This was an invited talk at the Royal Sutani Hospital, Muscat , Oman in 2007 delivered by: Dr Ahmed Elwatidy, MD, FRCS Senior consultant cardiac Surgeon Associate clinical professor of cardiac surgery

1. 5/31/2009 6:46 AM ISMICS Winter Course, Okinawa, Japan, Nov 08

2. The Art of Mitral Valve Repair:Improved resultswith introduction of new techniques!! Ahmed M.F El-Watidy, MD, FRCS Consultant Cardiac Surgeon; PSCC; Riyadh, Saudi Arabia

3. “Swimming Pools” (300 m3 (X 500 X16 (240 million kg-m) 3776 m Mountain Fuji The work accomplished by the heart during human lifetime is comparable to that of raising 16 elephant the height of mount Fuji and the amount of blood pumped is the equivalent of emptying 500 swimming pools. (courtesy of Dr. M.Kameyama) Physiology & Pharmacology of the Heart. Brown H, Kozlowski R. Blackwell Science Ltd, 1997.

4. “Philosophy of Mitral Repair” “Is not only important to learn the basic principles and techniques of MV Repair, But also, more important to know how to produce a long-lasting repair… for life..”

5. Palliative Repairs: easy, fast, not durable Partial repairs: easy, little time, not durable Reconstructive repairs: complex, needs time and experience A. Carpentier

6. Strategy Functional Approach Segmental Analysis Pathology ? Operative Assessment Surgical Correction of all underlying factors Postoperative TEE is mandatory . Perfect MV (NO or less than mild MR & Good MVA) Is only acceptable

7. Let’s begin by the beginning!! “The Functional Approach to the valve” Functional Classification: Type-I: Normal leaflet motion, Dilated M. Annulus Type-II: Leaflet prolapse Type-III: Restricted Leaflet Motion III-a: Restricted opening in Diastole (Rheumatic) III-b: Restricted closure in systole (Ischemic)

9. Posterior leaflet: P1, 2, 3AML PC A3 AC A1 A2 P3 P1 PML P2

11. Myxomatous

12. Degenerative,

13. Fibro-elastic Disorder,

14. Endocarditis

16. TEE “when to do?” TEE is done if one of these questions can not be addressed TEE, Transgastric view 00 Shows very well all segments (THE EYE OF THE SURGEON) Postoperative TEE is Mandatory for all repairs PMC P3 A3 P2 A2 P1 A1 ALC

17. Result of Analysis Aetiology: Rheumatic, Degenerative, Fibro-elastic Disorder, SBE,.. Lesion: Regurge, Stenosis, both Dysfunction:(Mainly concerning leaflet Coaptation) Prolapse, restriction, dilated annulus, … etc

18. Repair Techniques Correction of ALL underlying factors Remodeling annuloplasty Ring

19. Different Repair Techniques For MR Ring Annuloplsty Simple Quadrangular resection PL Slideplsty Chordal Transfere Extended or Double Chordal Transfere Selective Chordal Transfere and Reimplantation Triangular Resection AML or PML Augmentation Papillary Ms Slideplasty Chordal Shortening

20. Posterior Annular Dilatation & Annulus Remodeling concept Surgeon’ View Dilatation AML PC AC PML AP/ IC =2/3 Remodeling AP/ IC >0.66

21. AML Extension Vertical If limitation on the IC Axis Transverse If restriction on the AP axis Autologous pericardium treated with Gluteraldehyde 0.6% Width should be ½ the length of the patch. Continuous suturing has no risk of burse-string effect Smooth surface on the atrial side No risk of SAM

22. Tips and Tricks (A. Carpentier) Never resect more than 1/10th of AML Circumference (1) In resection of PML (2) (quadrangular excision); it is good to preserve indentations is always good to keep leaflet motion. Repair of PML is advised to be interrupted to avoid the burse – string effect of continuous stitches. (1) Indentations (2)

23. Extended Chordal Transfer Technique Ahmed El-Watidy, MD, FRCS

24. A3 A1 Prolapsing A2 A2 P1 P3 P2 P2 segment Figure (1-a) In this diagram, the A2 segment is prolapsing.The dotted lines represent the segment to be resected, extended posteriorly as indicated by the arrow, and transferred to a wider A2 “double the width”

25. (1-c) Top View (1-b) side View A C B Anterior Posterior 1ry chordae (1-b) shows the arrangement of primary, secondary, and tertiary chordae on the resected segment before cutting. (1-c) The rectangular segment is cut, starting from the middle of the posterior margin along the posterior two third of the transferred segment. The two cut segments are stretched bilaterally and sutured to the AML. All chordae are transferred into primary. 2ry chordae 3ry chordae A Papillary Muscle C B

26. (1-d) Extended chordal transfer sutured to the AML Wide prolapsed A2 supported by the Extended chordal transfer from P2 AML PML PML before repairing the gap

27. 1- e A3 A1 A2 P1 P3 P2 Figure 1-e shows the final appearance of the mitral valve after extended chordal transfer.

28. Figure-2: Shows the horizontal rotation of transferred chordae Prolapsing A2 Prolapsing A2 A B B A B A 90 degree Rotation around the longitudinal axis of the PML chordae Narrow rectangular segment of P2 Posteromedial Papillary Muscle

29. Figure-3: Shows the vertical rotation of transferred elongated chordae Prolapsing A2 Prolapsing A2 Prolapsing A2 (c) Prolapsing A2 supported by vertically rotated quadrangular segment (b) 90 degree Vertical rotation around the inter-commissural axis (a) quadrangular resection from PML with elongated chordae

31. SAM “Systolic Anterior Motion” Definition: Discrepancy between the surface of the leaflet “Door” and the size of the annulus “Frame” leading to Excessive movement of AML LVOT Obstruction Causes: Excessive AML Tissue Excessive PML Tissue Too small Ring

32. Mechanism of SAM AO AML PML LV

33. How to avoid SAM ? Proper sizing of AML Choosing proper ring size Avoid excessive PML tissue (width of PML should be less than 2.0 cm, average 1.5 cm) < 2 cm

34. Different Repair Techniques For MS Simple Commissurotomy Papillary Ms. Splitting Chordal splitting and fenestration Chordal resection Decalcification and pealing Leaflet augmentation Restoring Chordal support at commissures

35. Debridement of all infected tissues Vegetectomy and patching of AML or PML Pericardial Skirting Correction of the underlaying mitral pathology Different Repair Techniques For Endocarditis

36. Tricuspid Annular Dilatation A P S

37. New insights Regarding TV Surgery Organic or functional. Dilatation of the TV annulus. How much tissue available. Continued pathology after MVR !

38. Results of Repair in Rh.H.D - iCirculation. 2001;104:1-14 From 1970-1994, 951 patients with rheumatic Mitral valve insufficiency were operated on with reconstructive techniques. Mean age 25.8 years (4-75 year SR in 63 % Functional classification: Type-I (7%), Type-II (33%), Type-III (36%), combined II & III (24%) Surgical techniques: Prosthetic ring in 95 % of patients Chordal shortening, leaflet enlargement, commissurotomy, …

39. Results of Repair in Rh.H.D - iiCirculation. 2001;104:1-14 Hospital mortality 2 % Mean FU 12 years, Max 29 years Actuarial survival 89+19 % at 10 years, 82+18 % at 20 years Rate of thromboembolic events was 0.4 % patients/year (33 events), with 3 deaths Freedom from reoperation 82+19 at 10 years, 55+25 at 20 years. The main cause (83 %) of reoperation was progressive fibrosis of the MV. The actuarial rate of reoperation was 2% patient /year and correlated to the degree of preoperative fibrosis.

40. Challenges in Rheumatic Patients

42. (2) Non compliance with anticoagulation

43. 3) Extensive Inflammatory Changes in the LA wall 2 1 Normal endocardial layer Thick endocardial layer Focal fibrosis (Masson Trichrome stain) 3

44. New Surgical technique “Modification” MV Repair/ Replacement +TVA Microwave Ablation Resection of LA Appendage + LA Reduction Atrial Restoration

45. “The Functional Anatomical unit” concept Of “Left Atrium & Mitral Valve” Atrial Restoration Function (+) Substrate (-) Trigger (-)

46. Technique of LA Reduction Left Atrium LA Appendage 8x9 Cm AML PML LV

47. Technique Ablation lines L.A.APP LIPV LSPV AML PML RIPV RSPV

48. “TEE” Pre and Post Atrial Restoration Preoperative LA (8.8x7.8 Cm) Postoperative LA (5.5X5.2 Cm)

49. AF Ablation Follow up

51. 6.8 % increase in SR

52. Analysis !!Recurrence of AF after Ablation Redo surgery MR, MS, TR, LA Dimensions AF Ablation tech, LA appendectomy, LA Reduction Histopathology ANP levels Factors analyzed: Age, sex, wt, ht, DM, HTN, COPD, SBE, RHD, EF, NYHA, Euroscore,

53. Predictors of AF ablation Failure in Rheumatic patients SPSS 7.5, Multiple logistic regression analysis,

54. Tissue Doppler for Lt. Atrial Function

55. 30 % REDUCTION IN LA SIZE (P<0.05)

56. Histopathology of LA Appendage (2) Focal LA endocardial Fibrosis

57. Histopathology of LA Appendage (3) Endocardial fibrosis and thickening N

58. Physiological Assessment Atrial Natriuretic Peptide “ANP” levels pre and post surgery (mean, pg/ml) N=6

60. Scarring, Dilated LV

61. PM Dysfunction

62. Displacement of PM

64. Ruptured Papillary Muscle

68. What to do?? Moderate+, and severe MR should be treated. Mild to moderate still debatable? (Mayo Clinic paper) Isolated , undersized annuloplasty ring is commonly used but it does not address the LV remodeling especially in dilated LV (LVEDD>65mm). Other techniques should be added: PL extension. P3 CHORDAL RESECTION, PTFE CHORDAE LV Remodeling device (echo-guided inflation balloons, or patch devices, or CORCAP… OR REPLACEMENT…

69. TENTING DISTANCE AND AREA IN ISCHEMIC MR AO AML PML TEE – Guided PLV Wall Remodeling Devices LV

70. FACTORS AFFECTING LATE SURVIVAL AFTER ISCHEMIC MRGrossi, Gallaway, et al, NY at EACTS/ESTS, 2004 AGE EF <30% (dilated LV >65mm LVEDD) COPD Residual MI (MR BEGETS MR) Tenting area size (Carpentier)

71. QUESTION TO THE AUDIENCE ???(250 cardiac surgeons/25 Countries) Who does believe that MV Replacement in case of ischemic MR can give better result than Repair ?? Just five surgeons out of 250 said YES for Replacement

72. Paris Course; Panel Discussion:Mitral Replacement vs. Repair In Ischemic MR MOHR: Always Repair, and Replacement in dilated LV G. Dreyfus: I follow LV Dimensions >65 mm->Replacement LVF is a major concern Mechanical valve is not a solution A.STARR: Valve replacement is a well taken option especially in dilated LV MESSAS: LVF is better with repair (in favor of repair) Dreyfus & Mohr

73. CABG – Mild MR (85%) CABG+MV Repair (70%) CABG +MV Replacement (60%) CABG+MV Surgery+ Severe LV Dysfunction (45%) IMR Medically treated (20%) SURVIVAL IHD, Surgical Management, P313

75. Start from the Start !

79. KING FAHD ARMED FORCES HOSPITAL Jeddah – Saudi Arabia

80. Fibro-elastic Disorder: Collagen-Elastin Degeneration Barlow and Fibro-Elastic Disorder, Both cause leaflet prolapse and severe MR (Q) How would u differentiate between Degenerative & Fibro-elastic Disorder by echo ?? (A) Just measure the leaflet thickness at an area which is not prolapsing (e.g. belly of the leaflet)

82. Demographic Data

84. Operative Data

85. Early Outcome

88. AF Ablation Follow up

89. Data Analysis Case Selection The full concept and strategy TEE was not routinely used intraoprative Target result

90. Conclusion: Reconstructive surgery of mitral valve insufficiency has to follow principles and rules that will result in a comprehensive strategy for valve repair and therefore improve the outcome Mitral valve repair has a low hospital mortality, and acceptable rate of reoperation. The results are excellent regarding the minimal risk of thromboembolic events.