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ISOLATED CONGENITAL MITRAL REGURGITATION LONG-TERM RESULTS AND THE ROLE OF PROSTHETIC RING Hung Dung VAN.MD.PhD, Hoang Khang HUYNH HCMC Heart Institute - VIETNAM INTRODUCTION • Congenital MR : isolated or associated with ASD,VSD, PDA… • 4.5% in total isolated MR ( Heart Institute HCMC statistic in 2013) VAN H DUNG-HNPTTMLN 2016-HCM Patients and Methodology • Retrospective study • Isolated Congenital MR (Excluded all case associated with VSD, ASD, PDA CAVD, ALCAPA…) • From 1993 to 2015 at The Heart Institute HCM city-Viet Nam • N = 128pts VAN H DUNG-HNPTTMLN 2016-HCM Patients Demographic Pre-op • Sex : male : 63 (49%) • Mean age : 12.5 ± 7.6 y.o ( 0.5 - 50 yo) < y.o : 42 (32.8%) • SR : 116 AF : 12 • LVEDd : 51 ± 9.7mm • LVEF : 66 ± 7% • SPAP : 44 ± 17mmHg VAN H DUNG-ATCSA 2014-HANOI Echocardiographic Findings • Type I : normal leaflet motion annulus dilatation : 112 cleft mitral valve : 16 (14/2) • Type II : leaflet prolapse anterior leaflet : 84 posterior leaflet : 20 • Type III : short chordae syndrome : 15 IIIP : 12 VAN H DUNG-HNPTTMLN 2016-HCM Surgical Findings Lesions Annular dilatation Cleft mitral valve : anterior posterior Absent chordae : anterior posterior Elongation chordae Commissural fusion Short chordae syndrome Double orifice Parachute – Hammock MV N 112 16 63 20 12 17 % 87.5 12.5 5.5 49.2 15.6 9.3 3.1 13.3 3.1 0.8 Surgical Procedures • Repair : 126 ( 98.4%) • Replacement : 02 ( 1.6%) (1 repair failure & primary replace) VAN H DUNG-HNPTTMLN 2016-HCM Double orifice MR Operative Data • Mitral valve approching trans-septal : 92 trans-inter atrial groove : 36 • Mean CPB time : 86.7 ± 33mn • Mean aortic clamp : 61.6 ± 24.9mn • CPG : 1- VAN H DUNG-HNPTTMLN 2016-HCM SURGICAL TECHNIQUES Techniques Annuloplasty Ring annuloplasty Posterior annuloplasty (pericardial/PTFE ) Closure of mitral cleft Triangular resection (anterior leaflet) Quadrangular resection (posterior leaflet) Leaflet extension (anterior leaflet) Shortening of chordae Transposition of chordae Marginalization of chordae Plication of redundant leaflet Artificial Chord Commissurotomy Fenestration of chordae Papillary muscle splitting N 118 93 25 23 29 17 21 30 5 4 % 72.6 19.5 17.9 22.6 13.2 16.4 6.3 23.4 5.4 3.9 3.9 3.1 3.1 2.3 P VAN H DUNG-HNPTTMLN 2016-HCM ICU data • Mean time in ICU • Mean time of MV • Mean time of Hosp : 2.2 ± 1.8 days : 16 ± 43 hrs : ± 4.7 days VAN H DUNG-HNPTTMLN 2016-HCM Immediate Results • Hospital Mortality • Complications - Severe CHD - Arrhythmias - Acute renal failure - Pulmonary infection - Septicemia : (LCO + sepsis) :8 : 20 :1 :4 :1 VAN H DUNG-HNPTTMLN 2016-HCM Follow-up • Mean time of FU : 94.8 ± 70.5 months (6 – 240 months) • Lost FU : pts • Late death : pts ( CVA, unknown) • 19 years actuarial survival = 96.8 ± 2.2% (KM) VAN H DUNG-HNPTTMLN 2016-HCM Re-operation • Early re-operation : ( week) • Late re-operation : 10 (11-180 months) - Re-plasty : 07 ( remove prosthetic ring) - Replace : 03 - Biopros deterioration : ( 51 months) • 19 yrs free of re-op : 84 ± 7.2% (KM) VAN H DUNG-HNPTTMLN 2016-HCM Long-term Mitral Regurgitation Evaluation ( N = 110) • Absent or Mild : 88 (80%) • Moderate : 15 (13.6%) • Severe : (6.4%) VAN H DUNG-HNPTTMLN 2016-HCM Discussion • Ring or without ring ? : Prosthetic Ring or Pericardial/Teflon Band/ Reed/ Kay annuloplasty • Timing of Surgery VAN H DUNG-HNPTTMLN 2016-HCM MV re-operation: ring or without ring Authors (N) Opido (2008) N= 34 Chauvaud (1998) N = 81 Our Study (2015) N = 128 Yoshimura (1999) N = 36 Wood (2005) N= 30 Prosth Ring Post.Band 0/9 8/70 (1.4%) 3/93 (3.2%) NA Plication/Compress Points/ Reed 5/18 (28%) 2/5 (40%) 4/25 (16%) NA Opido - JTCVS 2008, Wood- JTCVS 2005 Chauvaud - JTCVS 1998 ; Yoshimura - JTCVS 1999 0/7 3/11 (27%) 3/33 (9%) 2/30 (6.7%) Timing of Surgery • Age of Patients : >3 - months or as older as possible • Anatomic Lesions : less complex • Clinical Status ( delay until the onset of severe symptom) • Size of Mitral Annulus ≥ 20 Goal: maximum the changes for a more successful and satisfactory repair VAN H DUNG-HNPTTMLN 2016-HCM Authors Chauvaud (1998) N = 145 AE Wood (2005) N = 30 G Oppido (2008) N= 34 PJ del Nido (2011) N = 155 Our Study (2015) N = 128 Repair Replace Hop.Mort 95% 5% 5% Re-Op (FU) 15% ( 10y) 3.3% 13.3 %(5y) 6% 19.7% ( 4y) 0.8% 8.6% ( 10y) 100% 96.9% 3.1% 92.8% 7.2% 98.4% 1.6% VAN H DUNG-HNPTTMLN 2016-HCM CONCLUSION In small children, mitral valve repair should be the primary choice for isolated congenital MR Prosthetic ring has stabilized result of mitral valve repair in long-term Mitral valve repair with Carpentier’s techniques has very good long-term results with very low mortality and acceptable re-operation rate VAN H DUNG-HNPTTMLN 2016-HCM THANK YOU FOR YOUR ATTENTIO ... 5.4 3.9 3.9 3.1 3.1 2.3 P VAN H DUNG-HNPTTMLN 2016-HCM ICU data • Mean time in ICU • Mean time of MV • Mean time of Hosp : 2.2 ± 1.8 days : 16 ± 43 hrs : ± 4.7 days VAN H DUNG-HNPTTMLN 2016-HCM... re-op : 84 ± 7.2% (KM) VAN H DUNG-HNPTTMLN 2016-HCM Long-term Mitral Regurgitation Evaluation ( N = 110) • Absent or Mild : 88 (80%) • Moderate : 15 (13.6%) • Severe : (6.4%) VAN H DUNG-HNPTTMLN... y.o : 42 (32.8%) • SR : 116 AF : 12 • LVEDd : 51 ± 9.7mm • LVEF : 66 ± 7% • SPAP : 44 ± 17mmHg VAN H DUNG-ATCSA 2014-HANOI Echocardiographic Findings • Type I : normal leaflet motion annulus