Concomitant Mitral Valve Surgery Research Articles

The Ross-Konno Procedure With or Without Mitral Valve Surgery: A Systematic Review With Individual Data Pooling.

Background: The Ross-Konno procedure is a technically demanding surgical option to treat multilevel left ventricular outflow tract obstruction. Methods: A systematic review with pooled analyses was conducted according to PRISMA criteria on studies published between January 2000 and May 2022 that assessed outcomes following the Ross-Konno intervention in children. Individual patient data were extracted from published Kaplan-Meier curves using digitalization software. Overall survival and freedom from reintervention were assessed by time-to-event approaches. Determinants of one-year survival were investigated by meta-regression analyses. Results: Ten studies with a total population of 274 patients were included. The overall pooled early (≤30 days) survival rate was 86.9% (95% CI [87.6%-78.4%]). Five-year survival rates in patients without and with (N = 50 [18.2%] of 274 total patients) concomitant mitral valve surgery were 82.5% (95% CI [87.6%-77.4%]) versus 56.1% (95% CI [74.1%-38.1%]), hazard ratio 2.67, 95% CI (1.44-4.93), P < .0001. Five- and ten-year freedom from pulmonary autograft reoperation rates were 93.5% and 90.9%, respectively. Five- and ten-year freedom from right ventricular outflow tract reoperation rates were 74.3% and 57.3%, respectively. By meta-regression analysis, resection of endocardial fibroelastosis (N = 32 [11.7%] of 274 total patients) was associated with superior one-year survival (P = .027). Conclusion: The Ross-Konno procedure is associated with substantial early mortality and gradual attrition thereafter. Mortality is higher in patients with concomitant mitral valve surgery. Resection of endocardial fibroelastosis is associated with superior survival. Right ventricular outflow tract reinterventions are common.

Totally endoscopic concomitant aortic and mitral valve surgery in junctional epidermolysis bullosa: a case report

BackgroundJunctional epidermolysis bullosa is a rare skin and mucosal disorder characterized by blister formation in response to minor trauma and extracutaneous manifestations. There have been no reports of cardiac surgery and prognostication in patients with epidermolysis bullosa due to skin and mucosal fragility.Case presentationA 55-year-old man presented with congenital junctional epidermolysis bullosa, hypertension, and vasospastic angina. He complained of dyspnea on exertion, and transthoracic echocardiography revealed severe aortic valve regurgitation, moderate aortic valve stenosis (tricuspid valve), and severe mitral valve regurgitation. Considering that the skin condition in the right chest wall was relatively healthy, the right thoracotomy approach was preferred and totally endoscopic concomitant mitral valve repair and aortic valve replacement were performed using a sutureless bioprosthetic valve (Perceval™ (Corcym, Group, Milan, Italy)). Polyurethane and silicon dressing foams were used to protect the skin at the site of contact with the bag valve mask, arterial pressure catheter, intravenous catheter, and the tracheal intubation tube. Vertical mattress sutures were used for the skin sutures. The postoperative course was uneventful, and the patient was discharged nine days after the operation. There was no indication for reoperation until three years follow-up period.ConclusionsThe totally endoscopic concomitant aortic and mitral valve surgery using Perceval™ prosthesis can be performed safely in patients with junctional epidermolysis bullosa by adequate protection of the skin and mucosa.

Surgical ablation of atrial fibrillation during mitral valve surgery: a systematic review and meta-analysis.

Atrial fibrillation (AF) is a common tachyarrhythmia, affecting approximately 33 million people worldwide, and is frequently associated with mitral valve disease. Surgical ablation during mitral valve surgery provides an opportune circumstance for arrhythmia correction. The results of recent randomized trial data are promising, demonstrating both safety and efficacy. The aim of this systematic review is to report the efficacy and morbidity of concomitant surgical ablation for AF during mitral valve surgery. Five electronic databases were searched from inception to March 2023. All studies reporting the primary outcome, freedom from AF (FFAF), for patients with a history of AF undergoing concomitant mitral valve surgery were identified. Studies with patient cohorts less than 100 were excluded. Relevant data were extracted and a meta-analysis of proportions was conducted using a random-effects model. Survival data were pooled from original Kaplan-Meier curves and reconstructed, reporting aggregate FFAF and survival. Thirty-six studies with a total of 8,340 patients were included in the systematic review. All 36 papers reported postoperative FFAF with a pooled result of 76.9% [95% confidence interval (CI): 73.8-79.9%] at a weighted mean follow-up of 40.2 months, however this result was associated with significant heterogeneity (I2=89%). A total of 31 studies reported postoperative short-term mortality, with a pooled result of 1.68% (95% CI: 1.15-2.29%). Aggregate survival at 1 to 5 years was 93.7%, 92.5%, 91.3%, 89.4%, and 87%, respectively, and aggregate FFAF for 1 to 5 years was 90.2%, 83.5%, 79.5%, 76.4% and 73.2%, respectively. Evaluation of the evidence suggests that concomitant ablation for AF during mitral valve surgery is both safe and efficacious. The results were associated with significant heterogeneity, reflective of variable institutional protocols, patient characteristics, and lesion sets. Randomized data with longer term follow-up would help validate these results.

Mitral regurgitation decreases over time after successful thoracoscopic ablation, a subanalysis of a prospective cohort study

Abstract Background Patients with atrial fibrillation (AF) often present with mitral regurgitation (MR) without significant changes in the morphology of the valve leaflets. Even though these patients are at increased risk of developing and maintaining AF, concomitant mitral valve surgery still exclusively occurs in the setting of severe MR. The interplay between AF and MR is incompletely understood, particularly it has not been established how ablation of AF affects the grade of MR. We hypothesized that successful TA decreases the grade of MR. Purpose We aimed to to explore the course of MR severity after TA in patients with AF. Methods We performed a subanalysis of the MARK-AF registry, a single-arm single-center prospective cohort study on patients with paroxysmal and persistent AF undergoing thoracoscopic pulmonary vein isolation. Those with persistent AF were also treated with a roof and trigone line. All patients within this cohort without a history of morphological MR, prior mitral valve prosthesis and left ventricular ejection fraction (LVEF) &amp;lt;30% who underwent TA between January 2016-January 2022 were included. Transthoracic echocardiography (TTE) was performed 1 month preoperatively and at 6-9 months post-operatively. MR was graded ordinally 1-4 (1:None/Trivial, 2:Mild, 3:Moderate, 4:Severe). Successful TA was defined as absence of ≥1 episodes of AF, atrial flutter or atrial tachycardia lasting &amp;gt;30s on electrocardiogram or 24-hour Holter monitoring after a blanking period of 90 days, which were performed at 3, 6, and 12 months post-operatively. Results Of the 283 patients, 31 were excluded. The remaining 252 patients were on average 64 years old (IQR 49-71), 25% were women, and 75% had persistent AF. The median duration between AF diagnosis and TA was 4 years (IQR 2.2-8.0) and the median left atrial volume index (LAVI) 42.5 ml/m2 (IQR 35.1-50.7). Between baseline and follow-up, the median LAVI decreased from 43.5 (IQR 35-50) to 38.7(IQR 32-47) p&amp;lt;0.001, MR grade improved in 33% of patients by at least one grade, and worsened in 17%. In total, 70% of patients had no AF recurrences during follow-up of 12 months. 34% of patients with a successful TA improved in MR grade during follow-up, versus 26% after a failed TA. Mean MR grade improved after successful TA (2.22 ±1.01 versus 1.60± 1.4 p&amp;lt;0.001). MR improved less in patients with AF recurrence (2.13± 1.1 versus 1.80± 1.38 P=0.016). 40% of the patients with MR worsening had AF recurrence versus 23% in whom MR improved. In multivariable ordinal regression analysis, age &amp;lt;65 years and AF recurrence were negative predictors of MR grade at follow-up (OR 4.45: 95%CI 3.432–5.468 p=0.003and 3.83: 95%CI: 2.750–5.090 p=0.040, respectively). Conclusion Successful TA is associated with more MR grade improvement. More AF recurrence is observed in patients whose MR grade aggravates. Whether MR improvement relates to restoration of sinus rhythm or to a smaller left atrium, remains to be investigated.

Abstract 16917: Ross Procedure versus Biological Aortic Valve Replacement in Adults in a Single Center Setting: A Propensity Score Matched Comparison

Background: Guidelines suggested alternative for middle-aged adults undergoing aortic valve replacement is mechanical prosthesis, followed by the Ross procedure (Ross). However, increasingly more patients receive a biological prosthesis (bio AVR) even in young adult age. Is this practice justified? Objectives: To compare long-term outcomes in a single center after Ross vs bio AVR. Methods: For this retrospective study, we screened 2624 patients 04/2007 - 03/2020. Out of these, 231 received Ross, and 2393 received bio AVR ± CABG or aortic surgery. Exclusion criteria: emergency surgery and concomitant mitral or tricuspid valve surgery. Using 1:1 propensity score 99 matches were paired. Primary end-point was all-cause mortality. Secondary end-point was composite of death, need for repeat intervention, and stroke (MACCE). Median follow-up was 7.5 years (IQR: 4.4 - 10.6 years). Results: Mean age for Ross was 56.2±6.1, and for bio AVR was 56.2±5.9. Actuarial 10-year survival for Ross was 89.3%, but significantly lower for the bio AVR 57.9%. All-cause mortality was significantly lower after the Ross procedure compared to the bio AVR (log rank p&lt;0.001). The MACCE-free survival was significantly better after the Ross procedure (log rank p&lt;0.001). Conclusion: In middle-aged adults undergoing AVR, the Ross procedure was superior over the conventional bio AVR after 10 years F/U. Bio AVR should therefore be avoided in this patient population every time possible. Overall long-term survival after Ross vs bio AVR: MACCE free survival after Ross vs bio AVR:

Left ventricular assist device implantation and concomitant mitral valve surgery: A systematic review and meta-analysis.

The management of concomitant valvular lesions in patients undergoing left ventricular assist device (LVAD) implantation remains a topic of debate. This systematic review and meta-analysis aimed to evaluate the existing evidence on postoperative outcomes following LVAD implantation, with and without concomitant MV surgery. A systematic database search was conducted as per PRISMA guidelines, of original articles comparing LVAD alone to LVAD plus concomitant MV surgery up to February 2023. The primary outcomes assessed were overall mortality and early mortality, while secondary outcomes included stroke, need for right ventricular assist device (RVAD) implantation, postoperative mitral valve regurgitation, major bleeding, and renal dysfunction. The meta-analysis included 10 studies comprising 32 184 patients. It revealed that concomitant MV surgery during LVAD implantation did not significantly affect overall mortality (OR:0.83; 95% CI: 0.53 to 1.29; p = 0.40), early mortality (OR:1.17; 95% CI: 0.63 to 2.17; p = 0.63), stroke, need for RVAD implantation, postoperative mitral valve regurgitation, major bleeding, or renal dysfunction. These findings suggest that concomitant MV surgery appearsnot to confer additional benefits in terms of these clinical outcomes. Based on the available evidence, concomitant MV surgery during LVAD implantation does not appear to have a significant impact on postoperative outcomes. However, decision-making regarding MV surgery should be individualized, considering patient-specific factors and characteristics. Further research with prospective studies focusing on specific patient populations and newer LVAD devices is warranted to provide more robust evidence and guide clinical practice in the management of valvular lesions in LVAD recipients.

Pacemaker implantation following tricuspid valve annuloplasty

ObjectiveTricuspid annuloplasty is associated with increased risk of atrioventricular block and subsequent implantation of a permanent pacemaker. However, the exact incidence of permanent pacemaker, associated risk factors, and outcomes in this frame remain debated. The aim of the study was to report permanent pacemaker incidence, risk factors, and outcomes after tricuspid annuloplasty from nationwide databases. MethodsBy using data from multiple Swedish mandatory national registries, all patients (n = 1502) who underwent tricuspid annuloplasty in Sweden from 2006 to 2020 were identified. Patients who needed permanent pacemaker within 30 days from surgery were compared with those who did not. The cumulative incidence of permanent pacemaker implantation was estimated. A multivariable logistic regression model was fit to identify risk factors of 30-day permanent pacemaker implantation. The association between permanent pacemaker implantation and long-term survival was evaluated with multivariable Cox regression. ResultsThe 30-day permanent pacemaker rate was 14.2% (214/1502). Patients with permanent pacemakers were older (69.8 ± 10.3 years vs 67.5 ± 12.4 years, P = .012). Independent risk factors of permanent pacemaker implantation were concomitant mitral valve surgery (odds ratio, 2.07; 95% CI, 1.34-3.27), ablation surgery (odds ratio, 1.59; 95% CI, 1.12-2.23), and surgery performed in a low-volume center (odds ratio, 1.85; 95% CI, 1.17-2.83). Permanent pacemaker implantation was not associated with increased long-term mortality risk (adjusted hazard ratio, 0.74; 95% CI, 0.53-1.03). ConclusionsThis nationwide study demonstrated a high risk of permanent pacemaker implantation within 30 days of tricuspid annuloplasty. However, patients who needed a permanent pacemaker did not have worse long-term survival, and the cumulative incidence of heart failure and major adverse cardiovascular events was similar to patients who did not receive a permanent pacemaker.

Perceval Sutureless Aortic Bioprosthesis With Concomitant or Previous Mitral Valve Surgery

To investigate the clinical outcomes of patients who underwent an aortic valve replacement (AVR) with a Perceval sutureless bioprosthesis with previous or concomitant mitral valve (MV) surgery.

Impact of concomitant mitral valve surgery on the clinical outcomes of patients with moderate functional mitral regurgitation and HFpEF undergoing aortic valve replacement: a cohort study

BackgroundFunctional mitral regurgitation (FMR) worsens the prognosis of patients with heart failure with preserved ejection fraction (HFpEF). While concomitant mitral valve surgery (MVS) is recommended for severe FMR during aortic valve replacement (AVR), the optimal treatment of moderate FMR, especially in those with HFpEF, remains unclear. This study aimed to evaluate the effect of MVS in patients with moderate FMR and HFpEF undergoing AVR.MethodsA total of 212 consecutive patients (AVR: 34.0%, AVR-MVS: 66.0%) during 2010 and 2019 were enrolled. Survival outcomes were compared. Inverse probability treatment weighting (IPTW) was used to balance the baseline characteristics. Kaplan-Meier curve and log-rank test were applied to compare the survival outcomes. The primary endpoint was the overall mortality.ResultsThe mean age was 58.9 pm 11.9 years, and 27.8% of them were female. During a median follow-up of 16.4 months, AVR-MVS did not reduce the risk of mid-term MACCE (hazard ratio [HR]: 1.53, 95% confidence interval [CI]: 0.57–4.17, Plog-rank = 0.396), while it showed a tendency toward higher MACCE risk in the IPTW analysis (HR: 2.62, 95% CI: 0.84–8.16, Plog-rank = 0.096). In addition, AVR-MVS increased the risk of mortality as compared to isolated AVR (0 vs. 10%, Plog-rank = 0.016), which was sustained in the IPTW analysis (0 vs. 9.9%, Plog-rank<0.001).ConclusionIn patients with moderate FMR and HFpEF, isolated AVR might be more reasonable than AVR-MVS.

Long-term outcomes after surgical repair of subvalvular aortic stenosis in pediatric patients.

Subvalvular aortic stenosis (SAS) can occur as discrete or tunnel-like obstruction of the left ventricular outflow tract and as progressive disease often leads to aortic valve regurgitation. We report our 30-year single-center experience after surgical repair of SAS. A retrospective chart review of all patients aged < 18 years, who underwent surgical repair of SAS from May 1985 to April 2020, was conducted. Mortality was cross-checked with the national health insurance database (93.8% complete mortality follow-up in April 2020). Survival and competing risks analysis were used to analyze the primary endpoints survival and incidence of reoperations. From May 1985 until April 2020 103 patients (median age 5.5 years) underwent surgical repair of SAS. Survival was 90.8% at 10 years and 88.7% at 20 and 30 years. Age < 1 year at time of surgery, Shone's complex, mitral stenosis and concomitant mitral valve surgery were associated with mortality. The cumulative incidence of reoperation for SAS was 21.6% at 10 years, 28.2% at 20 and 30 years. The incidence of reoperation for SAS did not differ between the myectomy, membrane resection and combined myectomy and membrane resection groups. The cumulative incidence of reoperation on the aortic valve was 13.5% at 20 years. Recurrence rate of SAS is not to be neglected, though surgical repair of subaortic stenosis has good long-term results. Patients who needed a combined membrane resection and septal myectomy are not more prone to recurrence than patients who underwent solitaire myectomy or membrane resection.

Ninety-Day Risk-Standardized Home Time as a Performance Metric for Cardiac Surgery Hospitals in the United States.

Assessing hospital performance for cardiac surgery necessitates consistent and valid care quality metrics. The association of hospital-level risk-standardized home time for cardiac surgeries with other performance metrics such as mortality rate, readmission rate, and annual surgical volume has not been evaluated previously. The study included Medicare beneficiaries who underwent isolated or concomitant coronary artery bypass graft, aortic valve, or mitral valve surgery from January 1, 2013, to October 1, 2019. Hospital-level performance metrics of annual surgical volume, 90-day risk-standardized mortality rate, 90-day risk-standardized readmission rate, and 90-day risk-standardized home time were estimated starting from the day of surgery using generalized linear mixed models with a random intercept for the hospital. Correlations between the performance metrics were assessed using the Pearson correlation coefficient. Patient-level clinical outcomes were also compared across hospital quartiles by 90-day risk-standardized home time. Last, the temporal stability of performance metrics for each hospital during the study years was also assessed. Overall, 919 698 patients (age 74.2±5.8 years, 32% women) were included from 1179 hospitals. Median 90-day risk-standardized home time was 71.2 days (25th-75th percentile, 66.5-75.6), 90-day risk-standardized readmission rate was 26.0% (19.5%-35.7%), and 90-day risk-standardized mortality rate was 6.0% (4.0%-8.8%). Across 90-day home time quartiles, a graded decline was observed in the rates of in-hospital, 90-day, and 1-year mortality, and 90-day and 1-year readmission. Ninety-day home time had a significant positive correlation with annual surgical volume (r=0.31; P<0.001) and inverse correlation with 90-day risk-standardized readmission rate (r=-0.40; P <0.001) and 90-day risk-standardized mortality rate (r=-0.60; P <0.001). Use of 90-day home time as a performance metric resulted in a meaningful reclassification in performance ranking of 22.8% hospitals compared with annual surgical volume, 11.6% compared with 90-day risk-standardized mortality rate, and 19.9% compared with 90-day risk-standardized readmission rate. Across the 7 years of the study period, 90-day home time demonstrated the most temporal stability of the hospital performance metrics. Ninety-day risk-standardized home time is a feasible, comprehensive, patient-centered metric to assess hospital-level performance in cardiac surgery with greater temporal stability than mortality and readmission measures.

Surgical ablation for atrial fibrillation during aortic and mitral valve surgery: A nationwide population-based cohort study

ObjectiveThere is limited evidence on the effectiveness of surgical atrial fibrillation ablation in reducing mortality or thromboembolic events during aortic/mitral valve surgery. We evaluated the association of surgical ablation versus no ablation with risks of all-cause death and ischemic stroke or systemic embolization among patients with preoperative atrial fibrillation undergoing concomitant aortic valve or mitral valve surgery. MethodsWith the use of administrative healthcare datasets from the Korean National Health Insurance Service database between 2003 and 2018, adult patients with atrial fibrillation undergoing aortic/mitral valve replacement or mitral valve repair were enrolled, and their outcomes were compared according to the performance of concomitant surgical ablation. The primary end points were all-cause death and thromboembolic event of ischemic stroke or systemic embolization. ResultsAmong 17,247 patients with atrial fibrillation undergoing aortic/mitral valve surgery, 8716 (50.5%) received surgical ablation, whereas 8531 (49.5%) did not. During a median follow-up of 6.7 years (124,842.2 patient-years), death was less in the ablation group than in the no-ablation group (2.7 vs 4.1 patient-years; P < .001). The incidence of ischemic stroke or systemic embolization was also lower in the ablation group (0.9 vs 1.3 patient-years; P < .001). After adjustment with inverse probability of treatment weighting, surgical ablation was associated with decreased risks of all-cause death (hazard ratio, 0.86; 95% confidence interval, 0.80-0.92), ischemic stroke or systemic embolization (hazard ratio, 0.62; 95% confidence interval, 0.55-0.71), and hospitalization from heart failure (hazard ratio, 0.87; 95% confidence interval, 0.79-0.96). ConclusionsIn patients with atrial fibrillation undergoing aortic/mitral valve surgery, concomitant surgical ablation was significantly associated with lower risks of mortality and thromboembolic events.

Minimally Invasive Approaches Are Safe for Concomitant Mitral and Tricuspid Valve Surgery.

The need for concomitant tricuspid surgery during mitral valve surgery is associated with higher operative risk. We hypothesized that concomitant tricuspid surgery through a minimally invasive thoracotomy (MICS) is associated with noninferior risk compared with a sternotomy. All patients undergoing mitral valve surgery at a single institution (2010 to 2020) were evaluated. After excluding endocarditis, emergent operations, and concomitant aortic valve or coronary artery bypass grafting procedures, patients were stratified by MICS versus sternotomy. Multivariable logistic regression assessed the risk-adjusted association between concomitant tricuspid valve procedure and Society of Thoracic Surgeons major morbidity or mortality. An interaction term evaluated the impact of approach on concomitant tricuspid surgery. A total of 772 patients underwent mitral valve surgery, including 138 (17.9%) with concomitant tricuspid valve operation. Of the total cohort, 243 patients (31.5%) underwent the MICS approach. Concomitant tricuspid operation was performed in 104 sternotomy patients (19.7%) compared with 34 MICS patients (14.0%, P = 0.056). After risk adjustment, patients who underwent concomitant tricuspid valve surgery via sternotomy had nearly 2 times greater odds of morbidity and mortality relative to those undergoing isolated mitral surgery via sternotomy (adjOR = 1.86, P = 0.049), while patients who underwent concomitant tricuspid surgery via the MICS approach had no increased risk of the composite outcome (adjOR = 0.66, P = 0.543), relative to isolated mitral surgery via MICS approach. Concomitant tricuspid surgery at the time of mitral valve surgery carries additional risk in a broad patient population. A minimally invasive approach appears to be safe for selected patients requiring concomitant tricuspid valve surgery.

Comparing mid-term outcomes of Cox-Maze procedure and pulmonary vein isolation for atrial fibrillation after concomitant mitral valve surgery: A systematic review.

Although concomitant pulmonary vein isolation (PVI) is used more frequently than the Cox-Maze procedure, which is currently the gold standard treatment for atrial fibrillation (AF), data on the comparative effectiveness of the two procedures after concomitant mitral valve (MV) surgery are still limited. We conducted a systematic review to identify randomized controlled trials (RCTs) and observational studies comparing the mid-term mortality and recurrence of AF after concomitant Cox-Maze and PVI in patients with AF undergoing MV surgery based on 12-month follow-up. Medline, EMBASE databases, and the Cochrane Library were searched from 1987 up to March 2022 for studies comparing concomitant Cox-Maze and PVI. Additionally, a meta-analysis of RCTs was performed to compare the mid-term clinical outcomes between these two surgical ablation techniques. Three RCTs and three observational studies meeting the inclusion criteria were included in this systematic review with 790 patients in total (532 concomitant Cox-Maze and 258 PVI during MV surgery). Most studies reported that the concomitant Cox-Maze procedure was associated with higher freedom from AF at 12-month follow-up than PVI. Regarding AF recurrence, estimates pooled across the three RCTs indicated large heterogeneity and high uncertainty. In the largest and highest quality RCT, 12-month AF recurrence was higher in the PVI arm (risk ratio = 1.58, 95% CI: 0.91-2.73). In two out of three higher-quality observational studies, 12-month AF recurrence was higher in PVI than in the Cox-Maze arm (estimated adjusted probabilities 11% vs. 8% and 35% vs. 17%, respectively). RCTs demonstrated comparable 12-month mortality between concomitant Cox-Maze and PVI, while observational studies demonstrated the survival benefit of Cox-Maze. Concomitant Cox-Maze in AF patients undergoing MV surgery is associated with better mid-term freedom from AF when compared to PVI with comparable mid-term survival. Large observational studies suggest that there might be a mid-term survival benefit among patients after concomitant Cox-Maze. Further large RCTs with longer standardized follow-up are required to clarify the benefits of concomitant Cox-Maze in AF patients during MV surgery.

Commentary to: "Comparing midterm outcomes" of Cox-Maze procedure and pulmonary vein isolation for atrial fibrillation after concomitant mitral valve surgery: A "systematic review".

There is no solid evidence from the literature that compare Cox-Maze with pulmonary vein isolation techniques for atrial fibrillation in the context of concomitant mitral valve surgery. Although the first is perhaps more effective and linked to higher freedom from atrial fibrillation, it is more invasive compared to the pulmonary isolation.

Prognostic value of right ventricular remodelling in patients undergoing concomitant aortic and mitral valve surgery.

Long-term risk stratification and surgical timing remain suboptimal in concomitant aortic and mitral (double) valve surgery. This study sought to examine the predictors, changes, and prognostic implications of right ventricular (RV) remodelling in patients undergoing double-valve surgery. In 152 patients undergoing double-valve surgery, four RV remodelling patterns were characterized using transthoracic echocardiography: normal RV size and systolic function (Pattern 1); dilated RV (tricuspid annulus diameter >35 mm) with normal systolic function (Pattern 2); normal RV size with systolic dysfunction (percentage RV fractional area change <35%; Pattern 3); and dilated RV with systolic dysfunction (Pattern 4). The primary endpoint was the composite of heart failure hospitalization and all-cause mortality. Patterns 1, 2, 3, and 4 RV remodelling were present in 41, 20, 23, and 16% of patients, respectively. Patients with Stage 4 RV remodelling had worse renal function, higher EuroSCORE II, and impaired left ventricular ejection fraction. During a 3.7-year median follow up, 45 adverse events occurred. Patterns 3 and 4 RV remodelling were associated with significantly higher adverse event rates compared with Pattern 1 (37 and 75% vs. 11%, P < 0.01) and had incremental prognostic value when added to clinical parameters and EuroSCORE II (χ2 increased from 30 to 66, P < 0.01). At 1 year after surgery (n = 100), Patterns 3 and 4 RV remodelling had a higher risk of adverse events compared with Pattern 1. Right ventricular remodelling was strongly related to adverse outcomes and deserves consideration as part of the risk and decision-making algorithms in double-valve surgery.

Surgical treatment of patients with aortic valve disease complicated with moderate functional mitral regurgitation and heart failure with midrange ejection fraction: a cohort study.

Background Controversies exist on the treatment of moderate functional mitral regurgitation (FMR) in patients with severe aortic valve disease undergoing the aortic valve replacement (AVR). While a substantial proportion of these patients can be complicated with heart failure with midrange ejection fraction (HFmrEF), established studies show that the latter might compromise the patient outcome. This study was aimed to evaluate the prognostic value of concomitant mitral valve surgery during AVR in patients with severe aortic valve disease followed by moderate FMR and HFmrEF.MethodsA total of 78 consecutive patients were retrospectively recruited. Patients were divided into control (isolated AVR) and treatment (AVR + mitral valve surgery) groups. Follow-up outcomes were compared by Kaplan-Meier method, followed by multiple adjustment with inverse probability treatment weighting (IPTW) analysis. The primary outcome was the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE).ResultsThirty-six patients received isolated AVR, while 42 received AVR with mitral valve repair or replacement. The median follow-up time was 28.7 months. Unadjusted analysis showed that there was no significant difference in the rate of MACCE between the two groups [hazard ratio (HR): 1.14, 95% confidence interval (CI): 0.48–2.69, Plogrank=0.770], which was sustained in IPTW analysis (HR: 1.64, 95% CI: 0.59–4.55, Plogrank=0.342). In addition, while concomitant mitral valve surgery improved follow-up FMR more completely (P=0.026) in the IPTW analysis, the ejection fraction was comparable between the two groups (P=0.276). Furthermore, IPTW analysis also showed that mitral valve surgery was associated with the increased risk of postoperative acute kidney injury (P=0.007).ConclusionsIn patients with aortic valve disease followed by moderate FMR and HFmrEF, mitral valve surgery concomitant to AVR may not bring extra benefit in the MACCE-free survival and the improvement of HFmrEF. However, while concomitant mitral valve surgery has priority on the complete improvement of FMR, it might increase the risk of postoperative acute kidney injury.

Robotic-assisted cryothermic Cox maze for persistent atrial fibrillation: Longitudinal follow-up

ObjectivesSurgical ablation of atrial fibrillation (AF) is recommended as a stand-alone therapy for patients refractory to medical or catheter-based treatment, or as a concomitant therapy when associated with structural disease. We report a single-therapy robotic approach to the Cox maze with longitudinal follow-up. MethodsConsecutive patients who underwent robotic biatrial cryothermic Cox maze for nonparoxysmal AF between November 2016 and January 2022 were examined at 1, 2, 3, 6, 9, 12, 18, 24, 36, 48, and 60 months. Freedom from atrial tachyarrhythmia was assessed with 24-hour continuous electrocardiogram or pacemaker interrogation in all patients after 6 months. Mean follow-up was 17 ± 14.5 months (range, 1-60 months). Time to event analysis with competing risks was used to determine risk-adjusted associations with late outcomes. ResultsPatients (n = 135) had a median AF duration of 4.0 years (interquartile range, 0.8-7.0), with 29.6% in whom 1 or more catheter ablations had failed. Stand-alone maze was performed in 25.2%, whereas 61.4% underwent concomitant robotic mitral valve surgery, 7.4% tricuspid valve repair, and 4.4% aortic valve replacement. No patients were discharged in AF. There were 3 operative mortalities (2.2%), none in stand-alone patients. One patient required catheter ablation at 8 months postoperatively, and one had a nonembolic stroke at 18 months. There were 9 late deaths. Freedom from atrial tachyarrhythmia and antiarrhythmic drugs at 9, 12, 18, 24, 36, and 48 months was 97.0%, 96.7%, 98.1%, 97.1%, and 100%, respectively. Lower ejection fraction and need for concomitant mitral valve replacement and/or aortic valve replacement were independently associated with worse survival. ConclusionsFor persistent AF, robotic biatrial cryothermic Cox maze offered greater than 90% 1-year longitudinal freedom from stroke, oral anticoagulation, repeat ablation, and recurrent AF without the need for antiarrhythmic drugs.

Health-Related Quality of Life Analysis Supports the Recommendation for HeartMate3 Implantation without Concomitant Mitral Valve Surgery

<h3>Purpose</h3> Functional mitral valve regurgitation (MR) is common in patients with end-stage heart failure awaiting left ventricular assist device (LVAD) implantation. The resolution of functional MR in LVAD patients has been detected for different LVAD types and across all grades of MR severity. However, it should be proven if the health-related quality of life (HRQoL) after LVAD implantation is comparable in patients with different preoperative MR grades. <h3>Methods</h3> We performed a single-center HRQoL analysis including 34 patients with HeartMate 3 (HM3) implantation using the SF12 Health Survey and the Hospital Anxiety and Depression Score (HADS) at least 1 year after LVAD implantation. The study groups were classified according to echocardiographically defined grade of MR. The group without severe MR (none, mild or moderate MR) comprised 24 patients; the group with severe MR comprised 10 patients. Clinical characteristics including the six-minute walk test (6MWT) were documented. <h3>Results</h3> Age, gender, history of prior heart valve surgery as well as the rate of heart transplantation, ECMO and RVAD implantation, right heart failure, ventricular arrhythmias, stroke, suction events, LVAD thrombosis, and bleeding events were comparable between LVAD patients with severe and not severe MR (p < 0.05). The 6MWT was comparable in the postoperative period (p = 0.13) and one year after LVAD implantation (p = 0.57). No significant differences were apparent in the SF-12-determined physical health (severe MR: 36.6 ± 8.4; not severe MR: 40.1 ± 9.3; p = 0.32) and mental health (severe MR: 49.5 ± 9.7; not severe MR: 54.3 ± 10.5; p = 0.22) as well as in the HADS-determined anxiety (severe MR: 5.6 ± 3.6; not severe MR: 4.9 ± 3.3; p = 0.58) and depression grade (severe MR: 6.3 ± 3.7; not severe MR: 4.6 ± 4.1; p = 0.28). <h3>Conclusion</h3> Physical and mental health as well as anxiety and the depression grade that were measured with standardized questionnaires are comparable in LVAD patients with preoperative severe and not severe MR. The results of this HRQoL pilot study support the recommendation of the International Society for Heart and Lung Transplantation for a HM3 implantation without concomitant MV repair and replacement.

Comparison of a full sternotomy with a minimally invasive approach for concomitant mitral and tricuspid valve surgery.

The need for concomitant tricuspid surgery in patients who need mitral valve surgery casts doubt on its feasibility via a minimally invasive approach. Our goal was to evaluate the short-term outcomes of patients undergoing concomitant mitral and tricuspid valve surgery either with a standard full sternotomy (full-MTS) or a minimally invasive approach (mini-MTS). The outcomes of patients who had combined mitral and tricuspid valve surgery in 11 centres were retrospectively evaluated. The primary outcome was the incidence of 30-day mortality. A propensity score matched cohort was selected to create 2 comparable groups stratified by surgery (valve replacement or repair). During the study period, 1048 consecutive patients had combined mitral and tricuspid valve surgery (730 full-MTS, 318 mini-MTS). The matching procedure paired 192 full-MTS to 192 mini-MTS procedures. After matching, mini-MTS was associated with longer cardiopulmonary bypass [123 min, standard deviation (SD) 46, vs 102 min, SD 36, P = 0.001] and cross-clamping times (89 min, SD 34, vs 78 min, SD 29, P = 0.003). Although the hospital length of stay was shorter (8 days, interquartile range 7-12 vs 9 days, interquartile range 7-14, P = 0.034) with mini-MTS before matching, this difference disappeared after matching. No differences in other major complications or in 30-day mortality were observed: 48 deaths (4.6%), 36 of which (4.9%) occurred in patients who had a full-MTS and 12 (3.8%), in patients who had a mini-MTS (4.7% in both approaches paired by propensity). The mini-MTS approach proved to be safe and effective in patients requiring concomitant mitral and tricuspid surgery. We could not demonstrate any difference in short-term outcomes between the 2 surgical approaches, indicating that there is not a preferred surgical approach.