Current surgical standards for mitral leaflet or chordal

Current surgical standards for mitral leaflet or chordal repair: resect vs. respect ? Thierry Mesana, MD, Ph. D Division of Cardiac Surgery University of Ottawa Heart Institute Ottawa, Ontario, Canada

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

PL Quadrangular Resection Sliding PL Plasty. No SAM More Complex Reconstruction Triangular Resection Simpler, Faster FED > Myxoid No Excess Tissue Posterior Leaflet resection/repair Carpentier. 1978. Still a gold standard.

Respect. Using Artificial Chords David 1998 First applied to AL Seems simple A Plethora of Techniques to adjust Neo-Chords To implant in PM, to pass the leaflet edge… Not so easy when extensive MVP More than one neochord

Respect rather than Resect the Anterior Leaflet is a good idea • AL prolapse represents 10 -20% of MVP • Plus 20 -30% of Bileaflet prolapse • Anterior leaflet resection is rarely indicated (I never do it !) • Chordal transfer is now justified only in Bileaflet Prolapse (basal PL chords to AL) • The current standard to repair isolated AL is chordal replacement (PTFE, Goretex) Flip-over : segment of the posterior leaflet with its chordae is transferred to the anterior leaflet Chordal Transfer from normal PL Now rarely performed

Posterior leaflet artificial chordal replacement More recently introduced, even simpler Rankin J. S. et al. ; Ann Thorac Surg 2006; 81: 1526 -1528

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

Folding Plasty No leaflet resection and No neo-chords

Edge-to-Edge : Alfieri Technique Still there 15 years after and basis of percutaneous Mitraclip. “no resect, still respect… and no neochord” Not applicable to all MV pathology. Localized MVP ( central or commisural)

Freedom from death or repeat intervention after the Alfieri repair at 5 years Kuduvalli M. et al. ; Ann Thorac Surg 2006; 82: 1356 -1361 Copyright © 2006 The Society of Thoracic Surgeons

IS A CHORDAL APPROACH DURABLE for all prolapse subsets? …a word of caution

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 Includes 3+ and 4+ MR but not the MR 2+ 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), anterior (AL), and bileaflet (BL) prolapse David T. E. et al. ; J Thorac Cardiovasc Surg 2005; 130: 1242 -1249

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

Spectrum of Degenerative Mitral Valve Disease needs more than one approach FED + FED+ ++ Form Fruste +++ Barlow’s ++++ Excess Tissue Adams et al. Eur Heart J 2010; 31: 1958 -1967

UOHI : BILEAFLET PROLAPSE, in JTCVS 2012 Carpentier techniques + neo chords + Alfieri…. 142 patients 2 re-operations 1 Goretex, 1 MS

Conclusions 1 - Many techniques can work, as far as adequate line of coaptation is restored, leaflet motion is respected, and annuloplasty is performed, and no MS is generated 2 - Anatomy based : do not ignore excess of tissue 3 - One technique does not fit all, long-term and careful FU in dedicated MV clinic with regular echocardiograms 4 - MV prolapse is best treated in expert MV centers

Also Respect the Posterior Leaflet ? Increasingly popular But not yet a gold standard, FED more than Myxomatous Ann Thorac Surg 2008; 86: 718 -25 Observational Sympto/asympto J Thorac Cardiovasc Surg 2008; 136: 12006 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