Click To Edit Master Title Style: Management of Valvular Heart Disease Surgeon's Perspectives

Click to edit Master title style
Management of Valvular Heart Disease Surgeons Perspectives
M. Azhari Yakub Institut Jantung Negara
INSTITUT JANTUNG NEGARA National Heart Institute
INSTITUT JANTUNG NEGARA Click to edit Master title National Heart Institute
style
Click to edit Master title style PROCEDURES DONE

Expansion
Click Open to edit Master title style Heart Surgery

Congenital Isolated CABG Isolated Valve
1200 1000 800 600 400 200 0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Click to edit style Milestones in Master Valve title Surgery
1925
1957 1961
Souttar Closed Mitral

Commissurotomy
Lillehei Mitral Valve Surgery Starr Carpentier
using CPB via Rt. Thoracotomy Mitral Valve Replacement Mitral Valve Repair
1967
Ross
Pulmonary autograft
Click edit Master title style CHOICE OFto VALVE SUBSTITUTE

Factors for consideration Age Expected life expectancy Gender Lifestyle Socioeconomics Comorbid factors, renal failure, etc Etilogy of valve disease Annular size Surgeon-patient-preferences
REGURGITANT LESIONS REPAIR OR REPLACEMENT?
MITRAL VALVE REPLACEMENT Why not replacement?
DIFFICULTIES WITH VALVE title REPLACEMENT Click to edit Master style
Compliance Rigorous control of INR Accelerated degeneration of bioprosthesis Pregnancy
Click to edit Master title style VALVE REPLACEMENT
Mechanical prosthesis Bioprosthesis
Click to edit Master title style Innovations in Mechanical Valves
Haemodynamically better Better washout of leaflet hinge

Less thrombogenic eg ATS valve
Click to edit Master Evolutionary Improvement
title style
1977: SJM Masters Valve Intra-annular cuff Intra-annular carbon rim

1992: SJM Masters Hemodynamic Plus (HP) valve
Supra-annular cuff allows for larger orifice Intra-annular carbon rim Supra-annular cuff Supra-annular carbon rim, allowing for larger inner orifice Rotation mechanism completely housed within the carbon orifice
*2002: US Approval *2004: Japan Approval
1999: SJM Regent valve
13
Long term survival (30Master yrs) after mechanical valve Click to edit title style replacements
Click to edit Master WARFARINIZATION
title style
Mobidity Mortality
5 - 15% per year 0.2 - 1% per year
THROMBOEMBOLIC AND ANTICOAGULANT Click to edit Master title style RELATED BLEEDING Percent per year
Valve
StarrEdwards St. Jude Hancock IonescuShiley Reference Miller Czer Gallucci GonzalezLavin Thromboembolism 5.87 2.1 1.8 0.36 30% Bleeding 3.66 2.9 0.4 0.64 30% Total 9.53 5.0 2.2 0.99
Cumulative rate at 20 years
Click to edit Master title style BIOPROSTHESIS

2nd generation bioprosthesis
Hancock II
Carpentier-Edwards supra annular valve Carpentier-Edwards pericardial valve (1981) Gluteraldehyde fixed at low pressure treated with anti-calcification solution mounted on flexible struts better haemodynamic improve durability

Freedom from valve failures
Biological valves beyond 15 years
AVR
MVR
Edwards et al ATS 1995:60 (suppl) 5211-5
Click BIOPROSTHESIS to edit Master title style AVR

Freedom from Structural valve deterioration with age
Fann et al. ATS 1996, 62
DURABILITY OF BIOPROSTHESIS Click to edit Master title style (HANCOCK)
At 10 years in 47% redo rate Age is a strong determinant of durability < 20 y.o 40-50 y.o > 60 y.o : : : 50% redo rate at 10 years 10% redo rate at 10 years 3% redo rate at 10 years
If MV Replacement is unavoidable Click to edit Master title style Chordal apparatus should be preserved
Posterior chordal preservation Anterior chordal preservation (possible LVOTO) Both Chordal reconstruction with Gore-Tex sutures
Anterior Chordal preservation
Posterior Chordal Preservation
Chordal Reconstructed with Goretex suture
MITRAL VALVE REPAIR
Click to edit Master title style Improved survival after repair
Enriquez-Sarano et al. Circulation 1995, 91:1022-28
Annulo-ventricular continuity
Click to edit Master title style WHY REPAIR?

__ Repair . Bio --- Mech
Actuarial Survival
Freedom from thromboembolic events
Freedom from Reoperation
Yau, Tirone et al, JTCVS 2000, 119(1):53-61
Click toREPAIR? edit Master WHY VALVE
title style
Preservation of LV function Avoidance of warfarization Low thromboembolic incidence avoidance of valve prosthesis complications - clicking, structural failure
Click to edit Master MITRAL VALVE REPAIR
title style
Valves that have pliable leaflets and fairly preserved chordal apparatus are amendable for mitral valve repair. Calcifications of annulus, leaflet and chordae are relative contraindications.
Feasibility of repair is a structural consideration regardless of the aetiology.
Feasibility of to repair in mitral valve Click edit Master title style
degenerative > myxo > ischaemic > rheumatic 90% 40-50% Depends on functional/structural abnormality
Degenerative Degenerative Rheumatic
Rheumatic
Reoperation-free
Event-free
Deloche et al. J Thorac Cardiovasc Surg 1990, 99:990-1002

Our Experience
Mitral Valve Click to editOperations Master titleIJN style

220 200 180 160 140 120 100 80 60 40 20 0 92/93 94 94 96 97 98 99 2000 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10
Tissue Mechanical Repair
Click Mitral to edit Valve Master Repair title style

250
202
Median age = 27.0 Age range =2m -77 yrs
200
Frequency
150
128 106 97 99 82 64 61 45 43 69 49 82 81
100
50
13
0 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80
Age (years)
1997 2010 Total: 1344 pts

Etiology
60%
60 50 40 % 30 20 10 0 1
19% 10% 9% 2%
Rheumatic Congenital Degenerative Ischaemic Others
Etiology
Yakub, Dillon et al; EJCTS (2013) 1-9 doi:10.1093/ejcts/ezt093
Feasibility of MV Repair in Click to edit Master title style Rheumatics
Feasibility of repair improved significantly 39% in 1992-2000 65% in 2001-2010 p<0.0001
Feasibility of repair last 5 years is 70%
Click to editResults Master title style

Mean X-Clamp time (min): 85 37 (21-296)
Mean CPB time(min) :
11453 (42-632)
30-day mortality :
2.4% (15/627)
Causes of early deaths

Myocardial failure(LCOS) Septicemia ARDS Malignant Ventricular Arrhythmia 7 4 2 1 (1.1%) (0.6%) (0.3%) (0.2%)
Click Actuarial to edit Master title style survival
Actuarial survival at 10 years
98.5%
Click to edit Master title style Freedom from re-operation

92.0% 87.3%
374
183
101
30
12
Freedom from re-operation at 5 years is 92.0% 10 years is 87.3%

Click to edit Master title style Freedom from valve failure

Defined as recurrent MR >2+ and/or reoperation
85.6%
72.8%
374
183
101
30
12
Freedom from valve failure at 5 years is 85.6% 10 years is 72.8%

ofMaster risk factors for style ClickAnalysis to edit title valve failure
95% CI
1.681 5.321 0.348 1.388 0.317 1.347
Univariate
Variables
Age <20 years NYHA III/IV AF MR Mixed MS Severe residual MR Leaflet procedure Chordal procedure Pap musc split
Multivariate
p value
< 0.001 0.303 0.249
HR
2.991 0.645 0.654 1 2.375 0.899 7.932 0.426 1.208 2.014
HR
95% CI
P value
1.214 4.646 0.123 6.564

3.846 -16.359 0.232 0.782 0.693 2.106 0.724 5.606
0.012 0.916
< 0.001 0.006 0.505 0.180 33.306 12.037 92.156 <0.001
Commisurotomy
Commisuroplasty Partial / Flexible ring
1.649
1.927 1.355
0.741 3.668
0.463 8.030 0.628 2.924
0.220
0.367 0.439
Comparison of durability between Click to edit Master title style
Rheumatics and Degenerative
Reoperation
Valve Failure
Degenerative Degenerative Rheumatic
Rheumatic
Reoperation-free
Event-free
Deloche et al. J Thorac Cardiovasc Surg 1990, 99:990-1002

Mitral Regurgitation : Changing Click tosurgery edit Master title indications for
style
Symptomatic Asymptomatic
deteriorating of LV function
EF < 60% end-systolic LV diam > 45mm RV dysfuntion
EF < 30 % Hochreiter C et al. Circulation 1986 ;73:900-912 EF change from rest to exercise Rosen SE, Am J Cardiol 1994
Aug 15;74(4):374-80
onset of AF
recent onset AF likely to convert after repair
Chua YL et al. J Thorac Cardiovasc Surg 1994, 107:408-415
MV Assessment
Commissurotomy

AL Peeling
PL Thinning
PL Thinning
AL Mobilization
AL Patching
Click to edit Master Mitral Valvetitle style

Pre repair
Post repair
Pre repair
Mitral Valve Click to edit Master title style
Post repair
AORTIC VALVE REPLACEMENT
Click VALVE to edit Master title style AORTIC RECONSTRUCTION

Techniques at our disposal : AV Replacement
Tissue - stented - stentless - sutureless - Mechanical
Ross Procedure Homograft AV Repair TAVI - transcatheter aortic valve implantation

ACTUARIAL SURVIVAL IN PROSTHESIS MISMATCH Click to edit Master title style VS ADEQUATE MATCH
Rao, Circulation 2000, 102(19) Suppl.
Click to edit Master Stentless Valve title style
Medtronic Freestyle-Stentless
Stentless pericardium (Sorin)

Click to edit Master title style Sorin stentless

subcoronary attachment.
Click toCOLOUR edit Master title style DOPPLER
Stented Bioprosthesis
Stentless
Click to edit Master title style STENTLESS BIOPROSTHESIS
very minimal transvalvular gradient

better regression of LV hypertrophy
hence
stentless valve confers survival advantage over stented bioprosthesis no data on long term follow ups, degree of structural valve deterioration
Click Sutureless to edit Master title style Aortic Valves
Perceval S
Intuity
3f Enable
AORTIC VALVE REPAIR
Feasibility Repair Clickof toAV edit Master title style

Feasibility for AV reconstruction is limited < 10% Mild-moderate AR is repairable Severe AR is for replacement Durability of repair in severe lesions is limited. 50%-60% reoperation rate at 5yrs
Click to editVALVE Master title style AORTIC SURGERY

CHOICE OF VALVE SUBSTITUTE
TAVI Stented Bioprosthesis Stentless Bioprosthesis Homograft Mechanical Valve Pulmonary Autograft 10 20 30 40 Pulmonary Autograft 50 60 70 80
AGE
MINIMALLY INVASIVE VALVE SURGERY
Minimally Invasive Approaches

Left Minithoracotomy Partial Sternotomy
ClickInvasive to editValve Master title Minimally Surgery
style
Potential advantages Good cosmesis Less pain Faster recovery Less cost Less risk of wound infection
PARTIAL STERNOTOMY Click to edit Master title- style
Lower
CONCLUSION Click to edit Master title style
Mitral Valve and its apparatus is an integral part of left ventricular function.
Current status of mitral valve surgery is to preserve the mitral apparatus whenever possible in order to preserve LV function
CONCLUSION Click to edit Master title style

Mitral Valve Repair is preferable whenever is possible. It better preserves LV function and has better long term survival.
Current technical innovations expand possibility and have improved durability of repair even in rheumatics
In Aortic Position Click to edit Master title style

Aortic repair is occasionally possible <10% - only in moderate lesions Aortic replacement remains the mainstay. Haemodynamic prolife of substitute is important for LV regression, poor LV. leading to better survival There will be increase use of bioprosthesis esp. stentless, sutureless valves. Better prolife Increasing role of TAVI esp in elderly and high risks.
Click edit Master title style CHOICE OFto VALVE SUBSTITUTE

Factors for consideration Age Expected life expectancy Gender Lifestyle Socioeconomics Comorbid factors, renal failure, etc Etilogy of valve disease Annular size Surgeon-patient-preferences
Thank You
AORTIC STENOSIS Click to edit Master title style
Indication for surgery: Symptomatic Asymptomatic with severe AS. AV area <0.7 cm Grey areas: Moderate AS, asymptomatic mild-moderate AS in pts for CABG
AORTIC REGURGITATION Click to edit Master title style
Indications for surgery: Symptomatic with AR Asymptomatic with deteriorating LV, Lvesd >55mm, LV dysfunction at rest
SEVERE AORTIC STENOSIS WHO ARE Click to edit Master title style ASYMPTOMATIC
Extremely low risk of sudden death in absence of antecedent symptoms.

AVR is justified in: evidence of LV dysfunction women who desire pregnancy very strenuous occupation / activities
AORTIC REGURGITATION WHO IS Click to edit Master title style ASYMPTOMATIC - INDICATION FOR AVR
1. Lvesd > 55 mm or Lves volume index > 60 ml/m2
2. Evidence of progressive of LV dilatation over time

3. EF < 50%, Lvedd > 80 mm. Lvedp > 20 mm Hg maybe helpful
AVR IN SEVERE WITH POORtitle LV FUNCTION Click toAR edit Master style / EXCESSIVE LV DILATATION
Surgery is helpful in this group of patients.

Klodas et al JACC 1996; 27
31 patients with Lvedd > 80 mm - Low operative mortality - 5.6% - 10 year survival of 73% - EF improved from 47% - 53%
AORTIC STENOSIS IN LV DYSFUNCTION Click to edit Master title style

Mayo Clinic (Connolly et al)
154 patients with EF of 35% Operative mortality of 9% 5 yr survival 69% (cf 77% in good EF) EF improved in 70% of cases from EF 27% to 39%
ClickSTENOSIS to edit Master title style AORTIC IN THE ELDERLY
Operative mortality in octogenarians : 5 - 15% AVR in elderly is underuse Consider co-morbid factors Use of bioprosthesis
PROBLEMS Click to edit Master title style

Aortic Stenosis with low press gradient with poor LV function To distinguish between: a. Severe AS with poor EF - surgery will benefit b. Moderate AS with concurrent primary myocardial dysfunction - surgery will not benefit Test: 1.
Dobutamine stress echo a. if fixed valve area with stroke volume b. if valve area with stroke volume Assess degree of valve calcifation
2.
MILD TO MODERATE STENOSIS IN Click to editAORTIC Master title style PATIENTS UNDERGOING CABG
Recent prospective studies
75% of patients develop symptoms requiring AVR within 5 years
Repeat surgery for AVR was high mortality : 14 - 30%
ANY PLACE IN PROPLYLACTIC AVR AT Click to edit Master title style THE TIME OF CABG?
Baseline aortic jet velocity Velocity < 3.0 m/s
progression of symptoms 5 yr event free survival 84% no AVR needed 5 yr event free survival 21% need AVR
Velocity > 4.0 m/s
Intermediate 3-4 m/s
assess degree of calcification before deciding on AVR
COX REGRESSION IN INITIALLY Click to edit Master title style
ASYMPTOMATIC AS
Otto, Circulation 1997, 95
Predicted survival curve in ischemic mitral regurgitation Repair vs replacement
Good pts
A.
Lateral wall abN Complex MR jet
B.
Gillinov,Cosgrove JTCVS 2001, 122(6)

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Management of Valvular Heart Disease Surgeons Perspectives

M. Azhari Yakub Institut Jantung Negara

INSTITUT JANTUNG NEGARA National Heart Institute

INSTITUT JANTUNG NEGARA National Heart Institute

Click to edit Master title style PROCEDURES DONE

INSTITUT JANTUNG NEGARA National Heart Institute

Click Open to edit Master title style Heart Surgery

1200 1000 800 600 400 200 0

Click to edit style Milestones in Master Valve title Surgery

Souttar Closed Mitral

Lillehei Mitral Valve Surgery Starr Carpentier

INSTITUT JANTUNG NEGARA National Heart Institute