Current Surgical Standards For Mitral Leaflet or Chordal

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Current Surgical Standards For Mitral Leaflet or Chordal Repair Thierry G. Mesana, MD, Ph.

Current Surgical Standards For Mitral Leaflet or Chordal Repair Thierry G. Mesana, MD, Ph. D Division of Cardiac Surgery University of Ottawa Heart Institute

Thierry Georges Mesana, MD, Ph. D I have no real or apparent conflicts of

Thierry Georges Mesana, MD, Ph. D I have no real or apparent conflicts of interest to report.

COMMON SURGICAL BELIEFS ABOUT RESPECT Vs. RESECT 1 - Leaflet repair/reconstruction : Resect A.

COMMON SURGICAL BELIEFS ABOUT RESPECT Vs. RESECT 1 - Leaflet repair/reconstruction : Resect A. Carpentier 1978. Durable, More challenging, “ Expert” technique ? Learning curve 2 - Chordal repair/replacement, PTFE : Respect T. David 1998. Easier (? , many techniques…), greater MV area (? ), Mini-mitral, Long-term durability in complex MVP subsets? SAM? 3 - Other “respect” techniques : Folding plasty for PL only, Edge-to-Edge (Alfieri technique) for PL, AL and BL

Respect rather than Resect the Anterior Leaflet • AL less repairable? 80% ? •

Respect rather than Resect the Anterior Leaflet • AL less repairable? 80% ? • Avoid Anterior leaflet resection • Chordal transfer is now rarely performed in isolated AL prolapse • Most popular technique to repair the anterior leaflet is now chordal replacement (PTFE, Goretex) Flip-over : segment of the posterior leaflet with its chordae is transferred to the anterior leaflet

Respect the Posterior Leaflet ? Ann Thorac Surg 2008; 86: 718 -25 Not comparative

Respect the Posterior Leaflet ? Ann Thorac Surg 2008; 86: 718 -25 Not comparative Sympto/asympto J Thorac Cardiovasc Surg 2008; 136: 1200 -6 65 vs. 65 pts Ann Thorac Surg 2010; 89: 1163 -70 397 pts; 205/192 2 -year mean FU Ann Thorac Surg 2009; 87: 1715 -20 “ Mini-Mitral” 670 pts. 353/317 2. 8 year mean FU

FREEDOM FROM MITRAL REOPERATION Posterior leaflet only Ann Thorac Surg 2008; 86: 718 -25

FREEDOM FROM MITRAL REOPERATION Posterior leaflet only Ann Thorac Surg 2008; 86: 718 -25 , Perrier

FREEDOM FROM REOPERATION PL only Seeburger, Mini thoracotomy, 2. 8 mean FU Ann Thorac

FREEDOM FROM REOPERATION PL only Seeburger, Mini thoracotomy, 2. 8 mean FU Ann Thorac Surg 2009; 87: 1715 -20

IS A CHORDAL APPROACH DURABLE for all prolapse subsets and all types of anatomy?

IS A CHORDAL APPROACH DURABLE for all prolapse subsets and all types of anatomy?

David T. E. et al. ; J Thorac Cardiovasc Surg 2003; 125: 1143 -1152

David T. E. et al. ; J Thorac Cardiovasc Surg 2003; 125: 1143 -1152

Freedom from recurrent moderate or severe mitral regurgitation (MR) in all patients David T.

Freedom from recurrent moderate or severe mitral regurgitation (MR) in all patients David T. E. et al. ; J Thorac Cardiovasc Surg 2005; 130: 1242 -1249 Copyright © 2005 The American Association for Thoracic Surgery

Freedom from recurrent moderate or severe mitral regurgitation (MR) in patients with posterior (PL),

Freedom from recurrent moderate or severe mitral regurgitation (MR) in patients with posterior (PL), anterior (AL), and bileaflet (BL) prolapse David T. E. et al. ; J Thorac Cardiovasc Surg 2005; 130: 1242 -1249 Copyright © 2005 The American Association for Thoracic Surgery

IS A RESECTION BASED STRATEGY MORE DURABLE ?

IS A RESECTION BASED STRATEGY MORE DURABLE ?

AL Chordal shortening ? • • N=146 patients who had mitral repair for degenerative

AL Chordal shortening ? • • N=146 patients who had mitral repair for degenerative MR Between 1970 -1984 , published in Circulation 2001

Is it the technique ? Or is it the disease?

Is it the technique ? Or is it the disease?

Resection technique durability varies with anatomy FED vs Barlows No sliding as surgical risk

Resection technique durability varies with anatomy FED vs Barlows No sliding as surgical risk Flameng W. et al. ; J Thorac Cardiovasc Surg 2008; 135: 274 -282 Copyright © 2008 The American Association for Thoracic Surgery

Large Excess of tissue. Resection + Reconstruction

Large Excess of tissue. Resection + Reconstruction

Degenerative Mitral Valve Prolapse Anatomy based strategy Fibro-elastic deficiency Vs. Barlows Adams D. H.

Degenerative Mitral Valve Prolapse Anatomy based strategy Fibro-elastic deficiency Vs. Barlows Adams D. H. et al. ; J Thorac Cardiovasc Surg 2008; 136: 551 -556

Bileaflet Prolapse : PL resection + PL sliding plasty, Hybrid flip-over for anterior leaflet

Bileaflet Prolapse : PL resection + PL sliding plasty, Hybrid flip-over for anterior leaflet Mesana et al. Ann Thorac Surg 2007; 83: 322 -323

Isolated AL - 89 y-o Alfieri Technique Another ‘respect” technique

Isolated AL - 89 y-o Alfieri Technique Another ‘respect” technique

UOHI : BILEAFLET PROLAPSE, in press in JTCVS 142 patients 2 re-operations 1 Goretex,

UOHI : BILEAFLET PROLAPSE, in press in JTCVS 142 patients 2 re-operations 1 Goretex, 1 MS

Conclusions 1 - Many techniques can work, as far as adequate line of coaptation

Conclusions 1 - Many techniques can work, as far as adequate line of coaptation is restored, leaflet motion is respected, and annuloplasty is performed 2 - Anatomy based : respect or not respect excess of tissue ? 3 - One technique does not fit all, long-term and careful FU in dedicated MV clinic with regular echocardiograms

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