Mandalay 13

7/27/2019 Mandalay 13

1/87

Click to edit Master title style

INSTITUT JANTUNG NEGARA

National Heart Institute

Management of Valvular Heart DiseaseSurgeons Perspectives

M. Azhari Yakub

Institut Jantung Negara

7/27/2019 Mandalay 13

2/87




INSTITUT JANTUNG NEGARANational Heart Institute

7/27/2019 Mandalay 13

3/87




PROCEDURES DONE

Expansion

7/27/2019 Mandalay 13

4/87




Open Heart Surgery

0200

400

600800

1000

1200

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Congenital

Isolated CABG

Isolated Valve

7/27/2019 Mandalay 13

5/87




Milestones in Valve Surgery

1925 SouttarClosed MitralCommissurotomy

1957 Lillehei Mitral Valve Surgery

using CPB via Rt. Thoracotomy

1961 Starr Mitral Valve Replacement

Carpentier Mitral Valve Repair

1967 Ross Pulmonary autograft

7/27/2019 Mandalay 13

6/87




7/27/2019 Mandalay 13

7/87




CHOICE OF 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

7/27/2019 Mandalay 13

8/87




REGURGITANT LESIONS

REPAIR OR REPLACEMENT?

7/27/2019 Mandalay 13

9/87




MITRAL VALVE REPLACEMENT

Why not replacement?

7/27/2019 Mandalay 13

10/87




DIFFICULTIES WITH VALVE REPLACEMENT

Compliance

Rigorous control of INR

Accelerated degeneration of bioprosthesis

Pregnancy

7/27/2019 Mandalay 13

11/87




VALVE REPLACEMENT

Mechanical prosthesis

Bioprosthesis

7/27/2019 Mandalay 13

12/87




Innovations in Mechanical Valves

Haemodynamically better

Better washout of leaflet hinge

Less thrombogenic eg ATS valve

7/27/2019 Mandalay 13

13/87



National Heart Institute13

1977: SJM Masters ValveIntra-annular cuffIntra-annular carbon rim

1992: SJM Masters Hemodynamic Plus (HP) valve

Supra-annular cuff allows for largerorifice

Intra-annular carbon rim

1999: SJM Regent valveSupra-annular cuffSupra-annular carbon rim,allowing for larger inner orificeRotation mechanism

completely housed within thecarbon orifice

*2002: US Approval

*2004: Japan Approval

Evolutionary Improvement

7/27/2019 Mandalay 13

14/87




Long term survival (30 yrs) after mechanical valvereplacements

God e Fischlein ATS 1997:63:613-91

7/27/2019 Mandalay 13

15/87




WARFARINIZATION

Mobidity 5 - 15% per year

Mortality 0.2 - 1% per year

7/27/2019 Mandalay 13

16/87




THROMBOEMBOLIC AND ANTICOAGULANTRELATED BLEEDING

Percent per year

Valve Reference Thrombo-embolism

Bleeding Total

Starr-Edwards

Miller 5.87 3.66 9.53

St. Jude Czer 2.1 2.9 5.0

Hancock Gallucci 1.8 0.4 2.2

Ionescu-Shiley

Gonzalez-Lavin

0.36 0.64 0.99

Cumulative rate at 20years

30% 30%

7/27/2019 Mandalay 13

17/87




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 solutionmounted on flexible struts

better haemodynamic

improve durability

7/27/2019 Mandalay 13

18/87




7/27/2019 Mandalay 13

19/87




Biological valves beyond 15 years

Freedom from valve failures

Edwards et al ATS 1995:60 (suppl) 5211-5

AVR

MVR

7/27/2019 Mandalay 13

20/87



National Heart InstituteFann et al. ATS 1996, 62

BIOPROSTHESIS AVR

Freedom from Structural valve deterioration with age

7/27/2019 Mandalay 13

21/87




DURABILITY OF BIOPROSTHESIS(HANCOCK)

At 10 years in 47% redo rate

Age is a strong determinant of durability

< 20 y.o : 50% redo rate at 10 years

40-50 y.o : 10% redo rate at 10 years

> 60 y.o : 3% redo rate at 10 years

7/27/2019 Mandalay 13

22/87




IfMV Replacement is unavoidableChordal apparatus should be preserved

Posterior chordal preservation

Anterior chordal preservation (possible LVOTO)

Both

Chordal reconstruction with Gore-Tex sutures

7/27/2019 Mandalay 13

23/87




Anterior Chordal preservationPosterior Chordal Preservation

Chordal Reconstructed withGoretex suture

7/27/2019 Mandalay 13

24/87




MITRAL VALVE REPAIR

7/27/2019 Mandalay 13

25/87




Improved survival after repair

Enriquez-Sarano et al. Circulation 1995, 91:1022-28

7/27/2019 Mandalay 13

26/87




Annulo-ventricular continuity

7/27/2019 Mandalay 13

27/87




__ Repair. Bio

--- Mech

__ Repair. Bio--- Mech

__ Repair. Bio

--- Mech

WHY REPAIR?

Actuarial Survival

Freedom from Reoperation

Freedom fromthromboembolic events

Yau, Tirone et al, JTCVS 2000, 119(1):53-61

7/27/2019 Mandalay 13

28/87




WHY VALVE REPAIR?

Preservation of LV function

Avoidance of warfarization

Low thromboembolic incidence avoidance of valve prosthesis

complications

- clicking, structural failure

7/27/2019 Mandalay 13

29/87




MITRAL VALVE REPAIR

Valves that have pliable leaflets and fairly preservedchordal apparatus are amendable for mitral valverepair.

Calcifications of annulus, leaflet and chordae arerelative contraindications.

Feasibility of repair is a structural considerationregardless of the aetiology.

7/27/2019 Mandalay 13

30/87




Feasibility of repair in mitral valve

degenerative > myxo > ischaemic > rheumatic

90% 40-50%

Depends on functional/structural abnormality

7/27/2019 Mandalay 13

31/87




Deloche et al. J Thorac Cardiovasc Surg 1990, 99:990-1002

Degenerative

Rheumatic

Degenerative

Rheumatic

Reoperation-free Event-free

7/27/2019 Mandalay 13

32/87




Our Experience

7/27/2019 Mandalay 13

33/87




Mitral Valve Operations IJN

0

20

40

60

80

100

120

140

160

180

200

220

92/93 94 94 96 97 98 99 2000 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10

Tissue

MechanicalRepair

7/27/2019 Mandalay 13

34/87




128

106

202

97

64 61

45 43

6982

99

82 81

49

134

0

50

100

150

200

250

Freq

uency

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

Median age = 27.0

Age range =2m -77 yrs

Mitral Valve Repair

7/27/2019 Mandalay 13

35/87




60%

19%

10% 9% 2%

0

10

20

3040

50

60

%

1

Etiology

Etiology

Rheumatic

Congenital

Degenerative

Ischaemic

Others

7/27/2019 Mandalay 13

36/87




7/27/2019 Mandalay 13

37/87



National Heart InstituteYakub, Dillon et al; EJCTS (2013) 1-9 doi:10.1093/ejcts/ezt093

F ibilit f MV R i i

7/27/2019 Mandalay 13

38/87




Feasibility of MV Repair inRheumatics

Feasibility of repair improved significantly

39% in 1992-2000

65% in 2001-2010 p

7/27/2019 Mandalay 13

39/87




30-day mortality : 2.4% (15/627)

Causes of early deaths

Myocardial failure(LCOS) 7 (1.1%)

Septicemia 4 (0.6%)

ARDS 2 (0.3%)

Malignant Ventricular Arrhythmia 1 (0.2%)

Results

Mean X-Clamp time (min): 85 37 (21-296)

Mean CPB time(min) : 11453 (42-632)

7/27/2019 Mandalay 13

40/87




Actuarial survival at 10 years 98.5%

Actuarial survival

Yakub, Dillon et al; EJCTS (2013) 1-9 doi:10.1093/ejcts/ezt093

7/27/2019 Mandalay 13

41/87




Freedom from re-operation

374 183 101 30 12 7

92.0% 87.3%

Freedom from re-operation at 5 years is 92.0%10 years is 87.3%


7/27/2019 Mandalay 13

42/87




Freedom from valve failure

374 183 101 30 12 7

85.6%

72.8%

Freedom from valve failure at 5 years is 85.6%10 years is 72.8%

Defined as recurrent MR >2+ and/or reoperation


7/27/2019 Mandalay 13

43/87




Univariate MultivariateVariables HR 95% CI p value HR 95% CI P valueAge

7/27/2019 Mandalay 13

44/87




Comparison of durability betweenRheumatics and Degenerative

Reoperation Valve Failure


7/27/2019 Mandalay 13

45/87




Deloche et al. J Thorac Cardiovasc Surg 1990, 99:990-1002

Degenerative

Rheumatic

Degenerative

Rheumatic

Reoperation-free Event-free

Mitral

Regurgitation : Changing

7/27/2019 Mandalay 13

46/87




Mitral Regurgitation : Changingindications for surgery

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 1994Aug 15;74(4):374-80

onset of AF

recent onset AF likely to convert after repairChua YL et al. J Thorac Cardiovasc Surg 1994, 107:408-415

7/27/2019 Mandalay 13

47/87




MV Assessment

Commissurotomy

7/27/2019 Mandalay 13

48/87




AL Peeling

7/27/2019 Mandalay 13

49/87




PL Thinning

PL Thinning

7/27/2019 Mandalay 13

50/87




AL Mobilization

AL Patching

7/27/2019 Mandalay 13

51/87




Pre repair Post repair

Mitral Valve

C

Mitral Valve

7/27/2019 Mandalay 13

52/87




Mitral ValvePre repair Post repair

Cli k di M i l l

7/27/2019 Mandalay 13

53/87




AORTIC VALVE

REPLACEMENT

Cli k t dit M t titl t l

7/27/2019 Mandalay 13

54/87




AORTIC VALVE RECONSTRUCTION

Techniques at our disposal :

AV Replacement

Tissue - stented

- stentless- sutureless

- Mechanical

Ross Procedure Homograft

AV Repair

TAVI - transcatheter aortic valve implantation

Cli k t dit M t titl t lACT

UARIAL SURVIVAL IN PROSTHESIS MISMATCH

7/27/2019 Mandalay 13

55/87



National Heart InstituteRao, Circulation 2000, 102(19) Suppl.

ACTUARIAL SURVIVAL IN PROSTHESIS MISMATCHVS ADEQUATE MATCH


S l l

7/27/2019 Mandalay 13

56/87




Medtronic Freestyle-Stentless

Stentless Valve

Stentless pericardium (Sorin)


S i t tl

7/27/2019 Mandalay 13

57/87



Sorin stentless

subcoronary attachment.

http://cardiacsurgery.ctsnetbooks.org/content/vol3/issue2008/images/large/915fig22.jpeg?ck=nckhttp://cardiacsurgery.ctsnetbooks.org/cgi/content/full/3/2008/915/F12?ck=nckhttp://jtcs.ctsnetjournals.org/content/vol130/issue5/images/large/1265.05012833.gr4.jpeghttp://jtcs.ctsnetjournals.org/content/vol130/issue5/images/large/1265.05012833.gr2.jpeg

7/27/2019 Mandalay 13

58/87



StentedBioprosthesis

Stentless

COLOUR DOPPLER


STENTLESS BIOPROSTHESIS

7/27/2019 Mandalay 13

59/87



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 structuralvalve deterioration


7/27/2019 Mandalay 13

60/87



Perceval S Intuity 3f Enable

Sutureless Aortic Valves


7/27/2019 Mandalay 13

61/87



AORTIC VALVE REPAIR


Feasibility of AV Repair

7/27/2019 Mandalay 13

62/87



Feasibility of AV Repair

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


O C S G

7/27/2019 Mandalay 13

63/87



10 20 30 40 50 60 70 80

PulmonaryAutograft

PulmonaryAutograft

Mechanical Valve

Homograft

StentlessBioprosthesis

StentedBioprosthesis

AORTIC VALVE SURGERY


AGE

TAVI


7/27/2019 Mandalay 13

64/87



MINIMALLY INVASIVE VALVESURGERY


7/27/2019 Mandalay 13

65/87



Minimally Invasive Approaches

Left Minithoracotomy

Partial Sternotomy


Mi i ll I i V l S

7/27/2019 Mandalay 13

66/87



Minimally Invasive Valve Surgery

Potential advantages Good cosmesis Less pain Faster recovery Less cost Less risk of wound infection


7/27/2019 Mandalay 13

67/87




7/27/2019 Mandalay 13

68/87




PARTIAL STERNOTOMY -

7/27/2019 Mandalay 13

69/87



PARTIAL STERNOTOMY Lower


CONCLUSION

7/27/2019 Mandalay 13

70/87



CONCLUSION

Mitral Valve and its apparatus is an integral part of leftventricular function.

Current status of mitral valve surgery is to preserve themitral apparatus whenever possible in order to preserveLV function


CONCLUSION

7/27/2019 Mandalay 13

71/87



CONCLUSION

Mitral Valve Repair is preferable whenever is possible. Itbetter preserves LV function and has better long termsurvival.

Current technical innovations expand possibilityand have improved durability of repair even inrheumatics


In Aortic Position

7/27/2019 Mandalay 13

72/87



In Aortic Position

Aortic repair is occasionally possible

7/27/2019 Mandalay 13

73/87




Factors for consideration Age

Expected life expectancy

Gender

Lifestyle

Socioeconomics

Comorbid factors, renal failure, etc

Etilogy of valve disease

Annular size

Surgeon-patient-preferences


7/27/2019 Mandalay 13

74/87



Thank You


AORTIC STENOSIS

7/27/2019 Mandalay 13

75/87



AORTIC STENOSIS

Indication for surgery:

Symptomatic

Asymptomatic with severe AS.

AV area

7/27/2019 Mandalay 13

76/87



AORTIC REGURGITATION

Indications for surgery:

Symptomatic with AR

Asymptomatic with deteriorating LV, Lvesd >55mm,LV dysfunction at rest


SEVERE AORTIC STENOSIS WHO ARE

7/27/2019 Mandalay 13

77/87



ASYMPTOMATIC

Extremely low risk of sudden death in absence ofantecedent symptoms.

AVR is justified in:-

evidence of LV dysfunction

women who desire pregnancy

very strenuous occupation / activities

Click to edit Master title styleAORT

IC REGURGITATION WHO IS

7/27/2019 Mandalay 13

78/87



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

Click to edit Master title styleAVR

IN SEVERE AR WITH POOR LV FUNCTION /

7/27/2019 Mandalay 13

79/87



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

7/27/2019 Mandalay 13

80/87



AORTIC STENOSIS IN LV DYSFUNCTIONMayo 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%


AORTIC STENOSIS IN THE ELDERLY

7/27/2019 Mandalay 13

81/87



AORTIC STENOSIS IN THE ELDERLY

Operative mortality in octogenarians : 5 - 15%

AVR in elderly is underuse

Consider co-morbid factors

Use of bioprosthesis


PROBLEMS

7/27/2019 Mandalay 13

82/87



PROBLEMS

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 volumeb. if valve area with stroke volume

2. Assess degree of valve calcifation

Click to edit Master title styleMILD

TO MODERATE AORTIC STENOSIS IN

7/27/2019 Mandalay 13

83/87



PATIENTS UNDERGOING CABG

Recent prospective studies : 75% of patients

develop symptoms

requiring AVR within5 years

Repeat surgery for AVR was high mortality : 14 - 30%

Click to edit Master title styleAN

Y PLACE IN PROPLYLACTIC AVR ATTHE TIME OF CABG?

7/27/2019 Mandalay 13

84/87




THE TIME OF CABG?

Baseline aortic jet velocity progression of symptoms

Velocity < 3.0 m/s 5 yr event free survival 84%

no AVR needed

Velocity > 4.0 m/s 5 yr event free survival 21%

need AVR

Intermediate 3-4 m/s assess degree of calcificationbefore deciding on AVR


COX REGRESSION IN INITIALLY

7/27/2019 Mandalay 13

85/87




ASYMPTOMATIC AS

Otto, Circulation 1997, 95

Click to edit Master title stylePred

icted survival curve in ischemic mitral regurgitationRepair vs replacement

7/27/2019 Mandalay 13

86/87




Repair vs replacement

Gillinov,CosgroveJTCVS 2001, 122(6)

A.

Good pts

B.Lateral wall abNComplex MR jet


7/27/2019 Mandalay 13

87/87

y

Mandalay 13

Documents

Transcript of Mandalay 13