Secondary Mitral Valve Regurgitation

208 Pages·2015·14.069 MB·English

by  Khalil Fattouch, Patrizio Lancellotti, Gianni D. Angelini (eds.)

Khalil Fattouch
Patrizio Lancellotti
Gianni D. Angelini
Editors
Secondary Mitral
Valve Regurgitation
123
Secondary Mitral Valve Regurgitation

Khalil Fattouch (cid:129) P atrizio Lancellotti
Gianni D. Angelini
Editors
Secondary Mitral Valve
Regurgitation
Editors
Khalil Fattouch Gianni D. Angelini
GVM Care and Research Group Hammersmith Hospital
University of Palermo Imperial College of London
Palermo London
Italy UK
Patrizio Lancellotti Bristol Heart Institute
CHU Sart Tilman Bristol
University of Liège UK
Liège
Belgium
ISBN 978-1-4471-6487-6 ISBN 978-1-4471-6488-3 (eBook)
DOI 10.1007/978-1-4471-6488-3
Springer London Heidelberg New York Dordrecht
Library of Congress Control Number: 2014955605
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Foreword
This is not originally a disease of the valve but the consequence of a malfunctioning left ven-
tricle (LV): usually a segmental dysfunction in ischemic mitral regurgitation (MR), a more
diffuse one in nonischemic MR.
In many cases, it is a dynamic disease: The quantifi cation at rest has to be adapted, and
exercise test is a must in doubtful cases.
I maging must nowadays be extensive and characterize the LV substrate, dimensions, vol-
umes, the position of the papillary muscles (PM), and the leafl ets’ systolic restriction: tenting
distance, area, and anterior and posterior angles. The dynamic of the LV posteroinferior wall
segment comprised between the base of the posterior PM and the mitral annulus must be care-
fully analyzed as it might play a determinant role in postoperative MR recurrence.
Surgery should only be considered as a last resort: Optimal medical treatment and, when
appropriate, cardiac resynchronization therapy should come fi rst as well as PTCA, certainly in
acute cases.
Surgery should ideally be performed before an “irreversible” LV dilatation has developed,
but the surgical strategy remains for many a matter of discussion. Restrictive mitral annulo-
plasty (RMA) is the most applied technique, but the extreme variability in terms of valve siz-
ing, ring sizing, grade of undersizing, type of ring, and defi nition of procedural success has
yielded quite divergent outcomes even at short term.
For my part, the sizing of the ring is based on the maximum length of the anterior leafl et,
and the grade of undersizing depends on the type of complete rigid/semirigid ring used: two
sizes down for Physio I (Edwards Lifesciences), one size for Memo 3D (Sorin), or the saddle-
shaped rings of SJM and Medtronics. My defi nition of success is no residual MR a nd a coapta-
tion length in A2/P2 equal to or more than 8 mm. This technical strategy leads in our hands to
MR recurrence rates of less than 20 % after 4 years…
O ther groups have reported disappointingly high MR recurrence rates, and a recent pro-
spective randomized study published by ACKER et al. in NEJM has showed a 33 % recurrence
after 1 year in the repair group and therefore supported valve replacement … although the LV
reverse remodeling was found signifi cantly superior in the group of s uccessful repair. The lat-
ter fortunately prompted of one of the authors (I. KRON) to further analyze the repair group
and, accordingly, to propose 10 predictors of MR recurrence among which an akinetic or dys-
kinetic posteroinferior LV segment below the posterior leafl et (see above) played a preponder-
ant role.
An array of complementary subvalvular techniques comprising resuspension or relocation
of the PMs has been proposed with encouraging early results. Even basal chordal cutting had
been advocated although I do not support the rationale behind it in terms of LV health!…
J . MAGNE et al. have stressed a negative infl uence of post-RMA higher transmitral gradi-
ents at exercise, but this has not been confi rmed by others and our group: “Higher” gradients
usually correlated in our patients with better physical capacity on exercise…
Whatever the strategy, it should get rid of the MR, and no patient should leave the operating
room with any residual MR even at the cost of a mitral valve replacement.
The recent irruption of the mitral clip in the fi eld of secondary MR allows improving the
condition of desperately ill patients who are contraindicated for surgery.
v
vi Foreword
And fi nally, one should not forget the “forgotten” valve, the tricuspid valve, certainly in the
nonischemic secondary MR, where the tricuspid annulus also tends to be distended.
M y friends Khalil, Patrizio, and Gianni should be praised for their immense courage and
audacity to conceive a book on such a controversial and evolving subject. The numerous and
talented contributors have done a magnifi cent job in boldly addressing each of the abovemen-
tioned controversies.
Robert A. Dion , MD, PhD, FECTS, FESC
Department of Cardiac Surgery
Ziekenhuis Oost-Limburg , Genk , Belgium
Pref ace
Open-heart surgery has been in a continuous state of evolution since its earliest day. Few prob-
lems have proven as vexing to cardiologists, cardiac surgeons, and patients as the management
of secondary mitral valve regurgitation. Reduced coaptation of the valve leafl ets, a requirement
for mitral valve competence, regardless of the lesion type, is at the base of mitral regurgitation.
The treatment for primary mitral regurgitation is straightforward and has as its primary aim
timely intervention, which will prevent left ventricular remodeling and left ventricular dys-
function. On the contrary, the management for treating secondary mitral regurgitation is more
doubtful as the mitral valve is not the primary cause of the disease. Furthermore, it is not a
guarantee that correcting the mitral regurgitation without changing the left ventricular geom-
etry will be either benefi cial or curative.
O ur aim in this international multiauthor text has been to draw together contributions from
a range of cardiac surgeons, cardiologists, anesthetists, and scientists to provide comprehen-
sive coverage on the anatomy, hemodynamics, mechanism, echocardiography assessment, and
outcome of secondary mitral regurgitation and present current opinions on treatment modali-
ties. We have paid particular attention to presenting the subject in a structure that will be of
great interest to all practising cardiologists and cardiac surgeons. Many of the elusive details
surrounding the best management of secondary mitral regurgitation are presented in a compre-
hensive manner so that this book may serve as an important primary source for its readers.
T he contributing authors are all authorative and experienced in their fi eld, and a particular
attempt is being made to present the work in a manner which is meaningful to clinicians. The
subject is of great importance, and the future should show further evaluation in our understand-
ing of the management of secondary mitral regurgitation.
For our own part, close links have developed between the Bristol Heart Institute, the
National Heart and Lung Institute, London, the University of Liège Hospital, CHU Sart
Tilman, Liège, and Villa Maria Eleonora Hospital, Palermo, not only in terms of friendship but
also in allowing the interchange of clinical skills and research ideas.
We are indebted to our expert colleagues in those institutions for their contribution.
However, we must also particularly thank our friends and mentors across the globe, many of
whom are widely recognized as experts in their fi elds, for their endeavors in facilitating our
tasks by the excellence of their contribution.
F inally, we must thank those people who have provided us with so much practical help and
in particular Marco Moscarelli and Emma Sinclair for their work on the manuscript. We hope
that those who read this book will learn as much as we have during the editing process, and we
encourage the reader to adopt the practical guidelines within the text since they should provide
a sound basis for clinical practice.
London, UK Gianni Davide Angelini
vii

Contents
1 Prevalence and Defi nition of Secondary Mitral Regurgitation . . . . . . . . . . . . . 1
Bernard Iung and Alec Vahanian
2 Anatomical Changes Associated with Secondary Mitral
Regurgitation: Difference Between Ischemic and Idiopathic
Cardiomyopathy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Khalil Fattouch, Giacomo Murana, Sebastiano Castrovinci,
Marco Moscarelli, and Giuseppe Speziale
3 Clinical Prognostic Value of Secondary Mitral Valve Regurgitation . . . . . . . . 13
Yan Topilski, Francesco Grigioni, and Maurice Enriquez-Sarano
4 Functional Classifi cation of Secondary Mitral Valve Regurgitation. . . . . . . . . 19
Luigi Paolo Badano, Sorina Mihaila, Denisa Muraru, Dragos Vinereanu,
and Sabino Iliceto
5 Three-Dimensional Echocardiographic Imaging of Secondary
Mitral Valve Regurgitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Raluca Dulgheru, Paaladinesh Thavendiranathan, Khalil Fattouch,
Mani Vannan, and Patrizio Lancellotti
6 Dynamic Stress Evaluation of Secondary Mitral Regurgitation. . . . . . . . . . . . 41
Patrizio Lancellotti, Raluca Dulgheru, and Luc A. Pierard
7 Timing and Patient’s Selection for Surgical Repair of Secondary
Mitral Valve Regurgitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Julien Magne, Christine Henri, and Patrizio Lancellotti
8 Preoperative Echocardiographic Evaluation of Secondary Mitral
Valve Regurgitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Timothy C. Tan, Eric Brochet, and Judy W. Hung
9 Perioperative Anesthesia Management in Secondary Mitral
Regurgitation and Heart Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Massimiliano Conte
10 Prosthetic Ring Choice in Secondary Mitral Regurgitation . . . . . . . . . . . . . . . 97
Amit Arora and Anelechi C. Anyanwu
11 Papillary Muscle Relocation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Cynthia E. Wagner and Irving L. Kron
12 Chordal Cutting: State of the Art. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Emmanuel Messas and Catherine Szymanski
13 The Role of the “Edge-to-Edge” in Mitral Valve Repair . . . . . . . . . . . . . . . . . . 117
Ottavio Alfi eri and Michele De Bonis
ix