Isolated congenital mitral regurgitation long-term results and the role of prosthetic ring

 ISOLATED CONGENITAL MITRAL REGURGITATION 
 LONG-TERM RESULTS AND THE ROLE OF 
PROSTHETIC RING 
Hung Dung VAN.MD.PhD, Hoang Khang HUYNH 
HCMC Heart Institute - VIETNAM 
INTRODUCTION 
• Congenital MR : isolated or associated with 
ASD,VSD, PDA 
• 4.5% in total isolated MR ( Heart Institute HCMC 
statistic in 2013) 
VAN H DUNG-HNPTTMLN 2016-HCM 
Patients and Methodology 
•Retrospective study 
• Isolated Congenital MR (Excluded all case 
associated with VSD, ASD, PDA CAVD, 
ALCAPA) 
•From 1993 to 2015 at The Heart Institute 
HCM city-Viet Nam 
•N = 128pts 
VAN H DUNG-HNPTTMLN 2016-HCM 
Patients Demographic Pre-op 
• Sex : male : 63 (49%) 
• Mean age : 12.5 ± 7.6 y.o ( 0.5 - 50 yo) 
 < 6 y.o : 42 (32.8%) 
• SR : 116 AF : 12 
• LVEDd : 51 ± 9.7mm 
• LVEF : 66 ± 7% 
• SPAP : 44 ± 17mmHg 
VAN H DUNG-ATCSA 2014-HANOI 
Echocardiographic Findings 
•Type I : normal leaflet motion 
 annulus dilatation : 112 
 cleft mitral valve : 16 (14/2) 
•Type II : leaflet prolapse 
 anterior leaflet : 84 
 posterior leaflet : 20 
•Type III : short chordae syndrome : 15 
 IIIP : 12 
VAN H DUNG-HNPTTMLN 2016-HCM 
Surgical Findings 
 Lesions N % 
Annular dilatation 
Cleft mitral valve : anterior 
 posterior 
Absent chordae : anterior 
 posterior 
Elongation chordae 
Commissural fusion 
Short chordae syndrome 
Double orifice 
Parachute – Hammock MV 
 112 
 16 
 7 
 63 
 20 
 12 
 4 
 17 
 4 
 1 
 87.5 
 12.5 
 5.5 
 49.2 
 15.6 
 9.3 
 3.1 
 13.3 
 3.1 
 0.8 
Surgical Procedures 
• Repair : 126 ( 98.4%) 
• Replacement : 02 ( 1.6%) 
 (1 repair failure & 1 primary replace) 
VAN H DUNG-HNPTTMLN 2016-HCM 
Double orifice MR 
Operative Data 
•Mitral valve approching 
 trans-septal : 92 
 trans-inter atrial groove : 36 
•Mean CPB time : 86.7 ± 33mn 
•Mean aortic clamp : 61.6 ± 24.9mn 
•CPG : 1- 5 
VAN H DUNG-HNPTTMLN 2016-HCM 
SURGICAL TECHNIQUES 
 Techniques N % 
Annuloplasty 
 Ring annuloplasty 
 Posterior annuloplasty (pericardial/PTFE ) 
Closure of mitral cleft 
 Triangular resection (anterior leaflet) 
 Quadrangular resection (posterior leaflet) 
 Leaflet extension (anterior leaflet) 
 Shortening of chordae 
 Transposition of chordae 
 Marginalization of chordae 
 Plication of redundant leaflet 
 Artificial Chord 
Commissurotomy 
Fenestration of chordae 
Papillary muscle splitting 
 118 
 93 
25 
 23 
 29 
 17 
 21 
 7 
 30 
 7 
 5 
 5 
 4 
 4 
 3 
 72.6 
 19.5 
 17.9 
 22.6 
 13.2 
 16.4 
 6.3 
 23.4 
 5.4 
 3.9 
 3.9 
 3.1 
 3.1 
 2.3 
 P 
VAN H DUNG-HNPTTMLN 2016-HCM 
ICU data 
•Mean time in ICU : 2.2 ± 1.8 days 
•Mean time of MV : 16 ± 43 hrs 
•Mean time of Hosp : 8 ± 4.7 days 
VAN H DUNG-HNPTTMLN 2016-HCM 
Immediate Results 
•Hospital Mortality : 1 (LCO + sepsis) 
•Complications 
- Severe CHD : 8 
- Arrhythmias : 20 
- Acute renal failure : 1 
- Pulmonary infection : 4 
- Septicemia : 1 
VAN H DUNG-HNPTTMLN 2016-HCM 
Follow-up 
•Mean time of FU : 94.8 ± 70.5 months 
 (6 – 240 months) 
•Lost FU : 5 pts 
•Late death : 2 pts ( 1 CVA, 1 unknown) 
•19 years actuarial survival = 96.8 ± 2.2% 
 (KM) 
VAN H DUNG-HNPTTMLN 2016-HCM 
Re-operation 
•Early re-operation : 1 ( 1 week) 
•Late re-operation : 10 (11-180 months) 
 - Re-plasty : 07 ( remove prosthetic ring) 
 - Replace : 03 
 - Biopros. deterioration : 1 ( 51 months) 
•19 yrs free of re-op : 84 ± 7.2% (KM) 
VAN H DUNG-HNPTTMLN 2016-HCM 
1 
2 
3 
4 
Long-term Mitral Regurgitation 
Evaluation ( N = 110) 
•Absent or Mild : 88 (80%) 
•Moderate : 15 (13.6%) 
•Severe : 7 (6.4%) 
VAN H DUNG-HNPTTMLN 2016-HCM 
Discussion 
•Ring or without ring ? : Prosthetic Ring or 
Pericardial/Teflon Band/ Reed/ Kay 
annuloplasty 
•Timing of Surgery 
VAN H DUNG-HNPTTMLN 2016-HCM 
MV re-operation: ring or without ring 
Authors (N) Prosth. Ring Post.Band 
Plication/Compress 
Points/ Reed 
Opido (2008) 
N= 34 
0/9 5/18 
(28%) 
 0/7 
Chauvaud 
(1998) N = 81 
 8/70 
(1.4%) 
 2/5 
(40%) 
 3/11 (27%) 
Our Study 
(2015) N = 128 
3/93 
(3.2%) 
 4/25 
 (16%) 
Yoshimura 
(1999) N = 36 
NA 3/33 (9%) 
Wood (2005) 
N= 30 
NA 2/30 (6.7%) 
Opido - JTCVS 2008, Wood- JTCVS 2005 
Chauvaud - JTCVS 1998 ; Yoshimura - JTCVS 1999 
Timing of Surgery 
• Age of Patients : >3 - 6 months or as older as possible 
• Anatomic Lesions : less complex 
• Clinical Status ( delay until the onset of severe symptom) 
• Size of Mitral Annulus ≥ 20 
Goal: maximum the changes for a more successful and satisfactory 
repair 
VAN H DUNG-HNPTTMLN 2016-HCM 
 Authors Repair Replace Hop.Mort Re-Op 
(FU) 
Chauvaud 
(1998) N = 145 
95% 5% 5% 15% ( 10y) 
AE Wood (2005) 
N = 30 
100% 3.3% 13.3 %(5y) 
G Oppido 
(2008) N= 34 
96.9% 3.1% 6% 19.7% ( 4y) 
PJ del Nido 
(2011) N = 155 
92.8% 7.2% 
Our Study 
(2015) N = 128 
98.4% 1.6% 0.8% 8.6% ( 10y) 
VAN H DUNG-HNPTTMLN 2016-HCM 
CONCLUSION 
In small children, mitral valve repair should be the 
primary choice for isolated congenital MR. 
Prosthetic ring has stabilized result of mitral valve 
repair in long-term. 
Mitral valve repair with Carpentier’s techniques 
has very good long-term results with very low 
mortality and acceptable re-operation rate. 
VAN H DUNG-HNPTTMLN 2016-HCM 
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