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Mitral Valve Operations through Standard and Smaller Incisions

Mitral Valve Surgery Current Practice: Historical Facts. The early history of MV surgery centered on repair The middle history centered on replacementThe current history centers on diagnosis based decisions about repair vs. replacementIs the era of anatomic repair coming to an end?. Mitral Va

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Mitral Valve Operations through Standard and Smaller Incisions

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    1. Mitral Valve Operations through Standard and Smaller Incisions Published in: The Heart Surgery Forum #2004-1023, 7(4), 2004

    4. Describe the population of patients who require mitral valve repair or replacement Summarize operative results on these patients Outline the population that may benefit from small incision operations

    5. Mitral Valve Replacement (MVR) vs. Mitral Valve Repair (MVV)

    6. Operative Categories for All MVR (n=346)

    7. Operative Categories for All MVV (n=475)

    8. CAB AVR Maze TVV/R Aortic Root Enlargement Aortic Root Reconstruction LVA Resection Ascending Aortic Reconstruction Other

    9. Operative Incidence for All MVR (n=346)

    10. Operative Incidence for All MVV (n=475)

    11. Procedure by Diagnosis

    12. Prolapse Ischemic Rheumatic Calcific Annular Dilatation Prosthetic Valve Dysfunction Failure of Prior Repair Endocarditis Paravalvular Leak Other

    13. Endocarditis Calcific Ischemic Prosthetic Valve Dysfunction Failure of Prior Repair Annular Dilatation Rheumatic Prolapse Paravalvular Leak Other

    18. Type of procedure (replacement vs. repair) is a univariate predicator of mortality (p<0.001), but not a predictor in multivariate analysis (p=0.431).

    19. Age (decades) Female Hx of Renal Failure Emergent/shock TV Procedure NYHA Class IV

    20. Comparison of Observed vs. Expected Mortality by Risk Deciles (Multivariate Model)

    21. Case Study of Clinical Risk Assessment An 80-year old woman with one previous cardiac operation needs an urgent MVR and AVR. Age=2 # of Procedures Required = 2 Previous Cardiac Surgery = 1 Operative Urgency = TOTAL SCORE = 6 (High Risk)

    22. All Mitral Cases: % Mortality by # of Procedures

    23. All Mitral Cases: % Mortality by Operative Incidence

    24. All Mitral Cases: % Mortality by Operative Status

    25. All Mitral Cases: % Mortality by NYHA Class

    26. Clinical Risk Assessment Model Total Score 1-2 3-5 6+

    28. The Future Which technical advances will reduce morbidity and mortality for patients who require mitral valve operation? Is the era of anatomic repair coming to an end? …3D Echo? …New Prostheses? …Robotic Approaches?

    29. Identifying Patients Eligible for Less Invasive Incisions: 1/97-12/02

    30. Identifying Valve Patients Eligible for Less Invasive Incisions: 1/97-12/02

    31. Conversion to Full Sternotomy Events that may require conversion to full sternotomy: Inadequate exposure Bleeding Hypotension

    32. Increasing Use of Limited Incision in Eligible Mitral Cases: 1/97-12/02

    33. Patient Characteristics Mitral Valve Repair (n=261)

    34. Patient Characteristics Mitral Valve Replacement (n=95)

    35. Postoperative Outcomes Mitral Valve Repair (n=261)

    36. Postoperative Outcomes Mitral Valve Replacement (n=95)

    37. Limited Incision Intracardiac Surgery Conceptual guidelines for smaller incision valve operations (anatomic repair): Should not be much more difficult Should not take much longer Should not be more expensive Should not utilize groin cannulation Should not be uglier

    38. Techniques: Incision Limited median sternotomy (8-10 cm) Right Inframammary thoracotomy (10-15 cm)

    39. Techniques: CPB Ascending aortic cannulation Venous: vacuum assisted Single right atrial – limited sternotomy Bicaval – inframammary thoracotomy Myocardial protection: Antegrade Retrograde cardioplegia using TEE

    41. Expected Benefits: Lower Mortality Lower Morbidity – particularly stroke Shorter Length of Stay Less Cost Quicker Rehabilitation Higher Patient Acceptance and/or Cosmesis

    42. New technology often follows the law of unintended consequences…

    43. Consequences: Aortic side biting in a working heart Groin cannulation and/or intra-arterial manipulation Longer operating times and clamp times

    44. New technology is being sold to practitioners before there are convincing data that the new technology is as good as the current technology

    45. The repair and replacement populations have substantially different preoperative characteristics, diagnoses, and outcomes The results of repair are much better than those of replacement because the populations are so different About 40% of mitral valve patients are eligible for smaller incision operations At present, we perform MVR and MVV via smaller incisions in about 25-30% of all MV patients

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