disclosure david h. adams, md - american...

Inventor with Royalty Agreements with Edwards

Lifesciences and Medtronic:

Physio II Mitral Annuloplasty Ring

IMR ETlogix Mitral Annuloplasty Ring

TriAd Tricuspid Annuloplasty Ring

National Co-PI: Core Valve-Medtronic US Pivotal Trial

Disclosure

David H. Adams, MD

David H. Adams, MD Marie-Josée & Henry R. Kravis

Professor & Chairman

Department of Cardiothoracic Surgery

The Mount Sinai Medical Center

New York, NY

Mitral Valve Repair: Which Technique

is Best for Which Lesion

Annulus, Leaflets, Commissures, Chordae,

Papillary Muscles and the left Ventricle

Structures Involved in Mitral Function

Adams et al In Hurst’s the Heart 2011;Vol 2:1721-37

Structures Involved in Mitral Function

The Pathophysiological Triad

Carpentier et al. J Thorac Cardiovasc Surg 1983;86

Etiology

Lesions

Dysfunction

Mitral Repair Surgical Strategy

Etiology

Lesions

Repair

Strategy

Anyanwu AC and Adams DH ; J Thorac Cardiovasc Surg 2008;36

Mitral Valve Repair

Optimize Valve

Exposure

Surgical Tips

Place Annuloplasty

Sutures First

Valve / Lesion

Analysis

Optimize Valve Exposure

• Develop Sondergaard’s Groove

• Curvilinear Left Atrial Incision

• Specialized Mitral Retractor

Mitral Valve Repair

Optimize Valve

Exposure

Surgical Tips

Place Annuloplasty

Sutures First

Valve / Lesion

Analysis

Valve and Lesion Analysis

• Assess All Structural Components

• Identify All Lesions (consider MR jets)

• Plan Surgical Strategy

Mitral Valve Repair

Optimize Valve

Exposure

Surgical Tips

Place Annuloplasty

Sutures First

Valve / Lesion

Analysis

Place Annuloplasty Sutures First

• Backhand on the Horizontal

• Forehand on the Vertical

• Interlocking Sutures are Fine

Mitral Valve Repair

Consider Leaflet

Indentations

Surgical Tips

Magic Suture to Correct

Commissural Lesions

Neochord Adjustment

after Ring

Consider Leaflet Clefts

• Distinguish Clefts and Indentations

• Close Clefts to Create Single Segments

• Target Clefts in Leaflet Resections

Mitral Valve Repair

Consider Leaflet

Indentations

Surgical Tips

Magic Suture to Correct

Commissural Lesions

Neochord Adjustment

after Ring

Magic Suture at Commissure

• Advances the Commissure and Coaptation

• Corrects Commissural Prolapse

• Corrects Commissural Restriction

Mitral Valve Repair

Consider Leaflet

Indentations

Surgical Tips

Magic Suture to Correct

Commissural Lesions

Neochord Adjustment

after Ring

Neochord Adjustment after Ring

• Allows Discrimination of Prolapsing Segments

• “Functional” Assessment of Chordal Height

Adams et al In Hurst’s the Heart 2011;Vol 2:1721-37

Carpentier’s Functional Classification

Assessment of Leaflet Integrity and Annular Dilatation

Leaflet Perforation Annular Dilatation

Surgical Strategy - Type I

Patch Augmentation Annuloplasty

Patch Augmentation

Assessment of Leaflet Integrity and Annular Dilatation

Leaflet Perforation Annular Dilatation

Surgical Strategy - Type I

Patch Augmentation Annuloplasty

Annuloplasty

Type II - Prolapse

Adams et al. Eur Heart J 2010;31:1958-1967

+ ++ +++ ++++

FED FED+ Forme Fruste Barlow’s

Leaflet Tissue

Minimal Leaflet Tissue

Chordal

Transfer

PTFE

Neochordoplasty

Triangular

Resection

Surgical Strategy - Type II

Chordal Transfer

Minimal Leaflet Tissue

Chordal

Transfer

PTFE

Neochordoplasty

Triangular

Resection

Surgical Strategy - Type II

PTFE Neochordoplasty

Minimal Leaflet Tissue

Chordal

Transfer

PTFE

Neochordoplasty

Triangular

Resection

Surgical Strategy - Type II

Triangular Resection

FED – Bileaflet Prolapse

FED – Bileaflet Prolapse

Minimal Leaflet Tissue: Annular Plication

Excess Leaflet Tissue

Targeted

Resection(s)

Leaflet Sliding

Plasty

Leaflet

Displacement

Surgical Strategy - Type II

Leaflet Displacement

Excess Leaflet Tissue

Targeted

Resection(s)

Leaflet Sliding

Plasty

Leaflet

Displacement

Surgical Strategy - Type II

Targeted Resection

Excess Leaflet Tissue

Leaflet

Displacement

Leaflet Sliding

Plasty

Targeted

Resection(s)

Surgical Strategy - Type II

Leaflet Sliding Plasty

Barlow’s Disease – Bileaflet Prolapse

Barlow’s Disease – Bileaflet Prolapse

Assessment of Lesions and Tissue Availability

Surgical Strategy - Type IIIa

Commissural Fusion Leaflet Retraction Chordal Restriction

Glutaraldehyde Fixed

Pericardium Techniques Commissurotomy

& “Magic Suture”

Chordal Fenestration

Chordal Replacement

Commissurotomy

Assessment of Lesions and Tissue Availability

Surgical Strategy - Type IIIa

Commissural Fusion Leaflet Retraction Chordal Restriction

Glutaraldehyde Fixed

Pericardium Techniques Commissurotomy

& “Magic Suture”

Chordal Fenestration

Chordal Replacement

Leaflet Enlargement

Assessment of Lesions and Tissue Availability

Surgical Strategy - Type IIIa

Commissural Fusion Leaflet Retraction Chordal Restriction

Glutaraldehyde Fixed

Pericardium Techniques Commissurotomy

& “Magic Suture”

Chordal Fenestration

Chordal Replacement

Chordal Cutting and Fenestration

Assessment of Leaflet Tethering

Surgical Strategy - Type IIIb

Less Severe More Severe

Downsized Rigid

Annuloplasty

+ Adjunctive

Techniques

Downsized Annuloplasty

Assessment of Leaflet Tethering

Surgical Strategy - Type IIIb

Less Severe More Severe

Downsized Rigid

Annuloplasty

+ Adjunctive

Techniques

Chordal Cutting in IMR

MAC with Adequate Leaflet Tissue

Surgical Strategy: MAC

Less Severe More Severe

Oversized

Annuloplasty

Unconventional

Annuloplasty

Oversized Annuloplasty - Respect

Oversized Annuloplasty - Respect

Oversized Annuloplasty - Respect

Oversized Annuloplasty - Respect

Oversized Annuloplasty - Respect

MAC with Adequate Leaflet Tissue

Surgical Strategy: MAC

Less Severe More Severe

Oversized

Annuloplasty

Unconventional

Annuloplasty

Unconventional Annuloplasty

Unconventional Annuloplasty

Unconventional Annuloplasty

Calcification with Inadequate

Leaflet Tissue

Targeted Debridement -

Patch Augmentation En bloc Resection -

Patch Augmentation

Surgical Strategy - MAC

Less Severe More Severe

Targeted Debridement – Patch Augmentation

Targeted Debridement – Patch Augmentation

Targeted Debridement – Patch Augmentation

Calcification with Inadequate

Leaflet Tissue

Targeted Debridement -

Patch Augmentation En bloc Resection -

Patch Augmentation

Surgical Strategy - MAC

Less Severe More Severe

En bloc Debridement – Patch Augmentation

En bloc Debridement – Patch Augmentation

En bloc Debridement – Patch Augmentation

Castillo et al. J Thorac Cardiovasc Surg 2012;144:308-12

Castillo et al. J Thorac Cardiovasc Surg 2012;144:308-12

Castillo et al. J Thorac Cardiovasc Surg 2012;144:308-12

Castillo et al. J Thorac Cardiovasc Surg 2012;144:308-12

Castillo et al. J Thorac Cardiovasc Surg 2012;144:308-12

Castillo et al. J Thorac Cardiovasc Surg 2012;144:308-12

Blending Strategies is the Key to

Successful Mitral Valve Repair