PLENARY SESSION III: MITRAL VALVE REPAIR TIPS AND TECHNIQUES

POSTERIOR LEAFLET PROLAPSE REPAIR

AATS CARDIOVASCULAR VALVE

SYMPOSIUM 2015

RENATO A. K. KALIL

CONFLICT OF INTEREST DISCLOSURE

THERE IS NO CONFLICT OF INTEREST TO DISCLOSE, RELATED TO THIS PRESENTATION

Anderson RH & Becker A. Atlas de Anatomia Cardíaca. Livr Edit Santos, SP. 1983

Atrial view of mitral valve showing anterior or septal leafletand posterior or mural leaflet with its 3 portions

Antero-lateral comissure Anterior leaflet Postero-medial comissure

SCALLOP 1 - P1

Posterior leaflet

SCALLOP 2 - P2 SCALLOP 3 - P3

Anderson RH & Becker A. Atlas de Anatomia Cardíaca. Livr Edit Santos, SP. 1983

Anderson RH & Becker A. Atlas de Anatomia Cardíaca. Livr Edit Santos, SP. 1983

Anderson RH & Becker A. Atlas de Anatomia Cardíaca. Livr Edit Santos, SP. 1983

Coaptation line Free margin

Mitral valve morphology with its largerough zone of leaflet coaptation

Rough zone Clear zone

Mitral Valve Physiology

Mitral valve physiologic mechanism includes participation from several related strutures

Leaflets

Chordae

Papillary muscles

Left ventricular wall

Valve annulus

Left atrial wall

• When the jet of blood flowing into the ventricle as a result of atrial

contraction suddenly ceases, a negative pressure occurs on the

inner aspect (atrial side) of the valve leaflets, causing these leaflets

to be drawn toward each other.

• The valve leaflets come together first in the area near the valve ring

and last at the valve margins.

• During the last stage of ventricular contraction, the annular area is

constricted by approximately 30% in comparison to the maximum

open orifice. However, two-thirds of this is due to atrial contraction.

Willerson, Cohn, McAllister (Guest editors) Manabe, Yutani (editors): Atlas of Valvular Heart Disease, Churchill Livingstone Inc. 1998, pág.21.

Adams DH, Rosenhek R, Falk V. European Heart Journal 2010; 31: 1958-1967

Degenerative mitral valve regurgitation

FED FED+ Forme fruste Barlow’s

Leaflet tissue

General Requisites for a Valvuloplasty Technique

Maintain an adequate minimal useful orifice

Maintain a large coaptation zone, > 5mm

Maintain leaflet support by chordae

Preserve flexibility

Preview fibrosis and calcification

Use compatible chordae or membranes

Maximum of autologous material “Respect rather than resect”

Valvuloplasty RequisitesRelated to Posterior Repair

QUADRANGULAR RESECTION

TRIANGULAR RESECTION

SLIDE PLASTY

CHORDAL FOLDOPLASTY

NEOCHORDAE

1. RESTORE CHORDAL SUPPORT

Valvuloplasty RequisitesRelated to Posterior Repair

2. REDUCE ANNULAR DIMENSION

POSTERIOR ANNULOPLASTY

WOOLER TYPE ANNULOPLASTY

POSTERIOR RING

POSTERIOR BAND

FLEXIBLE OR RIGID COMPLETE RING

Nunley DL, Starr A – The evolution of reparative techniques for the mitral valve. Ann Thorac Surg. 1984;37:393-397.

Quadrangular resection

Wooler et al. Thorax 17:49-57, 1962

Wooler Annuloplasty

Kalil et al. Annuloplasty for rheumatic mitral regurgitation. JACC 1993, 22(7):1915-20.

Annuloplasty(Wooler, Thorax 1962)

Triangular resection(Mcgoon DC,

JTCS 1960)

Chordal shortening

Pomerantzeff P et cols. J Heart Valve Dis 2002 / Rev Bras Cir Cardiovasc 2007

Double Teflon Pledget Technique

94,7+/- 3,6%100

90

80

70

60

50

40

30

20

10

00 12 24 36 48 60 72 84 96 108 120

Tempo (meses)So

bre

vid

a (%

)

100

90

80

70

60

5040

30

20

10

00 12 24 36 46 60 72 84 96 108 120

Sob

revi

da

Livr

e d

e

Re

op

era

ção

(%)

Tempo (meses)

99,2 +/- o,8%

Braz J Cardiovasc Surg 2015; 30(3):325-24

12,50

5,50

9,50

8,50

7,50

6,50

4,50

Pre IPO 6-month 1-year

Mit

ral a

nn

lus

Cir

cun

fere

nce

(cm

)

*

*p<0.05

11,50

10,50

*

5,00

1,50

3,50

3,00

2,50

2,00

1,00

Pre IPO 6-month 1-year

ML

Dia

met

er(c

m)

**p<0.05

4,00

4,50*

0,50

0,00

ADVANTAGESTechnical standardization

Reproducibility

Redilation prevention

Support to the surgeon

Possible “valve in ring” later

Compromises dynamic nature

Reduces basal LV contraction

Changes the saddle shape of mitral annulus

Difficults growing, in children

Useless in anterior portion and may cause SAM

Deiscence

DISADVANTAGES

Rings

1,0

0,8

0,6

0,4

0,0

0,2

115 66 29 9 3 n

Time (years)

Surv

ival

(%)

1,0

0,8

0,6

0,2

0,0

0,4

115 73 42 15

0 4 8 12

Time (years)

Even

t-fr

eeSu

rviv

al%

0 5 10 15 20 25

Reoperation (Kaplan-Meier)

Arq Bras Cardiol 2009; 90(6): 363-369

Alexsandra L. Balbinot¹, Renato A. Kalil¹’², Paulo R. Prates¹, João Ricardo M Sant’Anna¹, Orlando C. Wender¹, Guaracy Fernandes Teixeira Filho¹, Rogério S. Abrahão¹ Ivo A. Nesralla¹.Instituto de Cardiologia do Rio Grande do Sul, Fundação Universitária de Cardiologia¹, Universidade Federal de Ciências da Saúde de Porto Alegre, Instituto de Cardiologia do Rio Grande do Sul Fundação Universitária de Cardiolosia¹, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre RS-Brazil.

Unsupported Valvuloplasty for Degenerative Mitral Regurgitation: Long-Term Results

972 962 927 897 860 868 832 799 746 679 612 592 561 561 %

08 12 24 31 35 40 46 55 71 89 109 131 137 117 SE

151 117 86 71 60 58 45 42 33 30 29 25 21 13 n

2 4 6 8 10 12 14

100

80

60

40

20

TIME (years)

EVEN

T FR

EE S

UR

VIV

AL

(%

)

Kalil R et al (J Am Coll Cardiol1993;22:1915..20)

Late Outcome of Unsupported Annuloplasty for Rheumatic Mitral Regurgitation

100

80

60

40

20

981 973 964 931 907 893 885 865 840 820 795 771 745 722 710 %

07 12 21 27 30 33 37 41 45 49 53 57 62 69 74 SE

154 151 122 97 83 74 62 53 49 40 38 35 32 29 21 n

30cl 2 4 6 8 10 12 14

TIME (years)

Pat

ien

t Su

rviv

al (

%)

Lorier G, Kalil R et al Arq Bras Cardiol 2001; 76: 215-20

Number of patients

Population n=21

N=12(57.1%) Mean age=6.09±3.42

N=6(28.6%) Mean age=2.95±2.22

N=3(14.3%) Mean age=7.67±3.21

p=NS0 5 10 15

Insufficiency

Stenosis

Double lesion

Unsupported Valvuloplasty in Children with Congenital Mitral Valve Anomalies. Late Clinical Results

100

90

80

70

60

50

40

30

20

10

0

90%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Years

Surv

ival

Actuarial survival probality curve in the group of with congenital mitral insufficiency

Period 1975-1998

Patients distribution by groups with congenital mitralvalve malformations. Patients with complete defects of the atrioventricular septum were exclued from the sample. 100

90

70

60

50

40

30

20

10

80

00 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

86%

Surv

ival

Years

Actuarial survival probability free of reoperation in the group of congenital mitral insufficiency

A) Kaplan–Meier curve showing the number of patients at sinus rhythm as a function of time, according to surgical technique

Albrecht A, Kalil R, Schuch et al. J Thorac Cardiovasc Surg. 2009; 138(2):454-9.

ControlMazeSPVI

100

90

80

70

60

50

40

30

20

10

0

0 12 24 36 48 60

Log-rank p<0,001

Sin

us

Rh

yth

m (

%)

Follow-up (months)

Randomized study of surgical isolation of thepulmonary veins for correction of permanent atrial

fibrillation associated with mitral valve disease

Conclusions

Posterior mitral leaflet prolapse repair can be achieved with quadrangular ressection and corresponding unsupported annuloplasty. This preserves annular flexibility and motion.

Triangular ressection + posterior ring annuloplasty and/or complete ringannuloplasty are preferred by some authors.

Proper chordal support & large area of leaflet coaptation is essential for repair durability

Renato A. K. KalilCardiac Surgeon Instituto de Cardiologia do Rio Grande do Sul

Full Professor of Surgery – Federal University of Health Sciences (UFCSPA)Emeritus Professor – Post-Graduation Program/ Fundação Univ. Cardiologia

Coordinator – Clinical Research Center/ Fundação Univ. Cardiologia

kalil@cardiologia.org.br

CLASS MEDICAL AND MEDICAL ILLUSTRATIONS

rodrigo@tonan.com.brwww.tonan.com.br

Marcelo Miglioranza and Álvaro Albrecht the collaboration, the slide of videos

Surgical team, the Post-Graduation Program and Units of Teaching and Research of Rio Grande do Sul Cardiology Institute.

At the Federal University of Health Sciences of Porto Alegre (UFCSPA)

THANKS

Guedes MAV,et al. – Mitral annulus morphologic and functional analysis using real time tridimensionalEchocardiography in patients submitted to unsupported mitral valve repair

5,10

5,00

4,90

4,80

4,70

4,60

4,50

Pre IPO 6-month 1-year

An

teri

or

mit

ral a

nn

ulu

s(c

m)

**p<0.05

5,00

1,50

3,50

3,00

2,50

2,00

1,00

Pre IPO 6-month 1-year

AP

Dia

met

er(c

m)

**p<0.05

4,00

4,50*

0,50

0,00

Smooth zone

Rough zone Free margin

Anderson RH & Becker A. Atlas de Anatomia Cardíaca. Livr Edit Santos, SP. 1983

Annulus

Coaptation line (atrial)

Source: Ryomoto et al: The Annals of Thoracic Surgery 2014; 97:492-497 (DOI:10.1016/j.athoracsur.2013.09.077

Is physiologic annular dynamics preserved after mitral valve repair with rigid or semirigid ring?