ESCTS 2012

1. Prof. Walaa Ahmed Saber MD

3. ADVANTAGES OF MITRAL REPAIR OVER
REPLACEMENT:
* Lower operative mortality
* Better LV function
* Lower incidence of thromboembolism
* Lower incidence of bleeding
* Lower incidence of infective endocarditis
* Increased long term survival

4. Controversial problems of mitral valve Repair In General:
-Predictability of results.
-Reproducibility of techniques
-Selection of patients.

5. - In 1970’s: Carpentier used to say that:
- All mitral valves are repairable until proved otherwise.
Is that a true statement??

6. 1. Leaflets
2. Chordae tendineae
3. Annulus
4. Papillary muscles
5. Left ventricle
6. Left atrium
The function of the mitral valve is wonderfully
complex and involves precisely timed interactions
among all the six components of the mitral valve
to function properly.

8. Type Description
Type 1 *normal leaflet motion
-annular dilatation
-leaflet perforation
Type 2 *leaflet prolapse
-chordal rupture
-chordal elongation
-papillary muscle rupture
-papillary muscle elongation
Type 3 *restricted leaflet motion
-commissural fusion, leaflet
thickening
-chordal fusion/ thickening

9. - Continuous inflammatory process.
- Aggressive pathological changes.
- Decreased repair durability.

11. Degenerative Rheumatic
-Generous leaflet tissue -Reduced leaflet tissue
-Thin leaflet -Thickened leaflet
-Elongated thin chordae -Shortened thick chordae
-Free MR -Mainly stenotic

12. Mitral valve repair in the setting of rheumatic changes
can be technically difficult to perform and the late results
are adversely affected by new episodes of acute rheumatic
inflammation.

13. Up to 95% of degenerative mitral valves can be repaired
with current techniques. But only 75% of the patients
with rheumatic mitral valves disease are amenable to
reparative procedures.

14. - Mitral valve repair is more challenging and controversial
in rheumatic patients.
- There is a higher probability of valve replacement
compared to valve repair.
- The durability of mitral valve repair is also limited in the
rheumatic pathology due to its progressive nature

15. Mitral valve repair in rheumatic disease showed
satisfactory early results.
Long-term results were poor because of high mortality
and a high number of valve-related reoperations.
Of the 144 Patients who survived the operation, 63
(41.2%) required reoperation because of valve
dysfunction.

16. 55 publications reviewed
29 publications were included (10,000 cases)
Divided into 4 etiologies:
i.Degenerative
ii.Ischemic
iii.Rheumatic
iv.Mixed

17. In rheumatic lesions, patients undergoing mitral
replacement had the following increased risks ,
compared to mitral repair:
I.Almost 3 times the risk of early mortality.
II.More than twice the risk of thromboembolism.
III.More than twice the risk of dying in the long term.
Shuhaiber&Anderson, 2007

18. In a young Saudi population <20 years
Isolated MR of rheumatic etiology
Actuarial survival was around:
98% at 6.5 years for repair
75% at 4 years for replacement
Gometza et al. J Heart Valve Disease, 1996

19. Reoperation rate at 10 years: 18-28%.
Mean delay to reoperation: 9.3 years.
Mortality of reoperation: 0-6.5%
Yau et al.

20. Nice study with follow up data for 36 years:
The rheumatic patients who survive more than 20 years
after repair require reoperation (more than 90%)

21. In conclusion, it is quite obvious that, even in rheumatic
pathology, mitral valve repair is still worthwhile and that
the percentage of valves repaired increases with the
experience and the will of the surgeon to preserve the valve.
In my view, mitral valve replacement is only justified when
a good repair is not feasible, but the experience of the
surgeon is absolutely vital. This can only be obtained by
exposure to an adequate number of patients, which is
usually made difficult by the political and economical
situation in our country.

22. Rheumatic mitral regurgitation in the young
population group is amenable to repair, although the
results are less favorable than those observed with
other types of mitral valve disease, especially in older
populations. However, a better knowledge of the
pathology and evolution of the techniques of repair
have led to improved results. The latter include
avoidance of resection of anterior leaflet, use of PTFE
chordae versus shortening of the chordae and use of
pre-shaped rigid rings.

23. Intra-operative transoesophageal echocardiography
has proven most valuable. On the other hand,
continued prophylaxis of rheumatic fever remains a
very important component of the treatment of
these patients.