Dr. Michael Ibrahim, Dr. Wilson Szeto, Dr. Clark Hargove, and Dr. Roy Arjoon of Penn Medicine discuss degenerative mitral regurgitation from the mitral surgeon perspective.
Related Links: Twitter @PennMDForum Dr. Ibrahim’s physician profile Dr. Arjoon’s physician profile Dr. Hargrove’s physician profile Dr. Szeto’s physician profile
Yeah. Mhm. Mhm. Mhm. Can you hear me? Yeah clark we can. Okay just checking. I'll put it on mute. Hey linda. Um Do we send this to our surgical team? This link? I think so. Right. Yes. Yeah. Hey linda? Yes. Can you, can you send us the link or send me a link? I want to send it to the residents, sort of jen chung has it? Should we get started linda? Yes, it's 7:30. Right? Um Looks like we're getting a fair amount of attendees at this point. Perfect. Okay let's get started. Um Good morning everyone. My name is Wilson Zito. Welcome to uh cardiac surgery. Grand rounds at penn presbyterian. Um For the month of April 2021. Thank you again for joining us this morning. Um uh On the screen here uh some housekeeping um um topics for you on the screen here is the CMI credit code. The event code. Um again, thank you for your time with us this morning. The code is 71 2- one. Again, the event code is 712- one. Uh This morning we're going to have a continued discussion regarding the management of mitral regurgitation. Um and this will be a didactic short session followed by K space discussion around table um focusing on degenerative micro regurgitation or damar. Uh It's a pleasure to have uh for me to have a panel, a roundtable of providers, my colleagues and friends uh dr Clark Hargrove, um Michael Ibraham, ian Gallagher. And of course myself, we look forward to not only a educational our but also a robust discussion about really insightful options, treatment options and management of challenging cases or for patients with degenerative mitral regurgitation. So having said that, I will kick it off and pass it to Mike Abraham um who will be joining our group here in july as a new surgeon. So we're very, very excited to have him with us. And um he's going to start off with a short presentation and then we're going to dive into the cases. So, Mike, Good morning and thank you for joining us. Great, thank you doctor um Good morning. So today we're going to talk about deterrent of em are from the micro surgeons perspective and I have no financial disclosures. The mitral valve is very sophisticated structure and this is a sort of mathematical model that was put together by the Yale group which looks at the movements of every element of the mitral valve. And it's sub valvular apparatus during the cardiac cycle. And what you can see is that there are rational changes of the cell valvular apparatus. The analyst undergoes very dynamic movements during system. The the leaflets, similarly in the ventricle participates in the function of the mitral valve is very sophisticated structure I think. From a mitral valve surgeon's point of view when preparing these valves are trying to assimilate that structure and And really achieved three things. The first is relief from Mitral insufficiency so that no patient leaves the operating room with more than mild M. R. And ideally no M. R. Um We're interested in durability. We know that we have good data or review very briefly. Um That's long or very long. We're talking about decades and importantly we want to have excellent valve performance um freedom from functional micro stenosis with a minimal gradient both at rest and during exercise and this is really important and this is really the standard that we have to achieve whatever modality of treatment we adopt. Um This is uh a study of several international Reference centers in microsurgery comparing repair with replacement. Um and again you can see that the um survival is significantly enhanced after mitral repair with the living sophisticated mitral valve structure compared to replace them. This is also true in match cohorts and even in patients over 75. They also found that that repair what was better than replacement in terms of survival. And if you look at any co morbidity, age, gender, diabetes and so on and so forth. There really was not a group that did better with replacement than repair. And so you know I think it's an exceptional operation. It can be done with three minimal access, either poor access or robotically. This is a study from the U. K. Uh You know in a propensity match way looking at patients who have either some of the many invasive access essentially showing that you can achieve similar outcomes. Um You know through either mechanism. This has been replicated many times. So where are we today in terms of repair um or treatment of degenerative M. R. Really the class one indications symptomatic patients with severe primary um are in asymptomatic patients if they have some element of um left ventricular dysfunction or enlargement surgery is recommended. And in patients who have an indication for surgery repair is strongly um uh sort of preferred. And I think that the other sort of interesting is that is the flip side which is the Class three harm that patients who have a collapsing leaflet who are amenable to repair should not have a replacement until the repair has been attempted at the reference center like ours. Um There are some class to a indications probably the most interesting one is the new one. Uh For high risk patients to undergo transgressed the edge to edge repair tear. Um You know, if they are at high risk, this is a slightly complex subject that we're going to talk about a little bit. Um Well in terms of these guidelines, you know, what should we do with the patient that presents with these sort of very mild symptoms with severe um Are this is a study basically showing that if you adopt a strategy early on of medical management and watchful waiting, there is a survival disadvantage to that as opposed to early surgery. This has been replicated in other groups. This is a paper from the Mayo clinic showing that basically survival follows these three curves that if you uh if you sort of go on. Class one um indications so symptoms symptomatic lV dysfunction. You know, you sort of have poor poorer survival over time and this gets less and less the sort of soft of the indication that the weaker the indication so dr shafts group, you know sort of suggested that this implies that there is a survival penalty um for in strict adherence to the guidelines in terms of waiting for LV dysfunction, waiting for frank symptoms. We are certainly under treating michael insufficiency in the community. This is a paper again from the Mayo Clinic looking at robson County and they followed in a period of a decade between 2000, 2000 and 10, 1300 patients who have moderate or severe M. R. And in that time only 15% of those patients underwent surgery. And that's in the backyard of the Mayo Clinic. And we can we can be sure that they know how to do my shoe repair at the Mayo clinic. So um you know, it's certainly very undertreated. This has been replicated in other centers. This is from Canadian study showing that even amongst patients with class one indications, the percentage of patients even in university practices getting repair is very low. Um And overall uh where it is estimated that there are over four million patients with mitral insufficiency. Um and of those, about 1.6 million eligible for treatment in that they have severe um are but we're only doing a very small number of those every year for various reasons. But you know, I think there is one element of the perspective of the metro surgeon. What is the risk profile of michael repair for the generative risk? Well, you know, remember that the tear studies um you know, Everest and so on. They really were targeting 6 to 12 as a predicted risk of mortality. And sts predict the risk of mortality. This is the 2019 data from the sts of not predicted but actual more talent you can see that mitral valve repair is associated with extremely low mortality. These tend to be very healthy patients and the 75% of risk is 1.2. And so this begs the question, what is high risk. When we're talking about the generative M. R. Um and and so we have to be careful that you know the sort of you may be at the 80th%ile of risk but you absolute risk may be low. It's probably the most successful operation in the history of cardiac surgery in terms of its longevity, durability and survival advantages with very low risk. This compares with the low risk have a trials that were at two or 2 for a micro degenerative Mars at the 70 is above the 75th%ile of risk. So we have to kind of interpret that for this space. Um this is just showing really where this uh recommendation that has new for edge to edge repair in D. M. R. came from uh from Australia. And they were targeting a predictive risk of mortality of 12%. But actually they were sort of close to 14 and 15 in their actual patients and rolls very high risk. In terms of micro patients. Of course these are a mixed bag of degenerative and functional patients. And so when we think about edge to edge repair uh you know it is said uh this is uh from the Everest uh to you know this is a model of surgical Alfieri um uh stitch which when performed with annual capacity has excellent results. But I think we have to remember that the results of surgical healthy area without annual capacity actually pretty dismal. And so we cannot directly translate um you know, the complete repair within any of us to to repair without any of us. You have to be careful and little bit cautious in adopting this, especially if it's going to prohibit surgical repair of these valves later on um subjects with complex anatomies in in these trials have basically had, you know, also with severe and ma have tended to have non complex anatomies. And that's the other thing. We have to be very careful about patient selection. And we're looking at transkaryotic therapies and the higher and intermediate risk groups. This is a screen grab of dots McCarthy's uh discussion of the repair. Um our trial which would describe briefly at the sts. But you know, really saying that there is no Louris trial actually. I don't think this is true. I think we're already doing low risk major clip and and it will uh it is being done. I'll show you a little bit more about that from the NIH. So repair Amara is targeting people with moderate surgical risk where basically the valve is felt to be repairable by microsurgeon. I think one of the criticisms of Everest was that many of these valves were not really repairable to begin with. Um and they have targeted freedom from moderate M. R. As their efficacy or one of the efficacy endpoints. And basically based on this data that there seems to be no survival disadvantage of residual moderate M. R. Um I think we have to be cautious about translating this to younger patients and low risk DM our patients but you know, so we have to wait and see on that. This is an NIH trial of transcript the edge to edge repair that is being currently finalized and will begin enrollment at some point in the, in the near future. It is, it is primarily interested in a moderate risk but it does include low risk patients. Um in terms of, you know, the overall landscape of micro therapy micro clip uh is occupying a significant portion and an increasing portion of the space. And I expect that to be the case with other transkaryotic therapies that are taking hold. And again, this is true for the across the spectrum of risk. If you look at the sts risk profiles, these patients, there are certainly most of them are on the higher spectrum but remember that this is still 75% of these patients is low risk in absolute terms. This was a survey from the NIH of surgeons um to see what they felt was intermediate risk and as you can see, most people felt that was an sts above 31 that's very dramatically higher than than the 80th and 90th percentile of Ritz. But these other factors frailty problem to this function are important as well. Harpoon is is another therapy that's emerging which involves transit vehicle surgical um uh neo chords but without bypass and also without open heart surgery. Um and and beating heart. And this is something that we're involved with peppers and then it will begin enrolling but it really is for very um for very um specified anatomies. And it is for low and intermediate risk patients above 18 with severe degenerative mitral regurgitation but really isolated Posterior leaflet prolapse who who are selected to be good candidates for the therapy. And it's not targeting people with an SSR above six Or your score above eight. So it really is the low and intermediate risk patients. So with that we'll move on to the case presentations I think Amy's going to describe some these cases for us morning. So just to highlight a few cases and then we will open things up for discussion. This first case is a 50 year old man Um who presents with mild symptoms low risk by STS 0.6 um um significant history of hypertension and just mild sleep apnea. Um But you know is uh presented and that the discussion for this particular patient would be to relieve his mitral regurgitation um offer a minimally invasive approach um and avoid um michael stenosis in the future with a long term durability. With prepare my cousin images of the posterior prolapse. Yeah, so you can see here this is a 1° Hargrove's cases. Um This is a view from the endoscope showing here. You can see this is the inside of the left atrial appendage and this is a fail cord and peter that's prolapse ng this is the atrial retractor this patient. Well they had a partial angioplasty ring and a resection of that P. Two. And really left the O. R. With um Minimal Mitral insufficiency on first up to four. And that really is sort of standard um dr Zito dr Hargrove, what do you think of this patient? Would you would you have considered this patient for a Cancun or something like that? Well Michael thank you very much and amy thanks for presenting the case and I think this was a very interesting case. And before I answer your question mike I'm um um I'm going to just sort of take a take a step back and walk through the process of what hard team would do when this patient sort of come to our clinic. Um I guess the first question of Roy's available, you know Roy doctor or june is one of our um elite echocardiography furs. He's encounters these patients quite a bit and obviously a key component part of our heart team. When you see a patient like this with this type of path of physiology on the T. E. Um what are some thoughts that are going through your head and in terms of treatment options, assuming obviously we've made a decision that this patient needs to be treated. Yeah. I think that you know, the ideal candidate for For surgery or or if you go down the tear out is a kind of middle scallop prolapse most commonly p. two. When you start having commission real stuff, it typically becomes more difficult to do per Catania slee. And then the other thing you kinda have to look at as far as making that decision between surgery or not is um how bad the flavor is, how bad the prolapse is. If there's a large degree of flail sometimes it's difficult to cash that leaflet to do a tear. And also if there's multi scallop prolapse it becomes very difficult to do it here. So patients generally better suited for surgery for for this person. I think it was I think it was like a P. Two people. Can you back up on the preoperative pe for doctor or june? Okay yep. There you go. I know it's a limited view Roy yeah so it looks like there's a flail. Yeah so that would be like a flail P1 because you have the aortic valve in view And it looks like there's probably involvement of p. two. So when you have a commissioner flail, those patients tend to be more difficult to do per cutaneous lee. Um So I think I would look at it as you know the commission will flail Plus p. two. You know like this multi scallop um Prolapse. Like I said whatever it involves a common shirts just more difficult to do for cutaneous lee. So it has to be a pretty good surgical case. Well first of all I think our pictures it's it's a it's a p to flail. It's not a p one flail. So I wouldn't say this is a common sure flail. Um And in fact if you look at the, I can't really see the three D. T. Because it blocked out on my screen. But I believe it's pissed this P. P. Two on the P. One side. The second thing I just point out for the audience uh we've we've come in and using the jargon of tear. I'll give my editorial that I I still prefer the use of micro clip because everybody knows what we're talking about. When we say we're micro clip here. I don't know. I might be talking about some exotic uh a belly dance or something. So I prefer the word micro clip at any rate. Uh Again, I I don't I think this patient's risk was so low, you wouldn't consider a micro clip, but you might consider the harpoon. But Wilson can comment on this. We've seen quite a few echoes to the core lab and they seem to be looking for the perfect candidate. It looks like to me this patient would be a candidate for a harpoon. And uh you know, we don't have the long term data, but certainly the short term data is very promising. It still involves a surgical procedure, but it is, you know, off bypass theoretically would have some advantages. I don't know whether you want to comment about uh harpoon wilson. Yeah. Thanks clark. I would agree. I mean I think you sort of hit it right in the head here. You know my question to you would have been you know, patient selection and risk profile. I would agree that, you know, for DM our patients at least certainly the data currently would support that low to my risk patients. Uh open surgery, whatever that is minimal, invasive robotic strain on to me is the gold standard. So I would agree with you harpoon um which is a trans a pickle beating hard core to reconstruction. Um It is still an open procedure as you mentioned, but it does avoid um cardiff home and bypassing cross clamp and it does reproduce somewhat of the surgical techniques We currently use Iaea Kordell reconstruction. It is under clinical trial. We are at penn a study site. We're fortunate to be part of that study. Um And right now the inclusion criteria is fairly conservative. I will use to work conservative P. Two prolapse isolated peak to prolapse with adequate answer a leaflet um tissue for appropriate co optation. So it is a strength, is a very robust screening process and we're still learning and I think that's okay. I think it's a new technology. I think we want to be sure um that we get a good outcome because at the end of the day uh these patients ie low risk patients with damar. The ultimate outcome needs to be a good repair. So I think there is any hesitation that the trial may not be ideal. We need to fall back on a proven outcome, which is open surgery. I mean, let me raise this point. And, you know, one of the things that transpired from the maitre clip experience is that the, the valves are not repairable after Micro club jojic. We just presented this at the sts a 5% repair rate after my triplets. If that turns out to be the same, that would be somewhat concerning for a patient like this, that would have a very straightforward operation and have a durable repair uh, for for other therapies, we don't really know whether, you know, these other therapies will impinge upon their operability of these canals. I think that's a great point mike. And, and I do think that's something that we have to keep in mind when we're talking about edge to edge repair. Um, we know we know this clark. You can comment on this. You know, we do occasionally use the Alfieri technique even with open procedure. So obviously we have some experience with that, but I think the harpoon experience will learn more. But because it is a quarter reconstruction, I would think that the harpoon platform would not preclude you from future repair strategy as opposed to an edge to edge. But I think you bring up a good point is um and you will highlight this on one of these cases might coming up is re repairing a fail repair. I think that's a key concept that we have to think about and keep in mind when we're dealing with these low risk patients clark. Do you want to talk about the Alfieri stitch at all? Well, sure. I mean, I mean I use it particularly now and in fact we've, you know, we've moved less to reception um and we use uh Alfieri particularly uh say a patient with the bar lows valve, which you almost never have trouble repairing the valve. The only issue you need to worry about in the bar lows is whether you're gonna get sand post operatively. So we'll frequently add a and Alfieri sits, which we know well prevent, prevent sam in the post op period. And I think again, you put a ring in so you should expect good long term results. I mean, as far as the harpoon, I don't see why that would preclude a micro valve repair because you haven't you haven't destroyed the leaflet edges and you'd just be going back and doing the standard techniques. The other thing that surprised me when we went to the training courses that in addition to bringing the leaflets into co optation, it also pulls the Angelus down so it actually has an effect uh in addition to give you a great surface. Co optation is also to decrease the Michael Aniela size, which again over the long haul would decrease the tension on the leaflet edges. And so theoretically decrease the incidence of my uh my trigger recurrence of my trigger education. Find out the absence. Although we're experts at minimally invasive surgery that when you have degenerative m are the thing that matters is is Michael has pointed out is to have a competent durable repair. And I don't think it makes any difference where if you you know, if you can if you have if you you asked me what, I'd rather have a stern on to me uh in a good might repair or or minimally invasive micro replacement. I take a strain on to me any time and I think we should always emphasize that. So it's the it's the operation and not the incision dr Hargrove. You know, part of this is is we don't have an annual capacity procedure in any of these transkaryotic therapies. And that seems to be one of the things that guarantees durability. What do you think about that with with harpoon and these other therapies? Well, I mean obviously with with the micro cliff or tear you don't have any you don't have any uh annual plastic. But again with the harpoon that actually if you look at the data that actually pulls in the ambulance by pulling the leaflet back into uh a lot to actually pull the ambulance in. And so you decrease the angle assad's that weather. You know, I don't have I don't obviously don't have any long term data. It is a little worrisome, but but again, I think it's certainly worth, worth trying. And particularly in an intermediate risk patient where you know, you say okay, so it's worth trying and it looks like a slam dunk. So I I certainly would support that that trial. So mike, why don't you forward to the the post repair? Um I have a couple of comments and questions but just to keep this engaging dr waxman from the panelists or from from the audience. That one question for the group um um here and I'll read it out to the group here has pointed out prior on this discussion. Alfieri stitch was not a very good procedure and yet we are seeing good results with trans catheter edged edge repair. Any thoughts from the panel about the discrepancy? So clark you want to comment on that? And I think harvey, I think my first caveat to your question is I would agree, but I would push back a little bit about saying that tear has had good results. Um Good what does good results mean? And I think it's all relative. I do think fair amount of these patients do leave the micro clip procedure with them are that is probably not acceptable for an open patient with that slow risk. So good has to be put in quotations. But clark can you comment because you have the most experience here? Why are we seeing quote unquote good results with trans catheter edge to edge. Whereas we surgeons have abandoned the Alfieri stitch would open surgery. Well we haven't abandoned it. We just we only use it with an annual plastic ring which Michael showed that slide from the bonus. Who's you know there is in the outfit airy group. Which so the results weren't great when you did an Alfieri with no annual plastering. But they were good when you do. In fact. Yeah he has uh I mean I don't have the paper right at the tip of my tongue but Otavio has you know 10 15 Year data on Alfieri stitch uh with Angela plastering. Which is comparable to standard operative procedures. It's interesting if you if you're in one of these micro clip or tear procedures when the when the clip goes on the left atrial precious drop immediately even if you've got a little recurring EMR. So uh you know clearly that's the key and these patients are you know almost get almost immediate symptomatic relief so clearly as physiologically helping. And I mean I guess it I mean in the O. R. We would never accept some of these uh what's left residual micro gravitation. But you wonder whether we need to be quiet as is diligent about having you know even the small jet of em are. But we certainly that's that's the way we're trained. But even when you watch one of these tear procedures and you see the left actual pressure's dropped so dramatically instantaneously then you know clearly it's working. Yeah I would agree. And I and I don't really have a good answer as to why. Um you know the result somewhat to be slightly different between trans catheter versus open edge to edge I'm sure is multifactorial. You know it's a it's a bigger physiologic insult to the patient to be going on pump and cross clamp. I suspect that may have something to do with it. Um Here are the other thing if I may just say is durability because you know it's fine to have early results that are good. Um but and you know that even the surgical Alfieri without annual capacity has reasonable early results. The question is what happens over time? And if you're dealing with low risk patients, especially if if if your procedure is going to prohibit a classical mitral repair, that's a big deal. Um So that's the thing that would give me pause. So clark just before we move onto the next case, just briefly. If you don't mind through your vast experience, walk us through your mind when when when we're looking at this repair. Um If this looks like a resection to me, correct, if I'm wrong, looks like you did a P. Two resection, an annual plastic band. Can you sort of talk through? Talk us through what you how you decide in a resection, how you decide on chords, how you decided to ring versus a ban and why you did what you did with this particular case? Well, in terms of reception, uh if it looks like a simple P. two reception, I don't even I think it's something simple. I'd keep it simple. I you could have treated this patient with uh with with Neo chords just as well as you could with a resection or if you want to do a small reception and then put neo chords in. Uh So uh in terms of I mean, you know, Patrick Perry is uh adage respect rather than resect in the old days you to you know, taking a large quadrangular section and maybe done a sliding plastic and move everything together. But the keep the key issue is to have a good surface of co optation At the end of the procedure. And I don't know whether you measure it here is probably at least five or six, maybe eight cm. Uh And uh once you have that, I don't think it makes any difference how you achieve it. Um So again, we were doing less and less reception. We do using more neo course. But as you'll see in the next case, near cords are not without their issues. To the other thing about near, cause you talk to Tyrone David. Um They actually can start breaking after 15 or 20 years. They can get calcified and then the knee accord we'll crack. So, well, we'll have to see what the long term sequelae of most people going straight to the uh to the neo cord repair now versus the standard Carpentier techniques. All right, well, great. Thank you. Let's go to move. Let's move on the case to mike. Yeah. Amy, you want to present? Yeah. So uh this case um highlights 57 year old man who had a previous uh mitral repair, a minimally invasive with an angioplasty bring um who presented after, I believe it was two or three years with um and my AJ two symptoms. Um shortness of breath otherwise, uh mostly healthy hypertension, mildly dilated aortic root. Yes. Um Right. Can you hear me? Okay? Sorry? Yes. Okay, good. So um this is the preoperative echocardiogram. So what was the prior operation? Can you articulate that? Yeah. The patient had a right to, you got to be a heart bought mitral repair with an annual capacity and with chords um at a local another another center here um and presented symptomatic with, as you can see, pretty bad prior corridor reconstruction as clark was alluding to earlier. Right Prior prepare with neo cords, yep. And an annual last year. Right. And you know, I think one of the entry points is his pre sts 10.5, but this is what I probably, you know, at the very highest level of complexity. I mean, we'll see what we did here before you get to that. Can you show the echo again for the audience and get Roy to comment on this? I know this is a limited view Roy, but any first thoughts? Yeah, I mean, I you hear me? Yeah, yeah. So it, it looks like at least looks like it's all intra valvular, there's a pretty, pretty sizable being a contractor there and it's very eccentric. So I, my guess is there something going on with where the poster leaflet is on the repair? But I can't really tell their um, and there's a lot of looks like there's a lot of calcification on the posterior side of the valve. How much is this calculation of rain? It's kinda hard to tell off of one image, but I think the main thing is there's a pretty huge Vienna contractor there and it's intra ring rather than para. Good point. I think that's important to distinguish intra versus para. Okay. Yeah. So, you know, risk does not equal complexity is very low risk, but very high complexity. Um I think one thing I have to think about a source of the risk of replacement in terms of, you know, where these patients are going and and do you want to show this video now that Yeah, let's do it. So obviously we decided for a Repair. Um well, I'll ask everyone to comment on, you know, what are the other options? But he is young. He's 57. Yes. So this is uh you know, again, I redo right thoracotomy um approach, which is, you know, very high complexity I would say. And the first thing dr Hargrove was doing here is analyzing the valve. Um you know, I don't know if you want to make any comments, Dr Grover you know about the things that you notice. Uh Well first thing we come here about the pre R. T. I. Although it was just a one view you could see from the pre our tv T. That you still had plenty of leaflet mobility which made you think well the valve can be re repaired. I mean if you had everything was plastered down and you say well you can't do that. So so I would say based on that. And clearly they either either the cortex came untied, Remember with Gortex, you gotta you gotta put 10 knots in it, otherwise you're it's not gonna hold. And also they clearly um I didn't do any reception at the initial procedure. So yeah, so this is a walk us through your technique here. Clark. Well I just again, we we did this we did a small reception, as you can see, I don't think you could see the whole reception and now we're putting it back together. Uh And then we we did put a neo cord there to support the repair. Uh So we we basically did a quite a triangular section with a neo cord to support the repair. So this is the initial echocardiogram coming off. I think it's important. This is a really important point. So you know, there is some residual my trans efficiency. What do people think of this patient was getting a clip here? Would this be acceptable? Probably not, I'm sure. Well I don't know. Uh the issue here was that the the annual plasticky ring Was actually placed into the leaflet along the P one p. 2 area. And I thought well it will probably be okay because we've hit fix the the leaflet prolapse. But it turns out that that was sort of, I think restricting the posterior leaflet. So at this point, I felt like, well, I got to go back and take the whole annual plastic ring out, which is the hardest part of the procedure because it's, you know, it's completely uh into serialized and you know, trying to get that thing out is a bear. So that's what we're doing here. We're picking away at that. And you see, we we did a little, we roughed up the annual, it's a bit, but not not bad enough that we couldn't put it back, couldn't put humpty dumpty back together again. So that's what we're doing right now. Yeah, so this is only a partial seizures. Yeah, I think the question for you, I mean, obviously, you are one of the world's experts on minimal invasive surgery. What are your thoughts about? Uh we do through the same small incision? And why did you decide to do that is supposed to start on a me. I know you made a comment earlier about a good repair is better than in an end of replacement. Um Well again we've done it on multiple occasions, so I feel like I felt like it wasn't um Again, it was a young patient, that's what he preferred. And obviously we we've had experience with it. So the issue is once you want, you can always tell these people look if your lungs plastered up against the chest wall, then I'm gonna abandon it. This this incision and go to the store anatomy. So you may end up with two incisions. And I there's no way I can tell that until we get started. So sometimes we can sneak in the inter space above and and frequently the longest. Not stuck up except right along the incision. So the other place. And we uh this gentleman the hard part was they hadn't closed his pericardium. So if you don't close the pair of card and then I don't understand the lung gets plaster against the right heart. And so I think that was the hardest part in this patient was dissecting the the lung off the right heart without leaving you know with a you know a million holes in the long. So we always closed the pericardium because we realized that no matter who does the micro valve repair you can you can have a recurrence and that that actually helped. So if in in our own patients who we re operated on we we all we we we don't encounter that issue but in that this patient we in fact did. so. I don't know if you were if you said I would prefer to do this patient to astronaut. I mean I certainly wouldn't I wouldn't quibble with it. I mean again I think the important thing in this man was to get a re repair which we were able to successfully accomplished. I mean clark, I mean this is uh impressive. I mean as as um uh mike alluded to. Not only is this a high end complex re repair you've added on top of it? A minimally invasive approach. That's that's high end. Congratulations. This is a really complex case. Um Well I completely agree. I just make one comment. The you know, I think an important point in this case is is you know, when you're in the I mean most people, I think around the country would have probably replaced this valve because they would not have had the confidence to attempt to re repair. It's just my gut feeling, I think, you know, we we've tried to repair obviously, but but the other thing is when you have an inter operative echocardiogram with residual M. R. To go back and to say I'm going to repair this vow that is the mark to me of a valve reference center. And that's that, you know, the sort of the whole deal really is a commitment to doing whatever it takes. I agree. Now Roy um from a cardiologist perspective, what goes through someone's of what goes through your mind if you had a patient like this, um are you thinking this is too high risk and you're thinking catheter based therapy? Like what is your first instinct? What would you your first instinct or reaction be if this was your patient? Yeah, I think I think it was my patient. You know you have severe entering regurgitation. Um uh Most if there are some places that will clip with a ring in place, I don't I couldn't really tell what was going on with the poster leaflet. I'm not sure if that would even be an option. Um And I think you guys mentioned this guy was kind of young to so probably also not a great option to go down the detainees drought. Um I mean I'm also pretty impressed you were able to get a pretty good result with a re repair. I would have I would have 100 yes that he would have gotten an M. B. A. full replacement with with a ring already in place. So I think that's that's pretty impressive. Yeah. Absolutely. So I think it does I think reflect the as Mike said the commitment of this team, you know from the from the first visit through a me through the nurse practitioner side to the echocardiography side. I don't know who did the echocardiogram but obviously that I mean I think this really does reflect the entire hard team approach to getting a young patient like this through with a great results. So I applaud everybody. That's fantastic. I mean just to You know, this guy had an STS 0.5 so it really is on paper low risk but a very complicated procedure and he got out of the hospital on pathway on post update five, impressive. Okay. In the next case, sorry The next case, I'm sorry here is Amy if you want to go ahead. Sure. So the third case is a 77 year old female Um with prior correct me pancreatitis um with ongoing elevated light pays breast cancer in the 80s with a lumpectomy and radiation and chemotherapy without recurrence. Who presents with N. Y. H. A. Class 2 to 3 symptoms. And severe regurgitation with anterior we directed jets and normal ventricular function. All right so. Um. Right. This is the Depakote advantage of three D. Any comments Roy for starts here. Yeah so it it stopped playing on but I think it looks like the entire poster leaflet was prolapsed predominantly P. Two. I can't tell if there's a small flail segment kind of at p water like the junction of P. One P. Two. Um Yeah I think when it involves the entire poster leaflet And and on the two D. View it's it's very eccentric there. So you know if you have to be careful to make sure you take a lot of pictures on the T. And make sure you kind of get the entirely the severity of the jet and the degree of eccentricity there would suggest there's probably a flail segment there. Um But I 100 believe it's severe just looking at the pathology of it. Um You know, as far as choosing between per cutaneous or repair. I think because it involves the entire post your scallop. You're looking at um at least two clips there. I'm depending on how much more there is to begin with. I'm not sure how easy it'll be to get a like a trace result with with doing a tear. So depending on what her risk is, you know, she's older and has comorbidities with the XRT in her chest. Um surgery theoretically. Probably be a better idea for just just based on the pathology. Yeah. Michelangelo, calcification, Roy this kind of, it's hard to tell on So on the on the 2D images, it looks like there's some poster Mac. There doesn't look that bad, to be honest with you. I can tell it to. The other issue would be how long the leaflets are most of the time. In a degenerative case. It's not a huge problem. It's hard for me to tell how much how far the map comes out onto the leaflet. But you're right that that could present a problem with doing a tear and just looking at these clips clark. I'm given the degree of poster released the pathology. I'm fairly confident this would not be a candidate for for for what Wilson are. Yeah, they turned her down. Yes. I mean, I don't think that's inappropriate at this point in time. Yeah. So, you know, she goes and has a calf and you can see that the MAC is certainly not insignificant. Um so, you know, I think this sort of makes the point again that although the risk is low, that's not the whole story. Um And you know, she has MAC, this is a paper from the Framingham heart study just showing that MAC alone in non surgical patients as the worst survival portends a worse survival of the long term. So the second patient obviously make the repair more challenging and more hazardous. But it doesn't appear anywhere in the sts risk profile, obviously. And so, you know, it's not just the sort of risk profile that we have to take into account the complexity and it's the other factors that are that are sort of relevant. And I think this calf that this this calf points out that you can usually see MAC better on the calf and you frequently can on your T. E. So this kind of tells you exactly where it is. And I'll offer editorial on my end. Um I'll take the privilege to do that since Clark main editorial earlier. I think this needs to be added to our sts database as a predictor at some point. This is something that really needs to be addressed much like cirrhosis home and retention often forgotten sort of, you know, hidden risk that really matters to the clinician. Uh I think this kind of gets lost in big data. Um and everyone knows how I feel about big data. And I think micro annual constipation needs to somehow finds way to a risk protector. I don't know how I'm not a statistician, but this clearly would make depiction at an elevated risk. I think the .9 is probably under under appreciating what Mac needs to an operating surgeon exactly. Okay, what do you guys end up doing? Um So this is not the same patient that's actually a patient I did with the people that have had a replacement but I just wanted to show and in fact you know the son of a pet which is a ultrasonic agreement of MAC. Um but certainly the MAC would not have been this severe in in the patient just presented. But um you know what we did was we did we did that the MAC a little bit. This is the case with Dr Acker and Um did an annual bastion a. p. two reception. Um And uh yeah you can see this thing sort of just chipping away at the account. Yeah, patient had a good result. Um Yes I left the hospital with minimal mara and normal function. Here's a question from the audience um for for the panelists and this obviously has MAC this patient but not the world's worst MAC. But the question from the audience is regarding T. A. V. R. Uh in math patients especially in patients who are heavy MAC or high risk redo clark. You've had some experience with putting a tavern valve into MAC with you know through an open incision. Um When do you consider that? Um um an option? When do you do it when you don't do it? What are some of your thoughts behind how to plan for that operation if you decide to do it? Uh Well we've done six so far and we've, the issue is you need circumferential MAC. Not just post here annular calcification. Um And when you do it you you uh I mean as you know with the trans uh the per cutaneous micro valve replacement. The issue is you must do something about getting the anti relief it out of the way. You're gonna have left ventricular outflow tract obstruction when you're done. So of we actually do it. We've done it both through uh the right uh right. The hard court decision instrument ought to me. I think the important the one we had, the failure we had was patient has severe circumferential mac. But the annual list was too big for any of the type of ours we had. So I was at that point I didn't have a plan B. And I always tell all my all the fellows always have a plan B. And there was no plan being that patients. So I tried to replace it in the patient, got a poster and a distance and died. But the other five did well and and basically have minimal micro regurgitation at the end. So I think you need to look at the C. T. As you would for a regular tavern and and calculate the mitral valve uh you know the circumference and the diameter to make sure that one of the type of ours, the biggest one you have now is 29 correct. Wilson correct 20. Make sure that that five the safety and will fit in there and and occupy the angle. Some people have been putting a cuff around the same thing but we've just put we've taken the anterior leaf it out. Maybe a half a dozen searches around the animals where we could you know where it was soft enough to get a needle through there. Then put the type of Alvin expanded it and then put the the suitors through the through the cuff to to keep it from immobilizing. And I mean knock on wood. They've all done well except for the one patient where the valve is too small to fit in the ambulance. So you need circumferential MAC before you. You need you think about doing that so circumferential mac inappropriate size. Right? Yeah. Great thank you. Alright. Last case. Right. Case for mike yep. I guess for go ahead. The last case highlights um Um low risk 86 year old man who presents with now severe my trigger vegetation and um N. Y. H. A. Two symptoms of shortness of breath and palpitations. Um You know where the where the discussion would be maintained, his quality of life and relief relieve his symptoms. Well amy from your from your perspective you know you're you're a valuable part of team and often not often always sort of our first interaction in first sort of evaluation of his patients. When we start to process, Walk us through your mind when you see it on paper, an 86 year old and what you're thinking and then what do you do when you walk in a room and you actually see the patient? What has your experience been in terms of risk stratification or risk profile? Was was this an 86 year old? I looked every bit 86 or as we often get ridiculed for? Is he a good age sex? What what were your thoughts when you saw this gentleman? Yeah. So I would say You never walk in a room thinking anyone is going to be a good 86. Right. So um this particular patient was and is active and um you're thinking that you know or I'm thinking I would like him to continue to be active and um a large open operation while he would survive that he might not have the quality of life that he had prior to. Even if he did well with surgery, I would take a long time for him to recover at that age. Even a good 86. Yeah, I think that's a great point. You see so many people that we we don't really worry about getting them through the operation, but the issue will ever get over it. And I think that's a great point that Amy brought out. So uh this guy is clearly closer to the end in the beginning, but he's still active. Mhm. It's amazing how much the age has an impact on the sts risk patient doesn't really have a whole bunch of common with these, but it's just really the age. Yeah. Well let's look at the T. I. Um and I mean, I think this is a good discussion here depending on your perspective. You know, this could go down the surgical route or a term trans catheter route. I'd love to hear, you know, the thought process behind that. But yeah, let's let's look at this tea and and maybe have Roy make some comments about the tv in terms of treatment options. Yeah. So I got off off of this one image. It looks like an eccentric jet um Probably involving Pete at least P one probably P two like you guys said. I mean typically this view your mostly seeing P one higher up where the orders. Um it's kind of hard to tell if there's some calcification on the tip or not. And that would potentially affect whether he would be a candidate for tear. It's hard for me to stay off of off of the one image. Um Hey, how how how extensive the pathology is um and be if there's calcification there on the on the leaflet tip, which would make it difficult to grasp and it's obviously eccentric. So I'm sure it's worse than other images. Okay, great, great comments. Um so what do we have doing? Uh like I know respectful of the time we're getting close to our, well we're doing and thought process behind treatment option. Yes. This is what we end up doing, which is a trans gathered that um thanks Angela micro clip dot com group. Um um but you know, really it was a discussion with the patient about his own Preferences and what was important to him. Obviously, you know, I think the important point about this case, you know, 2.9 is not at risk for in our world. But um he doesn't stand to benefit the from from the benefits of durability and long term valve performance at rest and exercise to the, you know, even at two point or even a higher risk patient who are the younger would benefit from a surgical reconstruction. You know, really, we just want his priority is to eliminate his symptoms. And so I think this is absolutely appropriate thing for this patient. Um and we'll definitely be in the intermediate range of moderate risk. This is just a three day of the quick there across them. Can see here. The result is pretty good. Yeah. Terrific. Yeah. I mean, I think this case is a nice summary and highlights. I think what's really becoming more and more clear to everyone in this structural heart spaces. It's a team approach, um you know, it's patients first, The team 2nd in the individual. You know, physicians last and I think this really does highlight how important it is to have a robust discussion and a team approach to structural art and microbial disease. Yeah, I I could just wrap it up to summarize, I think from the micro surgeons perspective, we're aiming for relief of micro insufficiency, this common goal of trance capture and surgically repair. But we have to do this in a manner that restores normal valve structuring function. And it's durable for decades, which is in credit, which is, you know, even more important in the younger cohort. We wish to achieve a minimal gradient that is stable over time at rest and during exercise. I think we know that GMR is undertreated. The risk profile is important in determining treatment without it, but it's not the whole story as we've seen life expectancy and the impact of transplant therapy and subsequent repairability of these valves is also critical considerations. And we have to wait long term data on transcript of therapy to compare against the excellent long term results of repair to make a decision that would do in the in the sort of middle ground of the intermediate low risk patient. And you know D. M. R. Risk is really a complex thing because the overall risk profile is incredibly low and therefore what is higher low risk to be at risk in the population of patients Where the 75th%ile of risk is just in the 1-2 rain. Well, fantastic. The hour is out. Thank you for everyone's time and joining us today. I thought this was a really uh robust and important discussion housekeeping. Just a reminder to everyone again. Thank you for joining us to CM CM. E. Code is 712 to 1 Again 7 1 2- one. And thank you so much for your time and we're happy to answer any questions by email or phone in the future linda. Thank you very very much for helping us organize this. We couldn't have done it without you. Um And thank you for an entire panel. Um, amy and mike for putting all these cases together. Um And everyone have a good day. Thank you. Take care.
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