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PLENARY SESSION III: MITRAL VALVE REPAIR TIPS AND

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PLENARY SESSION III: MITRAL VALVE REPAIR TIPS AND
AATS CARDIOVASCULAR VALVE
SYMPOSIUM 2015
PLENARY SESSION III: MITRAL VALVE REPAIR TIPS AND TECHNIQUES
POSTERIOR LEAFLET PROLAPSE REPAIR
RENATO A. K. KALIL
CONFLICT OF INTEREST DISCLOSURE
THERE IS NO CONFLICT OF INTEREST TO
DISCLOSE, RELATED TO THIS PRESENTATION
Atrial view of mitral valve showing anterior or septal leaflet
and posterior or mural leaflet with its 3 portions
Anderson RH & Becker A. Atlas de Anatomia Cardíaca. Livr Edit Santos, SP. 1983
Antero-lateral comissure
SCALLOP 1 - P1
Anterior leaflet
SCALLOP 2 - P2
Posterior leaflet
Anderson RH & Becker A. Atlas de Anatomia Cardíaca. Livr Edit Santos, SP. 1983
Postero-medial comissure
SCALLOP 3 - P3
Anderson RH & Becker A. Atlas de Anatomia Cardíaca. Livr Edit Santos, SP. 1983
Coaptation line
Free margin
Anderson RH & Becker A. Atlas de Anatomia Cardíaca. Livr Edit Santos, SP. 1983
Mitral valve morphology with its large
rough zone of leaflet coaptation
Rough zone
Clear zone
Mitral Valve Physiology
Mitral valve physiologic mechanism includes
participation from several related strutures
Leaflets
Chordae
Papillary muscles
Left ventricular wall
Valve annulus
Left atrial wall
•
•
•
When the jet of blood flowing into the ventricle as a result of atrial
contraction suddenly ceases, a negative pressure occurs on the
inner aspect (atrial side) of the valve leaflets, causing these leaflets
to be drawn toward each other.
The valve leaflets come together first in the area near the valve ring
and last at the valve margins.
During the last stage of ventricular contraction, the annular area is
constricted by approximately 30% in comparison to the maximum
open orifice. However, two-thirds of this is due to atrial contraction.
Willerson, Cohn, McAllister (Guest editors) Manabe, Yutani (editors): Atlas of Valvular Heart Disease, Churchill Livingstone Inc. 1998, pág.21.
Degenerative mitral valve regurgitation
FED
FED+
Forme fruste
Leaflet tissue
Adams DH, Rosenhek R, Falk V. European Heart Journal 2010; 31: 1958-1967
Barlow’s
General Requisites for a Valvuloplasty Technique
Maintain an adequate minimal useful orifice
Maintain a large coaptation zone, > 5mm
Maintain leaflet support by chordae
Preserve flexibility
Preview fibrosis and calcification
Use compatible chordae or membranes
Maximum of autologous material “Respect rather than resect”
Valvuloplasty Requisites
Related to Posterior Repair
1. RESTORE CHORDAL SUPPORT
QUADRANGULAR RESECTION
TRIANGULAR RESECTION
SLIDE PLASTY
CHORDAL FOLDOPLASTY
NEOCHORDAE
Valvuloplasty Requisites
Related to Posterior Repair
2. REDUCE ANNULAR DIMENSION
POSTERIOR ANNULOPLASTY
WOOLER TYPE ANNULOPLASTY
POSTERIOR RING
POSTERIOR BAND
FLEXIBLE OR RIGID COMPLETE RING
Quadrangular resection
Nunley DL, Starr A – The evolution of reparative techniques for the mitral valve. Ann Thorac Surg. 1984;37:393-397.
Wooler Annuloplasty
Wooler et al. Thorax 17:49-57, 1962
Annuloplasty
(Wooler, Thorax 1962)
Triangular resection
(Mcgoon DC,
JTCS 1960)
Chordal shortening
Kalil et al. Annuloplasty for rheumatic mitral regurgitation. JACC 1993, 22(7):1915-20.
Double Teflon Pledget Technique
100
94,7+/- 3,6%
Sobrevida (%)
90
80
70
60
50
40
30
20
10
0
0
12
24
36
48
60
72
84
96
108 120
Tempo (meses)
Sobrevida Livre de
Reoperação (%)
100
99,2 +/- o,8%
90
80
70
60
50
40
30
20
10
0
0
12
24
36
46
60
72
84
96 108 120
Tempo (meses)
Pomerantzeff P et cols. J Heart Valve Dis 2002 / Rev Bras Cir Cardiovasc 2007
Mitral annlus Circunference (cm)
12,50
11,50
*
10,50
9,50
8,50
7,50
6,50
5,50
4,50
Pre
5,00
ML Diameter (cm)
*p<0.05
*
4,50
4,00
3,50
IPO
6-month
1-year
*p<0.05
*
*
3,00
2,50
2,00
1,50
1,00
0,50
0,00
Pre
Braz J Cardiovasc Surg 2015; 30(3):325-24
IPO
6-month
1-year
Rings
Technical standardization
ADVANTAGES
Reproducibility
Redilation prevention
Support to the surgeon
Possible “valve in ring” later
Compromises dynamic nature
Reduces basal LV contraction
Changes the saddle shape of mitral annulus
Difficults growing, in children
Useless in anterior portion and may cause SAM
Deiscence
DISADVANTAGES
Unsupported Valvuloplasty for Degenerative Mitral
Regurgitation: Long-Term Results
Alexsandra L. Balbinot¹, Renato A. Kalil¹’², Paulo R. Prates¹, João Ricardo M Sant’Anna¹, Orlando C. Wender¹,
Guaracy Fernandes Teixeira Filho¹, Rogério S. Abrahão¹ Ivo A. Nesralla¹.
Instituto de Cardiologia do Rio Grande do Sul, Fundação Universitária de Cardiologia¹, Universidade Federal de Ciências da Saúde de Porto Alegre,
Instituto de Cardiologia do Rio Grande do Sul Fundação Universitária de Cardiolosia¹, Universidade Federal de Ciências da Saúde de Porto Alegre
(UFCSPA), Porto Alegre RS-Brazil.
Reoperation (Kaplan-Meier)
1,0
1,0
Event-free Survival %
Survival (%)
0,8
0,6
0,4
0,8
0,6
0,4
0,2
0,2
0,0
115
66
0
5
29
10
9
15
3
20
n
25
0,0
115
73
42
15
0
4
8
12
Time (years)
Time (years)
Arq Bras Cardiol 2009; 90(6): 363-369
Late Outcome of Unsupported Annuloplasty for
Rheumatic Mitral Regurgitation
100
80
80
Patient Survival (%)
60
40
981 973 964 931
20
07
12
21
154 151 122
30cl
2
907 893 885
27
30
33
97
83
74
4
37
62
6
865
840
41
53
820 795
771
45
49
53
57
49
40
38
8
10
35
745 722
62
32
12
69
29
710
%
74
SE
21
n
EVENT FREE SURVIVAL
(%)
100
60
40
972 962
20
927 897
860
868
832
799
746
679 612 592
08
12
24
31
35
40
46
55
71
89
109 131
151
117
86
71
60
58
45
42
33
30
29
25
561
561
137
117
SE
21
13
n
14
TIME (years)
2
4
6
8
10
12
TIME (years)
Kalil R et al (J Am Coll Cardiol1993;22:1915..20)
%
14
Unsupported Valvuloplasty in Children with Congenital
Mitral Valve Anomalies. Late Clinical Results
Period 1975-1998
Insufficiency
Population
n=21
N=12(57.1%) Mean age=6.09±3.42
Stenosis
N=6(28.6%) Mean age=2.95±2.22
Double lesion
N=3(14.3%) Mean age=7.67±3.21
0
5
10
Number of patients
15
p=NS
Patients distribution by groups with congenital mitralvalve malformations.
Patients with complete defects of the atrioventricular septum were
exclued from the sample.
100
86%
90
80
90%
90
70
80
70
60
50
40
30
20
60
Survival
Survival
100
40
30
20
10
10
0
50
1
2
3
4
5
6
7
8
9
10
11 12
13
14
15
Years
Actuarial survival probality curve in the group of with congenital
mitral insufficiency
16
0
0
1
2
3
4
5
6
7
8
9
10
11
12
13 14
15
Years
Actuarial survival probability free of reoperation in the group of
congenital mitral insufficiency
Lorier G, Kalil R et al Arq Bras Cardiol 2001; 76: 215-20
Randomized study of surgical isolation of the
pulmonary veins for correction of permanent atrial
fibrillation associated with mitral valve disease
100
90
Sinus Rhythm (%)
80
70
Log-rank p<0,001
60
50
40
30
Control
Maze
SPVI
20
10
0
0
12
24
36
48
60
Follow-up (months)
A) Kaplan–Meier curve showing the number of patients at sinus rhythm as
a function of time, according to surgical technique
Albrecht A, Kalil R, Schuch et al. J Thorac Cardiovasc Surg. 2009; 138(2):454-9.
Conclusions
Posterior mitral leaflet prolapse repair can be achieved with quadrangular
ressection and corresponding unsupported annuloplasty. This preserves
annular flexibility and motion.
Triangular ressection + posterior ring annuloplasty and/or complete ring
annuloplasty are preferred by some authors.
Proper chordal support & large area of leaflet coaptation is essential for
repair durability
Renato A. K. Kalil
Cardiac Surgeon Instituto de Cardiologia do Rio Grande do Sul
Full Professor of Surgery – Federal University of Health Sciences (UFCSPA)
Emeritus Professor – Post-Graduation Program/ Fundação Univ. Cardiologia
Coordinator – Clinical Research Center/ Fundação Univ. Cardiologia
[email protected]
THANKS
Marcelo Miglioranza and Álvaro Albrecht
the collaboration, the slide of videos
Surgical team, the Post-Graduation Program and Units of Teaching and Research of
Rio Grande do Sul Cardiology Institute.
At the Federal University of Health Sciences of Porto Alegre (UFCSPA)
CLASS MEDICAL AND MEDICAL ILLUSTRATIONS
[email protected]
www.tonan.com.br
Anterior mitral annulus (cm)
*p<0.05
5,10
*
5,00
4,90
4,80
4,70
4,60
4,50
Pre
AP Diameter (cm)
5,00
4,50
4,00
3,50
IPO
6-month
1-year
*p<0.05
*
*
3,00
2,50
2,00
1,50
1,00
0,50
0,00
Pre
IPO
6-month
Guedes MAV,et al. – Mitral annulus morphologic and functional analysis using real time tridimensional
Echocardiography in patients submitted to unsupported mitral valve repair
1-year
Smooth zone
Rough zone
Annulus
Free margin
Coaptation line (atrial)
Anderson RH & Becker A. Atlas de Anatomia Cardíaca. Livr Edit Santos, SP. 1983
Is physiologic annular dynamics preserved after mitral valve
repair with rigid or semirigid ring?
Source: Ryomoto et al: The Annals of Thoracic Surgery 2014; 97:492-497 (DOI:10.1016/j.athoracsur.2013.09.077
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