Rheumatic Mitral Valve Repair Strategies
Taweesak Chotivatanapong, MD.
AATS 2014 Annual Meeting
AATS/STS Combined Adult‐ Congenital Cardiac Valve Symposium
27th April 2014
Toronto, Canada
Heart Care Foundation , Nonthaburi, Thailand
Disclosure
• Honorarium from Edwards Lifescience for conducting workshop and training.
Prof. Carpentier
Repair Strategy
• Restore type I mobility • Coaptation surface
• Remodelling of annulus
• 3 Scenarios
• MS MR
• Severe calcified MS
• Post PBMV re‐stenosis MS MS MR
Crucial Approaches and Techniques
• Commissurotomy
• Aggressive subvalvular mobilization ‐ Papillotomy down to mid part
‐ resection of any restrictive chords
• Leaflet thinning • Annular remodelling
Severe Calcified MS
Crucial Approaches & Techniques
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Commissurotomy
Subvalvular mobilization down to papillary m.
Aggressive decalcification
Resection of full thickness calcified valve
Chordal replacement with PTFE suture
Ring annuloplasty
Post PBMV Restenosis MS
Crucial Approaches & Techniques
• Sub‐valvular mobilization :
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Papillotomy down to mid papillary m
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Resection of any restrictive chords
• Restoration of 3‐ D pliability :
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Fenestration
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leaflet thinning
• Calcium :
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Decalcification
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Resection • Tissue Repair :
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Autologous pericardium
• Annulus :
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Preferably rigid or semi rigid.
Rheumatic MV : Obstructive PML
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Crucial dynamics
Severe calcified or fibrosed
bar of PML obstructs flow
even with commissurotomy
Excision of this bar is needed
to improve flow to LV
Rheumatic MV : Thickened Leaflets & Restrictive Chords
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Crucial dynamics
Thickened leaflets and restrictive chords impede
good coaptation
Peeling of leaflet and cutting
of restrictive chords improve
coaptation and distribution
of stress. BETTER RESULT !
Rheumatic MV : Calcified AML
Calcified AML : 2 Options
1. Debridement of calcium when the calcification has not penetrated too deeply to the valve tissue
2. Excision of of calcium when it involves the whole thickness of leaflet. Autologous pericardium and PTFE suture , if necessary, are excellent for tissue and chordal
repair.
3. Fenestration , aggressive papillotomy are often required to restore good pliability .
4. Calcicification is the tip of the iceberg of severe tissue retraction. Leaflet augmentation is often needed.
Rheumatic MV : Leaflet Augmentation
Leaflet Augmentation
1. Leaflet augmentation for severe leaflet retraction in rheumatic MV is required frequently.
2. It can be done by either anterior or posterior approach.
3. Anterior approach has an advantage of enlarging AML and achieving a larger ring. In addition to this, surgeon can resect shortened secondary chord, a very common finding, to restore normal movement and orientation of the leaflet.
4. A cut closed to the hinge should be extended ACROSS the commissural line to augment the retracted commissure
and ensure normal valve closure.
Repair Strategy for Rheumatic MV
• Restore mobility :
‐ Type I
‐ 3 dimensional movements
‐Up& down, transverse , billowing
• Tissue repair
‐ Good quality and adequate tissue.
• Coaptation surface
• Remodelling of annulus
• Rheumatic Mitral Valve Repair : Current Approaches and Results at Central Chest Institute of Thailand
• Taweesak Chotivatanapong, MD.
Between March 2003 – June 2013
♦ 358 patients : RHD MV repair
♦ MR : 144 , MS MR : 145 , MS : 69 ♦ F : 233 M : 125 , AV age : 46.05 y • Follow up :
• Range : 10 Y 3 m – 1 m
• Mean : Overall : 30. 4 m
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MR : 46.7 m
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MS MR : 23. 4 m
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MS : 22.0 m
Overall
Pre‐op. Post‐op
LVEDD 52.29 47.21
LVESD 35.83 32.75
EF 58.78
58.11
MR 0.18
2.25 MVA 1.73 1.94
NYHA FC 2.37 1.16
Technique 5.56
P.O Mean gradient 4.9 Max gradient 9.2
MR
Pre‐op. Post‐op
LVEDD 59.39 49.94
LVESD 39.38 36.13
EF 60.33
55.5
MR 0.2
3.26 MVA 2.78 2.3
NYHA FC 2.45 1.16
Technique 4.16
MS MR
Pre‐op. Post‐op
LVEDD 51.18 46.88
LVESD 35.56 32.38
EF 57.78
57.74
MR 0.13
2.2 MVA 1.35 1.72
NYHA FC 2.28 1.13
Technique 6.16
MS
Pre‐op. Post‐op
LVEDD 46.31 44.81
LVESD 32.56 29.75
EF 57.78
61.09
MR 0.21
1.29 MVA 1.07 1.81
NYHA FC 2.38 1.19
Technique 6.35
• Results :
• Hospital mortality = 6 (1.6% )
• Readmission
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‐ Pericardial effusion 19 •
‐ CHF 14
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‐ Coumadin overdose 5
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‐ Severe MR 2
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‐ Transient CVA 1 • Late Death : 6
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Cardiac : 4
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Non‐cardiac : 2
• Reoperation : 6
‐ Redo MVR 4
‐ Redo MV re‐repair 2
Decision Making
• We should try our best to repair rheumatic MV especially in :
• Young patients
• Need for pregnancy
• Poor compliance for medication
• Inappropriate health care system
• For those elderly with complex pathology, high co‐morbidity, MVR with bioprosthesis
should be proceeded.