disclosure david h. adams, md - american...

Inventor with Royalty Agreements with Edwards

Lifesciences and Medtronic:

Physio II Mitral Annuloplasty Ring

IMR ETlogix Mitral Annuloplasty Ring

TriAd Tricuspid Annuloplasty Ring

National Co-PI: Core Valve-Medtronic US Pivotal Trial

Disclosure

David H. Adams, MD

David H. Adams, MD Marie-Josée & Henry R. Kravis

Professor & Chairman

Department of Cardiothoracic Surgery

The Mount Sinai Medical Center

New York, NY

Mitral Valve Repair: Which Technique

is Best for Which Lesion

Annulus, Leaflets, Commissures, Chordae,

Papillary Muscles and the left Ventricle

Structures Involved in Mitral Function

Adams et al In Hurst’s the Heart 2011;Vol 2:1721-37

Structures Involved in Mitral Function

The Pathophysiological Triad

Carpentier et al. J Thorac Cardiovasc Surg 1983;86

Etiology

Lesions

Dysfunction

Mitral Repair Surgical Strategy

Etiology

Lesions

Repair

Strategy

Anyanwu AC and Adams DH ; J Thorac Cardiovasc Surg 2008;36

Mitral Valve Repair

Optimize Valve

Exposure

Surgical Tips

Place Annuloplasty

Sutures First

Valve / Lesion

Analysis

Optimize Valve Exposure

• Develop Sondergaard’s Groove

• Curvilinear Left Atrial Incision

• Specialized Mitral Retractor

Mitral Valve Repair

Optimize Valve

Exposure

Surgical Tips

Place Annuloplasty

Sutures First

Valve / Lesion

Analysis

Valve and Lesion Analysis

• Assess All Structural Components

• Identify All Lesions (consider MR jets)

• Plan Surgical Strategy

Mitral Valve Repair

Optimize Valve

Exposure

Surgical Tips

Place Annuloplasty

Sutures First

Valve / Lesion

Analysis

Place Annuloplasty Sutures First

• Backhand on the Horizontal

• Forehand on the Vertical

• Interlocking Sutures are Fine

Mitral Valve Repair

Consider Leaflet

Indentations

Surgical Tips

Magic Suture to Correct

Commissural Lesions

Neochord Adjustment

after Ring

Consider Leaflet Clefts

• Distinguish Clefts and Indentations

• Close Clefts to Create Single Segments

• Target Clefts in Leaflet Resections

Mitral Valve Repair

Consider Leaflet

Indentations

Surgical Tips


Commissural Lesions

Neochord Adjustment

after Ring

Magic Suture at Commissure

• Advances the Commissure and Coaptation

• Corrects Commissural Prolapse

• Corrects Commissural Restriction

Mitral Valve Repair

Consider Leaflet

Indentations

Surgical Tips


Commissural Lesions

Neochord Adjustment

after Ring

Neochord Adjustment after Ring

• Allows Discrimination of Prolapsing Segments

• “Functional” Assessment of Chordal Height

Adams et al In Hurst’s the Heart 2011;Vol 2:1721-37

Carpentier’s Functional Classification

Assessment of Leaflet Integrity and Annular Dilatation

Leaflet Perforation Annular Dilatation

Surgical Strategy - Type I

Patch Augmentation Annuloplasty

Patch Augmentation

Assessment of Leaflet Integrity and Annular Dilatation

Leaflet Perforation Annular Dilatation

Surgical Strategy - Type I

Patch Augmentation Annuloplasty

Annuloplasty

Type II - Prolapse

Adams et al. Eur Heart J 2010;31:1958-1967

+ ++ +++ ++++

FED FED+ Forme Fruste Barlow’s

Leaflet Tissue

Minimal Leaflet Tissue

Chordal

Transfer

PTFE

Neochordoplasty

Triangular

Resection

Surgical Strategy - Type II

Chordal Transfer


Chordal

Transfer

PTFE

Neochordoplasty

Triangular

Resection


PTFE Neochordoplasty


Chordal

Transfer

PTFE

Neochordoplasty

Triangular

Resection


Triangular Resection

FED – Bileaflet Prolapse

Minimal Leaflet Tissue: Annular Plication

Excess Leaflet Tissue

Targeted

Resection(s)

Leaflet Sliding

Plasty

Leaflet

Displacement


Leaflet Displacement


Targeted

Resection(s)

Leaflet Sliding

Plasty

Leaflet

Displacement


Targeted Resection


Leaflet

Displacement

Leaflet Sliding

Plasty

Targeted

Resection(s)


Leaflet Sliding Plasty

Barlow’s Disease – Bileaflet Prolapse

Assessment of Lesions and Tissue Availability

Surgical Strategy - Type IIIa

Commissural Fusion Leaflet Retraction Chordal Restriction

Glutaraldehyde Fixed

Pericardium Techniques Commissurotomy

& “Magic Suture”

Chordal Fenestration

Chordal Replacement

Commissurotomy








Chordal Replacement

Leaflet Enlargement








Chordal Replacement

Chordal Cutting and Fenestration

Assessment of Leaflet Tethering

Surgical Strategy - Type IIIb

Less Severe More Severe

Downsized Rigid

Annuloplasty

+ Adjunctive

Techniques

Downsized Annuloplasty

Assessment of Leaflet Tethering

Surgical Strategy - Type IIIb


Downsized Rigid

Annuloplasty

+ Adjunctive

Techniques

Chordal Cutting in IMR

MAC with Adequate Leaflet Tissue

Surgical Strategy: MAC


Oversized

Annuloplasty

Unconventional

Annuloplasty

Oversized Annuloplasty - Respect

MAC with Adequate Leaflet Tissue

Surgical Strategy: MAC


Oversized

Annuloplasty

Unconventional

Annuloplasty

Unconventional Annuloplasty

Calcification with Inadequate

Leaflet Tissue

Targeted Debridement -

Patch Augmentation En bloc Resection -

Patch Augmentation

Surgical Strategy - MAC


Targeted Debridement – Patch Augmentation

Calcification with Inadequate

Leaflet Tissue

Targeted Debridement -

Patch Augmentation En bloc Resection -

Patch Augmentation

Surgical Strategy - MAC


En bloc Debridement – Patch Augmentation

Castillo et al. J Thorac Cardiovasc Surg 2012;144:308-12

Blending Strategies is the Key to

Successful Mitral Valve Repair

disclosure david h. adams, md - american...

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