VALVE SURGERY / HEART FAILURE
Dr. F. Wellens
O.-L.-Vrouwziekenhuis Aalst
1) AORTIC VALVE
2) MITRAL VALVE
3) TRICUSPID VALVE
AORTIC VALVE SURGERY
Aortic valve surgery
Aortic valve stenosis
Heart failure
systemic arterial
compliance
valvular
stenosis
left ventricular
function
AVR is efficient in heart failure patients
With:
1) Preserved systolic function
2) Reduced ejection fraction and high after
load
3) Low ejection fraction, low gradient and
inotropic reserve
AVR is not efficient in patients
With:
1) Low ejection fraction, low gradient and no
inotropic reserve
2) Low ejection fraction, low flow and pseudo
aortic stenosis
Epidemiology studies of patients with AS:
demonstrate that an important cohort will not
undergo AVR although the conservative
management showes a dismal prognosis
Euro Heart Surgery: 32%
Loma Linda experience: 39%
Predictors of reduced survival:
• Advanced age
• Low ejection fraction
• Heart failure
• Renal failure
Annals of Thoracic Surgery 2006, vol. 82, p 2111 - 2115
Annals of Thoracic Surgery 2006 vol. 82, p 2111 - 2115
How do we indentify high risk or
unoperable patients?
• STS risk algorithm
• Euroscore (additive and logistic)
These algorithms
1) Are based upon operated patients
2) Factors like stroke, discharge disposition
and quality of life are not included
3) Many risk variables are not included:
- chest irradiation
- redo with open grafts
- porcelain aorta
- cirrhosis
- neurocognitive disorders
- frailness or debility
In the “unoperable” group we need to
identify these patients who are candidates
for transcatheter AVR
• Highest tenth percentile of predicted risk by
the STS risk algorithm
• Other candidates independant of risk
algorithms:
- porcelain aorta
- chest irradiation
- multiple sternotomies
- with open grafts
- CRF
Surgery for AVR and heart failure:
1) Short ECC and Ao cc
2) Meticulous haemostasis
3) Optimal myocardial protection (Buckberg
blood cardioplegia)
4) Avoidance of prosthesis – patient mismatch
Prosthesis mismatch after AVR
Ruel et all, Journal of Thoracic and Cardiovascular Surgery 2006, vol. 131, p 1039
Survival (x 2)
Freedom from heart failure (x 5)
Left ventricle mass regression
Percutaneous
• Transcatheter
• Transapical
How to discriminate the individual patients
who still will benefit from AVR?
Evaluation of aortic stenosis in Heart
Failure patients
• Value of
• Dobutamine stress echo
• BNP
Bergher – Klein et al, Circulation 2007, vol. 115, p. 2484 - 2855
BNP  550 ug/ml: poor outcome in:
• true aortic stenosis
• pseudo aortic stenosis
CONCLUSION
Absolute need for development of other
algorithms in clinical practice.
increase of age
new technology
economics
MITRAL VALVE SURGERY
Mitral valve surgery – Heart failure
Organic M.R
- Rheumatic
- Degenerative
Functional
- Ischaemic CMD
- Dilated CMD
Highly successfull
A failed innovation?
Functional Mitral valve regurgitation –
Heart failure
1) Normal anatomy of the mitral valve
2) Left ventricular dysfunction
When physiology is disrupted, attempts at
restoring anatomy are futile.
The ischaemic Heart failure patient:
•
•
•
•
•
•
Mitral valve regurgitation
Left ventricular volume
Asynergic areas
Remote myocardium
Coronary disease
QRS
JACC 2005, vol. 45, p 388 - 390
Expansion of surgeon familiarity with basic
and complex valvuloplasty techniques
All Mitral Valve Surgery 1991-2006
(n = 3122 )
300
275
250
225
MVR
MVP
200
175
150
125
100
75
50
25
0
'91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06
Endoscopic Mitral Valve surgery, 1997 – 2006
(+/- tricuspid surgery)
(Total = 1140, MVP = 842, MVR = 298)
250
Total
MVP
MVR
200
150
100
50
0
'97
'98
'99
'00
'01
'02
'03
'04
'05
'06
'07
Patients with impaired left ventricular
function and even a mild degree of M.R
will have a decreased five year survival
B.H. Trichon et al; American Journal of Cardiology; 2003; vol. 91
Surgical expertise
Natural history
MVP as treatment for end
stage heart failure
No convincing data for:
• Increased longevity
• Improval of symptoms
• Reduction in ventricular size
Mitral valve anatomy
Ventricular dysfunction creates:
• Annular dilatation
• Increase of interpapillary muscle distance
• Amplified leaflet thetering
• Decreased closing forces
Knowledge of:
• Presence of leaflet malcoaptation
• Malapposition
• Annulus diameter
• Interpapillary distance
• Chordal length
is critical for the mode of repair
Additional techniques
•
•
•
•
External devices (CorCap, …)
Section of secondary chordae
Repositioning papillary muscles
Remodeling infero –
posterior infarct zone
• Leaflet extension
• Edge to edge technique
+ Treatment of atrial fibrillation (Minimaze)
+ CRT (left ventricular epicardial lead)
Mitral valve replacement
In case of:
• Complex multiple jets
• No annular dilatation
• Large tenting area
• Coaptation depth > 15 mm
Results of repair operations for functional
MR in Heart Failure patients are mostly
analyzed with an overwhelming bias that
mitral intervention in heart failure must be
beneficial.
Efficacy of mitral surgery in heart failure:
• LV remodeling (ventricular size and
function)
• symptoms (need for medication –
hospitalisation)
• survival
Survival
• Medical treatment:
1990 – 2000 : ± 50%
• Cleveland clinic experience for ischaemic
M.R: survival at 5 years, ± 50 %
• MV repair is better than MVR
Journal of Thoracic and Cardiovascular Surgery 2001, vol. 122, p 1125 - 1141
Combined MVR + CABG
No survival benefit from MVP
5 year survival: 50% or less
Harris et al; The Annals of Thoracic Surgery ; 2002, vol. 74, p 1468 – 1475
Diodato et al; The Annals of Thoracic Surgery; 2004, vol. 78, p 794 – 799
Michigan experience 1995 – 2002
No clearly demonstrable mortality benefit.
Irrespective of heart failure etiology.
1) Earlier patients
2) MVP rings:
complete
rigid
smaller
Wu et al, JACC 2005, vol. 45, p 381 - 387
Effect on remodeling
• Exceedingly limited information
• Braun et al. (Leiden):
In 87 patients:
• meticulous F.U
• small but significant reduction in moderately
dilated hearts
• but:
- no control group
- 75% combined CABG
Braun et al., European Journal of Cardiothoracic Surgery, 2005, vol. 27, p. 847 - 853
The Leiden protocol
LVEDD < 65 mm: MV repair: downsizing
2 sizes
coaptation depth: 8 mm
LVEDD > 65 mm: MV repair + ACORN device
LVEDD > 80 mm: - orthotopic HTX
- destination therapy /
mechanical assist
- (Batista?)
Tricuspid valve repair when A – P diameter
exceeds 40 mm
1) Two year surgical benefit of MVP
2) CorCap cardiac support device
Very limited differences compared to
medical controll group
Acker, Bolling et al, J. Thoracic and Cardiovascular Surgery 2006, vol. 132, p 368 – 577
Effect on symptoms
Extensive empiric clinical experience is the
basis of widespread belief that MV surgery has
a beneficial effect on symptomatic heart failure.
Unfortunately:
• Only improvement in NYHA class
• No quantitative data
on - exercice tolerance
- reduction hospitalization/medication
Why is MV-surgery for functional MR less
convincing?
1) Is the current repair technique not durable?
Most studies: high recurrence of MR > 2+
Braun et al: a very small (24-26) use of
semirigid complete rings may result in
improved durability.
2) Stimulus of remodeling is severe in
ischaemic pathology
3) FMR is dependant on loading conditions
and activity levels
Has minimal access surgery an impact on the
results of MV-surgery for Heart Failure?
• No studies available
• Empiric results: favorable minimal access with
decreased mortality and morbidity (more
pronounced in redo settings)
Future role of percutaneous mitral valve
remodeling?
Probably very limited in Heart failure patients
with:
• LVEDD > 60 mm
• LVESD > 50 mm
Conclusion:
Functional MR in heart failure patients is a poor
prognostic sign.
MVR data retrospective:
- survival benefit?
- remodeling: limited
- symptoms: limited
How to indentify the patient groups that derive
significant benefit?
Randomized study is urgently needed
THE TRICUSPID VALVE
The tricuspid valve
• Tricuspid regurgitation will never dissappear
after correction of left-sided lesions.
• Progressive evolution towards TR post mitral
and/or aortic valve surgery
The Annals of Thoracic Surgery 2005, vol. 79, p 127 - 132
More agressive approach to tricuspid
valve surgery
Tricuspid valve regurgitation
Fysiology
Diuretics
Vasodilators
Pre- or perioperative echography or surgical
measurement of tricuspid valve diameter will
indicate the surgical indication and not the
presence or absence of tricuspid valve
regurgitation
CONCLUSION
There is a most intimate interdependence of
physiology, pathology and surgery.
Without progress in physiology and pathology,
surgery could advance but little, and surgery
has paid its debt by contributing much to the
knowledge of the pathologist and physiologist,
never more than at the present.
William Stewart Halsted, 1852 - 1922