Drs. Randolph Martin, Anelechi Anyanwu, MD and Gilles Dreyfus, MD discuss the impact of Carpentier’s milestone paper “The French Correction” 40 years after its publication. Drs. Dreyfus and Anyanwu also provide an overview of the legacy of Alain Carpentier in the field of mitral valve repair.
About the AATS Mitral Conclave: David H. Adams, MD, and Anelechi C. Anyanwu, MD, serve as the Program Directors of the AATS Mitral Conclave – a meeting that Dr. Adams created with the American Association for Thoracic Surgery in 2011. The biennial meeting brings the world’s leading experts together to examine all aspects of mitral valve disease, associated conditions, and treatment. The meeting featured more than 350 presentations, 40 focused breakout or lunch sessions, combined with four main plenary sessions – with over 900 attendees from 52 countries.
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I'm Doctor Andy Martin. We're here at the 2023 A ATS MA conclave which you can see over our shoulder. And this morning we had an interesting discussion by these two fine colleagues, Jill Dreyfus and a a and A and gels. You. We're talking about the French connection. This is 40 years to sort of the anniversary of the famous paper. And the professor Carpenter is what's been the impact of that paper specifically when it was introduced four years ago. The impact 40 years ago was it was such a tremendous change in the paradigm of how to treat my valve regurgitation that everybody was interested that it took some time to be adopted because you well know that the rate of my there was kept very until the last 10 years, right? And, and in the last 10 years, there has been a a burst due to some very selected centers, centers of excellence providing uh close to 100 repair rate with less than 1% mortality and treating the elite. So all the valve that are amenable to be treated by a valve repair. But before that, uh there was sort of a reluctance because you need to, to really uh from a replacement to repair, you need to take time. You need to be prepared to face a second run. So it was not easy. You gave a talk on that this morning about basically the 40 years in duration. So if I understand what Giles is saying, even though the paper was, was presented at the A TS and then published, it didn't lead to a rapid confirmation of that. No, it didn't. It, it was sort of a paper ahead of its time. So, so the impact was delayed. So I think what it did was to, you know, bring the awareness that there's this operation that might work for micro valve regurgitation. But it took, I would say a good two decades because even when I was a resident training, I trained with Professor Dreyfus. And I remember sometimes we'll be in one operating room and in the next operating room, another surgeon is replacing Valve for P two prolapse in the same hospital and this was in the early two thousands. Yeah, I'm back in. So I was at Stanford in the seventies. OK. And then, then we went to the University of Virginia in the late seventies and I didn't hear anything at that period of time. It was all valve replacement mechanical at Stanford, obviously, the biologic valves and stuff. What's his legacy? I know that's a, that's a difficult question you both worked with and you, you spent some time you talked about, you talked about it this morning and I thought it was interesting. You made some really interesting comments. What's his legacy to you? And then to the field, his legacy to me is huge. We have uh today, lots of publications on techniques results that I really think nothing that he has done today except few minor changes have not been described by. And what an showed very well in his talk is that basically he picked up 10 principles, but these 10 principles remain intangible. You can do whatever you want. You can use, go text and use cord transfer. You can avoid resecting or not. But I mean, what you want to have is a perfect closure line parallel to the Syrian because if you don't have that, you don't have a good crap hide and restore a hide. And once you've done that, whatever the technique, basically, you've done a good repair, which should be lasting for a long time. I really think that what top point cried 40 years ago is still true. I mean, it's not because, you know, we've abandoned quadrangular resection because it's put the tissues under tension. Although the results at 20 years were very good, but I mean, yes, triangular section seems to be more suitable. And but aside of that, I don't think there is a major change. Yes, you can use a band and set incomplete rings and instead of compete rings. But I don't think it has been a major change. I think the other important thing to note is that those principles you're talking about apply to percutaneous therapy too. And if you have a percutaneous technique that doesn't follow those principles is bound to fail, it's the same principles of, you know, that laid out that will get you a competent valve for a durable period of time, no matter the method you use 10 was built upon his knowledge of anatomy and function. I mean, it's really pretty dramatic. It is he was he and is he a futurist? In other words, he's obviously the way you talked about him. He's, he was driven, he was insightful. He was, he asked to committed, but was he, was he a futurist? I sort of got that from your talk. I mean, you said he was before his time. I'm biased because I've been working with him and I have some uh feelings because he was my mentor and intellectually truly admirable person. Now, even what Annie says reinforces this message. But what also we heard this morning is that, you know, he described all the disease without the echo and, and you know, this has been confirmed by the findings of that. I can remember that, you know, he used to have uh a stethoscope which was a sterile phys. So he would put a stethoscope to hear if there was a, a residual murmur of the. But I mean, we had nothing. And then the first echoes, you know, we put a probe on the heart and then we were trying to find the incidents which we were searching to, to see sort of a hazy image to see whether the micro was correct or not. But I mean, all what he described was coming from his mind and this is truly some something which was an admirable, had complete integrity to it. And, and, and the way he approached the subject, in other words, he was interested in helping the patient and the outcomes not make him himself think. Oh yeah, of course. I mean, you know, I think he did and I think that he was able to develop that in Vietnam where I worked also with him and where he get developed this center. But for instance, I've done the same thing in Africa and it's a bit difficult that they understand that a repair is better than a mechanical valve. The problem is then can they afford a second operation when it fails? This is all the point about the durability of repair which which we face even in developed countries such as America or Europe. Your thoughts, you put together, you gave a talk this morning, but you obviously knew him and knew all and have known him putting the talk together. Did you learn new things about him or new insights? I learned a lot about him like this morning when Professor Perry was saying, oh, he wasn't just doing my, he did a lot of other things. So, in doing my research for this talk, I came across a lot of work from the 19 seventies, sixties and seventies that he had done. And I sort of got the impression as prof said this morning that he and his Chief Du Bois were not necessarily on the same path because I read some of the papers and read some of his papers that I could see read between the lines that there was a big difference of opinion. And when you say legacy, his biggest legacy is actually um the bio prosthetic valve, which many people don't know. That's really his biggest contribution to surgery was probably the was glutaraldehyde. He used fixation of bow, that's really what changed valve replacements worldwide. I know it's interesting. You were younger, obviously, he was, unfortunately, yes. Thank you. Everybody is younger than me. But, but, but so he was, and then you've obviously known him over the years. Um I still see him regularly. Has anything changed about him and your perception. In other words, if you've looked at him working with him being your mentor and you, you were both most younger, you see what, in other words, maturation age causes maturation in some people's personality but not their inherent who they are. Have you seen any difference in him besides you knew him as a trainee? And he was, I knew him also as a professor, I knew him a fully independent surgeon. That what has changed is I think he accepted, he, he didn't want to always be right. I think he gave his message and if people didn't believe it was right, because you see today you, you, you hear the development of micro repair, it seems that there is a sort of a new era. I really think it's a bit exaggerated. I, I think that, you know, uh whether it's or whether it's native and as is presenting a paper at the A CS which he did present all a bit of today saying that, you know, if you use, go, there are 690 ways should use. If there are 690 ways, it means that has a bit of a problem. Uh At, at least I don't, I'm not against putting in one or two. If you put 10, go in order to achieve an evenly distributed closure line, it's getting very difficult, it's getting very difficult. So people never talk about that. And I think that delivered many talks, tried to be convincing. Uh I know that there are pros and cons of what he said. But I mean, I thought that he was a bit reluctant to try to convince people who didn't want to believe what he says. That that's, that's what comes with aging, you know, who you are and you know, who they are with aging, I mean, his, the integrity at doing what he thought was right? Was not based upon popularity or how many Twitter followers you could have as people do today. But it was, it was, but it was not instantaneous. I mean, he developed this whole concept with all he told. I mean, the one time I had a chance to sit with him with David at the A TS in Toronto when he was uh he talked about the sheep, sheep got loose from his uh his operative sheep were running down the street in Paris and talked about this and it would just showed his how he really developed his techniques, methodologically and and really perfected them if I may, you know what seems to be today part of the momentum to treat my regurgitation is accepted and no one can discuss it. The gold standard is mitro repair. But I mean, in 30 years ago, 40 years ago, 20 years ago, treating a valve that was diseased. I heard so many times people say, how can you get a good result as the valve is a disease tissue? How can you restore a proper valve? And and even this concept is revolutionary and it remains such as you're trained, you both are still training young surgeons today. Are there things you can see in the way he trained people? And I don't mean, I mean one on one and then the team concept or the concept of how you plan operations, you do operations. Is that a, a transferable message? Well, I never trained directly on the, except when I was doing my fellow Sinai, he used to come and operate. So I did scrub with him on a handful of cases. But I think training really comes from the legacy and what you transfer to your trainees. And although I didn't spend years with him, I feel like I did because I have spent years with Dreyfus and Adams combined who learned from him. So in many ways, I still, it still gets transferred down the line. And hopefully all the trainees of Dreyfus and trainees of myself and all the other students of students of Capon will continue to move that on over the years. Said you got the 10 or 11 principals. Yes, they teach the same principles. And I tell everyone like the French, correct. So I say this is one paper you have to read. The reason I asked about the futurist because he had to be a futurist in the sense of annoy thinking that you should repair the valve and knowing what force loy put it, you know, proving that to himself and to the patients, the highlights you had of what the operating the future. Yeah, he, he wrote that when, as Jeffrey said, Echo was barely just coming out at the time. And he was saying, look, we're going to be have three dimensional, the constructions and talking about robot assisted surgery and it's an amazing vision. But you look at Club Montrell, you know, which was a phenomenal tonight. I mean, it was, uh, not only from the knowledge you got but the, the relationship with the other members of that club and people. And then you look at a meeting like this where you've got almost 1000 people and you realize the legacy is really gigantic. I mean, the clement trial was really based on, on life cases and, and she would do something like 10 live cases in two days or three days. And it truly, you know, I mean, very often the last case, he was on his own, finishing the case. And uh all everybody had done for dinner and he was in the or until 10 pm or 11 pm. And he was very much patient. And what I said this morning is true is I had never seen a surgeon who had so much this concept of where there's a will, there's a way and he had his will at the tip of his needle holder when he wanted something to happen. He made it happen. I don't think you can make such a breakthrough in, in any cardiac surgery without having this kind of temper. It's interesting to me because I, when I left Emory medical School in 69 I went to Stanford and I got exposed to the and at that point in time. And although I didn't know professor well. And uh and obviously I had interacted with Shumway. Some, there's a lot of similarities in what, what I perceived as a young man then about them and about carpenter, I mean, basically very forceful, very driven to, we're gonna treat the patient when they need to be treated and not when the clock says. And a lot of, I think it was, you know, this concept that then you'd go to a restaurant or you sit out and he sort of drawing, drawing on the net, the same, same thing. I mean, so that so and I'm saying is innovative and great surgeons have a lot of sin, but they are focused on making the field and making the patient better. Is that correct? Absolutely. This is truly, I think one of the major messages uh that we can do, you think we have that same drive in transcatheter therapies that we had? And that's a hard question as we had in the surgical feel coming along. The fact that's the same principles are gonna exist. I think trans therapy has a bright future. There is also the industry pushing very hard on developing things. I really think that cardiologists should see what happened with surgery before. As Annie said, I think that provided they don't get a result with trait and even less than mild Mr, there will be a residual Mr, there will be a recurrent Mr and we have a problem. So I mean, the intention to treat should be stated in all the cardiological studies. Is it a compassionate use for a 90 year old man where if he has a regurgitation, residual regurge, I mean, it's not a problem, you're not gonna do anything you got, it will improve his symptoms and you, it will facilitate the drug impact. If you take someone 70 who has the choice of a surgery as opposed to per therapy, then you have to be very careful what you're doing. And if the results are not perfect, then the outcome will not be perfect. And when the guy will be 75 with to, he's going to be a high risk surgery for a patient who could be a low risk at the time of initial index intervention. I mean, I think the goal has to be to, to relieve the patients of their symptoms and treat the disease. The goal of percutaneous therapy cannot be to be an option against surgery. It's not all or none, it's not a competition. And I think if they see it that way because a lot of the innovators in surgery were talking about today, they were doing that because they wanted to help treat the disease. They were not doing that because they wanted more patients or wanted to compete against something else. And I think the drive in the, there's a lot of commercial interest and as opposed to, um, trying to help, you know, do what doctors to treat us. I guess that's what I, the point I was making is that having had an experience to watch, really to see surgery when I was in medical school in the sixties and then go to Stanford in the sixties and seventies and see, see the difference and, and what I think professor had, I mean, uh, you know, that it just makes the field so dynamic and so, so professional. I know it's not even those are not good choices. And I think that's the danger with now with transcatheter therapies is that it's basically focused on one procedure and not the concept of longevity and longevity is tied tied to your results. All right. Well, listen, I, I learned from both of you this morning. It was great to listen to and hear the comments from your history was really good. So, thank you. Thank you. Thank you. Thank you. Thank you. Thank you for joining us. It's fascinating. Read that 1983 paper on the French correction. It's fantastic.
