierry Mesana, MD, PhD
Division of Cardiac Surgery
University of Ottawa Heart Institute (UOHI)
Ottawa, Ontario, Canada

2. Thierry Georges Mesana, MD, PhD
I/we have no real or apparent conflicts of interest to report.

3. The Evolution of MV repair concepts
1- Leaflet repair/reconstruction and Annuloplasty
A.Carpentier Durable, More challenging, Less Reproducible?
Needs Learning curve
2- Chordal repair/replacement, PTFE :
T.David Made a big difference for Anterior leaflet. Now extended to Posterior leaflet. Easier, More reproducible . Greater MV area ? As Durable?
More applicable to minimally invasive.
3- Other “respect” techniques : leaflet work but no chordal work
Folding plasty for PL only
Edge-to-Edge (Alfieri technique) for PL, AL and BL.
4- Mini-mitral and Percutaneous concepts
From standard sternotomy with CPB gold standard MV repair
to small incision with CPB (mini-mitral) ? ……………….Potential realized ?
to percutaneous /no CPB ? ……………… Changing our concepts…. and goals ?

4. The Mitraclip reproduces the Alfieri technique. Safe and reproducible
The Mitraclip reproduces the Alfieri technique. Safe and reproducible. One or several clips
Mostly used in FMR and OMR with surgical contraindications. No annuloplasty associated.

5. NEO chord System. Trans apical. Not percutaneous. No annuloplasty

6. Annuloplasty is Mandatory for a Good and Durable MV Repair in a vast majority of patients
Bands vs.Rings
Flexible vs. Rigid
2D vs.3D
Risk of SAM ?
Risk of MS ?

7. Percutaneous coronary sinus annuloplasty ?

8. The Mitralign Procedure Approximating a Kay Annuloplasty
Surgical Repair:
Kay Annuloplasty
Deliver pledgets to P1 and P3 areas, plicate
Reduce anterior-posterior (AP) distance
Percutaneous Repair:
Plicated pledget pair
Commissures
Commissures
Commissures
Commissures P1 P3 P1 P3 P2 P2
(C) Completion of redo mitral repair, i.e. modified Paneth plasty with pericardial strip reinforcement and additional Kay–Wooler annuloplasty of the posteromedial commissure.
Completed repair
2 pairs of pledgets
Commissures
Commissures P3 P1 P1 P3 P2 P2

9. Percutaneous MV repair : the future for some…likely different goals
True MI techniques : no use of CPBypass
Percutaneous + Transapical. However, unlike AS and TAVI, MV disease is multi-faceted. Multiple MR mechanisms. One technique does not fit all
Perfect result or acceptable result ?
Long-term result of repair techniques ?
Percutaneous MV replacement may have more future

10. MINIMALLY INVASIVE MITRAL VALVE REPAIR (“MINI-MITRAL”)
Maintain goals of MV repair surgery :
1-Very low risk ( <1%, close to 0%), low complication rate
2-Very high repair rate in MVP of all types ( >95%)
3- No or mild residual MR on post-operative Echo
4-Excellent durability ( > 90% at 10 year)
5- If not, percutaneous may be more competitive…

11. Video-assisted vs. Robotic
MITRAL VALVE SURGERY

12. Real videoassited surgery. No retractor. Thoracoscopic instruments
Real videoassited surgery. No retractor. Thoracoscopic instruments. Looking at screen not through incision

13. MICS CHANGES THE GOALS OF THE OPERATION
Really minimally invasive ?
Smaller but multiple incisions + more traumatic and longer CPB
Include complicated picture. Describe the shift in objectives where differences in all aspects of heart surgery, de-airing, cannulation,

14. 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:

15. MORE STROKES AND DEATH for some Seeburger et al. EJCTS 2008
UOHI, 625 pts MVP, y-o (presented at EACTS, in press EJCTS)
No mini-mitral, all comers, 97% repair, 0% death, 1 stroke (day5).

16. Robotic surgery is not a benign surgery
Robotic surgery is not a benign surgery. Patient Misperception GREATER RISK OF BLEEDING & COMPLICATIONS for some
Mihaljevic et al. J Thorac Cardiovasc Surg 2011;141(1):72-80

17. MINI MITRAL Extent of repair : the same. Safety : the same
MINI MITRAL Extent of repair : the same ? Safety : the same ? 1- Mostly PL prolapse 2-More chordal repair or simple leaflet resection 3- More applicable to low-risk patients with normal LV function and no Annular Calcifications 4- Once you are “mini “ you are committed and should be ready to face safely unpredicted situations

18. MINIMITRAL : LOW REPAIR RATE for some
21/219 underwent replacement = 90% repair rate
52/52 patients with rheumatic underwent replacement
How to deal with unexpected anatomy ?
Extensive PLP, borderline AL pre-op
becoming more significant post,
post-op SAM,… things happen in MV Sx…
Casselman et al. Circulation 2003;108:II-48-II-54

19. Degenerative Mitral Valve Prolapse Increased Anatomical Complexity not necessarily corresponding with increased patient risk
Older patients
Younger patients

20. Evolving Spectrum of MV repair
The main goal should still be to offer a good and stable result.
Conventional surgical MV repair can offer a perfect and stable result with very low risk, low complication, and low cost in most patients
The spectrum of MV disease needs a spectrum of MV repair techniques
No such thing as simple, no risk mini-mitral. Tell the patient (misperception)
Mini-mitral only equivalent in experienced centers
Percutaneous MV repair should also be done only in expert MV centers with expert MV surgeons (<5% of cardiac surgeons do > 75 MV cases /year)
It should not be about “doing something” on the MV
Careful follow-up with dedicated clinic and serial echocardiograms with data > 2 years needed for FMR and > 5 years for OMR

21. Thank You

22. Gammie J. S. et al.; Ann Thorac Surg 2010;90:1401-1410
STS Database 20% do at least one/ year, very few more than 50 /year.
Average less than 5/year
50 out of 700 centers report use of robots
Gammie J. S. et al.; Ann Thorac Surg 2010;90:

23. 187 patients between February 1997 – October 2001
187 patients between February 1997 – October 2001 with one hospital death and 1 early and 6 late reoperations
187 patients between February 1997 – October 2001
One hospital death and 1 early and 6 late reoperations
Read at the 82nd meeting of the AATS

24. A “simple” Mini mitral which does not change the goals of surgery