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When is less more minimally invasive surgery in low ef
1. When Is Less More?
Minimally Invasive Surgery in Low EF
Michael Mack, M.D.
Baylor Scott& White Health
Dallas, TX
2. Conflict of Interest Disclosure
• Member of Executive Committee of the
PARTNER Trial of Edwards Lifesciences
• Co-PI of the COAPT Trial of Abbott Vascular
• Travel expenses paid by sponsors for trial
Steering Committee meetings
5. How are Patients with Isolated FMR Treated?
Duke Databank: 1,538 pts with echocardiographic 3+ - 4+ FMR
and LVEF ≥20% between 2000 and 2010 not undergoing CABG
11.4% 5.9% 8.4% 11.8% 18.4%
0%
25%
50%
75%
100%
All pts 20%-30% 30%-40% 40%-50% 50%-60%
Conservative management Isolated MV surgery
LVEF
N=1538 N=440 N=298 N=313 N=479
8 other pts had LVEF >60%; none underwent MV surgery c/o Mitch Krucoff
6.
7. Chronic Severe Secondary Mitral
Regurgitation: Intervention
Recommendations COR LOE
MV surgery is reasonable for patients with chronic
severe secondary MR (stages C and D) who are
undergoing CABG or AVR
IIa C
MV surgery may be considered for severely
symptomatic patients (NYHA class III-IV) with
chronic severe secondary MR (stage D)
IIb B
MV repair may be considered for patients with
chronic moderate secondary MR (stage B) who are
undergoing other cardiac surgery
IIb C
8. When Would You Consider MI Surgery
in Low EF?
•Redo
–Hostile reentry
–Grafts in jeopardy
•Elderly
•Frailty
8
9. When Would You NOT Consider MI
Surgery in Low EF?
• Patient needs SURGICAL revascularization
• Concerns about myocardial protection
• Ascending aorta > 4 cm
• Right chest adhesions
• Elevated right hemi-diaphragm
• Extreme morbid obesity
9
10. How to treat this 69-year old male ?
• Mitral regurgitation III-IV, EF 35 %, AFib, NYHA class III-IV
• Medical history:
– s/p anterior myocardial infarction 1988
– s/p posterior myocardial infarction in 1991
– 2-CABG 1993
– biventricular ICD 2005
• Concomitant diseases:
– COPD
– renal insufficiency III°
– hyperlipidaemia
– arterial hypertension
11. EF 29 %, LVEDD: 61 mm
MV: annulus 47 mm
restrictive AML, MI III°, Type IIIB
LA: 47 mm
Echocardiography
21. sternotomy
1569
24%
MIS
4887
76%
Mitral valve surgery, isolated
and combined with tricuspid valve procedures
1996 - 2013
sternotomy vs. MIS
Mitral valve surgery, isolated and combined with tricuspid valve
procedures – sternotomy vs. MIS
at Heart Centre Leipzig (1996-2013) n = 6456
22. Isolated MV repair in cardiomyopathy
(EF<35%) baseline characteristics
N 161
ICM/DCM 70.1 vs. 29.9 %
Age 61 ± 10 y
EF 25 ± 8 %
LVEDD 69 ± 11 mm
MI ≥ III° 93.2 %
NYHA ≥ III° 97.5 %
23. preoperative early postop long term evaluation
0
1
2
3
4
mitral regurgitation
p < 0.001
Isolated MV repair in cardiomyopathy (EF<35%)
echocardiographic MV function
27. 0 12 24 36 48 60 72
Postoperative months
0
20
40
60
80
100
NYHA class
Inotr. IV III < III
Survival (%)
Isolated MV surgery in cardiomyopathy (EF<35%)
Survival related to baseline NYHA class
28. When Should We Be Performing MV
Replacement for IMR?
• Ruptured papillary muscle (acute IMR)
• Patients in cardiogenic shock
• Severe apical tenting (>11mm)
• During second CPB run
• Complex MR leaks?
• Surgeons who do not do many repairs?
Valve of choice – bioprosthesis
29. Critical Appraisal / Conclusion
Residual MR up to 30% following
surgical MV repair poor survival
New developments are not superior to MV
surgery
FMR is and will remain a ventricular
disease!