The Cardiologist’s Role in Increasing the Rate of Mitral Valve Repair in Degenerative Disease

David H. Adams and Ani C. Anyanwu

Current Opinion in Cardiology; Volume 23, Issue 2, March 2008, Pages 105-110

In the hands of reference mitral valve-repair surgeons, 95-100% of degenerative valves are repairable, regardless of etiology; however, in the general cardiac surgical community, the repair rates are around 50%. In contrast to fibroelastic deficiency, Barlow's valves have more complex pathology and require advanced techniques to effect a repair. We present a simple algorithm that enables the cardiologist to stratify degenerative mitral valves into those that are repairable by any experienced cardiac surgeon and those that require reference-center referral to deliver a high probability of repair. Such targeted referral strategy should result in near 100% repair rate for degenerative disease.

Essentially, all degenerative mitral valves are repairable. By matching echocardiographic findings to the appropriate surgical skill level required to consistently deliver a repair, valve replacement for degenerative mitral valve disease should be infrequent.

Seminars in Thoracic and Cardiovascular Surgery

Volume 19, Issue 2, Pages 89-190 (Summer 2007)

 

Degenerative Mitral Valve Disease

David H. Adams, MD, Guest Editor

 

Degenerative Mitral Valve Disease: Introduction

David H. Adams

 

Etiologic Classification of Degenerative Mitral Valve Disease: Barlow's Disease and Fibroelastic Deficiency

Ani C. Anyanwu, David H. Adams

 

Barlow’s disease and fibroelastic deficiency are the two dominant forms of degenerative mitral valve disease and have unique differentiating characteristics on clinical and echocardiographic assessment. Preoperative differentiation of patients by both cardiologists and surgeons is important because the techniques, surgical skill, and expertise required to achieve a repair vary among these etiological subsets. Barlow’s patients often have multiple complex lesions, thus high rates of repair are only likely to be achieved by a reference mitral valve repair surgeon. In contrast, many forms of fibroelastic disease should be repaired at a high rate by experienced general cardiac surgeons. In this article, we highlight the differentiation of Barlow’s disease and fibroelastic deficiency.

 

Principles of Reconstructive Surgery in Degenerative Mitral Valve Disease

Farzan Filsoufi, Alain Carpentier

 

Degenerative mitral valve disease is the most common cause of mitral regurgitation (MR) in developed countries. The most common etiologies of valvular regurgitation are Barlow’s disease and fibroelastic deficiency. ... In patients with degenerative mitral valve disease and severe MR, reconstructive surgery should be performed before the occurrence of clinical symptoms, atrial fibrillation, pulmonary hypertension, and left ventricular dysfunction or enlargement. The goals of reconstructive surgery are preservation or restoration of normal leaflet motion, creation of a large surface of coaptation, and stabilization of the entire annulus with a remodeling annuloplasty. Today, reconstructive techniques are standardized, reliable, and reproducible, and therefore should be applied systematically to all patients with degenerative valvular disease.

The Intraoperative “Ink Test”: A Novel Assessment Tool in Mitral Valve Repair

Ani C. Anyanwu and David H. Adams

The Journal of Thoracic and Cardiovascular Surgery; Volume 133, Issue 6, June 2007, Pages 1635-1636

Mitral valve repair is the established therapy of choice for most patients with mitral regurgitation. Assessment of repair quality traditionally relies on visual inspection, saline testing, and transesophageal echocardiography (TEE). Although invaluable in assessing valve competency, the saline test is limited because it does not provide confirmation of the surface of coaptation; a valve that is competent on saline testing might actually have a minimal surface of coaptation or excess anterior leaflet tissue below the closure line. Although TEE might demonstrate such imperfections (specifically inadequate zone of coaptation or a tendency for systolic anterior motion), there is an understandable reluctance to reinstitute cardiopulmonary bypass to address such TEE findings if the valve is otherwise competent. Such a strategy, however, leaves some patients with an inadequate surface of coaptation and might be one explanation for recurrent mitral regurgitation.1 There is a need for a technique that allows the surgeon to confirm the amount of leaflet tissue below the valve closure line before weaning from cardiopulmonary bypass. We describe a simple “ink test,” which allows an accurate assessment (and optimization) of the surface of coaptation during mitral valve reconstruction.

Large Annuloplasty Rings Facilitate Mitral Valve Repair in Barlow’s Disease

Presented at the Forty-second Annual Meeting of The Society of Thoracic Surgeons, Chicago, IL, Jan 30–Feb 1, 2006.

David H. Adams, Ani C. Anyanwu, Parwis B. Rahmanian, Vivian Abascal, Sacha P. Salzberg, Farzan Filsoufi

The Annals of Thoracic Surgery; Volume 82, Issue 6, December 2006, Pages 2096-2101

Mitral valve repair can be predictably performed in Barlow’s disease with excellent early outcomes. Large annuloplasty rings help minimize the risk of systolic anterior motion and are an important adjunct to established repair techniques in this patient cohort with large annular size and excess leaflet tissue.

... as we acheived a 100% success rate (no significant residual MR), with minimal morbidity and no mortality, we believe such complicated mitral valve repairs are worthwhile and are preferable to valve replacement.

Physiologic Basis for the Surgical Treatment of Ischemic Mitral Regurgitation

Farzan Filsoufi, Parwis B. Rahmanian, Ani Anyanwu, David H. Adams

The American Heart Hospital Journal; Volume 4, Issue 4, Fall 2006, Pages 261-268

Ischemic mitral regurgitation (MR) can complicate severe coronary artery disease and myocardial infarction. Ischemic MR results from left ventricular remodeling after myocardial infarction and can also accompany acute myocardial ischemia. The most common mechanism of ischemic MR is Carpentier's type IIIb dysfunction due to an apical and lateral displacement of papillary muscles leading to a tethering of the mitral leaflets. This apical tenting of the leaflets prevents the free margin from reaching the plane of the annulus, significantly reduces the surface of coaptation, and causes MR. Recent advances in imaging studies have led to a better understanding of the pathophysiology of this condition as well as to the development of innovative surgical approaches to treat this disease. Current research efforts have mainly focused on 2 directions: (1) percutaneous approaches to correct MR, and (2) surgical therapy to address the ventricular component of the disease. In this article, the authors define ischemic MR and review its pathophysiology, current management strategies, and future directions.

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The Pathophysiology of Ischemic Mitral Regurgitation: Implications for Surgical and Percutaneous Intervention

Presented at the 2006 ACC i2 Summit in Atlanta, Georgia.

Ani Anyanwu, Parwis B. Rahmanian, Farzan Filsoufi, David H. Adams

Journal of Interventional Cardiology; Volume 19, Issue s1, October 2006, Pages S78–S86

Mitral regurgitation (MR) resulting from prior myocardial infarction is now recognized as an important clinical sequel that directly impacts the long-term outcome of patients. The pathophysiology of this disease process is now well established, and much clinical interest is currently directed toward defining the optimal management strategy of patients with ischemic MR. This review will focus on current concepts relating to the pathophysiology and therapy of ischemic MR.

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Current Concepts in Mitral Valve Repair for Degenerative Disease

David H. Adams, Ani Anyanwu, Parwis B. Rahmanian, Farzan Filsoufi

Heart Failure Reviews; Special Issue: Mitral Valve Repair, Volume 11, Number 3, September 2006, Pages 241-257

Mitral valve repair remains an underutilized technique for patients with degenerative mitral valve disease. A clear understanding of pathological anatomy and dysfunction helps the referring cardiologist and surgeon define the likelihood of repair for a given patient with mitral valve disease. With currently available surgical techniques, the majority of degenerative mitral valve patients should enjoy the benefits of a valve repair if referred appropriately. Patients referred in a timely fashion that receive a mitral valve repair can expect to enjoy a normal survival in line with the general population.

Mitral Valve Repair with Carpentier-McCarthy-Adams IMR ETlogix Annuloplasty Ring for Ischemic Mitral Regurgitation: Early Echocardiographic Results From A Multi-Center Study

Masao Daimon, Shota Fukuda, David H. Adams, Patrick M. McCarthy, A. Marc Gillinov, Alain Carpentier, Farzan Filsoufi, Vivian M. Abascal, Vera H. Rigolin, Sacha Salzberg, Anna Huskin, Michelle Langenfeld and Takahiro Shiota

Circulation; Volume 114, Issue 1 Supplement, July 2006, Pages I588-593

Surgical repair of IMR with the novel asymmetric CMA IMR ETlogix annuloplasty ring provided excellent early results with effective reduction of MR, MAD, and leaflet tethering. This novel etiology-specific strategy may result in improved outcomes in IMR patients.

Another Chapter In an Enlarging Book: Repair Degenerative Mitral Valves

David H. Adams, Farzan Filsoufi

Journal of Thoracic and Cardiovascular Surgery; Volume 125, Issue 6, June 2003, Pages 1197-1199

The superiority of mitral valve repair over replacement in patients with degenerative mitral valve disease is now widely held to be true. It would be surprising to see a single hand raised in a medical audience today if you asked, “Who would prefer to have his or her own valve replaced instead of repaired?” Intuitively it is attractive to keep the parts you were born with. Other potential advantages including better preservation of left ventricular function, avoidance of long-term anticoagulation (mechanical valves) or reoperation (bioprosthetic valves), and improved survival all favor mitral valve repair as the gold standard.

Pitfalls and Limitations In Measuring and Interpreting the Outcomes of Mitral Valve Repair

David H. Adams, Ani Anyanwu

The Journal of Thoracic and Cardiovascular Surgery; Volume 131, Issue 3, March 2006, Pages 523-529

We outline specific challenges in measuring and reporting outcomes of mitral valve repair. Although we illustrate these using the study of Serri and colleagues, the pitfalls are not unique to their study and apply to varying degrees in all studies of mitral valve repair. Knowledge of these pitfalls is necessary to improve the quality of outcomes-based research on mitral valve repair, to allow accurate interpretation of these studies, and also to permit useful extrapolation of results.

The Clinical Development of Percutaneous Heart Valve Technology: A Position Statement of the Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), and the Society for Cardiovascular Angiography and Interventions (SCAI)

Thomas A. Vassiliades, Jr, Peter C. Block, Lawrence H. Cohn, David H. Adams, Jeffrey S. Borer, Ted Feldman, David R. Holmes, Warren K. Laskey, Bruce W. Lytle, Michael J. Mack and David O. Williams

Journal of Thoracic and Cardiovascular Surgery; Volume 129, Issue 5, May 2005, Pages 970-976

Journal of the American College of Cardiology; Volume 45, Issue 9, 3 May 2005, Pages 1554-1560

The Annals of Thoracic Surgery; Volume 79, Issue 5, May 2005, Pages 1812-1818

Catheterization and Cardiovascular Interventions; Volume 65, Issue 1, May 2005, Pages 73-79

This joint position statement represents the combined efforts of four professional societies (Society of Thoracic Surgeons [STS], American Association for Thoracic Surgery [AATS], American College of Cardiology [ACC], and Society for Cardiovascular Angiography and Interventions [SCAI]), two government agencies (the U.S. Food and Drug Administration [FDA] and the Centers for Medicare and Medicaid Services [CMS]), and numerous industry representatives to assess the foreseeable directions of a class of emerging technologies being developed to enable the percutaneous treatment of cardiac valve dysfunction.

Current Management of Ischemic Mitral Regurgitation

Farzan Filsoufi, Sacha P. Salzberg, David H. Adams

The Mount Sinai Journal of Medicine; Volume 72 Number 2, March 2005, Pages 105-115

A better understanding of the pathophysiology of IMR and increased awareness of its negative impact on long-term survival explain the recent rise in the number of patients referred for surgical correction of IMR at the time of coronary revascularization. The most common mechanism of IMR is Carpentier's type IIIb dysfunction, for which an undersized remodeling annuloplasty is the treatment of choice. In this article we define ischemic mitral regurgitation and review its pathophysiology, clinical presentations, diagnosis, indication for surgery, and management.

High-Risk Mitral Valve Surgery: Perioperative Hemodynamic Optimization with Nesiritide (BNP)

acha P. Salzberg, Farzan Filsoufi, Anelechi Anyanwu, Kai von Harbou, Alan Gass, Sean P. Pinney, Alain Carpentier and David H. Adams

The Annals of Thoracic Surgery; Volume 80, Issue 2, August 2005, Pages 502-506

Nesiritide is a recombinant brain-type natriuretic peptide (BNP), which decreases pulmonary arterial (PA) pressures and myocardial oxygen consumption while increasing coronary flow and urine output. Mitral valve (MV) surgery in patients with severe mitral regurgitation (MR), impaired left ventricular function, and pulmonary hypertension is associated with a high operative mortality. We hypothesized that the perioperative use of Nesiritide is safe, and may improve surgical outcomes.

Current Results of Combined Coronary Artery Bypass Grafting and Mitral Annuloplasty in Patients with Moderate Ischemic Mitral Regurgitation

Farzan Filsoufi, Lishan Aklog, John G. Byrne, Lawrence H. Cohn, David H. Adams

The Journal of Heart Valve Disease; Volume 13, Number 5, September 2004, Pages 747-753

Recent decreased operative mortality in combined CABG and mitral annuloplasty for moderate ischemic MR suggests that a more liberal application of this approach may be warranted.

Surgical Treatment of the Ischemic Mitral Valve

David H. Adams, Farzan Filsoufi, Lishan Aklog

The Journal of Heart Valve Disease; Volume 11, Supplement 1, January 2002, Pages S21-S25

It is now understood that Carpentier type IIIb dysfunction is the basis for ischemic MR, and that a reduction remodeling annuloplasty can improve leaflet coaptation in this setting.

Mitral Valve Repair in Redo Cardiac Surgery

David H. Adams, Farzan Filsoufi, John G. Byrne, Alexandros Karavas, Lishan Aklog

Journal of Cardiac Surgery; Volume 17, Issue 1, January 2002, Pages 40-45

An increasing number of patients are being referred for mitral valve repair in the redo cardiac surgery setting. The most common clinical scenarios involve prior coronary bypass surgery or aortic valve replacement, each presenting special challenges in terms of gaining valve exposure to enable repair while limiting dissection as much as possible.