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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
Annular dilatation
Cleft mitral valve : anterior
posterior
Absent chordae : anterior
posterior

Elongation chordae
Commissural fusion
Short chordae syndrome
Double orifice
Parachute – Hammock MV

N
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
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

N
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
• Mean time of MV
• Mean time of Hosp

: 2.2 ± 1.8 days
: 16 ± 43 hrs
: 8 ± 4.7 days

VAN H DUNG-HNPTTMLN 2016-HCM


Immediate Results
• Hospital Mortality
• Complications
- Severe CHD
- Arrhythmias
- Acute renal failure
- Pulmonary infection
- Septicemia

: 1 (LCO + sepsis)

:8
: 20
:1
:4
: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)

Opido (2008)

N= 34
Chauvaud
(1998) N = 81
Our Study
(2015) N = 128
Yoshimura
(1999) N = 36
Wood (2005)
N= 30

Prosth. Ring Post.Band

0/9
8/70
(1.4%)

3/93
(3.2%)
NA

Plication/Compress
Points/ Reed

5/18
(28%)
2/5
(40%)
4/25
(16%)

NA
Opido - JTCVS 2008, Wood- JTCVS 2005
Chauvaud - JTCVS 1998 ; Yoshimura - JTCVS 1999

0/7
3/11 (27%)

3/33 (9%)
2/30 (6.7%)


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
Chauvaud
(1998) N = 145
AE Wood (2005)
N = 30
G Oppido
(2008) N= 34
PJ del Nido

(2011) N = 155

Our Study
(2015) N = 128

Repair

Replace

Hop.Mort

95%

5%

5%

Re-Op
(FU)
15% ( 10y)

3.3%

13.3 %(5y)

6%

19.7% ( 4y)

0.8%

8.6% ( 10y)

100%
96.9%

3.1%

92.8%

7.2%

98.4%

1.6%

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

THANK YOU FOR YOUR ATTENTIO