Mitral Valve studies

Question 1

25 years of Gore-Tex Mitral Valve Repair

Answer 1

Tirone David
JTCS 2012
“Chordal replacement with PTFE for mitral valve repair: 25 year experience”
1986- to 2004—606 patients
Isolated Anterior 17.6%, isolated posterior 29.5%, bileaflet prolapse 52.9%
Mean follow up 10.1 years
18 years freedom from re-operation was 90.2%
Freedom from severe MR was 67.5%

Question 2

Mitral Valve Surgical Procedures in the Elderly

Annals of Thoracic Surgery: 94; 5; Dec 2012: 2004

Answer 2

This is a strong study from Lepzig about Mitral valve surgery in patients at age 70 years and older.
2500 patients over a 10 year period. 97% had MR,

65% were mitral valve repair and rest were replacement. CABG was identified as associated with inferior short and long-term survival.

30 day mortality was 3.1% and 5 year 55.2%.

Relevant study because some centers report much higher rates of operative mortality (25% for MV). This study has good long term outcomes as well.

Question 3

Mitral Valve disease: if the mitral valve is not reparable/failed repair is a bioprosthesis suiting for replacement

Jamieson WE, Vancouver groupt
Eur J Cardiothorac Surg 2009 Jan25;(1)

Answer 3

Examined the mitral porcine bioprosthessis (CE SAV)

1135 patients from 2982 to 2000

Examined structural valve deterioration and freedom from composites of complications

For 51-60
actual freedom from SVD @ 18 year was 56.0%
actuarial freedom SVD @ 18 years was 14.7%
for 61-70
actual freedom from SVD @ 18 year was 69.2%
actuarial freedom from SVD @ 18 year was 26.5%
For > 70
actual freedom from SVD @ 15 years was 92
actuarial freedom from SVD @ 69 %

The overall actual freedom at 15 to 18 years for > 70 age grouo was for for valve-related reoperation 94 % and valve related mortality was 87%

Question 4

ISTIMIR: The Italian Study on the treatment of Ischemic Mitral Regurgitation

Answer 4

1006 patients with ischemic MR and impaired LV ventricular function (EF < 40%) at 13 italian centers between 1996 and 2011

29% underwent mitral valve replacement and 70.4% underwent mitral valve repair. Propensity scores and 244 pairs of patients were mattached
median f/u 46.5
Early death was 3.3% for repair and 5.3% for replacement

8 year survival was 81.6% and 79.6% for repair and replacement
Freedom from all-cause reoperation was 64% vs 80%
No improvement in LV function

suggest that mitral valve replacement is suitable for chronic IMR

Question 5

What are rates of post operative MR following restrictive annuloplasty

Answer 5

Moderate/severe MR has been shown to be as much as 33% in pts at months and more then 70% at 5 years.

predicting who is likely to benefit from replacement or repair is tough…Some say LVEDD of > 65mm should be replaced.

Question 6

Predictors of mitral regurgitation recurrence in pts with heart failure undergoing mitral valve annuloplasty

Robert Dion and a group…
Am J Cardiol 2010;1065:395-401

Answer 6

This study has good images for echo IMR values

Basal mitral anterior leaflet angle 
Posterior mitral leaflet angle
tenting area
tenting height
coaptation length 
mitral annulus 
Coapatiation-to-septum distance

Question 7

What outcomes from the Dion Study predicted failure of annuloplasty

Answer 7

Distal mitral anterior leaflet tethering

posterior leaflet tethering

Question 8

5 year CorCap outcomes: Beneficial effects of CorCap cardiac support device: Five year results from Acorn Trial

Answer 8

107 patients—no mitral valve repair/replacement and half in each group
treatment group had signficant reductions in left ventricular end-diastolic volume as well as small increase in sphericiity index.
More patients in treatment group had improve in NHYA 1 functional class
There was no differnence in freedom from composite end point of death major cardiac procedures

Question 9

What is CorCap

Answer 9

Passive polymer cardiac support device

a significant increase in ejection fraction and decrease of LV end-diastolic volume were observed

Question 10

Adjustable Annuloplasty ring (Micardia)

Answer 10

The enCorSQ is an adjustable ring (leaves a wire attached to the sub that can be heated and further reduce annuloplasty)

Question 11

What is EVEREST study II details

Answer 11

N = 279 pts (2:1 radndomization)
184 to mitra clip and 95 mitral repair
Primary composite endpoint—freedom from death, surgery for mitral dysfunction, and freedom from MR > 3+ at 12 months
Primary safety endpoint—included transfusion of >2U of Blood

Question 12

What were results of EVEREST II

Answer 12

mitral clip 55%
Surgery 73%

safety event was 15% with mitral clip and 48% with surgery. This was because of the blood transfusion data.

Question 13

EVERST-II

April 2011 NEJM

Answer 13

Randomized comparison of percutaneous repair with conventional surgery for mitral regurgitation to evaluate the efficacy and safety of the percutaneous approach.

Findings: No difference between two groups in terms of mortality and morbidity for major adverse cardiac events; only difference is need for transfusion (8.8% vs 53.2%)

At 30 days
E-clip: 6% mortality, 20 % converted to mitral valve surgery; 21% with grade 3+ or 4+ MR
Surgery: 6% mortality, recurrence of 3 - 4+ MR was also 20% (poor outcome)

The conclusion that E-Clip offers “superior safety”…crazy

Question 14

Mitral valve repair vs Mitral Valve Replacement

Answer 14

Enriquuez-Sarano et al., (Group from Mayo Clinic)
“Valve Repair Improves the Outcome of Surgery for Mitral Regurgitation”
1995- Circulation
195 pts with valve repair and 214 with replacement for organic MR.
Overall survival at 10 years was 68% with repair compared to 52% with replacement
Operative mortality 2.6% with repair vs 10% with replacement
Ejection fraction was lower with both groups but better with repair.