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

"'n

Rheumatic MS I Class I

l l '

I Cla.-;s IIa

I Cl

Very severe MS Sm>rc MS Progrcssi>'C MS l\.fVA<·:ni 1 \.(VAI.:S l m

1 MVA >1.5 em' T

) 220m: TI;C;Om; T !tl<1 50 ny.;

J, J, J,

A'cy'mptoruttic S. !lnptomatic Asymptomatic Sy•npt.ornali..: wi lh fKJ

(stage C) (stageD) (stage C) v:he.r :::ause

L ! L

Tn( rphOit)fl)' JD()rphology ' T.A clt!t No LA clol PC\\'P >'2$ mro Hg

No urmilcllvffi N<.1 vr flliltlMR - with cxcn.:isc

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No lAd<.lt

-YE&-'--N()-

"ical high I" ri•k Noor mildMR

N( YE: YE. '<(

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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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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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Risk Assessment STS Risk, Frailt¥ Organ System Dysfunction,and Procedure-Specific Impediments

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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

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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