Advances in Mitral Valve Surgery Robert Galll egos MD, Ph.D
Cardiac Surgery
Disclosure:
The author acknowledges no financial interests in the enclosed content. Unless indicated, use of devices are considered to be FDA approved.
Objectives:
1) Recognize and differentiate between mitral stenosis and mitral regurgitation.
2) Define how the severity of mitral valve disease can affect presentation as well as outcomes.
3) Identify risks and benefits to surgical vs percutaneous repair of mitral valve disease.
Advances in Mitral Valve Surgery
• Mitral Valve Disease - Incidence
• Classification of Disease • Stenosis
• Regurgitation
• Pre-operative assessment
• Surgical Approaches • Valve Replacement
• Valve Repair
• Minimally Invasive Approach Least Invasive Approach
Mitral Valve Disease The Age Factor- Increasing Incidence
Mitral Valve Stenosis Etiology
• Rheumatic heart disease
• Rheumatic fever
• 20 million cases/year
• Acquired before age 20
• Group A beta-hemolytic streptococcus
• Rheumatic valve disease
• Presents 3-5 decade
• 50 to 60% definite history of rheumatic fever
• Women>men 2:1 to 3:1
• Non-Rheumatic Mitral Disease
• Severe mitral annular and/or leaflet calcification in elderly people
• Congenital mitral valve deformities,
• Malignant carcinoid syndrome/Neoplasm
• LA thrombus
• Endocarditic vegetation
• Inherited metabolic diseases
• Previous commissurotomy or previous implanted prosthesis
se
Mitral Valve Stenosis Pathology
• Rheumatic valvulitis
• Isolated mitral valve involvement (40% of patients)
• Combined aortic/ mitral valve disea
• Aortic ± tricuspid valve disease
• Pathological characteristics
• Commissural fusion
• Leaflet fibrosis with stiffening and retraction
• Chordal fusion and shortening
Mitral Valve Stenosis - Severe Clinical Findings - Hemodynamics
Elevated Mean transvalvular gradient of 10 to 15 mm Hg.
Left atrial pressure: 15 to 20 mm Hg at rest
With exercise, the LA pressure and gradient rise substantially.
High LA pressure gradually leads to LA hypertrophy and dilatation, atrial fibrillation, and atrial thrombus formation
Pulmonary hypertension
Pulmonary arterial systolic pressure >60 mm Hg << RV emptying , Results in high RV EDP and RAP
Pulmonary arteriolar constriction, and pulmonary vascular obliterative changes
Mean LA pressure exceeds 30 mm Hg (>> oncotic pressure) Passive transmission of high LA pressure, pulmonary venous hypertension,
Transudation of fluid into the pulmonary interstitial <<lung compliance.
Progressive worsening leads to right-sided heart failure, tricuspid and pulmonic insufficiency
Mitral Valve Stenosis Clinical Findings - Hemodynamics
LV end-diastolic volume ≤ normal LV end-diastolic pressure ≤ normal
Peak filling rate and stroke volume ≤ normal
Result of inflow obstruction - Cardiac output thus is diminished
25 to 50% have LV systolic dysfunction
Right ventricular afterload increases as pulmonary hypertension develops in these patients, right ventricular systolic performance deteriorates
Mitral Valve Stenosis Clinical Findings
• Gradual development - asymptomatic for years
• Characteristic symptoms
Pulmonary venous congestion or low cardiac output
• Dyspnea on exertion, orthopnea, or paroxysmal nocturnal dyspnea and fatigue.
• Progressively symptomatic with less effort (<1 and 2 cm2)
Pulmonary hypertension and RV Failure
• Tricuspid regurgitation, hepatomegaly, peripheral edema, and ascites
• High LA pressure and increased pulmonary blood volume - hemoptysis
• Acute pulmonary edema with pink frothy sputum (alveolar capillary rupture)
Mitral Valve Stenosis Clinical Findings
• Systemic thromboembolism- may be first symptom of mitral stenosis • 20% of patients
• 40% cerebral circulation
• 15% visceral vessels
• 15% lower extremities
• Coronary arteries -> angina, arrhythmias, MI
• Risk Factors
• Low cardiac output, LA dilatation, atrial fibrillation, left atrial thrombus, absence of tricuspid or aortic regurgitation, and echocardiographic “smoke” in the atrium
• Patients with these risk factors should be anticoagulated
Mitral Valve Stenosis Clinical Findings
• Physical Exam • General : thin and frail (cardiac cachexia)
• Peripheral pulse normal, except with a decreased LV stroke volume
• Heart size – normal
• An apical diastolic thrill may be present
• RV lift can be felt associated pulmonary hypertension
• Auscultatory findings
• Presystolic murmur, Loud S1, Opening snap, Apical diastolic rumble
• S2 becomes prominent- with progressive PHTN
• Murmur of tricuspid and/or pulmonic regurgitation
• S4 originating from the right ventricle
• Long or holodiastolic murmur indicates severe mitral stenosis. The intensity of the murmur does not necessarily correlate with the severity of the stenosis
Mitral Valve Stenosis Clinical Work-up
EKG – non specific
CXR (LA enlargement is the earliest, Pulmonary congestion)
Pulmonary function testing
Echocardiography - primary diagnostic
TTE- valve pathology and pathophysiology, valve area,
gradient
TEE - details of valvular pathology
• valve mobility and thickness
• sub-valvular apparatus involvement
• extent of leaflet or commissural calcification
Cardiac catheterization
Not necessary to establish the diagnosis of mitral stenosis
Provides information regarding coronary artery status
Reversible pulmonary hypertension(inhaled nitric oxide)
Yli
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Rheumatic MS I Class I
l l '
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Very severe MS Sm>rc MS Progrcssi>'C MS l\.fVA<·:ni 1 \.(VAI.:S l m
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J, J, J,
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The Journal of Thoracic and Ca/ti/(Jiascular Sui!I•IY 2014 148,e1-e132DOI: (10.1016 .jtcvs.2014.05.014
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PRESBYTERIAN
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Risk Assessment STS Risk, Frailt¥ Organ System Dysfunction,and Procedure-Specific Impediments
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Mitral Regurgitation Classification
Type 1 - Nor mal leaflet rootion
Type 2-
leaflet proapse
Type 3 - leaflet restriction
Echocardiographic Guidance
• Echocardiography is the essential imaging modality
• Echocardiography in peri-interventional assessment is used for
• Patient selection
• Guidance of the procedure
• Identification as well as the assessment of the severity of any complications during the procedure
• Evaluation of the final result
• Assessment at follow- up of MR severity, left ventricular size and function as well as pulmonary artery pressures.
Table I Echocardiographic parameters for the grading of MR severity
Parameter-
QualitatiVe
Mitralvalve morpho ogy
MR co our fet
Flow convcrgcnc::c
CW-Oopp er signalof MR jet
Semi-quantitatiVe
Vena c::ontracta width (em)
Puhnonary vein fiow
Mitralinflow
lAflV size
Quantitative
Re-gurgitan t volume (R Vol) (mi.Jboat)'
R<gut'gitant fraction (Rf) (%)
ERective r.cgurgitant orffice area
(EROA) (em2)'
Mild
Normal /abnormal Smatlccntra! jet <4 cm1or
<20% of LA voulme
No or minimal now convf!:l'gencc
Soft de-nsity/parabolic
<0.3 em
Systo-lic dominant now
A-wave dominant
Normal V size
<30
<30
<0.2
Moderate
Normal /abnormal
Signs of MR >mi d but
no
criteria for severe MR
Signs of MR >mi d but
no
criteria for severe MR
DcnsefparaboUc
Signs of MR >mi d but
no criteria for severe MR
Intermediate signs
Intermediate signs
Intermediate signs
Mild-moderate:30-44,
moderate-severe:: 45-59
Mild-moderate:30-
39.
moderate-severe:: 40-49
Mild-moderate:0.2-0.29.
moderate-severe:: 0.3-
0.39
Signiftcant prolapse of a leaflet or leaflets.
flail teafiet or ruptu red papillary muscle.
severe lc-afl-ct(s) re-striction
large central jet >40% of LA volume/
e-cce-ntric
jet swirlJng in LA (any size)
large now convergence
Denseftriangular
l!0.7 em(> 0.8 em
biplane) SystOlic now
rc...CI"$al
E·wa\10 dominant (>1.5 mls)
Enlarged LA and V
>50
Mitral Regurgitation Etiology
• Myxomatous degeneration
• Rheumatic Disease
• Mitral Annular calcification
• Ischemic mitral regurgitation
osteogenesis imperfecta
Myxomatous Degeneration
• Most common cause of MR
• Symptoms
CHF, Declining stamina and fatigue 25-40%
Barlow’s syndrome: prolapse of the posterior leaflet, chest pain, palpitations, syncope, and dyspnea
• Etiology
Acquired
• Fibroelastic deficiency
• Older patients
Barlow’s valve
• Younger patients
• Congenital or heritable; excess spongy, weak fibroelastic connective tissue affecting leaflets and chordae tendineae
• Associated with connective tissue disorders
Marfan syndrome, Ehlers-Danlos and
Myxomatous Degeneration
• Mechanism of MR
• Annular dilatation and rupture/elongation of the first-order chordae (58%)
• Annular dilatation without chordal rupture (19%)
• Chordal rupture without annular dilatation (19%)
Presentation: Develops acutely in patients without any previous symptoms of
heart disease or suddenly becomes worse in those with known mitral valve
prolapse.
Posterior chordal rupture(P2)>>anterior chordal rupture>>combined
Myxomatous Degeneration
• Histologically
• Elastic fiber/collagen fragmentation and disorganization
• Acid mucopolysaccharide accumulation in the leaflets.
• Pathology
• Atrial aspect – focal leaflet thickening
• Ventricular aspect
• Thickening of the interchordal segments
• Fibrous proliferation into adjacent chordae and onto the ventricular endocardium
• Annular thickening and dilatation
Myxomatous Degeneration
All these changes are pronounced in young patients with Barlow’s valves but can be minimal in older subjects with fibroelastic deficiency, in whom the noninvolved posterior leaflet scallops and anterior leaflet are normal and thin (termed pellucid by Carpentier).
Can be segregated on clinical grounds
Repair techniques differ in major ways
Rheumatic Disease
• US Incidence decreasing
• Pathoanatomical changes differ
• Non-fused commissures
• Chordae tendineae
• Not thickened/fused
• Shortened
• Diffuse fibrous thickening of the leaflets with minimal calcific deposits
• Fibrous infiltration in papillary muscle
• Asymmetric annular dilatation (primarily posteromedial )
• Management
• Anterior leaflet prolapse tend to improve with medical management
• Posterior leaflet less favorable and often requires surgical repair
Mitral Annular Calcification
• Degenerative disorder
• Elderly (>60 years)
• Women>>men
• Pathogenesis
• Not well characterized
• Associated conditions • Systemic hypertension
• Hypertrophic cardiomyopathy
• Aortic stenosis
• Advanced Barlow’s disease
• Chronic renal failure
• Diabetes mellitus
Mitral Annular Calcification
• Initially, calcification begins at the mid-portion of the posterior annulus
• Progression of disease
Leaflets become upwardly deformed, stretching the chordae tendineae
Rigid curved bar of calcium surrounding the entire posterior annulus in
a horseshoe shape or even a complete ring
Mitral Annular Calcification Clinical Manifestations
• Atrioventricular/intraventricular conduction defects
• Calcific deposit spurs extend into the LV myocardium
• Infiltrate the conduction system
• Mitral regurgitation
• Displacement and immobilization the mitral leaflets
• Prevention of normal systolic coaptation
• Impaired presystolic sphincteric action of the annulus
• LV volume overload ->CHF
• Systemic embolization
• Annular calcific debris is extensive and friable
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Ischemic Mitral Regurgitation
Normalmitralval ve Mitral regurgitation
Apex Left ventrble
Displacement of the posteromedial
papillary museIe
Areaof
ischemic
distortion
Rigtt ventricle
Right
ventricle
Mlrai[Posterlor leaflet
lalve terior leaflet
MitlSI
regurg Biion
Lett atrium A B
Pre-Operative Assessment
• EKG
• Echocardiography
• Cardiac Cath
• CT imaging
• Frailty
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The Journal of Thoracic and Catt//(Jiascular Sui!I•IY 2014 148, e1-e132DOI: (10.1016 .jtcvs.2014.05.014
Follow-up years
1002 521
230 79 19 2 1
183 146 110 87 62 34 14
230 G4 25 9 5 1
0 10 20 30
Etiology of Mitral Regurgitation Determines longevity
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g! 0.5 · cil 0.4
0.3
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Number at risk: Myxomatous Rheumatic FMR
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Mitral Valve Stenosis Surgical Treatment
• Full sternotomy
• Cardiopulmonary bypass
• TEE – with 3-D imaging
Pre-operative assessment
Intra-operative
Post-operative assessment
Evacuation of air
Valve function
Cardiac Function
"Splitting my Chest Open"
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Minimally Invasive Aortic Valve Surgery Options for Incisions
Various Approaches/Incisions of Minimally-Invasive Valve Surgery
lhoraooromy
Right anteriof thoracotomy,second and thitd intercostalspaces
(52,78) Ri&llt anterior thoracotomy. fourth and fifth inter costalspaces
(85)
left lateral thor{IIC()tomy (40)
Lefl posteriOr thOracotomy (51)
Ri,th t vertlcal ln1'r3-axillaty thOracotomy (41)
Partialsternotomy
Paras;ernal incision {6,13.14)
Trons.stemallnclsion (6)
Upper otemotomy (7)
T mJnl-s:ternotomy (86)
Inverted T sternotomy (87)
Reversed ..s.haped panlal upper sternotomy (88)
Rfl\....ed L InciSiOn (89)
lnvetSe inciiion (86)
J Incision (6,90)
V incision (91)
V1deo-3SlSfsted
Po<t access (30-34)
Robot..as&is.ted
AESOP 3000(Computer Molion, Goleta, CBii fomia} (6 18)
Oa Vinci ( ntt.itive Surgical,Inc.., Sunnyvale., California)
(19)
Zeus (Computer Modon. Goleta.C811fomla) (6)
Sternal
Skin incision
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Jan D. 9:hmitto, MD,PHD, 9Jyog A. Mokashi, MD,Lawrence H. Cohn,MD
JAm Coli Cardiol2010;56:455-62
Standard Versus Minimally Invasive Techniques:
Is This All About Marketing?
NO!!!!
And
Yes!!!!
Minimally Invasive Valve Surgery History Dictates Progress and Change
1965 Fogarty Embolectomy
1975 Arthroscopic Knee
1977 PTCA
1985 Lap Cholecystectomy
1990 VATS
1995 MI Cardiac Surgery
2001 Robotic Cardiac Surgery
Today Percutaneous
Minimally Invasive Valve Surgery EVOLUTION IN VALVE SURGERY
• SAME QUALITY OF SURGERY
Primary/Re-operative approach
Safety/Minimal conversion rate
• ADVANTAGES
• Decrease pain and trauma
• Reduce blood transfusion requirements
• Reduce cost
• Increase patient satisfaction
Operative Techniques for MI Mitral Required Adjuncts
Incision
• Lower hemi-sternotomy
• Right mini-thorocotomy
• Robotic or thoroscopic
• Standard heparin levels
TEE
• Position of trans-femoral venous catheter
• Position of coronary sinus catheter)
• Evacuation of air
Changes in perfusion techniques
• Vacuum assisted drainage
• Trans-femoral Venous catheter 22 Fr
Operative Techniques for MI Mitral Surgery Right Anterior Thoracotomy
Operative Techniques for MI Mitral Surgery Robotic Mitral Valve Approach
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1
Actuarial Event-Free Survival
11 Year Freedom from Reoperation for Minimally Invasive MVP railure
- 100 ...... 97%--
95%
94%
92%
-?!. ...... 75 «..<. Q)
CL 0
50
.Eg E 0 5
u.
0
0 2.5 5 75 10 Kaplan-Meier CuNe
Time (years)
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>
Actuarial Survival Estimates
11 Year Survival Estlmato for Minimally lnva ive
Mttral Valve Repair
100 ..9ll'o 94% -
<---:fl
75 i 90%
83%
t'e 50
c: :::;)
(/)
25 -<
0 1
0 2.5 5 7.5 10
Kaplan-MIer Curve Teme (years)
Operative Techniques - Mitral Replacement
• Disease State and indications • MS
• Endocarditis
• MR • Non-repairable valve
• Ischemic MR
• Approach
• Suture technique – device dependent
• Preservation of sub-valvular chordal apparatus – LV function
Operative Mortality Mitral Valve Replacement
60%+------------------------------------------
g4o%+---------------
30%+----------------- Q; a. 0 20%-l-------
First/Elect Firsvurg First/Emer First/Salv Reop/Eiect Reop!Vrg Reop/Emer Reop!Salv
FIGURE 42-9 Operative mortality for ele<tive, urgent, emergen<v,and salvage pro<edures for primary operations and reoperations for mitral valvular repla<ements. (Dolo used with permission from Society of fhorocic Surgeons.)
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Mitral Valve Repair
Increasing incidence of
successful surgical repair of the
mitral valve (> 90%) has resulted
in the earlier referral of patients
with mitral valve disease for
surgical repair.
Operative Techniques - Mitral Repair Techniques
• TEE Pre-assessment • Determine pathology
• Probability of repair
• Guide repair technique
• Repair • Confirmation of pathology
• Resection of damaged tissue
• Repair of leaflet
• Reinforcement of annulus
• Static testing
• TEE Post-assessment • Success of repair
• Gradient assessment
Operative Techniques- Mitral Repair Techniques
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The Least Invasive Mitral Valve Repair The Heart Team Approach
Heart Failure/TEE cardiologist Surgeon Interventionalist
2
Least Invasive Mitral Valve Repair
• MitraClip is the only percutaneous technique currently available to reduce mitral regurgitation.
• Based on the creation of a mitral double orifice, a technique first introduced by Alfieri in 1991.
Suitability for Mitraclip
• Identification of Mitral Regurgitation
• Surgical referral Operability risk assessment • TTE/TEE
• Cardiac Catheterization
• Pulmonary function testing
• Frailty testing
• Inoperable status
Determination of the Morphology Imaging is Key
• Transthoracic echocardiography • Assess MR severity
• Cardiac function
• Transesophageal function • Etiology of MR
• Suitable MV morphology
Determination of the Morphology
Ideal valve for Mitraclip Unsuitable for MitraClip
• MR originating from P2
• No calcification in the grasping area
• Mitral valve area of > 4 cm2
• Posterior leaflet of > 10 mm
• Flail gap of < 10 mm
• Perforated mitral leaflets of clefts.
• Severe calcification in the grasping area
• Hemodynamically relevant mitral stenosis
• Length of posterior leaflet < 7 mm
• Rheumatic valve disease
• Endocarditic valve disease
• Gap between leaflets of > 2 mm
Guiding the MitraClip
1) Transseptal puncture
2) Introduction of the Steerable Guide Catheter into the left atrium
3) Advancement of the Clip Delivery System into the left atrium
4) Steering and positioning of the MItraClip above the mitral valve
5) Advancing the MItraClip into the left ventricle
6) Grasping the leaflets and assessment of proper leaflet insertion
7) Clip detachment
Transseptal Puncture Determination of Optimal Entry
• Determination of the puncture site is shown in a simultaneous x-plane view.
• Bi-caval view/Short axis view at the base.
• Four-chamber view at zero degrees demonstrates the evaluation of the height above the valve.
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Steerable Guide Catheter Accessingthe LeftAtrium
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Advancement of the Clip Delivery System
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Steering and positioning of the MitraCiip
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Grasping of the leaflets
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Grasping the leaflets
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Assessment of MitraCiip
Assessment of MitraClip Post Clip Release
• Mitral Valve Function • Valve area
• Residual regurgitation
• Gradient
• Atrial septum assessment
• Assess for pericardial effusion
Percutaneous Mitral Valve Replacement Future Concepts
Thank You