The when and how of surgery

for secondary mitral regurgitation

Ottavio Alfieri
S.Raffaele University Hospital, Milan
Secondary Mitral Regurgitation
(ischemic or non-ischemic)

•Normal valve morphology

-Changes in LV geometry
-Papillary muscles dislocation
-Leaflet tethering
-Annular dilatation
-Decreased closing forces
-Dyssynchrony in contraction
-Failure of leaflet expansion

MR
Levine, R. A. et al. Circulation 2005;112:745-758
 Surgical Risk vs Benefit in SMR
Optimum Surgical Risk
Value

Limited
Value ?
Clinical Benefit

Increasing age,frialty, comorbidities,LV dysf.

 Surgical Risk vs Benefit in MR
Optimum Surgical Risk
Value
Percutaneous methods

?
Medical treatment
Limited HTx / VAD
Value

Clinical Benefit

Increasing age,frialty, comorbidities,LV dysf.

How to characterize pts with SMR
Valve
Degree of MR , Symmetric/Asymmetric
Location of jet
Tenting area
Coaptation depth, coaptation length
Angle PL/angle AL – annular plane
…………..
Ventricle
LVEDD,LVESD
LVEDV,LVESV
EF
Sphericity index
Interpapillary distance
Ischemia/Viability/Contractile reserve/
Scar tissue
Coronary anatomy
 How to characterize pts with SMR
Valve
Degree of MR , Symmetric/Asymmetric
Location of jet
Tenting area
Coaptation depth, coaptation length
Angle PL/angle AL – annular plane
…………..
Ventricle
LVEDD,LVESD
LVEDV,LVESV
EF
Sphericity index
Interpapillary distance
Ischemia/Viability/Contractile reserve/
Scar tissue
Coronary anatomy

Echo, Coronary angiogram, CMR essential tools !!

 Impact of SMR on the Prognosis

Rossi et al. Heart 2011;97:1675-1680

 What is new in the 2017 Valvular Heart
Disease Guidelines?
Changes in recommendations
2012 2017
Indications for mitral valve intervention in secondary mitral
regurgitation
IIa C
Surgery should be considered in
patients with moderate Taken out
secondary mitral regurgitation
undergoing CABG
IIb C IIb C (modified)
When revascularization is not When revascularization is not
indicated, surgery may be indicated, surgery may be
considered in patients with severe considered in patients with severe
secondary mitral regurgitation secondary mitral regurgitation
and LVEF >30%,who remain and LVEF >30%, who remain
symptomatic despite optimal symptomatic despite optimal
medical management medical management (including
(including CRT if indicated). CRT if indicated) and have a low
surgical risk.
www.escardio.org/guidelines
2017 ESC/EACTS Guidelines for the Management of Valvular Heart Disease 9
(European Heart Journal 2017 - doi:10.1093/eurheartj/ehx391)
 What is new in the 2017 Valvular Heart
Disease Guidelines?

Changes in recommendations
2012 2017
Indications for mitral valve intervention in secondary mitral
regurgitation (continued)
IIb C (modified) (continued)
When revascularization is not
indicated and surgical risk is not
low, a percutaneous edge-to-edge
procedure may be considered in
patients with severe secondary
mitral regurgitation and LVEF
>30%, who remain symptomatic
despite optimal medical
management (including CRT if
indicated) and who have a
suitable valve morphology by
echocardiography, avoiding
futility.
www.escardio.org/guidelines
2017 ESC/EACTS Guidelines for the Management of Valvular Heart Disease 10
(European Heart Journal 2017 - doi:10.1093/eurheartj/ehx391)
 What is new in the 2017 Valvular Heart
Disease Guidelines?

Changes in recommendations
2012 2017
Indications for mitral valve intervention in secondary mitral
regurgitation (continued)
IIb C (modified) (continued)
In patients with severe secondary
mitral regurgitation and LVEF
<30% who remain symptomatic
despite optimal medical
management (including CRT if
indicated) and who have no
option for revascularization, the
Heart Team may consider
percutaneous edge-to-edge
procedure or valve surgery after
careful evaluation for ventricular
assist device or heart transplant
according to individual patient
characteristics.
www.escardio.org/guidelines
2017 ESC/EACTS Guidelines for the Management of Valvular Heart Disease 11
(European Heart Journal 2017 - doi:10.1093/eurheartj/ehx391)
 What is new in the 2017 Valvular Heart
Disease Guidelines?
Changes in recommendations
2012 2017
Indications for mitral valve intervention in secondary mitral
regurgitation (continued)
Additional statement:
The lower thresholds defining
severe MR compared to primary
MR are based on their association
with prognosis. However, it is
unclear if prognosis is
independently affected by MR
compared to LV dysfunction. For
isolated mitral valve treatment in
secondary MR, thresholds of
severity of MR for intervention
still need to be validated in clinical
trials. So far, no survival benefit
has been confirmed for reduction
of secondary MR.
www.escardio.org/guidelines
2017 ESC/EACTS Guidelines for the Management of Valvular Heart Disease 12
(European Heart Journal 2017 - doi:10.1093/eurheartj/ehx391)
Moderate SMR in CABG
pts
Severe SMR in CABG pts
Perioperative mortality
Late mortality Recurrence of moderate-to-
severe MR
Isolated severe SMR
Options for operable pts with severe
SMR

• Undersized anuloplasty
• Anuloplasty and procedures on the
subvalvular apparatus
• Valve replacement (with preservation of the
subvalvular apparatus)
UNDERSIZED ANNULOPLASTY
( preferably with a complete and rigid ring)
 Residual/recurrent MR≥2+ after
undersized annuloplasty

Magne et al. Cardiology 2009;112:244.

Selection of pts with SMR for undersized annuloplasty
PREDITORS OF ANNULOPLASTY
FAILURE AND RECURRENCE OF
MR
- Absence of annular dilatation

- Excessive leaflet tethering

- Coaptation depth >10mm
- Posterior leaflet angle > 45°
- Distal anterior leaflet angle
>25°
- Systolic tenting area >2.5cm2

- Advanced LV remodelling
- systolic sphericity index >0.7,
- LVEDD >65mm
- LVESV ≥ 145 ml (or ≥ 100
ml/m2)
- End-systolic interpapillary
muscle distance >20mm
Lee et al. Circulation
- Basal aneurysm/dyskinesis
2009;119:2606
Additional procedures to associate to undersized
annuloplasty to enhance effectiveness and
durability
Papillary Head Optimization（PHO）
A modification of Kron’s method

Komeda M. et al,. J Thorac

Cardiovasc Surg 2012;144:1262
-4
Kron’s relocation
Successful repair is associated with
the best reverse remodeling !!
MV REPLACEMENT WITH PRESERVATION OF THE
SUBVALVULAR APPARATUS
 Take-home message
• Surgery for SMR is only reserved to pts with an
acceptable operative risk
• Moderate SMR should be left untreated at the
time of CABG
• For severe SMR, repair is the optimal treatment
when expected to be durable, otherwise valve
replacement should be carried out
• With advancement in technology, it is likely that
in the near future surgery for SMR will be carried
out only if percutaneous methods are
contraindicated
Thank you