VALVE SURGERY / HEART FAILURE

1) AORTIC VALVE

2) MITRAL VALVE

3) TRICUSPID VALVE

Dr. F. Wellens

O.-L.-Vrouwziekenhuis Aalst

AORTIC VALVE SURGERY

Aortic valve surgery

Aortic valve stenosis

Heart failure

systemic arterial valvular left ventricular

compliance stenosis function

AVR is efficient in heart failure patients

With:

1) Preserved systolic function

2) Reduced ejection fraction and high after load

3) Low ejection fraction, low gradient and inotropic reserve

AVR is not efficient in patients

With:

1) Low ejection fraction, low gradient and no inotropic reserve

2) Low ejection fraction, low flow and pseudo aortic stenosis

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%

Predictors of reduced survival:

• Advanced age

• Low ejection fraction

• Heart failure

• Renal failure

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

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

How do we indentify high risk or unoperable patients?

• STS risk algorithm

• Euroscore (additive and logistic)

These algorithms

1) Are based upon operated patients

2) Factors like stroke, discharge disposition and quality of life are not included

3) Many risk variables are not included:- chest irradiation- redo with open grafts- porcelain aorta- cirrhosis- neurocognitive disorders- frailness or debility

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

Surgery for AVR and heart failure:

1) Short ECC and Ao cc

2) Meticulous haemostasis

3) Optimal myocardial protection (Buckberg blood cardioplegia)

4) Avoidance of prosthesis – patient mismatch

Prosthesis mismatch after AVR

Ruel et all, Journal of Thoracic and Cardiovascular Surgery 2006, vol. 131, p 1039

Survival (x 2)

Freedom from heart failure (x 5)

Left ventricle mass regression

Percutaneous

• Transcatheter

• Transapical

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

Evaluation of aortic stenosis in Heart Failure patients

• Value of

• Dobutamine stress echo

• BNP

Bergher – Klein et al, Circulation 2007, vol. 115, p. 2484 - 2855

BNP 550 ug/ml: poor outcome in:

• true aortic stenosis

• pseudo aortic stenosis

CONCLUSION

Absolute need for development of other

algorithms in clinical practice.

increase of age

new technology

economics

MITRAL VALVE SURGERY

Mitral valve surgery – Heart failure

Organic M.R Functional

- Rheumatic - Ischaemic CMD

- Degenerative - Dilated CMD

Highly successfull A failed innovation?

Functional Mitral valve regurgitation – Heart failure

1) Normal anatomy of the mitral valve

2) Left ventricular dysfunction

When physiology is disrupted, attempts at restoring anatomy are futile.

The ischaemic Heart failure patient:

• Mitral valve regurgitation

• Left ventricular volume

• Asynergic areas

• Remote myocardium

• Coronary disease

• QRS

JACC 2005, vol. 45, p 388 - 390

Expansion of surgeon familiarity with basic and complex valvuloplasty techniques

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

0

25

50

75

100

125

150

175

200

225

250

275

300

'91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06

MVR

MVP

Endoscopic Mitral Valve surgery, 1997 – 2006(+/- tricuspid surgery)

(Total = 1140, MVP = 842, MVR = 298)

0

50

100

150

200

250

'97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07

Total

MVP

MVR

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

Surgical expertise

MVP as treatment for end stage heart failure

Natural history

No convincing data for:

• Increased longevity

• Improval of symptoms

• Reduction in ventricular size

Mitral valve anatomy

Ventricular dysfunction creates:

• Annular dilatation

• Increase of interpapillary muscle distance

• Amplified leaflet thetering

• Decreased closing forces

Knowledge of:

• Presence of leaflet malcoaptation

• Malapposition

• Annulus diameter

• Interpapillary distance

• Chordal length

is critical for the mode of repair

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)

Mitral valve replacement

In case of:

• Complex multiple jets

• No annular dilatation

• Large tenting area

• Coaptation depth > 15 mm

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

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

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

Michigan experience 1995 – 2002

No clearly demonstrable mortality benefit.

Irrespective of heart failure etiology.

1) Earlier patients

2) MVP rings: complete

rigid

smaller

Wu et al, JACC 2005, vol. 45, p 381 - 387

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

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

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

1) Two year surgical benefit of MVP

2) 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

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 data

on - exercice tolerance - reduction hospitalization/medication

Why is MV-surgery for functional MR less convincing?

1) 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.

2) Stimulus of remodeling is severe in ischaemic pathology

3) FMR is dependant on loading conditions and activity levels

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)

Future role of percutaneous mitral valve remodeling?

Probably very limited in Heart failure patients

with:• LVEDD > 60 mm

• LVESD > 50 mm

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

THE TRICUSPID VALVE

The tricuspid valve

• Tricuspid regurgitation will never dissappear after correction of left-sided lesions.

• Progressive evolution towards TR post mitral and/or aortic valve surgery

The Annals of Thoracic Surgery 2005, vol. 79, p 127 - 132

More agressive approach to tricuspid valve surgery

Tricuspid valve regurgitation

Fysiology

Diuretics

Vasodilators

Pre- or perioperative echography or surgical measurement of tricuspid valve diameter will indicate the surgical indication and not the presence or absence of tricuspid valve regurgitation

CONCLUSION

There is a most intimate interdependence of

physiology, pathology and surgery.

Without progress in physiology and pathology,

surgery could advance but little, and surgery

has paid its debt by contributing much to the

knowledge of the pathologist and physiologist,

never more than at the present.

William Stewart Halsted, 1852 - 1922