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