1. How I treat Functional Mitral Regurgitation: The Surgeon’s perspective
Thierry MESANA, MD, PhD
President and CEO
Professor Cardiac Surgery
Valve Surgery Research Chair
University of Ottawa Heart Institute
Ottawa, Ontario, Canada

2. I have no relevant financial relationships

3. GUIDELINES for Surgery in FMR not clear
Symptomatic despite optimal medical management
J Am Coll Cardiol. 2014;63(22):e57-e185
European Heart Journal 2012;33:
US : Uncertain benefit if moderate MR and
need severe symptoms for isolated MV surgery
EU : CABG + MV with EF > 30 %
But Below 30% look forViability
ISOLATED ? Need to have symptoms ++
No specification of type of surgery

4. FACT: RECURRENT MR FOLLOWING REPAIR IS COMMON and no clear advantage on survival

5. No significant difference in left ventricular reverse remodeling or survival at 12 months between patients who underwent mitral-valve repair and those who underwent mitral-valve replacement.
Replacement provided a more durable correction of mitral regurgitation, but there was no significant between-group difference in clinical outcomes.

6. FACT: UNDERSTANDING FUNCTIONAL MR IS CHALLENGING “ALL FMR ARE NOT EQUAL”

7. CARPENTIER Functional Classification Type I
Dilated LV, Ischemic or non Ischemic
Free edge of the leaflets are at or below the annulus level
Leaflet tethering, MV tenting
ANNULAR DILATATION with often a LOW EJECTION FRACTION ++
Ø     Type I: Normal Leaflet Motion
Regurgitation can still occur with normal leaflet motion due to annular Dilation or leaflet perforation. One disease state typically causing Type I is dilated cardiomyopathy. Techniques of valve repair for this type of functional problem may include the following:
1.      Implantation of an annuloplasty ring
2.      Annular reduction
3.      Closure of leaflet defect

8. CARPENTIER FUNCTIONAL ANATOMY Restricted Leaflet(s) : Type III b
PL Restriction from posterior MI
Posteromedial PM displacement
Relatively anterior leaflet prolapse
NOT NECESSARILY LOW EF
NOT NECESSARILY LARGE MV ANNULUS
ASYMETRICAL ANNULAR DEFORMATION (P2-P3)
BASAL DYSKINESIA (RELATIVELY ANEURYSMAL)
Ø     Type IIIa: Restricted Leaflet Motion
Restricted leaflet motion often results in stenosis although regurgitation may also occur. Restricted leaflet motion may be due to one or more of the following:
1.      Commissural fusion
2.      Chordal fusion
3.      Leaflet thickening
One disease state typically causing Type IIIa restricted motion is rheumatic disease.

9. Measuring leaflet tenting (angles, lenghts, surfaces)
GEOMETRY OF FMR
Measuring leaflet tenting (angles, lenghts, surfaces)
N-51 consecutive patients; preoperative echos and postoperative echos performed at a mean of 9 days.
Magne et al. Circulation 2007;115:

10. FACT : SURGICAL REPAIR STRATEGIES ADDRESSING RESTRICTION ARE LIMITED

11. Alternatives/Additional solutions
ANNULAR.
Rigid vs. flexible
Full vs. partial
2d vs. 3D rings
CHORDS.
Second chord cutting (Messas, Borger)
Neochords for false AL prolapse
PAPILLARY MUSCLE .
Posteromedial PM relocation to MV annulus right (Kron),
“Ring and String” (Langer-Schaeffers) : Goretex from PM to aortic annulus
“Ring and Sling” (Hvass) : Goretex suture encircling both PM
LEAFLET STRATEGIES.
Posterior Leaflet extension
Edge-to-Edge

12. Carpentier-McCarthy-Adams IMR Etlogix ring .
Figure 1. The new asymmetrical Carpentier-McCarthy-Adams IMR Etlogix ring (CMA IMR ETlogix ring). This new ring is undersized with a 14% reduction in the postero-medial dimension (D2, D3 dimension). Note that this ring has a slight dip at P2-P3 (left) and a narrower dimension at P2-P3 (right; D2, D3).
Daimon M et al. Circulation. 2006;114:I-588-I-593
Copyright © American Heart Association, Inc. All rights reserved.

13. LEAFLET EXTENSION FOR IIIb MITRAL REGURGITATION
Parsonnet score of 38
Mean LVEF 33%
44 patients > initial results operated
From P2 to PM commissure- 1cm high and 4-5 cm long
90 % freedom of moderate /severe MR at 2 years
De Varennes et al. Circulation 2009;119:

14. Annuloplasty + Edge-to-Edge suture
“Alfieri technique augment leaflet coaptation when more tethering”
Advantage : Simple, Fast, Teachable, Reproduceable

15. Figure 4. Freedom from recurrence of MR of grade 3 to 4+ in the edge-to-edge and in the ring-only groups.
Figure 4. Freedom from recurrence of MR of grade 3 to 4+ in the edge-to-edge and in the ring-only groups.
De Bonis M et al. Circulation. 2005;112:I-402-I-408
Copyright © American Heart Association, Inc. All rights reserved.

16. No annuloplasty with E-to-E technique
Freedom from recurrence of mitral regurgitation (MR) of grade 3 to 4+.
Freedom from recurrence of mitral regurgitation (MR) of grade 3 to 4+.
De Bonis M et al. Circulation. 2014;130:S19-S24
Copyright © American Heart Association, Inc. All rights reserved.

17. Most Reliable Surgical Alternative today
VS.
MV Replacement with chordal preservation if :
Less experience with repair
Imperfect /uncertain immediate result
“Good replacement better than a bad repair”
Most of these patients do not do well with residual MR…

19. Mitral Valve Surgery Operative Risk
Alternatives to surgery in selected patients with a high EuroSCORE II and the STS risk score
Risk calculators do not accurately predict outcomes for a high volume center of MV surgery
Mitraclip should be developed by Heart teams in centers of excellence with high volumes of MV disease refferral and surgical expertise
Percutaneous therapies are a viable alternative to surgery in selected patients with a high estimated perioperative risk.
The 2 most commonly utilized risk calculators include the EuroSCORE II and the STS risk score.
These risk calculators were developed based on data from large registries and have been extensively validated.
Although well designed, these risk scores have certain limitations. Specifically, they may not accurately predict outcomes in under represented patient groups, such as those undergoing mitral surgery.

20. 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: (J Hopkins, Baltimore)

21. Observed & EuroSCORE II Predicted Mortality
All procedures including Mitral valve Surgery
Ottawa Heart Institute series
(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

22. MitraClip Therapy Broad Spectrum of Experience
EVEREST II
(Randomized Controlled Trial)
EVEREST II
(High Risk Cohort^)
ACCESS EU
(Europe)
MitraClip in clinical trials
In EVEREST II RCT patients are adjudicated through two years
In EVEREST II High Risk Cohort patients are adjudicated through 1 year
Remember pointing out to them the etiology mix in EVEREST II and show the progression in patient etiology with time
Look at the real world and how we can impact FMR
Note
Device time improvements: implantation efficiency increases with experience
Implant rate: Patient screening and implantation experience improve implant rates
Valve etiology of treated patients: Unmet need in FMR has driven driven commercial adoption of MR Rx (see section 3)
178 patients
Device time – 146 minutes
Implant rate – 89%
211 patients
Device time – 127 minutes
Implant rate – 95%
567 patients
Procedure time – 117 minutes
Implant rate – 99%
= DMR
= FMR 22

23. MITRACLIP UOHI EXPERIENCE
Total Cases: 101 patients
Average # of Clips per procedure: 1.62
Average MR reduction: -2.11
Average Clip Time: 133 minutes

24. Average MR after Implant
FMR MR Grade Post-Clip (74 pts)
Intra-Op TEE (Pre Implant)
Post Implant
In Hospital Echo
1 Month Echo
6 Month Echo
1 Year Echo
2 Year Echo
3 Year Echo 74 72 71 62 38 36 23 11
3.64
1.53
1.62
1.65
1.71
1.69
1.87
1.45
DEG MR Grade Post-Clip (21 pts) 21 19 20 16 10 8 1
3.76
1.84
1.88
1.82
1.70
1.75 2
Mixed MR Grade Post-Clip (6 pts) 6
3.17
1.17
1.67
1.5 X

25. Mitral Regurgitation Grade at 5 Years
DMR
FMR
MitraClip (N=130)
Surgery (N=62)
MitraClip (N=48)
Surgery (N=18)
p<0.005
p<0.005
p<0.05
p=0.82
81%
100%
86%
86%
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N=85 25

26. Our indications for FMR
Severe, Isolated FMR in DCMP:MITRACLIP is the preferred choice if medical therapy fails.
Moderate or severe FMR with associated cardiac surgery (CABG, AVR): MV procedure repair or replacement depending of anatomy and surgical comfort. Simpler is better
Severe Ischemic MR with no further revascularization : Clip or medical. Previous CABG ++

27. 1- As these technologies become available for patients with degenerative or functional MR, it will be important for experienced referral centers and cohesive heart teams to guide their deployment into clinical practice.
2- As well, the short- and long-term technologies must be evaluated through dynamic registry supported by relevant stakeholders.
JACC 2014:840-52

28. THANK YOU

29. CABG alone # CABG+ mitral Valve repair
The trial did not demonstrate a clinically meaningful advantage to the routine addition of MVr to CABG . Longer-term follow-up is ongoing: will the lower incidence of moderate or severe MR at one-year translate into a net clinical benefit for patients undergoing CABG + mitral repair?

30. Our experience of Edge-to Edge + annuloplasty in FMR
Mitral valve replacement is a viable alternative to mitral valve repair for ischemic mitral regurgitation: A case-matched study
Vincent Chan, MD, MPH; Marc Ruel, MD, MPH; Thierry G. Mesana, MD ,PhD
Ann Thorac Surg Oct;92(4): ; discussion
Our experience of Edge-to Edge + annuloplasty in FMR
29% recurrent 2+ MR after one year echo FU
4% MR 3+ or 4+
Same survival at 5 years
Limited Clinical impact of residual 2+ MR