Current Surgical Standards for Mitral Valve Repair Patient

Current Surgical Standards for Mitral Valve Repair: Patient Selection, Techniques and Clinical Results Niv Ad, MD Chief, Cardiac Surgery Inova Heart and Vascular Institute Washington DC Metropolitan Area

NO DISCLOSURES

Patient selection and surgical options • Indications and patient selection per AHA/ACC guidelines • Surgical options – MVR Vs. Repair – Mechanical Vs. Tissue – Midsternotomy – Minimally invasive • Direct vision • Indirect vision

Repair v. Replacement Ad N, Barnett SD, Speir AM, Massimiano PS. Institutional and national trends in isolated mitral valve surgery over the past decade. Current Opinion in Cardiology. 2008; 23(2): 99 -104.

Repair vs. Replacement (Mitral) Mohty D, Curr. Card. 2002

Repair Vs. Replacement (IHVI) • US trends are identical to European trends • Isolated mitral valve repair – 84% of all comers – 92% of all degenerative

Mitral Valve repair

Artificial chorda

Robotic Mitral Valve Surgery

Surgical incision at 1 week

Degenerative MR Adams et al. Ann Thorac. Surg 2006; 82: 2096 -2101

Complex MV repair: Infective Endocarditis

Complex MV repair: Bileaflet prolapse

Post operative result

Freedom from Reoperation (%) Freedom from Reoperation 100 Anterior. P=0. 90 80 5 years Anterior 97. 5± 2% 60 Posterior 97. 3± 2% p=0. 90 40 20 Posterior

Freedom from MR 3+ (%) 100 Anterior 80 4 years Anterior 85± 9% 60 Posterior 84± 9% p=0. 38 40 20 Posterior

Comparison of Minimally Invasive Techniques: 2001 -2008 Total Isolated MV repair 287 cases The Evolution of Minimally Invasive Mitral Valve Repair: From Heartport Through da Vinci to Fibrillation without Crossclamping Poster presented at 5 th Biennial Meeting of the Society for Heart Valve Disease in Berlin, Germany, June 2009 Paul Massimiano, MD; Henry A. Tran, MD, MSc; Linda Henry, Ph. D; Sharon Hunt, MBA; Waseem Sheikh, MD; Chidima Martin, BS; Niv Ad, MD Falls Church, Virginia, USA

Peri-operative complications The Evolution of Minimally Invasive Mitral Valve Repair: From Heartport Through da Vinci to Fibrillation without Crossclamping Poster presented at 5 th Biennial Meeting of the Society for Heart Valve Disease in Berlin, Germany, June 2009 Paul Massimiano, MD; Henry A. Tran, MD, MSc; Linda Henry, Ph. D; Sharon Hunt, MBA; Waseem Sheikh, MD; Chidima Martin, BS; Niv Ad, MD Falls Church, Virginia, USA

2008 valve Surgery outcomes mortality and length of stay Mitral Valve Repair Post Procedure LOS: 3. 6 days v. STS=6. 9 days Mitral Valve Repair Morality: 0. 0 % Aortic Valve Replacement LOS: 4. 0 days v. STS=7. 0 days Aortic Valve Replacement Mortality: 1. 2 %

Gillinov AM et al Valve Repair Versus Valve Replacement for Degenerative Mitral Valve Disease 2008; 135: 885 -93

The role of MV annuloplasty

Atrial Fibrillation The Cox Maze Procedure 30 -40% of MV patients need treatment for AF

Conclusions • In centers of excellence – Very high repair rate – Low complications – Minimally invasive • Reliable MV repair durability with a single procedure and predicted cost • Ability to address atrial fibrillation