2/12/2014

When to Repair a Rheumatic Mitral Valve

When to Repair a Rheumatic Mitral Valve

“Rheumatic disease enters the throat, licks the joints and bites the heart.” Jean Baptiste Bonilland (1835)

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When to Repair a Rheumatic Mitral Valve

Rheumatic fever and its sequel rheumatic heart disease (RHD) continue to cause a large burden of morbidity and mortality in disadvantaged populations.

When to Repair a Rheumatic Mitral Valve

o Coronary artery disease kills more than 7 million each year. o Stroke kills nearly 6 million. o Rheumatic fever and RHD kill 300,000 each year. Most of the deaths are in the young and in developing countries.

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When to Repair a Rheumatic Mitral Valve

Of the 15 million people currently affected by RHD, two-thirds are children 5-15 years of age.

When to Repair a Rheumatic Mitral Valve

Over 2 million require repeat hospitalization and over a million will require surgery in the next 520 years.

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When to Repair a Rheumatic Mitral Valve

When to Repair a Rheumatic Mitral Valve

Currently, RHD remains an alarming and unresolved health problem in the Southeastern Anatolia region. While almost 75% of affected subjects were females, males were more severely affected. In addition, subjects were relatively old, most were affected by mixed valvular disease of an advanced stage.

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When to Repair a Rheumatic Mitral Valve

RHD prevalence 1000Arabia Rheumatic in per Saudi Areaheart valve disease remains very prevalent. [range] North America

0.6

South America

5.3 (1.0 - 17)

Africa

6.7 (0.3 - 15)

Asia

6.0 (1.2 - 21)

Pacific

8.7 (1.0 - 18.6)

(excluding Japan)

Japan

Saudi Arabia

0.7

3.4 (2.4

6.4)

When to Repair a Rheumatic Mitral Valve

Rheumatic valvulitis leads to various degrees of valve involvement and destruction which will affect the surgical approach.

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When to Repair a Rheumatic Mitral Valve

When to Repair a Rheumatic Mitral Valve

Nowadays, many valvular problems can be tackled percutaneously. This field is expanding rapidly and is already changing the way we look at and treat valvular heart disease.

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When to Repair a Rheumatic Mitral Valve

Nevertheless surgery remains the main stay of therapy at present time.

When toRHEUMATIC Repair a Rheumatic Mitral Valve MITRAL VALVE: WHEN TO REPAIR? WHEN NOT TO REPAIR REPAIR

REPLACEMENT

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When to Repair a Rheumatic Mitral Valve

Prosthetic valve replacement in the young is associated with multiple problems.

When to Repair a Rheumatic Mitral Valve

Bioprothesis in the young degenerate early.

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When to Repair a Rheumatic Mitral Valve And contrary to common belief [even among physicians]

Mechanical Valves are not a permanent replacement.

 They can thrombose.  They can get infected.  They can form a pannus and get obstructed.  They need anticoagulation.

When to Repair a Rheumatic Mitral Valve

Repair has… • • • • • •

Lower mortality Better LV function Reduced thromboembolism Reduced bleeding Reduced endocarditis Improved Survival

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When to Repair a Rheumatic Mitral Valve

Overall survival comparison for MV Repair and Replacement

When to Repair a Rheumatic Mitral Valve

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When to Repair a Rheumatic Mitral Valve

When to Repair a Rheumatic Mitral Valve

Conclusion: During the last decade the practice of valve surgery has changed significantly. The surgical treatment for mitral disease has transitioned to primarily one of repair, not replacement, with the use of bioprostheses more than doubled. For the aortic position, the primary procedure remained valve replacement with bioprosthesis being the valve of choice. Regardless of valve disease, institutional costs and charges for the surgical treatment have greatly outpaced physician reimbursement.

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When to Repair a Rheumatic Mitral Valve

Rheumatic valves have an ongoing inflammatory process with aggressive pathological changes. This leads to shorter repair durability particularly in the young.

When to Repair a Rheumatic Mitral Valve

Freedom from reoperation after mitral valve repair with rheumatic and degenerative etiologies for MR

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In conclusion, valve repair although possible in a high percentage of rheumatic regurgitation patients carried a penalty of unsuccessful attempts and reoperations. However, in the follow-up period the rate of thrornboembolism and late mortality among the patients with prostheses offsets these disadvantages. (Eur Heart Journal 1991 Jul;12 Suppl B:34-8)

When to Repair a Rheumatic Mitral Valve Long Term (29 years) Results of Reconstructive Surgery in Rheumatic Mitral Valve Insufficiency S. Charvaud, et al Circulation 2001;104:1-12

…The mean follow up was 12 years… Mean Age 26 yrs (4-75) Freedom from reoperation was 82±19% at 10 years and 55±25% at 20 years. The main cause (83%) of reoperation was progressive fibrosis of the MV.

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When to Repair a Rheumatic Mitral Valve

Results of MV Repair in Rheumatic Mitral Valve Regurgitation A.S. Kumar et al (India) ICVTS 5(2006) 356-361 898 pts mean age 22.4 + 10years … Actuarial and reoperation free survival at 10 years were 92 ± 1.1% and 81 ± 5.2% respectively. Freedom from moderate or severe MR was 32 ± 3.9%.

Conclusions. Mitral valve repair in children with rheumatic valve disease has excellent immediate results with low operative risk and satisfactory midterm results and should therefore be the preferred treatment of choice. The use of biodegradable mitral valve ring results in a significant lower mean gradient during the first year of implantation compared with the Carpentier-Edwards ring and is available in a wide range of sizes.

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Conclusions. A more aggressive approach to resection of diseased valvular tissue with subsequent reconstruction is feasible, with good midterm results, and may extend the scope of valve repair in rheumatic disease patients.

Conclusion: Mitral valve repair provides better short-term and long-term event-free survival for rheumatic patients. With an acceptable reoperation rate, MVP is also more beneficial by avoiding troublesome lifelong anticoagulation. Thus, whenever possible, MVP should be attempted in patients with RHD.

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When to Repair a Rheumatic Mitral Valve

The possibility of an unsuccessful repair requiring immediate replacement during the same operation or at a later date, is the only negative factor of MV repair.

When to Repair a Rheumatic Mitral Valve

This is probably the major factor preventing some surgeons from pursuing repair… particularly that mortality in pts who have unsuccessful reconstruction followed by immediate valve replacement can be as high as 15-30%.

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When to Repair a Rheumatic Mitral Valve

Feasibility of MV Repair depends  Valve morphology/pathology  Experience of the surgeon  Desire of the surgeon  Patient selection is important

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When to Repair a Rheumatic Mitral Valve

Most important determinants of a successful MV repair:  Mobile annulus  Pliable leaflets  Adequate chordae  Secure papillary muscles  Desire and experience of surgeon

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When to Repair a Rheumatic Mitral Valve Factors that can bias selection for MV repair A.

MAJOR   

Valve pathology Valve lesions – annulus, leaflets, subvalvular Etiology – rheumatic, ischemic, degenerative

B. MINOR

CARDIAC Left atrial size Thrombus Rhythm Associated surgery Left ventricular function

NON-CARDIAC Age, sex Geographic Socio economic Lifestyle

When to Repair a Rheumatic Mitral Valve

Possible causes of Failure of a Valve Repair: 1. Wrong indication  Degree of valve destruction should have precluded attempt at repair (over enthusiasm!) 2. Technical Error  Misjudgment in the assessment of the lesion  Misjudgment in the performance of a particular maneuver (e.g. in estimating length of neo Gore-Tex chordae)

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When to Repair a Rheumatic Mitral Valve

Possible causes of Failure of a Valve Repair: 3. Instability of the repair technique  Non-use of an annuloplasty ring!?

When to Repair a Rheumatic Mitral Valve

Possible causes of Failure of a Valve Repair: The addition of an annuloplasty ring is considered an integral part of the repair. MV repair without a prosthetic ring annuloplasty is associated with accelerated return of MR. [Gillnov et al. ATS 2009;88:76-82]

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When to Repair a Rheumatic Mitral Valve Possible causes of Failure of a Valve Repair:

Conclusion: Ring annuloplasty alone failed to correct rheumatic mitral insufficiency in all cases. AML augmentation improved the quality of the repair, and decreased the risk of reoperation.

When to Repair a Rheumatic Mitral Valve

Possible causes of Failure of a Valve Repair: 4. Progression of the underlying pathology

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Conclusion: Rheumatic mitral regurgitation in the young remains a serious problem. The treatment of this frequent pathology in the

developing countries needs a new approach based on the knowledge that it starts at the annulus. Earlier surgery at this level might prevent its further progression, avoiding the problems of secondary chordal elongation.

When to Repair a Rheumatic Mitral Valve

All patients showed a rapid decrease in left ventricular dimensions. Early failures showed elongation of previously shortened chordae at reoperation, together with more reduction in systolic dimension that the other groups. Late failure were more related to progression of the rheumatic process. No clear relationship between rheumatic activity and failure rate was found.

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When to Repair a Rheumatic Mitral Valve

221 young patients with severe rheumatic MV regurgitation underwent MV repair. Age Mean 19 years Range 3.7-39.5 years 26% trace MV regurgitation)

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When to Repair a Rheumatic Mitral Valve

Follow up 2-15 years 50% at least 8 years 75% at least 5 years Lost to follow up 20 patients

When to Repair a Rheumatic Mitral Valve

Failure (defined as need for reoperation or at least moderate MR)

occurred in 48% [75% of the failures occurring within 5 years]

Clearly suboptimal result

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When to Repair a Rheumatic Mitral Valve

Re-repair was only possible in 7%. Though at reoperation there was evidence of disease progression, recurrence of rheumatic activity could only be documented in 10% of reoperated patients.

When to Repair a Rheumatic Mitral Valve

PREDICTORS OF FAILURE Factors evaluated and found to influence outcome of repair VARIABLE

CUT OFF POINT

% REDO

P VALUE

Ischemic Time*

< 57 mins > 57 mins

35% 62%

1995

58% 31%

0.001). Age