MV Repair for CHF 2012 Steven F Bolling

MV Repair for CHF 2012 Steven F Bolling Professor of Cardiac Surgery University of Michigan

Steven F. Bolling, MD § Royalty: § Edwards Lifesciences LLC

CHF : An Expanding Unmet Need 5 yr mortality = 50% 10 yr mortality = 75% Annual Deaths from Congestive Heart Failure United States: 1979 -1999 # cases/yr : 600, 000 # transplants : 2, 000 Source: National Center for Health Statistics, AHA

Mitral Regurgitation in CHF 558 pts, NYHA III – IV 39% > Mod MR, 25% TR 5 yr survival - 37%, Mayo Patel JB et al. J Cardiac Fail 2004; 10: 285 -291 Robbins JD Am J Cardiol 2003; 91; 360 -3. Trichon BH. Am J Cardiol 2003; 91: 538 -43. Koelling, Bolling et al: Circulation 85, 2001

Geometric MR in Dilated Cardiomyopathy “loss of closure cylinder” Badhwar, Bolling , chapter in: Advances in Heart Failure, 2004

survival Optimal Medical Therapy of CHF/FMR : is not optimal! MR grade None Mild Moderate Severe No. 9, 405 2, 062 210 171 Years Hickey et al: Circulation 78: 1 -51, 1988

In fact, . . . it’s terrible !! ERO RVol Grigioni et al: Circulation 103: 1759, 2001

And 2011, they still do terribly… Multivariate predictor : Age Vena contracta > 2 mm (EF & EDV = ns) Szymanski et al Am J Cardiol 2011 Sep 21.

Mean age 67 Mean EF 32% NYHA I 150 (15%) II 500 (49%) III 316 (31%) IV 57 (6%) Mean f/u 2. 7 y Rossi et al Heart 2011; 97: 1675 -80

FMR - Not just a “late marker” … it’s really BAD! Odds ratio of

“Undersized” Mitral Repair Nyah, Nyah !… Surgeons can fix FMR !!

Mitral Repair for GMR in CHF Bolling Chen Bishay Calafiore Buffolo Bitran Dreyfus Suma ACORN JTCVS Circ Eur JCTS Ann TS Ar Br Card J Card Surg JHLT JTCVS 1995 1998 2000 2001 2006 200 pts 81 pts 44 pts 49 pts 80 pts 21 pts 45 pts 44 pts 193 pts 30 day mortality 1 - 5 %

“Undersized” Mitral Repair Feasible Low mortality Relief of MR Better Quality of life

Mitral Repair and CHF : benefit ? Yikes - No mortality benefit !

Mitral Repair and CHF : benefit ? Why - No mortality benefit ?

FMR controversial : recurrent MR Progression of 3 or 4+ MR post-undersized annuloplasty (585) 11/24/2020 Mc. Gee, Gillinov et al, JTCVS, 2004; 128: 916 -24

MVR and CHF Even a good operation, when done badly… will not help a sick patient ! …recurrent MR is still bad

Surgical Predictors of recurrent MR Anterior annulus dilates : don’t “size” don’t use partial rings Hueb JTCVS 12/02 , Gorman ATS 10/04, Miller JTCVS 9/03, Kaji, Circ 2006, ACORN Circ 2007

Surgical Predictors of recurrent MR Flexible = 5 x recurrent MR ! Use rigid complete ! Spoor, Geltz, Bolling : Circulation , 11/06

Flexible bands don’t provide a durable solution for IMR Magne et al. Cardiology 2009; 112: 244 -259

Strongest predictor of recurrent MR AP diameter > 3. 7 cm Recurrent MR Failed Repair AP diameter reduction !!! Kongsaerepong V et al. Am J Cardiol 2006; 98: 504 -8

IMR-FMR ring designs Disproportionate AP dimension reduction Bothe W, Swanson J, et al. , JTCVS 2010

MV repair – 30 day mort 1. 6% Freedom from >1+ MR = 90% !!

MVr - Survival

Randomized IMR trial – JTCVS Fatouch 2009

IMR

2+ IMR - survival

2+ IMR – exercise echo MR

Braun J, et al. , Leiden Ann Thorac Surg 2008; 85: 430 – 437

CHF Mitral Repair - Kron

CHF Mitral Repair - Hvass

Valve sparing replacement vs repair Survival for 4+ IMR Al Radi et al, Ann Thorac Surg, 2005; 79: 1260 -7

Mt Sinai - High risk CABG/MVr

High Risk 100 80 80 60 60 40 20 00 40 Worst 20% !! I 1 Medium Risk II 20 2 3 4 5 6 1 2 3 Low Risk 100 Survival 00 7 80 Replace 60 p o 4 80 %6 5 7 T Repair 40 20 00 III - V 1 2 Gillinov et al, JTCVS 2001; 122: 1125 -41 3 4 5 6 7

ACC/AHA guidelines: The Current Standard of Care for Functional MR 2012

FMR - 2012 Overall 6. 5 year survival – 86% - uniform, complete, undersized, rigid ring repair De. Bonis et al – Eur J of CV and Thor Sur, 2012, in press 134 propensity matched pts- CHF / severe MR

The Current Standard of Care for FMR Optimal Rx CRT Surgery Percutaneous therapy

FMR still gives me a HEADACHE!!