Denti Paolo Hybrid Surgeon

Cardio-thoracic and Vascular Surgery Dept.

San Raffaele Hospital, Milan

Italy

Esperienza condivise: L’opinione del Cardiochirurgo

MV repair is superior to MVR

• Better preservation of LV function

• Avoidance of prosthesis related events

• Reduced hospital mortality

• Reduced morbidity and LOS

• Improved long term survival

Thourani et al, Circulation 2003; 108:298-304

Zaho et al, JTCVS 2007;1257-1263

Shuhaiber J et al, EJCTS 2007; 31:267-275

Perrier P et al, Circulation 1984;70:187

Akins CW, et al. ATS 1994; 58:668-676

The role of Annuloplasty • Annuloplasty has been routinely added to the Alfieri procedure

• Absence of annuloplasty is associated with increased stresses on the suture and on the valve structures

• Absence of annuloplasty may be associated with accelerated failure (but not in multivariate analysis)

- 647

- 520

- 394

- 267

- 140

- 134

+ 113

+ 240

+ 367

+ 493

+ 620

+ 747

+873

+100

0

SI (kPa)

Alfieri et al. JTCVS 2001, Maisano et al JTCVS 2003, Nielsen et al Circulation 2005

OSR MitraClip in octogenarians

AJC 2015

OSR MitraClip in octogenarians

MitraClip in the elderly

Impact of 2+ residual MR 2+ is APC!!!

Degenerative MR

Mitraclip Second Choice • In high volume center,

degenerative MR is treated with optimal results and low risk but: – 50% of patients are denied to

surgery because of age (Euro Heart Survey) (Mirabel EHJ 2007)

– Age and comorbidity change

risk profile(STS database, 2010)

– QoL is not improved in old

operated patients (Maisano et al EJCTS 2009)

Durability using conventional non “disease-specific” rings

25-30% late

recurrence

rate

Hung et al. Circulation 2004.

Reverse remodeling

Beeri et al. J Am Coll Cardiol 2008;51:476–86

De Bonis, et al . Ann Thorac Surg 2008;85:932–9

Mitraclip

Good Option for Functional MR

• Surgical Treatment is

associated:

– High Mortality

– High recurrence

– Prolonged LOS

– Prognostic Benefit ?

Surgery vs Mitraclip

Chance of correcting MR with Mitraclip

Ris

k

of

su

rgery

L

ow

H

igh

Low High

Risk of

Mitraclip

procedure

•Risk of Mitraclip

procedure •Preservation of

surgical option •Long term results of

Mitraclip

OSR MitraClip in octogenarians

OSR Experience: Re-hospitalization for CHF

Reduction of re-hospitalization for CHF

205

87

7 7

12 months pre-OP

12 months post-OP

12 months pre-OP

12 months post-OP

# Patient # CHF Hosp

Cost effective??

Cost- effectiveness

Armeni et al, Int J Card 2016

Mitraclip Procedure

Mitraclip Procedure

Post TPMVP Pre

Suitable Patient N = 351

Total Patients Evaluated in OSR N = 758

Not Suitable Patient N = 407

Treated Mitraclip Therapy N = 287

Surgery N = 189

MR≤2+ N = 75

Not Treated N = 35

Treated in other centers N = 29

Patient Selection

Unfavourable Anatomy N = 143

• 46% asymmetric apposition • 36% coaptation absence • 18% both

Heart Team and

Hybrid Operator

Individualize the therapy

• Anatomy and function

• Comorbidities, Life expectancy

• Compare risk and probability of success

• Preservation of surgical option

• Improving Devices and Imaging

• Surgeons will do procedures

Heart

Team