DEBATE Mitral Regurgitation: What is the ideal therapeutic option for my patient with mitral regurgitation - Yasir Abu-Omar, MD, DPhil, discusses the surgical options.
looking at this, looking at the topic. So it's the ideal treatment. So the ideal treatment varies options for repair replacement or perkiness options. Indeed for the mitral valve, the patient's treatment or the treatment for the patient patient can be depends on the age of the patient, comorbidities, functional status, etcetera. And what about michael regurgitation? So, you know, it's a vast, diverse topic with michael regurgitation, depends on the etiology. Of course this can be related to degenerative, which is a communist disease that we see of the mitral valve but also effective functional and ischemic element of the marshall valve and all are treated differently. But really it goes down to repairing the mitral valve has remained the gold standard over the last three or four decades. Following this paper by Carpentier, the french correction when he had the experience of performing quadrangular reception on the marshall valves in the communist form of structural model valve disease that we see, which is really for prolapse with excellent durability and results. This is in an area where patients were having mechanical valves. There's a significant reduction in the need for regulation and need for re operation in these patients. But really there's a stigma attached to it. Now you can't be a surgeon and do a martial valve replacement and everyone, I mean the cleaner is going to know that you did a martial replacement. You've got to repair the Marshall Valve. Right? So it's become sexy. It's the right thing to do for the patient and it is where we aspire to get more than 95% of structural, at least degenerate Marshall Valve repaired. Um And what does the data tell us? This is historical data even telling us that repair is better than replacement, whichever way you look at it for both the the for both personally for prolapse, but also for patients with anterior leaflet prolapse or by leaflet prolapse, it's still better than replacement. And uh several meta analyses have demonstrated a substantial benefit of repair versus replacement in terms of survival re operation and thrombin embolism. But we got so good at this that even now we have we can operate on patients who have who have asymptomatic marshall regurgitation. Why? Because we know is there a point to you. Okay, okay. So if you look at the effective office area which is really a which really indicates the severity of regurgitation. If you have severe mitral regurgitation with a large effective office area then your outcome is poor. Even if you're asymptomatic and if you operate on these patients and you can see here on the right panel displayed in red then you have a significant survival benefit in these patients. Of course this has to be balanced against the risk they subject the patient from surgery. But across the board now the mortality of undergoing operation now in the form of repair is less than 1%. This is data that we published our own data from the when I was in the UK and we looked at of course the clear benefit that we knew for patients with preserved left ventricular function. But even patients with impaired LV function repair still supremely superior to replacement. And now talking about the carpentry, I'm sure most of you are aware of the classification of micro valve dysfunction, which is really depends on the definition of the whether the leaflet motion is normal in type one, type two, where there is excessive motion, Type three, where there is restricted leaflet motion. And this really we can classify any disease of micro valve under one of the three. And Carpentier really taught us how to repair the martial valor and how to achieve the durable repair of the martial arts to preserve and restore full leaflet motion to create a large surface of co optation of the marshall valve leaflets and to remodel and stabilize the angelus. With surgery, we can achieve all that with any other therapy out there. You cannot achieve all these principles to ensure long term durable repair of the mitral valve. The spectrum of degenerative disease of the valve is also very variable and that dictates what operation we can do. There is not one size fits all is not a single procedure that I can perform on all these patients. There are patients that have far more elastic deficiency with very little tissue and the other extreme we have patients with Barlow's disease. We've got the luxury of excess tissue and the technique for a mitral valve surgeon to repair or replace these valves varies and the simplest form of repair of the marshall bob is a quadrangular section which is the original repair that has been described by carpenter and his colleagues, still a durable way of performing martial about repair. But we evolved since then triangular section and subsequently. Now we can perform repair of patients with anterior leaflet prolapse or or by leaflet prolapse. Using the newer techniques of gortex chords. These are putting new codes into patients have had ruptured the tendon and we always place a ring around the marshal bob and that ensures the durability in the long term. And this is why we're achieving excellent results approaching the durability of posterior leaflet prolapse repair. And now even patients who have degenerate marshall bob disease with extensive calcification of the angelus. As you can see here this is severe posterior annular calcification in this patient we can achieve excellent repair in these patients by reconstructing the analysts, removing the calcium and we can achieve excellent results in these patients. What's the office as well is that we're able to perform concomitant procedures. Many of these patients as we know have atrial fibrillation. We can perform mais operations. We can achieve more than 90% freedom from atrial fibrillation. In the long term, patients with with with with paroxysmal atrial fibrillation and we can achieve excellent results and also in patients longstanding persistent, we can also close the left atrial appendage and my colleague dr rushing is going to be talking about this in due course that has substantial benefit to the patients in terms of stroke risk reduction. But then we evolved in terms of a surgical approaches. So it's not all performed throughout anatomy now a large part and this is these cases uh We perform here at U. H. My friend, my very good friend and colleague doctor Pelletier um and myself we performed this operation and most people with isolated mitral valve disease even patients with mitral valve disease can have an operation through an incision. This small this really gives us the advantage of improved osmosis recovery times quicker patients can get back to work a lot quicker. External restrictions in these patients there's less blood loss. We get great visibility. You can see here how we can put this cage through the mitral valve and how we can get amazing views of the papillary muscles and put these gortex cords in place. And all this done is through this tiny incision with video assistance and many of these patients can be excavated in the are the following day. They can be home in three or four days afterwards and they would have had an operation that is as good as that. That is performed through an open procedure moving to a different animal altogether which is patients having functional mitral regurgitation. Now this is a completely different disease is a disease of many of the other components mitral valve is a very complex structure involves Annelise leaflet Cody papillary muscles and the my condom itself. And really with for example, ischemic functional mitral regurgitation. This is not the fault of the mitral valve is a disease of the ventricle and the mechanism can be very complicated involves a multitude of leaflet tethering, popular displacement and annular dilatation and this can be treated with annual place. This is the simplest way we can treat that in selected patients. But really once with the publication of the CTS. Net trials randomizing patients undergoing repair versus replacements for severe ischemic mitral regurgitation demonstrated better durability as depicted here on the red line with micro replacement versus repair. And so replacement is not always a bad option. It's really the treatment has to be tailored to the individual patients. But because of this now, there are a lot of other techniques and that that have been applied to patients with ischemic and functional marshall marshall regurgitation. That's for example, papillary muscle approximation, papillary muscle relocation. The use of the edge to edge repair using Alfieri stitch along with the ring placement. But really what really matters here and what I look at as a surgeon when I choose what to do with these patients with functional model. I look at the degree of tenting, which for me indicates how much popular muscle displacement and how much annual allocation there is with this. People have gone to extremes of complex analysis of what tenting, height and annual diameter. And then until then we reached the panacea of all my ailments. The introduction of the micro clip. Isn't that amazing with all the surgical techniques and all the variations? Now the clip that does everything for us now, that's what it does. And I'm going to here introduce my colleague, doctor who's going to talk to us about this in more detail. But while she may talk against the surgeons, she enjoys hanging out with surgeons in the cd restaurants on the west side of Cleveland. That's a very good food. But this is one of her papers. Edge to edge repair, past challenges, current case selection and future compared to surgery. This is my final slide by the way, starting to compare similar safety profile and shorter length of stay in high risk patients at the expense of increased increased residual mitral regurgitation and high re operation rate. Despite this long term mortality appears comparable between the two techniques, suggesting that a patient tailored approach will lead to optimal results. I couldn't have put it better myself and to this and thank you very much