Novel Surgical Approaches to Treatment of Mitral Regurgitation€¦ · Millipede. Chordal Repair...
Transcript of Novel Surgical Approaches to Treatment of Mitral Regurgitation€¦ · Millipede. Chordal Repair...
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Novel Surgical Approaches to
Treatment of Mitral Regurgitation
Eric L. Sarin, MDCo-Director, Structural Heart and Valve Disease
Co-Director, Cardiovascular ResearchInova Heart and Vascular Institute
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Disclosures
• none
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Relevant Anatomy
• The mitral valve is complex
• Proper mitral valve function is determined at multiple levels
• Effective repair often utilizes a combination of techniques
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Implications for catheter approaches
• Complex anatomy
• Not circular
• Not 2D
• Sizing
• Fixation
• Sealing
• Annular-LV chordalinteraction
• Adjacent structures (Cx, CS, AVB)
• LVOT obstruction
• Durability
Seen from LA
Seen from LV
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Etiology of Regurgitation
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Type I
Normal Leaflet Motion
• Annular dilatation
• Annuloplastyrestores normal anatomic shape
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Type II
Excess leaflet motion
• Prolapse secondary to elongation or rupture
• Strategy determined by amount of leaflet tissue– Excess
•Leaflet displacement
•Targeted resection•Sliding plasty
– Minimal•Chordal transfer•Neochords
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Type II
Excess leaflet motion (triangular resection)
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Type II
Excess leaflet motion
• Prolapse secondary to elongation or rupture
• Strategy determined by amount of leaflet tissue
– Excess
• Leaflet displacement
• Targeted resection
• Sliding plasty
– Minimal
• Chordal transfer
• Neochords
• Triangular resection (more tissue)
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Type IIIRestricted Leaflet Motion
• IIIA- Restricted opening
– Commisural Fusion
• Comissurotomy
– Leaflet Retraction
• Leaflet augmentation
– Chordal Retraction
• Chordal Fenestration
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Type IIIRestricted Leaflet Motion
• IIIA- Restricted opening
– Commisural Fusion
• Comissurotomy
– Leaflet Retraction
• Leaflet augmentation
– Chordal Retraction
• Chordal Fenestration
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Type IIIRestricted Leaflet Motion
• IIIB - Restricted closing
– Leaflet tethering
– Downsized annuloplasty
•Rigid ring
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Repair often requires combination of techniques
• PL prolapse from ruptured chord, AL prolapse from chordal elongation.
• Severe myxomatous degeneration and annular dilatation
• Repair with quadrangular resection of the PL, sliding leaflet plasty, and neochords to posterior and anterior leaflets
• 38-mm Carpentier-Edwards Physio Ring
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Mitral Valve Therapy Technologies
• There are a number of TMV-Repair and TMV-Replacement devices
currently in development , each with unique approaches and features.
Leaflet Repair
Valve leaflets are secured together creating two new smaller valves
Annular Repair
Shape and dimension of the annulus or LV are modified
Valve Replacement
A new valve is delivered inside the native valve
Chordae Repair
Artificial chordae are attached between leaflet and LV
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Mitraclip
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COAPT
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COAPT
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COAPT
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Annuloplasty Devices (Direct and indirect)
Indirect Direct
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Carillon
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Coronary Sinus Annuloplasty
Problems:
• coronary sinus often too
atrial
• circumflex artery
compression
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Arto
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Transcatheter Annuloplasty
Valtech Cardioband• transseptal access
• anchor screws
• Adjustable
• CE mark
• US clinical trial beginning
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Cardioband
Expert Rev Med Devices, 2017
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Cradioband
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Millipede
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Chordal Repair
NeochordHarpoon
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Neochord 1 yr Results
Eur J Cardiothor Surg, 2018
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Chordal Repair
JACC, 2018
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TMVR
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TMVR
• Different
approaches to
fixation
• Anatomic
challenges (LVOT
obstruction)
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Medtronic Intrepid
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Medtronic Intrepid
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Tendyne Mitral Valve
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Summary
• Mitral regurgitation is often multifactorial
• Competent repair requires a through understanding of the underlying pathophysiology and the ability to utilize multiple repair strategies
• Successful catheter-based strategies will likely apply multiple repair techniques
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Thank You