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Surgical Treatment of Ischemic Mitral Regurgitation

Surgical Treatment of Ischemic Mitral Regurgitation. 충북대학교 의과대학 흉부외과 홍 종 면. “ Most often the entire valve appears normal;… There is little to fix, yet the valve leaks… the valve is structurally normal; it need not be replaced, but currently we do not know how to fix it…”

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Surgical Treatment of Ischemic Mitral Regurgitation

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  1. Surgical Treatment of Ischemic Mitral Regurgitation 충북대학교 의과대학 흉부외과 홍 종 면

  2. “ Most often the entire valve appears normal;… There is little to fix, yet the valve leaks… the valve is structurally normal; it need not be replaced, but currently we do not know how to fix it…” • - L. Henry Edmunds Jr. 1997 (Cardiac Surgery in the Adult)

  3. Ischemic Mitral Regurgitation(IMR) • Life-threatening ; ventricular ds, not valvular • Limits functional capability & life expectancy - if CHF (+), 52% 1 yr mortality with medication • Suboptimal long-term results (50% in 5 YSR) • Tremendous consumption of health care sources - D. Craig Miller, JTCS ‘01

  4. Significance of IMR after AMI(SAVE trial -substudy) No MR (n=586) MR (n=141) P=0.0022 Lamas et al., Circulation, 1997.

  5. IMR after PCI for acute MI CADILLAC trial (PCI, 2000 pts), JACC 2004,

  6. Subdivision of IMR • Ruptured PM • Infarcted PM w/o rupture • Functional regurgitation - normal PM, chordae, & leaflets but, fail to coapt (type I & IIIb)

  7. Definition of Functional IMR • MR caused by CAD • Previous MI >30 days before CABG • r/o rheumatic, infectious, or degenerative (myxomatous) mitral disease • r/o PM rupture or elongation • Lam, Guillinov, et al, CCF, ATS ’05

  8. Definition of FIMR (2) • Normal-appearing valve leaflets, chordae, & PMs • MR caused MI - at least one previous MI from : 1) review of clinical information, 2) echo, 3) direct surgical inspection Gillinov et al., CCF, ATS ‘05

  9. Definition of Moderate IMR • Significant sx (+) multivessel CAD, w/ or w/o documented prior MI • Gr 3+ MR ( 0 ~ 4+) - documented on preop echo or VG while not actively ischemic - regurgitant jet to LA w/o reversal or blunting of PV flow - no MS • Type I or IIIb • Aklog et al., Harvard Medical School, Circ ‘01

  10. Causes of FIMR • Annular dilatation (type I) • Leaflet tethering (type IIIb) • both

  11. Coronary Revasc. & IMR Background • Mitral Insufficiency and CABG • Dilemma • Mortality and morbidity • Neglected  long-term mortality • Lack of consensus on… “When to operate?”

  12. Coronary Revasc. & IMR Gold Standard • Ischemic MR grade 3-4 • Carpentier type IIIb dysfunction • Reduction annuloplasty

  13. Coronary Revasc. & IMR Moderate Ischemic MR (2+) • No gold standard • Remodeling annuloplasty optional • Pros • Cons

  14. CABG alone (1) Revascularization alone suffices with advanced ischemic cardiomyopathy & mild-to-mod IMR “Revascularization alone suffices in patients with advancehy and mild-to-moderatTolis GA, Yale Univ (ATS 2002) Clinical + echographic outcome - 49 patients - 1-3+ MR - LVEF < 30% - MR 1+: 18 (38%) pts 2+: 26 (52%) pts 3+: 5 (10%) pts Op. mort.: 2% LVEF: 31% (22%) MR: 1.73  0.54 (p<0.05) Survival: 50% (5 years) Conclusion: - Advanced ischemic cardiomypathy - Mild to moderate MR - Isolated CABG - Reasonable option

  15. CABG alone (2) “The importance of gr. 2+ IMR in CABG” Ryden T (Eur J Cardiothorac 2001) Grade 2+ IMR - Case-control study - MR vs. no MR (n=89) - Matched: Age, gender, LVEF MR patients: - Older (68 vs. 65yrs) - Lower LVEF ( 42 vs. 58%) Kaplan-Meier: MR vs. none - 30 days mort.: 4.5% vs. 4.5% - 1 year surviv.: 91 vs. 93% - 3 year surviv.: 84 vs. 88% NYHA: similar improvement MR pts: - 62% reduced MR - 36% unchanged - 2% inccreased Conclusion: - Similar morbidity - Similar survival - MR reduced or unchanged - Support conservative treatment

  16. CABG alone (3) “ MV repair vs. revascularization alone in the treatment of IMR “ • Whether adjunctive MV repair with CABG is beneficial ? Kang DH, Asan Medical Center, Circ ’06 • 107 pts with mod or severe IMR • 50 (with repair) vs 57 CABG only • - higher Af & severe MR in repair gp repair only CABG Op. mort.: 12 % 2 % 5 YSR : 88 % 87 % Improving MR : all 67 % in severe MR 75 % 67 % in mod. MR Conclusion: - CABG alone may be preferable option in moderate IMR & high risk factors such as old age or Af

  17. with MV repair (1) “Does CABG alone correct moderate IMR?” Aklog L, Brigham & women’s hospital (Circ ‘01) Optimal Tx of moderate 3+ MR - 136 patients - 70 years - NYHA: 2.7 - LVEF: 38% Op. mort.: 2.9% Residual MR: 40%  3+4+ 51%  2+ 9%  0+ Conclusion: - WithCABG alone - Significant residual MR - Not optimal

  18. with MV repair (2) 535 pts undergoing MV repair ( primarily rigid ring annuloplasty) - 1993 to 2002 - IMR 141 pts vs. non-ischemic 394 pts IMR pts had ; - older age, higher comorbidity, lower EF, higher NYHA & reop rate (all p<0.001) - higher 30-day mortality (4.3% vs 1.3%, p=.01) - higher unadjusted 5-yr mortality (44% vs. 16%) Patient Survival characteristics after routine MV repair for IMR - whether IMR remains an independent predictor of outcome after valve repair Donald D. Glower, Duke Univ Medical center (JTCS ‘05), In multivariable models ; - only No. of preop. comorbidities & advanced age were independent factors of survival (p < 0.0001) • Conclusion • with routine application of rigid ring annuloplasty, • long-term survival is more influenced by • baseline pt characteristics & comorbidity than • by ischemic cause of MR per se.

  19. OPCAB and IMR What should we do? • Moderate-severe ischemic MR and CAD should be fixed • Moderate ischemic MR is still a difficult problem to treat

  20. Conventional CABG and IMR Conventional CPB Surgery • If MR is not fixed • Not necessarily problematic • IABP and inotrops may be needed • The patient could get by… on short-term “What about OPCAB?”

  21. OPCAB and IMR OPCAB surgery • If ischemic MR ignored • Could be problematic • Manipulation and ischemia exacerbates MR • Cause severe hemodynamic instability • Conversion to CPB needed

  22. OPCAB and IMR “ Perioperative and long-term outcomes after isolated OPCABwith mild to moderate IMR ” Cartier R, Montreal Heart Institute - 67 pts (6.7%) with mild or moderate IMR among 1000 consecutive OPCAB - To evaluate the perioperative and long-term outcomes (survival & MACE-free) • OPCAB pts with mild-to-moderate IMR • Had  prevalence of preoperative risk factors • Comparable perioperative mortality and morbidity •  long-term survival compare to no-IMR pts • OPCAB pts with mild-to-moderate IMR • IMR itself was not found a significant risk for • the long-term mortality

  23. Repair vs. MVR for IMR • Guillinov AM et al, CCF, JTCS ’01 • IMR ; n=482 (’85~’97, 397 repair vs. 85 MVR) • Functional IMR in 65 % • Central MR jet (type I) in 58% • Complex jet (type IIIb) in 15% • Repair pts very different from MVR (NYHA I-II, FIMR, ITA graft, non-emergent)

  24. Repair vs. MVR for IMR • Operative 30 day mortality - 13% • Risk fc for death : older age, higher NYHA, LV dysfunction, renal dysfunction, Af, and MVR • Mortality risk fc after repair : complex MR jet, lateral LV dysfunction, pericardial annuloplasty (no ring), no ITA graft

  25. Repair vs. MVR for IMR • Medium-term survival is still poor • Most pts benefit from repair • But, survival similar btw repair & MVR in the sickest pts • Durability of repair ; 91% at 5 yrs

  26. MGH thrust #1 -“ Guerrero procedure” • Design of a New Surgical approach for ventricular remodeling to relieve IMR : insight from 3-D echo Guerrero JL et al, MGH, Circ 2000

  27. MGH thrust #2 -2o chordae cutting to AMVL • Chordal cutting : A New therapeutic approach for IMR Messas, Gerrero, MGH, Circ 2001

  28. MGH thrust #3 -External balloon-inflated patch “reverse remodeling” • Reverse ventricular remodeling reduces IMR : echo-guided device application in the beating heart Hung J, Guerrero, et al, MGH, Circ ‘02

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