Mitral Valve RepairBileaflet Prolapse

A. Marc Gillinov, M.D.

Speaker/consultant• Edwards Lifesciences• Medtronic• Abbott• Cryolife• AtriCure• ClearFlow

Research support• Abbott

Disclosures

Barlow’s Disease

• Excess mucopolysaccharides on histology

• Young age at presentation

• Excess leaflet tissue

• Annular dilatation

• Bileaflet prolapse and/or billowing of leaflets into atrium during systole

0

100

80

60

40

20

06 8 10 12

AL

PL

P=0.019

Free

dom

from

Reo

pera

tions

(%)

Years Postoperatively

Freedom from Reoperation

David et al. / The Journal of Thoracic and Cardiovascular Surgery ● November 2005

BL

42

Freedom from Recurrent Moderate or Severe Mitral Regurgitation

David et al. / The Journal of Thoracic and Cardiovascular Surgery ● November 2005

0

100

80

60

40

20

6 8 10 12

ALPL

P=0.0013

Free

dom

from

MR

3+

or 4

+ (%

)

Years Postoperatively

BL

42

0

Rat

e/ye

ar (%

)

2.0

0.5

1.0

1.5

PL BL ALSuri et al, (Ann Thorac Surg 2006;82:819 –27)

MechanicalReplacementRepair

Reoperation and Site of Prolapse

0

100

80

60

40

20

05 10 15

Repair

Replacement

P<0.001

Surv

ival

(%)

Years after Surgery

Patients over 60 Years

G.F. Coutinho et al. / European Journal of Cardio-Thoracic Surgery

Repair for Bileaflet Prolapse

• Survival• Superior to replacement

• Durability• Good• Lower than for repair of posterior prolapse

Repair for Bileaflet Prolapse

Best Option

Repair StrategyRepair for Bileaflet Prolapse

Repair for Bileaflet Prolapse

Jet DirectionJet Direction + SAM Risk

SAM Predictors• Coaptation-septum distance <25 mm• Aorto-mitral angle <120 o• Posterior leaflet height >15 mm• Ant/post leaflet height < 1.3• Basal septal diameter > 15 mm• EDD < 45 mm• Hyperdynamic ventricle

Varghese et al. European J C-T Surg 2013

SAM Predictors

Too much leaflet tissueRelative to the ventricle

Repair for Bileaflet Prolapse

Jet DirectionJet Direction + SAM Risk

Bileaflet Prolapse: Jet Direction

• Central jet• Low SAM risk: Annuloplasty band alone• High SAM risk: Posterior leaflet resection/annuloplasty band

• Anterior jet• Posterior leaflet resection/annuloplasty band

Central Jet: Low SAM Risk

Central Jet: Low SAM RiskAnnuloplasty Band Alone

Zekry et. al., JTCS: Volume 150, Number 5

Barlow’s disease is characterized by an enlarged annulus and excess prolapsing leaflet tissue

Reducing annular size with ring reduces triangular base mitral leaflets are pushed down toward the left ventricle to coapt at the left ventricle level

Triangle with enlarged base

Central Jet & High SAM RiskOR

Anterior JetQuadrangular Resection & Sliding Repair

Anterior JetBileaflet Prolapse

Gillinov et. al., Ann Thorac Surg, 821,1999;68:820–4

Normal anatomy: leaflet coaptation occurring at the annular level

Anterior chords intact but loss of posterior leaflet support to anterior leaflet at the zone of coaptation allows anterior leaflet prolapse

Gillinov et. al., Ann Thorac Surg, 821,1999;68:820–4

Sliding Repair

“True” Bileaflet Prolapse

Pronounced Bileaflet Pathology

• Jets- Multiple- Anterior and posterior

• Bileaflet repair- Posterior leaflet: sliding repair- Anterior leaflet: artificial chordae

Minimally Invasive Approach?

Freedom from MR >2+

Borger et. al., JTCS: October 2014

0 2 4 6 8 100

.2

.4

.6

.8

1.0

Cum

ulat

ive

free

dom

fr

om M

R >

2+

(%)

Time since surgery (years)

5-year: 90.2% ± 3.4%10-year: 88.4% ± 3.9%

0 2 4 6 8 100

.2

.4

.6

.8

1.0

Cum

ulat

ive

free

dom

fr

om re

oper

atio

n (%

)

Time since surgery (years)

5-year: 96.8% ± 1.6%10-year: 93.8% ± 2.6%

Freedom from Reoperation

Borger et. al., JTCS: October 2014

Barlow’s

Valve repair

• Preferable

• Possible in most

• Guided by jet direction and SAM risk

• Minimally invasive approach not precluded

Thank You