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VALVE SURGERY / HEART FAILURE

VALVE SURGERY / HEART FAILURE. Dr. F. Wellens O.-L.-Vrouwziekenhuis Aalst. AORTIC VALVE MITRAL VALVE TRICUSPID VALVE. AORTIC VALVE SURGERY. Aortic valve surgery. Aortic valve stenosis Heart failure systemic arterial valvular left ventricular

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VALVE SURGERY / HEART FAILURE

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  1. VALVE SURGERY / HEART FAILURE Dr. F. Wellens O.-L.-Vrouwziekenhuis Aalst • AORTIC VALVE • MITRAL VALVE • TRICUSPID VALVE

  2. AORTIC VALVE SURGERY

  3. Aortic valve surgery • Aortic valve stenosis • Heart failure • systemic arterial valvular left ventricular • compliance stenosis function

  4. AVR is efficient in heart failure patients • With: • Preserved systolic function • Reduced ejection fraction and high after load • Low ejection fraction, low gradient and inotropic reserve

  5. AVR is not efficient in patients • With: • Low ejection fraction, low gradient and no inotropic reserve • Low ejection fraction, low flow and pseudo aortic stenosis

  6. Epidemiology studies of patients with AS: • demonstrate that an important cohort will not • undergo AVR although the conservative • management showes a dismal prognosis • Euro Heart Surgery: 32% • Loma Linda experience: 39%

  7. Predictors of reduced survival: • Advanced age • Low ejection fraction • Heart failure • Renal failure

  8. Annals of Thoracic Surgery 2006, vol. 82, p 2111 - 2115

  9. Annals of Thoracic Surgery 2006 vol. 82, p 2111 - 2115

  10. How do we indentify high risk or unoperable patients? • STS risk algorithm • Euroscore (additive and logistic)

  11. These algorithms • Are based upon operated patients • Factors like stroke, discharge disposition and quality of life are not included • Many risk variables are not included:- chest irradiation- redo with open grafts- porcelain aorta- cirrhosis- neurocognitive disorders- frailness or debility

  12. In the “unoperable” group we need to identify these patients who are candidates for transcatheter AVR • Highest tenth percentile of predicted risk by the STS risk algorithm • Other candidates independant of risk algorithms:- porcelain aorta- chest irradiation- multiple sternotomies- with open grafts- CRF

  13. Surgery for AVR and heart failure: • Short ECC and Ao cc • Meticulous haemostasis • Optimal myocardial protection (Buckberg blood cardioplegia) • Avoidance of prosthesis – patient mismatch

  14. Prosthesis mismatch after AVR Ruel et all, Journal of Thoracic and Cardiovascular Surgery 2006, vol. 131, p 1039

  15. Survival (x 2) • Freedom from heart failure (x 5) • Left ventricle mass regression

  16. Percutaneous • Transcatheter • Transapical

  17. How to discriminate the individual patients who still will benefit from AVR?

  18. Evaluation of aortic stenosis in Heart Failure patients • Value of • Dobutamine stress echo • BNP

  19. Bergher – Klein et al, Circulation 2007, vol. 115, p. 2484 - 2855 • BNP  550 ug/ml: poor outcome in: • true aortic stenosis • pseudo aortic stenosis

  20. CONCLUSION • Absolute need for development of other • algorithms in clinical practice. • increase of age • new technology • economics

  21. MITRAL VALVE SURGERY

  22. Mitral valve surgery – Heart failure • Organic M.R Functional • - Rheumatic - Ischaemic CMD • - Degenerative - Dilated CMD • Highly successfull A failed innovation?

  23. Functional Mitral valve regurgitation – Heart failure • Normal anatomy of the mitral valve • Left ventricular dysfunction • When physiology is disrupted, attempts at restoring anatomy are futile.

  24. The ischaemic Heart failure patient: • Mitral valve regurgitation • Left ventricular volume • Asynergic areas • Remote myocardium • Coronary disease • QRS

  25. JACC 2005, vol. 45, p 388 - 390

  26. Expansion of surgeon familiarity with basic and complex valvuloplasty techniques

  27. All Mitral Valve Surgery 1991-2006(n = 3122 )

  28. Endoscopic Mitral Valve surgery, 1997 – 2006(+/- tricuspid surgery)(Total = 1140, MVP = 842, MVR = 298)

  29. Patients with impaired left ventricular function and even a mild degree of M.R will have a decreased five year survival B.H. Trichon et al; American Journal of Cardiology; 2003; vol. 91

  30. Natural history Surgical expertise • MVP as treatment for end stage heart failure No convincing data for: • Increased longevity • Improval of symptoms • Reduction in ventricular size

  31. Mitral valve anatomy • Ventricular dysfunction creates: • Annular dilatation • Increase of interpapillary muscle distance • Amplified leaflet thetering • Decreased closing forces

  32. Knowledge of: • Presence of leaflet malcoaptation • Malapposition • Annulus diameter • Interpapillary distance • Chordal length • is critical for the mode of repair

  33. Additional techniques • External devices (CorCap, …) • Section of secondary chordae • Repositioning papillary muscles • Remodeling infero – posterior infarct zone • Leaflet extension • Edge to edge technique • + Treatment of atrial fibrillation (Minimaze) • + CRT (left ventricular epicardial lead)

  34. Mitral valve replacement • In case of: • Complex multiple jets • No annular dilatation • Large tenting area • Coaptation depth > 15 mm

  35. Results of repair operations for functional MR in Heart Failure patients are mostly analyzed with an overwhelming bias that mitral intervention in heart failure must be beneficial. • Efficacy of mitral surgery in heart failure: • LV remodeling (ventricular size and function) • symptoms (need for medication – hospitalisation) • survival

  36. Survival • Medical treatment:1990 – 2000 : ± 50% • Cleveland clinic experience for ischaemic M.R: survival at 5 years, ± 50 % • MV repair is better than MVR Journal of Thoracic and Cardiovascular Surgery 2001, vol. 122, p 1125 - 1141

  37. Combined MVR + CABG • No survival benefit from MVP • 5 year survival: 50% or less Harris et al; The Annals of Thoracic Surgery ; 2002, vol. 74, p 1468 – 1475 Diodato et al; The Annals of Thoracic Surgery; 2004, vol. 78, p 794 – 799

  38. Michigan experience 1995 – 2002 • No clearly demonstrable mortality benefit. • Irrespective of heart failure etiology. • Earlier patients • MVP rings: complete rigid smaller Wu et al, JACC 2005, vol. 45, p 381 - 387

  39. Effect on remodeling • Exceedingly limited information • Braun et al. (Leiden):In 87 patients: • meticulous F.U • small but significant reduction in moderately dilated hearts • but: - no control group - 75% combined CABG

  40. Braun et al., European Journal of Cardiothoracic Surgery, 2005, vol. 27, p. 847 - 853

  41. The Leiden protocol • LVEDD < 65 mm: MV repair: downsizing • 2 sizes • coaptation depth: 8 mm • LVEDD > 65 mm: MV repair + ACORN device • LVEDD > 80 mm: - orthotopic HTX • - destination therapy / mechanical assist • - (Batista?) • Tricuspid valve repair when A – P diameter • exceeds 40 mm

  42. Two year surgical benefit of MVP • CorCap cardiac support deviceVery limited differences compared to medical controll group Acker, Bolling et al, J. Thoracic and Cardiovascular Surgery 2006, vol. 132, p 368 – 577

  43. Effect on symptoms • Extensive empiric clinical experience is the • basis of widespread belief that MV surgery has • a beneficial effect on symptomatic heart failure. • Unfortunately: • Only improvement in NYHA class • No quantitative dataon - exercice tolerance - reduction hospitalization/medication

  44. Why is MV-surgery for functional MR less convincing? • Is the current repair technique not durable?Most studies: high recurrence of MR > 2+Braun et al: a very small (24-26) use of semirigid complete rings may result in improved durability. • Stimulus of remodeling is severe in ischaemic pathology • FMR is dependant on loading conditions and activity levels

  45. Has minimal access surgery an impact on the • results of MV-surgery for Heart Failure? • No studies available • Empiric results: favorable minimal access with decreased mortality and morbidity (more pronounced in redo settings)

  46. Future role of percutaneous mitral valve remodeling? • Probably very limited in Heart failure patients • with: • LVEDD > 60 mm • LVESD > 50 mm

  47. Conclusion: • Functional MR in heart failure patients is a poor • prognostic sign. • MVR data retrospective: • survival benefit? • remodeling: limited • symptoms: limited • How to indentify the patient groups that derive significant benefit? • Randomized study is urgently needed

  48. THE TRICUSPID VALVE

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