Complexity Of Mitral Valve Repair Research Articles

A complexity evaluation system for mitral valve repair based on preoperative echocardiographic and machine learning

BackgroundTo develop a novel complexity evaluation system for mitral valve repair based on preoperative echocardiographic data and multiple machine learning algorithms. MethodsFrom March 2021 to March 2023, 231 consecutive patients underwent mitral valve repair. Clinical and echocardiographic data were included in the analysis. The end points included immediate mitral valve repair failure (mitral replacement secondary to mitral repair failure) and recurrence regurgitation (moderate or greater mitral regurgitation [MR] before discharge). Various machine learning algorithms were used to establish the complexity evaluation system. ResultsA total of 231 patients were included in this study; the median ejection fraction was 66% (63–70%), and 159 (68.8%) patients were men. Mitral repair was successful in 90.9% (210 of 231) of patients. The linear support vector classification model has the best prediction results in training and test cohorts and the variables of age, A2 lesions, leaflet height, MR grades, and so on were risk factors for failure of mitral valve repair. ConclusionThe linear support vector classification prediction model may allow the evaluation of the complexity of mitral valve repair. Age, A2 lesions, leaflet height, MR grades, and so on may be associated with mitral repair failure.

A complexity scoring system for degenerative mitral valve repair

ObjectiveTo develop a score to allow stratification of complexity in degenerative mitral valve repair. MethodsRetrospective modeling of data from 668 consecutive patients who underwent surgery for mitral valve prolapse. A complexity scoring scale was developed using a consensus approach, assigning a score to each valve, based on the following: prolapsing segments (weight 1 for each posterior segment; weight 2 for each anterior or commissural segment); presence of valve restriction (weight 2); presence of calcification (weight 3 if annulus involved, otherwise weight 2); and prior mitral valve repair (weight 3). Valve repairs were categorized into 3 groups based on the complexity score: 1: Simple (n = 244); 2-4: Intermediate (n = 260); ≥5: Complex (n = 164). ResultsMitral valve repair was successfully performed in 667 patients (repair rate: 99.9%). The complexity score was directly correlated with surrogates of technical complexity. The mean cardiopulmonary bypass time increased with lesion complexity ([in minutes] simple: 152; intermediate: 167; complex 195; P < .001). The median number of repair techniques utilized was related to lesion complexity (simple: 3; intermediate: 4; complex: 5; P < .001). Barlow's type etiology was more prevalent in complex cases (63%), compared with simple (9%) and intermediate (35%) cases (P < .001). Advanced repair techniques were required to complete repair in 51% of complex cases, compared with 14% of intermediate and 0% of simple cases (P < .001). Early and late outcomes were similar. ConclusionsOur scoring system may allow effective stratification of complexity of mitral valve repair. Future studies are required to evaluate the use of our score in a prospective setting.

Impact of real-time three-dimensional transesophageal echocardiography on procedural success for mitral valve repair.

For mitral valve repair, minimally invasive cardiac surgery as well as transcatheter valvular intervention have been developed. Under these conditions, three-dimensional transesophageal echocardiography (3D-TEE) plays a key role for planning the surgical treatment strategy. However, few data exist regarding the role of 3D-TEE in mitral valve repair. Therefore, we examined the impact of 3D-TEE on procedural success of mitral valve repair. We examined 86 consecutive patients who underwent mitral valve repair for degenerative mitral valve prolapse. Among them, 39 patients were examined by only two-dimensional transesophageal echocardiography (2D-TEE) and 47 patients underwent 3D-TEE in addition to 2D-TEE. The cardiac surgeons and physicians discussed the repair procedure preoperatively with the echocardiographic images. As a result, 18 patients of the 2D-TEE group and 37 patients of the 3D-TEE group underwent mitral valve repair by small thoracotomy including robotic approach. Simple repair was done in 21 with 2D-TEE and 21 with 3D-TEE and complex repair was done in 18 with 2D-TEE and 26 with 3D-TEE. Importantly, three patients with 2D-TEE before surgery had to undergo reoperation due to recurrent severe mitral regurgitation with dehiscence of the annuloplasty rings, although none with 3D-TEE did. These results demonstrate that 3D-TEE is helpful in assessing the morphology of mitral apparatus and complexity of mitral valve repair, particularly in minimally invasive cardiac surgery including robotic ones. We would suggest that sonographers, cardiologists, and cardiac surgeons should be familiar with 3D-TEE and work together throughout the perioperative period for better outcomes.

Quantification of Mitral Valve Anatomy by Three-Dimensional Transesophageal Echocardiography in Mitral Valve Prolapse Predicts Surgical Anatomy and the Complexity of Mitral Valve Repair

Three-dimensional (3D) transesophageal echocardiography (TEE) is more accurate than two-dimensional (2D) TEE in the qualitative assessment of mitral valve (MV) prolapse (MVP). However, the accuracy of 3D TEE in quantifying MV anatomy is less well studied, and its clinical relevance for MV repair is unknown. The number of prolapsed segments, leaflet heights, and annular dimensions were assessed using 2D and 3D TEE and compared with surgical measurements in 50 patients (mean age, 61 ± 11 years) who underwent MV repair for mainly advanced MVP. Three-dimensional TEE was more accurate (92%-100%) than 2D TEE (80%-96%) in identifying prolapsed segments. Three-dimensional TEE and intraoperative measurements of leaflet height did not differ significantly, while 2D TEE significantly overestimated the height of the posterior segment P1 and the anterior segment A2. Three-dimensional TEE quantitative MV measurements were related to surgical technique: patients with more complex MVP (one vs two to four vs five or more prolapsed segments) showed progressive enlargement of annular anteroposterior (31 ± 5 vs 34 ± 4 vs 37 ± 6 mm, respectively, P = .02) and commissural diameters (40 ± 6 vs 44 ± 5 vs 50 ± 10 mm, respectively, P = .04) and needed increasingly complex MV repair with larger annuloplasty bands (60 ± 13 vs 67 ± 9 vs 72 ± 10 mm, P = .02) and more neochordae (7 ± 3 vs 12 ± 5 vs 26 ± 6, P < .01). Measurements of MV anatomy on 3D TEE are accurate compared with surgical measurements. Quantitative MV characteristics, as assessed by 3D TEE, determined the complexity of MV repair.

Can three-dimensional echocardiography accurately predict complexity of mitral valve repair?

Feasibility of mitral repair is a key factor in the decision to operate for mitral regurgitation. Repair feasibility is highly dependent on surgical experience and repair complexity. We sought an objective means of predicting complexity of repair using three-dimensional (3D) transoesophageal echocardiography. In a cohort of 786 patients who underwent mitral valve surgery between 2007 and 2010, 3D transoesophageal echocardiography was performed in 66 patients with mitral regurgitation prior to the institution of cardiopulmonary bypass. The surgeon reviewed the 2D echocardiographic images for all patients pre-operatively, but did not view the 3D echocardiographic quantitative data or volumetric analysis until after surgery. Repairs involving no or a single-segment leaflet resection, sliding-plasty, cleft closure, chordal or commissural repair techniques were classed as standard repairs. Complex repairs were defined as those involving bileaflet repair techniques, requiring multiple resections or patch augmentation. Disease aetiology included Barlow's disease (n = 18), fibroelastic deficiency (n = 22), ischaemic (n = 5), endocarditis (n = 5), rheumatic (n = 2) and dilated cardiomyopathy (n = 2). No patient required mitral replacement or had more than mild mitral regurgitation on pre-discharge echocardiography. Anterior and posterior leaflet areas, annular circumference, anterior and posterior leaflet angles, prolapse and tenting heights and volumes were most strongly predictive of repair complexity. As 21 of the 22 patients with bileaflet pathology and multisegment prolapse were complex repairs, we sought to develop a model predicting repair complexity in the remaining patients. The most predictive model with a c-statistic of 0.91 included three predictors: multisegment pathology, prolapsing height and posterior leaflet angle. After bootstrap validation, the revised c-statistic was 0.88. 3D transoesophageal echocardiography provides an objective means of predicting mitral repair complexity in mitral regurgitation due to a range of aetiology.

Initial clinical experience with Myxo-ETlogix mitral valve repair ring

Complexity of mitral valve repair for myxomatous disease has led to low adoption. We report initial experience with a new ring designed specifically for myxomatous disease, the Myxo-ETlogix (Edwards Lifesciences LLC, Irvine, Calif). From March 15, 2006, through November 19, 2007, 129 patients underwent mitral valve surgery for pure myxomatous disease, and 124 valves (96.1%) were repaired. The Myxo-ETlogix ring was used in 100 cases and the Physio ring (Edwards) in 24. The Myxo-ETlogix design includes a 3-dimensional shape to reduce systolic anterior motion and a larger orifice to accommodate elongated leaflets and decrease need for sliding plasty. Direct mitral valve measurements were made. Sizing was based on A2 height, and choice of ring type was based on unresected leaflet heights. There was no operative mortality or lasting perioperative morbidity. The Myxo-ETlogix group had taller A2, P1, P2, and P3 leaflet segments than the Physio group (P < or = .003). Only 1 sliding plasty was performed for asymmetry in the Myxo-ETlogix group. Predischarge and follow-up echocardiograms (n = 338 in 124 patients) disclosed transient nonobstructive chordal systolic anterior motion in 3 echocardiograms in 3 patients. No patients had 2+ or greater mitral regurgitation. At discharge, 5.7% had 1+ mitral regurgitation; this proportion was 17.3% at last follow-up (mean 6.1 +/- 4.4 months). In initial experience with the Myxo-ETlogix ring, nonobstructive systolic anterior motion has been rare and obstructive systolic anterior motion not observed. Ongoing prospective echocardiographic and clinical studies will elucidate the role of this etiology-specific ring.

Overreduction of the Posterior Annulus in Surgical Treatment of Degenerative Mitral Regurgitation

The concept of overreduction of the posterior annulus was applied in surgical treatment of degenerative mitral valve disease. From April 1993 to November 2004, 141 patients underwent overreduction of the posterior annulus of the mitral valve in mitral valve repair for degenerative disease. Mean scallop involvement per patient was 2.3 and increased to 3.0 in the last period. Correction of the prolapse of the posterior leaflet included resection with focal sliding (n = 100), or application of artificial chordae (n = 28), with (n = 11) or without (n = 17) plication of one or more scallops. The anterior leaflet prolapse was corrected with edge-to-edge technique (n = 20) or chordal replacement (n = 28). An overreducting ring, 40 (n = 81) or 50 (n = 60) mm long (autologous pericardium in 64 cases and Sovering Miniband [Sorin, Saluggia, Italy] in 77) was used in all the patients. Three patients died in the early period (2.1%) and 3 (2.1%) were reoperated on from 3 to 24 months due to endocarditis (2 cases) and failure of repair (1 case). Ten-year freedom from death any cause was 91.6%, from reoperation 96.4%, from death any cause and reoperation 87.7%, from death any cause, reoperation, and New York Heart Association class III-IV 79.8%. Sixty-four patients out of 68 who survived more than 2 years (94.1%) at a mean follow up of 4.2 +/- 2.5 years had no or 1+ residual mitral regurgitation. Although the complexity of mitral valve repair for degenerative disease increased, results of surgery remained stable. Apposition of a posterior overreductive ring was useful to cover any mistake performed during the correction.