davos cardiology update 2013
TRANSCRIPT
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Minimally invasive mitral
valve surgery –
Standard of Care
V. Falk
Volkmar Falk, MD
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What is the status and
rate of implementation?
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MVR repair rate 2004-2011
DGTHG 2011
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Isolated MV surgery – MIC vs sternotomy
2004-2011
DGTHG 2011
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Isolated MVR for MR – MIC vs sternotomy
2004-2011
DGTHG 2011
2011: MIC
exceeds
sternotomy!
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Repair rate in MIC exceeds sternotomy
Germany:
MIC repair rate better than national databases
(DGTHG 2011 65.1%)
MIC MVR >90% for PML, AML and bileaflet prolapse
US:
Higher MV-repair rates with minimally invasive technique
(89% vs 67%, STS database 2008)
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Advantages of MIC MVR
• No Sternotomy
• Excellent visualization
• Fast Recovery
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Small thoracotomy approach
Muscle sparing incision Femoral cannulation for CPB
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Operative TechniqueDirect antegrade cardioplegia
(one shot cristalloid)
Transthoracic Aortic clamp
Venous cannula
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Repair-Techniques
• Enables every
known repair
technique
• Allows for complete
ring implantation
• Enables
replacement
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Principles of repair II
After a good repair…
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After a good repair…
…the valve should smile at you!
. .
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Mitral Clips don‘t smile!
. .
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Treat the whole spectrum of degenerative MR
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Cleft 3 D
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Classic P2 resection
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Classic P2 Resection
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MVR Loop Technique
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Chordal replacement PML
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Chordal replacement AML
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Commisural prolapse A1/P1
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Commisural prolapse A1/P1
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M. Barlow (excessive bileaflet prolapse) (II)
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Ablation Concept
LLPV
LUPV
RUPV
RLPV
LAA Mitralannulus(P3)
Mitralvalve
Atriotomy
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Surgical Plan
1. Quadrangular resection P2
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Surgical Plan
1. Quadrangular resection P2
2. Decalcification posterior
annulus
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Surgical Plan
1. Quadrangular resection P2
3. Triangular resection A2
2. Decalcification posterior
annulus
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Surgical Plan1. Quadrangular resection P2
2. Decalcification posterior
annulus
4. Chordae replacement A2
3. Triangular resection A2
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Surgical Plan1. Quadrangular resection P2
4. Chordae replacement A2
5. Ring implantation
3. Triangular resection A2
2. Decalcification posterior
annulus
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Post repair result – excellent coaptation
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Repair in endocarditis
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Added procedures• Tricuspid repair easy to accomplish
(beating heart)
• Atral ablation and LAA closure
• No restrictions by access
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Results match standard sternotomy
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Reoperation for Bleeding
• Fewer reexplorations for bleeding
• Similar need for transfusion
Modi P EJCTS 2008
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Neurological events
• 6 studies (1801 patients)
• No difference
Stroke rate MVR 1.6%
Modi P EJCTS 2008
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Hospitalization
• LOS less with minimally invasive approach (US)
Modi P EJCTS 2008
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Mortality
• 6 studies (1641 patients)
No difference
Modi P EJCTS 2008
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Pain and Speed of Recovery
• 4 studies
• Less postoperative pain
• Faster return to normal activity
• Fewer requirements for post-hospital
rehabilitation
Modi P EJCTS 2008
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533
115
291
0
100
200
300
400
500
600
PML AML Bileaflet
97.3% 93.5% 91.5%
* p<0.05
Repair rate 91.5% – 97,3%
Isolated PML, AML, und Bileaflet
Prolapse HCL (n=989) 2000-2007
Heartcenter Leipzig
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Seeburger J EJCTS 2010
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Long-term results MIC
Similar survival and freedom from
reoperation
Modi EJCTS 2009
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Svensson LG JTCVS 2009
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Residual MI
Propensity matched comparison
Svenson LG JTCVS 2009
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Galloway AC ATS 2009
8y freedom from Re-OP
Sternotomy 91%
MIC 95%
8y freedom from all valve
related complications
Sternotomy 86%
MIC 90%
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MIC MVR for bileaflet repair ?
Randomized trial (MIC vs Conv. MVR in Barlows disease)
140 patients mean FU 12,4 months
MIC Sternotomy p
Repair rate (%) 98.5 100 ns
Mortality (%) 2.8 1.3 ns
ICU (d) 1.2 2.3 0.02
LOS (d) 8.6 11.8 0.03
FU freedom from MI> 2+ (%) 97 98 ns
Speziale G JTCVS 2011
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MIC MVR for bileaflet repair ?
Speziale G JTCVS 2011
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2012 reference: MVR - Sternotomy
Castillo JG JTCVS 2012
Repair rate 99%
Mortality 0,9%
Freedom from MR>2+
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2012 reference: MVR – Sternotomy MIC MVR
Castillo JG JTCVS 2012
Perrier P PC 2012
Repair rate 99% 98.6%
Mortality 0,9% 0,15%
Freedom from MR>2+
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MIC MVR for reoperation
• 5 studies
• Less bleeding
• Less reoperation
• Fewer wound infections
• Decreased LOS
• Similar or better mortality (Non randomized)
• Patients with sternotomy experience prefer lateral
approach (2 studies)
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Redo Case
55 yo male s/p AVR (Mechanical Conduit)
Perforation of AML
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Redo Case repair of AML perforation
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Minimally invasive MVR USZ
0
10
20
30
40
50
60
70
80
90
100
2008 2009 2010 2011 2012
MKRinMIC-Technik
Repair rate in MR USZ: 85-90%
MIC MVR
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Obstacles for implementation
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Low average case load
Gammie ATS 2010
Median =3 (IQR 1-7)
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Likelihood of mitral valve repair and surgeon volume
Bolling SF ATS 2010
. . . . . . . . . . . . .
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The mitral repair lottery
Repair vs. Replacement in the UK
Variability – 20-90% between different hospitals (n = 46)
National repair rate UK 51% (Ger 60%)
Anyanwu A Heart 2010
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Kilic A JTCVS 2012
• 50152 patients
• Isolated MVR for MR
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Thank you!