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

2. AORTIC VALVE SURGERY

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

4. 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

5. 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

6. 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%

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

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

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

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

11. 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

12. 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

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

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

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

17. Percutaneous
Transcatheter
Transapical

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

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

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

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

23. MITRAL VALVE SURGERY

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

25. 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.

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

27. JACC 2005, vol. 45, p

28. Expansion of surgeon familiarity with basic and complex valvuloplasty techniques

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

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

31. 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

32. 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

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

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

35. 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)

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

37. 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

38. 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

39. 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

40. 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

41. 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

42. Braun et al. , European Journal of Cardiothoracic Surgery, 2005, vol
Braun et al., European Journal of Cardiothoracic Surgery, 2005, vol. 27, p

43. 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

44. 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

45. 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

46. 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

47. 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)

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

49. 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

50. THE TRICUSPID VALVE

51. 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

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

53. 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

54. 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,