valve surgery / heart failure 1)aortic valve 2)mitral valve 3)tricuspid valve dr. f. wellens...
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VALVE SURGERY / HEART FAILURE
1) AORTIC VALVE
2) MITRAL VALVE
3) TRICUSPID VALVE
Dr. F. Wellens
O.-L.-Vrouwziekenhuis Aalst
AORTIC VALVE SURGERY
Aortic valve surgery
Aortic valve stenosis
Heart failure
systemic arterial valvular left ventricular
compliance stenosis function
AVR is efficient in heart failure patients
With:
1) Preserved systolic function
2) Reduced ejection fraction and high after load
3) Low ejection fraction, low gradient and inotropic reserve
AVR is not efficient in patients
With:
1) Low ejection fraction, low gradient and no inotropic reserve
2) Low ejection fraction, low flow and pseudo aortic stenosis
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%
Predictors of reduced survival:
• Advanced age
• Low ejection fraction
• Heart failure
• Renal failure
Annals of Thoracic Surgery 2006, vol. 82, p 2111 - 2115
Annals of Thoracic Surgery 2006 vol. 82, p 2111 - 2115
How do we indentify high risk or unoperable patients?
• STS risk algorithm
• Euroscore (additive and logistic)
These algorithms
1) Are based upon operated patients
2) Factors like stroke, discharge disposition and quality of life are not included
3) Many risk variables are not included:- chest irradiation- redo with open grafts- porcelain aorta- cirrhosis- neurocognitive disorders- frailness or debility
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
Surgery for AVR and heart failure:
1) Short ECC and Ao cc
2) Meticulous haemostasis
3) Optimal myocardial protection (Buckberg blood cardioplegia)
4) Avoidance of prosthesis – patient mismatch
Prosthesis mismatch after AVR
Ruel et all, Journal of Thoracic and Cardiovascular Surgery 2006, vol. 131, p 1039
Survival (x 2)
Freedom from heart failure (x 5)
Left ventricle mass regression
Percutaneous
• Transcatheter
• Transapical
How to discriminate the individual patients who still will benefit from AVR?
Evaluation of aortic stenosis in Heart Failure patients
• Value of
• Dobutamine stress echo
• BNP
Bergher – Klein et al, Circulation 2007, vol. 115, p. 2484 - 2855
BNP 550 ug/ml: poor outcome in:
• true aortic stenosis
• pseudo aortic stenosis
CONCLUSION
Absolute need for development of other
algorithms in clinical practice.
increase of age
new technology
economics
MITRAL VALVE SURGERY
Mitral valve surgery – Heart failure
Organic M.R Functional
- Rheumatic - Ischaemic CMD
- Degenerative - Dilated CMD
Highly successfull A failed innovation?
Functional Mitral valve regurgitation – Heart failure
1) Normal anatomy of the mitral valve
2) Left ventricular dysfunction
When physiology is disrupted, attempts at restoring anatomy are futile.
The ischaemic Heart failure patient:
• Mitral valve regurgitation
• Left ventricular volume
• Asynergic areas
• Remote myocardium
• Coronary disease
• QRS
JACC 2005, vol. 45, p 388 - 390
Expansion of surgeon familiarity with basic and complex valvuloplasty techniques
All Mitral Valve Surgery 1991-2006(n = 3122 )
0
25
50
75
100
125
150
175
200
225
250
275
300
'91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06
MVR
MVP
Endoscopic Mitral Valve surgery, 1997 – 2006(+/- tricuspid surgery)
(Total = 1140, MVP = 842, MVR = 298)
0
50
100
150
200
250
'97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07
Total
MVP
MVR
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
Surgical expertise
MVP as treatment for end stage heart failure
Natural history
No convincing data for:
• Increased longevity
• Improval of symptoms
• Reduction in ventricular size
Mitral valve anatomy
Ventricular dysfunction creates:
• Annular dilatation
• Increase of interpapillary muscle distance
• Amplified leaflet thetering
• Decreased closing forces
Knowledge of:
• Presence of leaflet malcoaptation
• Malapposition
• Annulus diameter
• Interpapillary distance
• Chordal length
is critical for the mode of repair
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)
Mitral valve replacement
In case of:
• Complex multiple jets
• No annular dilatation
• Large tenting area
• Coaptation depth > 15 mm
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
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 1125 - 1141
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
Michigan experience 1995 – 2002
No clearly demonstrable mortality benefit.
Irrespective of heart failure etiology.
1) Earlier patients
2) MVP rings: complete
rigid
smaller
Wu et al, JACC 2005, vol. 45, p 381 - 387
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
Braun et al., European Journal of Cardiothoracic Surgery, 2005, vol. 27, p. 847 - 853
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
1) Two year surgical benefit of MVP
2) CorCap cardiac support deviceVery limited differences compared to medical controll group
Acker, Bolling et al, J. Thoracic and Cardiovascular Surgery 2006, vol. 132, p 368 – 577
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
Why is MV-surgery for functional MR less convincing?
1) 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.
2) Stimulus of remodeling is severe in ischaemic pathology
3) FMR is dependant on loading conditions and activity levels
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)
Future role of percutaneous mitral valve remodeling?
Probably very limited in Heart failure patients
with:• LVEDD > 60 mm
• LVESD > 50 mm
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
THE TRICUSPID VALVE
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 127 - 132
More agressive approach to tricuspid valve surgery
Tricuspid valve regurgitation
Fysiology
Diuretics
Vasodilators
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
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, 1852 - 1922
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