1. ACUTE AND LATE RESULTS AFTER SURGICAL REPAIR/REPLACEMENT OF DEGENERATIVE MITRAL REGURGITATION
Thierry MESANA, MD, PhD
President and CEO
Professor Cardiac Surgery
Valve Surgery Research Chair
University of Ottawa Heart Institute
Ottawa, Ontario, Canada

2. I have no relevant financial relationships

3. Important questions
Immediate results : Operative Risk in mitral valve surgery and Variations in repair rates : Variations depending on Volumes and Expertise
Long-term results : Durability of MV repair for MV Prolapse Recurrence of MR, Functional MS due to small rings

4. EARLY MORTALITY/OPERATIVE RISK
Mitral Repair
Mitral Replacement
0.9% (Castillo JTCVS 2012)
1.2% (Coutinho EJCTS 2016)
Expert centers usually below 0.5 %
1.8% (Coutinho EJCTS 2016)
3.3% (Bourguignon JTCVS 2014)
7.2% (McClure Ann Thorac Surg 2010)
CRT 2017

5. Mitral Valve Replacement
Perioperative deaths after MV operations
may be overestimated by contemporary risk models
Presented at STS meeting January, 2014., Annals of TS July 2014
Mitral Valve Surgery
N = 1154
Mitral Valve Repair
N = 851
Mitral Valve Replacement
N = 303
Follow up and also this is not clear
Study Dates:

6. Observed & EuroSCORE II Predicted Mortality Isolated Mitral Surgery
Ottawa Heart Institute series
(Annals TS, July 2014)
EuroSCORE II Quartile N
Observed Mortality
Predicted Mortality
Lower Limit (%)
Upper Limit (%) 1
141
0 (0%)
0.5
0.7 2
143
1.0 3
142
2 (1.4%)
1.8 4
144
25.2
Patients were also grouped into quartiles according to their EuroSCORE II. Again,
Overall O:E ratio 0.3

7. Observed & EuroSCORE II Predicted Mortality
All procedures including Mitral valve Surgery
Ottawa Heart Institute series
(Annals TS, July 2014)
EuroSCORE II Quartile N
Observed Mortality
Predicted Mortality
Lower Limit (%)
Upper Limit (%) 1
285
1 (0.4%)
0.5
0.9 2
291
2 (0.7%)
1.7 3
288
3 (1.1%)
1.8
3.9 4
290
5 (1.7%)
31.1
Patients were also grouped into quartiles according to their EuroSCORE II. Again,
Overall O:E ratio 0.3

8. Low Surgeon volume + low hospital volume : 5.6 %
The effect of hospital volume on outcomes in MV surgery is also driven by individual surgeon within this hospital 30-day Mortality
Low Surgeon volume + low hospital volume : 5.6 %
Low surgeon volume + high Hospital Volume : 3.3%
High surgeon volume + low Hospital volume : 2.3%
High surgeon volume + high hospital volume : 2.0%
Kilic et al . JTCVS 2013:146: (J Hopkins, Baltimore)

9. REPAIR RATE Depends on surgeon and on anatomy for a given surgeon
Nationwide Isolated MV surgery , including 25,427 MV repairs (50.7%) Median volumes was 61 for hospitals and 12 for surgeons.( Kilic et al JTCVS 2013:146:638-46). Repair rates from 30 to 60% for all etiologies.
Expert centers between 95 and 100% for MV Prolapse repair
Only 3 surgeons >100 MV/year, majority less than 25/year
Only 4 hospitals >200 MV /year, majority below 100/year
A given surgeon may have an overall repair rate of 90%, a repair rate of 90-95% for fibroelastic deficiency with single segment posterior leaflet prolapse due to chordal rupture, but a lower success rate for bileaflet Barlow’s disease (<90%)
Patients referred for MV repair should be considered on an individual basis, i-e for each case probability of repair by the surgeon > institution.

10. VARIATION IN SURGEON MITRAL REPAIR RATES
J Thorac Cardiovasc Surg 2014;148:

11. LONG-TERM DURABILTY OF MITRAL VALVE REPAIR Excellent , not perfect

12. Chordal replacement with PTFE 25-year experience (T David
Chordal replacement with PTFE 25-year experience (T David. JTCVS 2013;145:1563-9)
; 606 consecutive pts
AL 18%, PL 30%, BL 52%, 13 annular reconstructions (3%),
2 to 38 neochords per patient (mean 13), resection if PL height >20mm
90 % freedom from reoperation at 18 years
90% freedom from severe MR
67% freedom from mod/severe MR
Anterior Leaflet Prolapse predictive for reoperation, as well as older age, HBP and low EF (<40%)
Total of 35 reoperations. 32 replacement, 3 re-repairs (1 week to 22 y)

13. David T. E. et al.; J Thorac Cardiovasc Surg 2005;130:1242-1249
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:

14. Long-Term Durability Edge-to Edge for Anterior Leaflet Prolapse M
Long-Term Durability Edge-to Edge for Anterior Leaflet Prolapse M.DeBonis (Alfieri’s Group)- JTCVS, 2014:Vol 148,
:139 pts, mean age 54 years, mean LVEF 56%
Isolated AL prolapse/flail. A2 in 105 pts (75%), A1 or A3 (25%)
E-to-E technique plus annuloplasty
11 years mean duration of follow-up 11 years, up to 21 years
Moderate MR at discharge : 9pts (6,4%)
72% actuarial survival, 89% freedom from reoperation
82% freedom from severe MR (Grade 3 or 4)
Predictors of severe MR : more than mild MR at discharge and pericardial ring annuloplasty instead of Prosthetic

15. Very Late outcomes after MV replacement with CE pericardial bioprosthesis Bourguignon et al, J Thorac Cardiovasc Surg 2014;148:
450 Isolated MV Replacement (404 pts). CE Perimount in 404 pts
; Mean age 68; 53% female; Mean follow-up 7.2 years, up to 20 years
Pts <65 y-o, freedom from SVD was 47% (15 years) and 19 % (20 years) and freedom from reoperation was 50% (15 years ) and 25% ( 20 years)
Pts >65 y-o, freedom from SVD 62.5% at 15 y and 30% at 20 y , and freedom from reoperation 75% at 15 years

16. HOW DOES MITRAL VALVE REPAIR FAIL IN PATIENTS WITH PROLAPSE
HOW DOES MITRAL VALVE REPAIR FAIL IN PATIENTS WITH PROLAPSE? – INSIGHTS FROM LONGITUDINAL ECHOCARDIOGRAPHIC FOLLOW-UP
Vincent Chan, MD, MPH; Elsayed Elmistekawy, MD;
Marc Ruel, MD, MPH; Marc Hynes, MD; Thierry G. Mesana, MD PhD
PRESENTED at Society of Thoracic Surgeons
Annual Meeting January 2016
Published: The Annals of Thoracic Surgery
Volume 102, Issue 5, November 2016, Pages 1459–1465

17. Mitral Valve Repair of Myxomatous Degeneration N = 855
Study Dates:
Mitral Valve Repair of Myxomatous Degeneration N = 855
Patients assessed regularly in a dedicated clinic with serial echocardiographic assessments
1, 3-6 months, & 12-months
Clinical & Echocardiographic assessments
Annually thereafter
Follow up and also this is not clear
Clinical Follow-up 4.3 ± 3.5 years

18. MITRAL VALVE PATHOLOGY
Moderate-Severe MAC 83/855 =
Prolapse ≥2 Anterior Leaflet Scallops (4%)
Prolapse ≥2 Posterior Leaflet Scallops (12%)
Mitral Annular Calcification (13%)

19. REPAIR TECHNIQUES Annuloplasty Size 30.4 ± 5.8 mm
Sliding plasty 263 (31%)
Chordal Transfer 170 (20%)
Artificial Neochordae 241 (28%)
Edge-to-Edge 170 (20%)
Conversion to replacement: 25 (2.8%)
30-day mortality : 0.4 %
35% combined procedures

20. Fig 1. Freedom from New York Heart Association (NYHA) III/IV symptoms, recurrent mitral regurgitation (MR) of 2+ or higher, and mitral valve reoperation, and survival are described for 855 patients with a follow-up of 4.3 ± 3.5 years. A total of 2,754 postoper...
Vincent Chan, Elsayed Elmistekawy, Marc Ruel, Mark Hynes, Thierry G. Mesana
How Does Mitral Valve Repair Fail in Patients With Prolapse?—Insights From Longitudinal Echocardiographic Follow-Up
The Annals of Thoracic Surgery, Volume 102, Issue 5, 2016, 1459–1465

21. POSTOPERATIVE MR Proportion of Total (%)
Mean Echocardiographic Follow-up 3.8 ± 3.2 years

22. FREEDOM FROM MV REOPERATION
100%
75%
96.9 ± 5-years
50%
93.8 ± 10-years
25% 0% 1 2 3 4 5 6 7 8 9 10 11 12 13
Patients at risk
Reoperation

24. PREDICTORS FOR MITRAL REOPERATION
Recurrent MR after 1-year
Recurrent MR after 2-years
Recurrent MR after 3-years
afteroneyear |
After 2 years |
After 3 years | 1 5 10 15
Incident Rate Ratio

25. ASSESSING FUNCTIONAL MITRAL STENOSIS AFTER “SUCCESSFUL”MITRAL VALVE REPAIR
CRT 2017

26. RESULTS Functional MS after MV repair for Degenerative MR
Impact of Annuloplasty type . Bands vs, full rings
J Thorac Cardiovasc Surg 2013 Dec;146(6):
Mesana at al, University of Ottawa Heart Institute
The higher gradients observed in patients with rings at rest, were also observed at peak exercise. In fact, the mean mitral gradient at peak stress was higher in the ring group as compared to the band group for all annuloplasty sizes.
3 reoperations for severe MS post full Ring ring less than 30 mm size

27. SUMMARY
Severe MR after repair is rare, although some may have recurrent moderate MR (4-5%)
Patients who require subsequent mitral valve reoperation were most likely to have recurrent MR ≥2+ within the first year after surgery suggesting that valve surveillance beyond a year may not be needed in asymptomatic patients
Look for FUNCTIONAL MS in patients with FULL RINGS BELOW mm
In this series …
Although there was …

28. THANK YOU

29. MI mitral valve surgery is associated with adverse events
Nationwide STS Database LESS INVASIVE VERSUS CONVENTIONAL Stroke risk x2 (x3 if fibrillating heart)
Gammie et al. Ann Thorac Surg 2010;90:
EQUAL ONLY IN EXPERT/HIGH VOLUMES MIS CENTERS

30. Interval From Repair (years)
RECURRENT MR ≥2+
Mode of Failure
N (%)
Interval From Repair (years)
Prolapse
Recurrent
Other site 6 2 4
2.7 ± 2.1
3.9 ± 3.0
2.8 ± 2.8
No Prolapse
Central jet
Eccentric jet 43 14 24
3.2 ± 2.9
4.0 ± 3.6
3.1 ± 2.6
Group 1 |
Group 2 |
Group 3 |
Group 4 |