Mitral regurgitation :Mitral regurgitation :Surgical OptionsSurgical Options

Steven F. Bolling, M.D.Steven F. Bolling, M.D.Section of Cardiac SurgerySection of Cardiac Surgery

University of MichiganUniversity of Michigan

REPAIR !REPAIR !

Mitral RegurgitationMitral Regurgitation

Mitral replacement in the Mitral replacement in the repair era: Indications ?repair era: Indications ?

Steven F. Bolling, M.D.Steven F. Bolling, M.D.Section of Cardiac SurgerySection of Cardiac Surgery

University of MichiganUniversity of Michigan

NONE !NONE !

Mitral ReplacementMitral Replacement

Mitral Valve = Left VentricleMitral Valve = Left Ventricle

The LV = The MVThe LV = The MV

Mitral RepairMitral Repair

11/9/2011

Mitral Repair vs. ReplacementMitral Repair vs. Replacement

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General PopulationGeneral Population

ReplacementReplacementRepairRepair

p = 0.0004p = 0.0004

Sur

viva

l (%

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urvi

val (

%)

Time (Years)Time (Years)

68%68%

52%52%

Enriquez Sarano et al. Circulation 1995;91:1022

Mitral Valve RepairMitral Valve Repair

•• Simple AnnuloplastySimple Annuloplasty•• Quadrangular ExcisionQuadrangular Excision•• Leaflet Leaflet PlicationPlication•• Ring AnnuloplastyRing Annuloplasty•• Artificial ChordaeArtificial Chordae•• Combination RepairsCombination Repairs

•• Correct annular dilatation of the Correct annular dilatation of the posterior mitral leafletposterior mitral leaflet

•• Increase leaflet coaptationIncrease leaflet coaptation

•• Reinforce the annular suturesReinforce the annular sutures

•• Prevent future annular dilatationPrevent future annular dilatation-- rere--operationoperation

Ring AnnuloplastyRing Annuloplasty

““ItIt’’s not the ring,s not the ring,itit’’s the ringer!s the ringer!””

Mitral Valve RepairMitral Valve Repair

Mitral Valve ReplacementMitral Valve Replacement

BAD BAD RheumaticRheumatic

““HeavyHeavy”” calcificationcalcification

Mitral Valve ReplacementMitral Valve Replacement

IschemiaIschemia……but only but only --ruptured Pap muscleruptured Pap muscle

Mitral Valve ReplacementMitral Valve Replacement

Mitral Valve Replacement Mitral Valve Replacement -- ResultsResults

State of the Art State of the Art -- 19791979

What you want to drive What you want to drive –– 2011 !2011 !

Current Valves

• Gen 4 - Tissue valves : better– Improved hemodynamics– Improved durability

• Proven 20 years of data• Addition of anti-Ca

– Improved ease of implant

Mechanical Valves– 2% to 4% per yr risk of hemorrhage or TE

(Akins, Ann Thorac Surg 1995)

– Incidence of reop (mech): 25% at 12 years (Hammermeister, et al. J Am Coll Cardiol 2000)

– Mortality of reop (mech): 3 to 4 x tissue (Jones, et al. J Thorac Cardiovasc Surg 2001)

What are the risks of reoperation?

Potter, et al. Ann Thorac Surg 2004

UM = 3.8%400 redoJTCVS 2006 !

MVR Operative Mortality Mayo Clinic

1997 2001 2005 20100%

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1997 2001 2005 2010

Shift in Valve Prostheses :Mechanical Tissue

Mitral replacement: Mitral replacement: Indications ?Indications ?

Prior MV replacement !Prior MV replacement !Bad rheumaticBad rheumatic

Heavy calcificationHeavy calcificationRuptured ischemic pap muscleRuptured ischemic pap muscle

CarcinoidCarcinoidEndocarditisEndocarditis -- rarerare

Mitral repair : Indications ?Mitral repair : Indications ?

DegenerativeDegenerativeIschemicIschemic

FunctionalFunctional

90 % of MR 90 % of MR –– REPAIR !!REPAIR !!

Mitral RegurgitationMitral Regurgitation

If your surgeon advises If your surgeon advises replacementreplacement……..

I advise you to replace your I advise you to replace your SURGEON !!SURGEON !!