Valentin, I appreciate you inviting me and giving me 20 minutes today of your meeting. I want to use it to gather with you and really change something. I am a surgeon, and like Alain, I want to keep it simple. This is what I want to do for 20 minutes.
In 2007, I want to convince you degenerative mitral valve disease equals a mitral valve repair. It is very simple. I am not going to give a surgery talk, no videos, no how-we-do-it. I want to do this with you today. I should have a friendly audience.
Let us look at the cardiology textbooks. Here is Braunwald, “Centers are moving toward a more aggressive surgical approach with surgery recommended for patients with severe mitral regurgitation. Recommendation should be considered in centers where surgical expertise indicates the patient will undergo a successful mitral valve repair.”
I did not forget your book Valentin. “Management of the patient with mitral valve prolapse may require valve surgery. Most of these valves can be repaired successfully by surgeons experienced with mitral valve repair.” So far so good.
How about the guidelines. All of us like guidelines. They were just published a few months ago. What do they say? “The feasibility of repair is dependent on several factors including valve anatomy and surgical expertise. This prediction is based on the skill and experience of the surgeon in performing repair and on the location and type of mitral valve disease that caused the mitral regurgitation. Considering the beneficial effect of mitral valve repair on survival and left ventricular function, cardiologists are strongly encouraged to refer patients who are candidates for mitral valve repair to surgical centers experienced in performing mitral valve repair.” So far so good. All of the text books and all of the guidelines were all in agreement of mitral valve repair. That is the United States. That is the problem.
When we look at the United States, over the last decade, mitral valve replacement continues to be the dominant procedure and roughly half the patients today have a mitral valve replacement. Well you say that is the United States. In a sophisticated state that would not happen. That is New York. That is the highest density of cardiologists and cardiac surgeons in the United States. State Report 2006, dated still two years old, they reported two years later, “More isolated mitral valve replacement than mitral valve repair.” In the face of the textbooks and in the face of the guidelines.
The patients are the loser. Professor Carpentier says that the patients are the winner because of bio-prosthetic valves. I agree with you. In this area, the patients are the loser and that has been documented over and over again in surgeons that do not do repair always say, ‘Well, but that was before valve sparing or that was before this or that.’ There is always an excuse.
This paper was published from the Mayo Clinic this year and they just looked at their last 10 years of patients. These patients got valve sparing, lots of them got bio-prosthetic valve; did not matter. When you take a patient’s valve out, you decrease their survival, and it is about 1% per year over the first 10 years.
It does not matter whether it is a posterior leaf or a bi-leaflet prolapse and I always tell a patient that. The operation success is not here for degenerative mitral valve disease. The success is here. We have to quit thinking well the patient made it, it is okay. It is not okay. The patient is not going to live as long.
Here is another excuse, ‘Well you know the repair is not as durable, and as Jeff pointed out, and he is right, some patients have failure now following valve repair. I think a mechanical valve is going to be better, it is going to be more durable.’ Not true. From the same paper from the Mayo Clinic, a current era series from a high volume leading center, here is mechanical replacement. Posterior leaflet or bi-leaflet prolapse, these are the re-operation rates over a decade. Their conclusion; ‘these findings do not support the perception of many clinicians; that results of valve replacement from mitral prolapse are more predictable as regard subsequent risk of re operation.’ So again, I show this slide to patients. A mechanical valve is not for the rest of your life. In fact the re-operation rate roughly equals the failure rate of a valve repair and of course you commit yourself to a lifetime of anticoagulation. So they are bad and we are putting lots of them in, in 2006. Why is it the last decade, it has been a coin flip? Roughly half the patients get a metal valve and half the patients get a valve reconstruction. The answer is in the guidelines. I have highlighted them. There are two reasons. It is the surgeons fault. Surgical expertise; it’s the skill and experience of the surgeon, and it is the cardiologist’s fault. Refer the patient to surgical centers experienced in performing mitral valve repair. We are both at fault.
So I am back to my very simple concept. In 2007 degenerative mitral disease equals mitral valve repair. How do we get there? It is simple. Here is rule #1. In 2007, a cardiologist must carefully identify the etiology of mitral regurgitation. It is not enough to say anymore that the patient has severe mitral regurgitation. Turn the color off and understand the mechanism, take the history, and figure out why the patient has regurgitation. Here is why I say that. If you have a patient who has rheumatic disease, they are most likely to get a replacement. Some patients are a candidate for repair. I do not think it matters much where that patient has the surgery as long as they survive. How about endocarditis? Yes, some patients have repair. Lots of them are going to have a replacement. In ischemic heart disease, the operation really is the bypass operation. Of course, several others feel strongly that patients should have a repair but there is really no data that they would benefit from the repair. But in degenerative disease, in 2007; we want every patient to get a repair. So the first thing is you have to figure out, I am sure my patient has degenerative disease. That is rule #1.
The second thing in 2007, a cardiologist has to do is to make a determination if the patient with degenerative disease has fibroelastic deficiency or Barlow’s valve disease. So it is not enough to say there is prolapse. It is not enough just to identify dysfunction. In 2007, if we want to repair more valves, we have to go a step further.
We have to differentiate the disease. Why? Because the type of degenerative disease and identified lesions on echo should be the primary guide for referral to a specific surgeon. So think about your etiology and think about the lesions the etiology caused.
This is Carpentier’s triad; we have talked about it many times at this meeting, but use that to determine who should do the operation. Why? Here is a table that summarizes. If you want to look at the probability of successful degenerative valve repair think about the etiology and of course the surgical experience. So again, if you have an experienced cardiac surgeon and you have fibroelastic deficiency and a posterior leaflet prolapse, they are likely to get a repair. If you have fibroelastic deficiency and anterior bileaflet prolapse, a very good experienced cardiac surgeon; it is actually not that likely the patient is going to have a valve repair. If you have a patient with Barlow’s disease and you have a very experienced excellent cardiac surgeon that does not do a lot of mitral surgery, it is very unlikely that patient’s is going to have a mitral valve repair. Now if you have a reference mitral surgeon, I expect the repair rate for fibroelastic deficiency to be near 100%. In fact in Barlow’s disease, I think that repair rate is going to be at least 90% and in fact if you look at series’ and you dissect out why does the Cleveland Clinic have a 90% repair rate or Mayo Clinic of 91%, it is because of Barlow’s patients. It is not because of fibroelastic deficiency. So again, it starts with you, the cardiologist. Figure out which disease the patient has. That is going to help you decide where the patient should have their operation and it is not just the center, it is the surgeon. Let me tell you this way. If Dr. Greipp is doing Marfan’s disease and has a complex mitral valve, he calls up a good friend of his, a partner, to come to the room to look at it just like I call him to look at an aortic arch. You see you can be a great surgeon but unless you focus in mitral valve disease, you are not going to repair Barlow’s disease.
Okay, let us see what the disease is. This is fibroelastic deficiency first described by Dr. Carpentier. When you want to recognize it, it is actually easy. The patients are usually older, usually in their 60s. They have a short history of one or two years, three years, four years. They have thin leaflets and minimal tissue. The valves are generally normal except for the prolapsing segment. So when you look at an echo, you are going to see basically a normal valve, you will see a prolapsing segment, usually you will see a ruptured chord, but there is not a lot of excess tissue in the valve, and it is a short history, older patient. That is what it looks like when we see them. Again, the prolapsing segment where you will find the ruptured chord and these are anterior leaflets and here are two posterior leaflet prolapses, this is the medial scallop, P3, here is a P2 with single ruptured chord but notice the characteristic of the valve. The excess tissue is in the prolapsing segment. The rest of the valve is normal. I do not have to tell you how to do a valve repair. You can look in this picture as a cardiologist and understand to go from here to here is not that hard. It should be 100%. The patients deserve that.
Now what about Barlow’s? I keep saying find the Barlow’s patients. Here is Barlow’s disease. The patients are almost always under the age of 50. They typically come to the office and they say, “Well I have known I’ve have had mitral disease for 10 or 15 years. I have been followed for years by the cardiologist.” They have thick excess tissue, they have ballooning segments, they have billowing of the valve, and they are generally very large valves with complex jets. They are not hard to identify. When you see that, again, you do not need to know about how you fix it. You can just look at the lesions and understand that this is a totally different disease. Giant ballooning segments, posterior leaflets taller than the entire valve orifice, calcification in the papillary muscles, and calcification of the annulus. This is the microcalcification again, Dr. Carpentier describes, which precludes this. Very complicated valves. This valve cannot be repaired unless you do a lot of mitral valve surgery every week consistently. Again, I do not have to tell you how go from here to here. I think you can appreciate this requires a lot of what I call plastic surgery on the leaflets to get the valve back into a normal position. This takes a lot of time. In our series, it takes almost three hours to go from here to here, and that is in an experienced reference center. So again, identify Barlow’s valve disease.
Again, back to the guidelines. I will support what I said; posterior leaflet prolapse, degenerative mitral valve disease, or ruptured chordae are usually repaired. Less important, Barlow’s, involvement of the anterior leaflet or both anterior and posterior leaflet diminish the likelihood of repair. So FED (fibroelastic deficiency)with bileaflet prolapse, or anterior leaflet prolapse, or Barlow’s; be careful, these patients require a reference surgeon.
This is a paper that is getting a lot of attention. It was written by a collaborative group in Great Britain this year. First author is Bridgewater. They got together; cardiologist, surgeons, and anesthesiologists in Great Britain. They are ahead of the curve. They want to setup best practice guidelines for mitral surgery in Great Britain for the National Healthcare System and they make the same conclusions. I will show you some of this paper a few different ways. Some types of mitral repair (such as pan-leaflet prolapse in Barlow’s disease and complex repeat repair) represent particular technical challenge and require a high level of judgment and expertise. We feel the best results in these cases are likely to be achieved by surgeons who are undertaking a very high volume of surgery and a regional referral practice to super specialists may prove to give the best results. It is not that you are a great cardiac surgeon; you need to be a super specialist to operate on complex mitral valve disease if we are going to change those curves.
So here it is very simply said, if you have fibroelastic deficiency and a posterior leaflet prolapse, I hope and expect that experienced surgeons are going to have a very high success rate repairing the valve for the patient.
If you see patients that you suspect have Barlow’s disease, because of the characteristics on an echocardiogram, are young patients, and we do not have time to talk about asymptomatic patients although Jeff has already brought this up, I think the bar is very high for asymptomatic severe mitral regurgitation or patients that have anterior leaflet or bileaflet prolapse. If you want to have a very high success rate for the patient, they need to go to a reference mitral valve surgeon, not just a center, a reference mitral surgeon.
Two papers I think that show you what happens when a reference surgeon does those operations, this is a paper published last year from Tirone David where again he looked at his outcome across the spectrum of disease and I just pulled out one sentence to remind you that repair rates increased from 25% in 1982.. So you have got to look when they publish their series for the whole time, I want to know the recent interval, to approximately 95% since 1990. So again reference surgeon, 95% repair rate, all comers.
Here is a paper that our group just published this month in The Annals of Thoracic Surgery, looking at the most complex sub group, Barlow’s disease. I will just show you a few highlights. Again, in the most complex type of valve patients, all patients were repaired, 100% repair rate for Barlow’s disease. But we went further. We had our echoes core graded by a research cardiologist. We did not do the reports. We really wanted to know are we pushing too far to get to 100%. 93% of the patients had none or trace mitral regurgitation on their transthoracic discharge echo and 7% had mild. That is where we can go when reference surgeons do complex mitral valve surgery. We said if we achieved a 100% success rate with no residual mitral regurgitation, with minimal morbidity, and no mortality, we believe such complicated mitral valve repairs are worthwhile and are preferable to valve replacement. As mitral valve repair extends to completely asymptomatic patients (18% in our series), we must aim to guarantee a successful repair in every circumstance, regardless of cause, valve size, and valve lesions. That is what we have to do and we can do it. Cardiologists and surgeons can do it but we have to work together.
Back to this paper from Bridgewater, I just want to show you one other concept, which I hope we are going to see happen because I think we need it. Surgeons undertaking mitral repair surgery should subject their results to regular audit. Surgeons all have sort of a one-track memory. We do not remember the bad ones; we just remember the good ones. We need to audit our results because we are clearly not hitting the bar. The data shows it. The other thing I think is important is audit should include an analysis of residual and recurrent regurgitation after repair. It is not just your repair rate. How good is the repair? Audit data on results of mitral valve repair should be available to patients and referring cardiologists. That is how we are going to change the field. That is how we made CABG surgery safer in New York State 10 years ago, that is why heart transplantation is regulated, and we need to regulate mitral valve surgery.
It starts with you. When you see your patients with mitral regurgitation in 2007, identify their disease; a patient with fibroelastic deficiency, older, single ruptured chord, and no excess tissue. Be confident that patient is going to have a valve repair. Surgeons, if you are here, be realistic. We hate to admit we cannot do everything but we cannot anymore. If you see patients like this and unless you do lots of mitral valve surgery, it is much better for the patient and frankly the cardiologist will respect you more as well if you send that patient to a reference surgeon.
It is a simple concept. In 2007, would anyone in this room want your family member to have a mitral valve replacement for degenerative mitral valve disease? Of course, we would not. In 2007, let us make degenerative mitral disease equal mitral valve repair.
Thanks very much for your attention.
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