Concomitant Mitral Valve Surgery Research Articles

Biatrial or Left Atrial Lesion Set for Ablation During Mitral Surgery: Risks and Benefits

Controversy exists when performing surgical atrial fibrillation ablation whether there is an increase in postoperative complications using biatrial (BA) lesions compared with only left atrial (LA) lesions, and some studies indicate similar efficacy. This study compares the clinical outcomes of BA and LA ablation lesions in mitral valve surgery patients. From 2004 through 2014, 2,137 patients had mitral valve surgery with or without other surgeries in a single center. Of those, 836 (39%) had preoperative atrial fibrillation, and of those, 724 (86%) underwent atrial fibrillation ablation surgery; 257 patients had BA lesion sets and 359 had LA lesion sets. Propensity score matching of BA and LA patients was performed. Baseline differences included more postoperative complications in the BA group, specifically, permanent pacemaker placement (13% versus 7%; p= 0.006). Freedom from atrial fibrillation off antiarrhythmic drugs (72% BA versus 75% LA; p= 0.50), postoperative ablation (7% BA versus 5% LA; p= 0.20), stroke (0.11 versus 0.11 per 10 person-years; p= 0.91), and survival were similar between the groups. After matching, patients in the LA group had a higher freedom from postoperative ablation (p= 0.015), but no difference in freedom from atrial fibrillation off antiarrhythmic drugs (79% BA versus 69% LA; p= 0.09), and no difference inpermanent pacemaker placement (10% versus 12%; p= 0.57). Patients undergoing mitral surgery with LA or BA ablation had similar outcomes, survival, and complications. Limiting lesions to the LA is an effective alternative to BA ablation for patients undergoing ablation with concomitant mitral valve surgery.

Meta-Analysis of Usefulness of Concomitant Mitral Valve Repair or Replacement for Moderate Ischemic Mitral Regurgitation With Coronary Artery Bypass Grafting

Moderate ischemic mitral regurgitation (MR) is often present in patients undergoing coronary artery bypass grafting (CABG). However, the clinical benefit of repairing moderate MR during CABG is unproven. We searched multiple databases to identify original studies comparing isolated CABG versus combined CABG and MR surgery (mitral valve surgery with coronary artery bypass grafting [MVCABG]); survival (either early or midterm) was the primary end point. Risk ratio (RR) or standardize mean difference was selected as the effect estimates; survival was compared by pooling hazard ratios. All results are presented with 95% CIs; p <0.05 is statistically significant. Eleven studies (7 retrospective and 4 randomized controlled trials; 547 MVCABG and 900 CABG patients) were included in our meta-analysis. Concomitant mitral valve repair significantly prolonged surgical duration (p <0.01). Early mortality (MVCABG 6.9% and CABG 6%) was comparable (RR 1.3 [0.9 to 1.8]; p= 0.11). At follow-up, the MVCABG patients had similar New York Heart Association class (standardize mean difference-0.73 (-1.64 to 0.18; p= 0.11). However, patients who underwent concomitant mitral valve surgery had less MR at follow-up (recurrent significant MR, RR 0.37 [0.22 to 0.62]; p= 0.001; mean MR grade, mean difference= 0.39 [0.26 to 0.59]; p <0.001). Midterm survival rate (mean follow-up 5years) was comparable in both groups (hazard ratio for mortality in the MVCABG cohort 1.1 [0.9 to 1.3]; p= 0.38). In conclusion, concomitant repair of moderate ischemic MR leads to improved mitral valve competence at follow-up; however, this was not translated into any functional or survival benefit for adding valve repair to CABG for these patients at 5years of follow-up.

Rapid deployment aortic valve replacement in the setting of concomitant mitral valve procedures.

The technique of rapid deployment aortic valve implantation in patients with concomitant mitral valve surgery is described and the outcome of our first 25 patients reported.

Mitral Regurgitation in Patients With Hypertrophic Obstructive Cardiomyopathy: Implications for Concomitant Valve Procedures

BackgroundIncidence and outcome of mitral valve (MV) surgery are unknown in patients with hypertrophic obstructive cardiomyopathy (HOCM) undergoing extended transaortic septal myectomy. ObjectivesThis study sought to define indications and suitable operative strategy for mitral regurgitation (MR) in patients with HOCM. MethodsA total of 2,107 septal myectomy operations performed in adults from January 1993 to May 2014 at Mayo Clinic in Rochester, Minnesota, were retrospectively reviewed. Patients with prior MV operation and apical hypertrophic cardiomyopathy were excluded. Overall, 2,004 operations were performed in 1,993 patients. ResultsPre-operative MR was grade ≥3 (of 4) in 1,152 operations (57.5%). Systolic anterior motion of mitral leaflets caused the MR in most patients. However, intrinsic MV disease was identified pre-operatively in 99 patients, all of whom had MV surgery (with septal myectomy). In 1,905 operations, no intrinsic MV disease was identified pre-operatively; in 1,830 (96.1%), septal myectomy was performed without a direct MV procedure. For 75 patients, intrinsic MV disease discovered intraoperatively led to concomitant MV repair (86.7%) or replacement (13.3%). After isolated septal myectomy, the percentage of patients with MR grade ≥3 decreased from 54.3% to 1.7% (p = 0.001) on early post-operative echocardiography. Among 174 patients with concomitant MV surgery, late survival was superior with MV repair (n = 133 [76.4%]) versus replacement (10-year survival: 80.0% vs. 55.2%; p = 0.002). ConclusionsIn most patients with HOCM, MR related to systolic anterior motion of the MV is relieved through adequate myectomy. Concomitant MV surgery is rarely necessary unless intrinsic MV disease is present. When MV procedures are required, repair is preferred because of improved survival compared with replacement.

High recurrence of atrial fibrillation in patients with high tissue atrial natriuretic peptide and amyloid levels after concomitant maze and mitral valve surgery

BackgroundHemodynamic burden is thought to play a role in valvular atrial fibrillation (AF), but the detailed pathophysiology is unclear. We hypothesized that atrial natriuretic peptide (ANP) tissue levels and amyloid deposits in the left atrial appendage (LAA) were associated with the pre-operative hemodynamic status and post-operative rhythm outcome in patients undergoing a concomitant mitral valve and maze surgery. MethodsWe quantified the fibrosis, atrial amyloid deposits, ANP tissue levels, and multiple biomarker proteins (Western blot) in LAA tissues taken from 26 patients (53.8% male, 58.4±9.7 years) who underwent concomitant maze and mitral valve surgery. The histologic and biochemical results were compared with the pre-operative pulmonary artery pressure (PAP) and post-operative rhythm outcome. ResultsThe ANP tissue level was positively correlated with the atrial amyloid deposit areas (R=0.880, p<0.001), but not with the degree of fibrosis. The pre-operative systolic PAP negatively correlated with both the ANP tissue expression level (R=−0.467, p=0.019) and atrial amyloid deposit area (R=−0.589, p=0.008). The angiotensin II tissue expression level was significantly higher in tissues without ANP expression than in those with expression (p=0.003). AF recurrence after the maze operation was significantly lower in patients without than in those with ANP expression (log rank p=0.031, HR 3.779, 95% CI 1.163–12.277, p=0.027). ConclusionsA lower ANP atrial tissue expression and amyloid deposits were correlated with a high pre-operative hemodynamic loading, and those patients had a paradoxically lower AF recurrence after relief of the hemodynamic burden by concomitant maze and mitral valve surgery.

Tricuspid annular plane systolic excursion (TAPSE) can predict the outcome of isolated tricuspid valve surgery in patients with previous cardiac surgery?

Isolated tricuspid valve replacement is rare when performed as a re-operation after a left side operation. It is important to know the factors that determine mortality and morbidity. Tricuspid Annular Plane Systolic Excursion (TAPSE) is a scoring system that is used with non-invasive Doppler echocardiography to determine right ventricular (RV) function. This study analyzed TAPSE scores and adverse outcomes of isolated tricuspid valve surgery in patients with previous cardiac surgery. All patients who underwent tricuspid valve replacement between January 2014 and December 2015 were retrospectively reviewed. Patients having concomitant mitral or aortic valve surgery were excluded. These patients were divided into two groups: TAPSE >14 mm and TAPSE ≤14 mm. In-hospital outcomes were compared. A total of 26 patients with severe tricuspid valve regurgitation underwent tricuspid valve replacement. There were 5 males (19.2%) and 21 females (80.8%). The average age at operation was 54.77±9.61 years (range, 27-69 years). There were 16 patients in the TAPSE >14 mm group and 10 patients in the TAPSE ≤14 mm group. The BNP in the TAPSE >14 mm group was significant (TAPSE >14 mm 672.34±229.98 versus TAPSE ≤14 mm 1,054.79±684.69, P=0.03). The median cardiopulmonary bypass (CPB) time and red blood cell (RBC) transfusions in the two groups were not different. The need for prolonged ventilatory support (>48 h) in the two groups was also not different (TAPSE> 14 mm 91.2±12.31 vs. TAPSE ≤14 mm 39.00±36.80, P=0.46). Moreover, hospital stays were similar between the two groups. No differences were found in postoperative renal and respiratory complications. It is important to determine the right ventricule function quantitatively. The TAPSE score is an important parameter that determines the cardiac index and right ventricle function. It should be used for the prediction of mortality and morbidity with all the other parameters as a whole.

Early and long-term outcomes and quality of life after concomitant mitral valve surgery, left atrial size reduction, and radiofrequency surgical ablation of atrial fibrillation.

Objective:Atrial fibrillation (AF) is the most formidable supraventricular tachyarrhythmia, which worsens the natural course of mitral valve disease. In this study, we evaluated early and long-term results and quality of life (QOL) after simultaneous surgical radiofrequency ablation (RFA) of AF, left atrial reduction and mitral valve repair or replacement.Methods:Overall, 147 patients with mitral valve diseases who underwent mitral valve surgery were included in this prospective cohort study. Patients were divided into two groups according to the type of operation: the study group—patients after mitral valve surgery with concomitant radiofrequency surgical ablation and left atrial reduction procedure (54 patients), and the control group—patients undergoing only mitral valve surgery (93 cases). We assessed AF recurrence and sinus rhythm restoration rates and mortality rates, QOL measures, postoperative complications rates, and left atrial size during follow-up.Results:In the study group, sinus rhythm restoration rate in the early postoperative period was 63%, but at the time of discharge it reduced to 29%; after 6 months, it significantly increased to 72% and after 3 years, to 81% (p=0.02). In the control group, the sinus rhythm restored only in 14% after 1 year, and at 3 years, it was 22%, although in the early postoperative period it, was 43%. Analysis of left atrial size before and after surgery showed that dimension significantly reduced in both groups (study group, p=0.013; control group, p=0.024). In addition, in patients undergoing surgical RFA procedure, there was a significant association between shorter heart disease history (p=0.02) and shorter AF history (p=0.074) with maintenance of sinus rhythm. The mortality rate in the study group was 4% (two patients) and in the control group 5% (five patients). Comparison of QOL measures between study and control groups after 1 year showed that patients undergoing concomitant atrial reduction surgery and RFA had significant improvement of QOL physical (p=0.03) and role (p=0.03) functioning, heartbeat (p=0.01), general (p=0.03) and mental health (p=0.01), vitality (p=0.007), and social role (p=0.02) functioning measures as compared to preoperative state, being higher than in patients who underwent only mitral valve surgery.Conclusion:Application of surgical RFA using irrigated cooling electrode and atrial reduction during mitral valve surgery is associated with higher restoration and maintenance of SR as compared to patients undergoing only mitral valve surgery. We did not observe complications related to AF surgery that required permanent pacemaker implantation. Performing concomitant surgery as surgical RFA, atrial reduction along with mitral valve surgery, improves QOL in the short- and long-term and reduces the feeling of heartbeat and discomfort. (Anatol J Cardiol 2016; 16: 797-803)

Correction of moderate secondary mitral regurgitation due to aortic valve disease: immediate results

To evaluate the impact of surgical strategy in concomitant mitral valve surgery or isolated aortic valve replacement (AVR) in patients with moderate secondary mitral regurgitation (MR), 1 574 patients underwent AVR over a period from January 2003 to December 2011. 241 patients had secondary MR 2+ and constituted the study population. Patients were stratified into two groups, those without concomitant mitral valve surgery (Group A, n = 113) and with it (Group B, n = 128). It was found out that AVR plastic correction of MI reduces its recurrence during short-term follow-up but increases the intervention time leading to an insignificant rise in lethality. In patients with aortic stenosis the age exceeding 70 years and the presence of atrial fibrillation are found to be the most significant predictors of preservation of residual mitral regurgitation in the early postoperative period, while more indicative for patients with aortic insufficiency is the presence of tricuspid regurgitation grade 2 or higher.

Tricuspid Annuloplasty for Tricuspid Regurgitation Secondary to Left-Sided Heart Valve Disease: Immediate Outcomes and Risk Factors for Late Failure

BackgroundTricuspid valve annuloplasty is the treatment of choice for tricuspid regurgitation (TR) secondary to left-sided heart valve disease (functional TR). MethodsBetween 1999 and 2014, 527 consecutive patients (mean age, 69.6 ± 9.5 years) with grade ≥ 1+ functional TR (graded from 0-3+) underwent tricuspid annuloplasty in addition to left-sided heart valve operations at the authors' institution. The operative risk (by the European System for Cardiac Operative Risk Evaluation II [EuroSCORE II]) was 10.4% ± 12.2%. Clinical data and echocardiographic studies were reviewed retrospectively during a mean follow-up of 5.2 ± 3.5 years. Risk factors for late repair failure were identified by multivariable analysis. ResultsEither suture (De Vega) or device annuloplasty was used in 14.8% and 85.2% of patients, respectively. Concomitant mitral or aortic valve surgery was performed in 92.6% and 35.9% of cases, respectively. There were 48 (9.1%) hospital deaths. The 10-year nonparametric estimates of freedom from all-cause death, cardiac and cerebrovascular deaths, and grade ≥ 2+ TR were 51.2% (95% confidence interval [CI], 47.8%-54.6%) 69.9% (95% CI, 67%-72.8%), and 77.8% (95% CI, 74.2%-81.4%), respectively. A left ventricular ejection fraction < 50% (P = 0.027), tricuspid annular diameter > 40 mm (P = 0.001), and use of De Vega annuloplasty (P = 0.019) were predictors of grade ≥ 2+ TR during the follow-up period. There was a strong link between grade ≥ 2+ TR and new left-sided valvular lesions (odds ratio, 5.3; P < 0.0001), primarily mitral regurgitation. ConclusionsAfter device annuloplasty and in the absence of preoperative left ventricular dysfunction and severe tricuspid annular dilatation, functional TR is generally controlled within grade 1+ during the follow-up period. Recurrent TR is associated with new left-sided valvular lesions.

Additional mitral valve procedure and coronary artery bypass grafting versus isolated coronary artery bypass grafting in the management of significant functional ischemic mitral regurgitation: a meta-analysis

Functional ischemic mitral regurgitation (IMR) is commonly present following acute myocardial infarction (AMI) and tightly associated with a poorer prognosis. The optimal surgical strategy for the management of significant IMR (≥2+ grade) remains controversial and mitral valve surgery (MVS) at the time of coronary artery bypass grafting (CABG) is still debated. The primary objective of this meta-analysis was to clarify the effects of additional MVS on the prognosis in the patients with significant IMR, compared with isolated CABG. A meta-analysis of eligible studies, reporting concomitant MVS and CABG in comparison with CABG alone in respects to in-hospital mortality, survival and postoperative residual mitral regurgitation (MR) and cardiac functional status, was carried out. The outcomes of interest included in-hospital mortality, one-, three- and five-year survival and postoperative New York Heart Association (NYHA) class, residual MR and left ventricular ejection fraction (LVEF). Pooling 2 randomized controlled trials (RCTs) (N.=175) and 11 observational studies (N.=2661) demonstrated that additional MVS did not significantly influence in-hospital mortality (odds ratio [OR]=1.45, 95% confidence interval [CI] 0.93-2.28, P=0.10) and one- (OR=0.89, 95%CI 0.68-1.15, P=0.37), three- (OR=1.10, 95%CI 0.79-1.55, P=0.56) and five- (OR=0.93, 95%CI 0.73-1.18, P=0.55) year survival in comparison with isolated CABG. And pooling neither RCTs nor observational studies alone presented any evidence of significant difference in in-hospital mortality and survival between the two groups. Additionally, concomitant MVS was associated with increased postoperative LVEF (standard mean differences [SMD]=0.28, 95%CI 0.10-0.46, P<0.01) and decreased postoperative residual MR (SMD=-4.22, 95%CI -6.48 to -1.97, P<0.0001). Similar outcomes were obtained when either RCTs or observational studies were pooled alone. Additional MVS appeared to decrease postoperative NYHA functional class (SMD=-0.48, 95%CI -0.97-0.00, P=0.05) with evident heterogeneity (I2=87.5%, P<0.0001). In the subgroup analysis, MVS significantly reduced postoperative NYHA functional class in RCTs (SMD=-1.32, 95%CI -1.67 to -0.97, P<0.0001) whereas it did not among observational studies (SMD=-0.08, 95%CI -0.27-0.11, P=0.42), and heterogeneity was completely eliminated (for RCTs, I2=0%, P=0.49; for observational studies, I2=0%, P=0.40). Concomitant MVS at the time of CABG is associated with greater improvement in postoperative residual MR and LVEF in the patients with significant IMR. However, the evidence is still lacking of advantages of combined surgery over CABG alone regarding in-hospital mortality, survival and postoperative NYHA function class. Additional RCTs are needed to assess the safety and efficacy outcomes of adding mitral valve procedure in the surgical intervention of significant IMR.

Does valvuloarterial impedance impact prognosis after surgery for severe aortic stenosis in the elderly?

BackgroundValvuloarterial impedance (Zva) was introduced as a prognostic measure in patients with aortic stenosis (AS). However, it is unclear whether Zva has a prognostic impact on survival after surgical aortic...

The Left Atrial Appendage: Target for Stroke Reduction in Atrial Fibrillation.

A patient with atrial fibrillation (AF) has a greater than 5% annual risk of major stroke, a 5-fold increase compared to the general population. While anticoagulation remains the standard stroke prevention strategy, the nature of lifelong anticoagulation inevitably carries an increased risk of bleeding, increased stroke during periods of interruption, increased cost, and significant lifestyle modification. Many patients with atrial fibrillation have had their left atrial appendage (LAA) ligated or excised by surgeons during cardiac surgery, a decision based largely on intuition and with no clear evidence of efficacy in stroke risk reduction. The observation that 90% of the thrombi found in nonvalvular AF patients and 57% found in valvular AF are in the LAA, triggered significant interest in the LAA as a potential therapeutic target. Until recently, the results were inconsistent, and high rates of incomplete occlusions precluded the medical community from confirming a definite relationship between LAA and stroke. As a result, anticoagulation is still the recommended first-line stroke risk reduction in AF, and the American College of Cardiology/American Heart Association guidelines recommend LAA exclusion only with surgical ablation of AF or in the context of concomitant mitral valve surgery. A handful of devices have been developed for LAA exclusion. This includes percutaneous options such as WATCHMAN™ Left Atrial Appendage Closure Device (Boston Scientific Corporation, Marlborough, MA), hybrid epicardial devices such as the LARIAT Suture Delivery Device (SentreHEART, Inc., Redwood City, CA), and epicardial surgical devices such as AtriClip® LAA Occlusion System (AtriCure, Inc., West Chester, OH). Studies of the Watchman device have shown noninferiority to Warfarin in stroke prevention and this device has recently gained approval from the U.S. Food and Drug Administration (FDA) following lengthy delays due to safety concerns. The Lariat device, which received 510K clearance by the FDA for tissue approximation but not LAA exclusion, has been the target of significant criticism due to serious procedural safety concerns and high incomplete closure rates. The surgical AtriClip has been FDA approved since 2009 and is currently the most widely used LAA exclusion device placed through an epicardial approach. Small studies have shown excellent reliability and success of complete LAA closure with the AtriClip device, which is implanted through an epicardial approach. Currently, we are conducting a multicenter trial to demonstrate the stroke prevention potential of this epicardial device through a short (45 minute), stand-alone, minimally invasive procedure in lieu of lifelong anticoagulation in patients at high risk of bleeding.

Factors related to sinus rhythm at discharge after radiofrequency ablation of permanent atrial fibrillation in patients undergoing mitral valve surgery.

Late recovery of sinus rhythm is unusual in patients with permanent AF treated by (radiofrequency) RF maze procedure during mitral valve surgery. Identification of clinical and instrumental preoperative factors predictive of early success of RF ablation in patients with permanent AF undergoing mitral valve surgery may improve selection of subjects to obtain long-term results. Hundred and thirty consecutive patients with permanent AF and mitral valve disease underwent modified RF maze procedure during concomitant mitral valve surgery. Rheumatic valve disease (61 pts) and mitral valve prolapse (41 pts) were the more common aetiology of valve abnormalities. Mitral valve replacement was performed in 54 % of patients and mitral valve repair in the remaining 46 %. Four patients died after surgery. At discharge, 87 patients (69 %) were in sinus rhythm (group 1) and 43 patients in AF persisted (group 2). At an average 24-month follow-up, sinus rhythm was present in 67 % of patients, and 33 % were in atrial fibrillation. In this period, late recovery of sinus rhythm was observed only in five patients, while eight discharged in sinus rhythm developed again atrial fibrillation. Among preoperative parameters at univariate analysis female sex, atrial fibrillation >24 months, left atrial diameter >54 mm, left atrial area >24 cm(2), rheumatic valve disease and NYHA class were associated with persistence of AF. At Cox regression multivariate analysis, increased left atrial area (OR 1.07 per unit increase-95 % CI 1.01-1.131) and rheumatic aetiology of valve disease (OR 4.52, 95 % CI 1.65-12.4) were associated with persistence of AF at hospital discharge. Persistence of AF after RF ablation in patients undergoing mitral valve surgery is related to aetiology, e.g. rheumatic valve disease, and to increasing left atrial diameter. Due to low rate of late recovery of sinus rhythm, indication to RF ablation associated with MV surgery should be carefully considered in patients with large atria and rheumatic mitral valve disease.

Rekonstruktion der Trikuspidalklappe: Indikation, Techniken und Ergebnisse

Tricuspid regurgitation secondary to left heart disease is the most common etiology of tricuspid valve (TV) insufficiency. Therefore, the majority of the patients, who require TV surgery, undergo concomitant mitral and/or aortic valve surgery. Uncorrected moderate and severe tricuspid regurgitation may persist or even worsen after mitral valve surgery, leading to progressive heart failure and death. For patients requiring mitral valve surgery, tricuspid valve annuloplasty should be considered even in the absence of significant regurgitation, when severe annular dilatation is present. Secondary or functional TV insufficiency is primarily treated with valve reconstruction which carries a lower perioperative risk than valve replacement. Tricuspid valve repair with ring annuloplasty is associated with improved survival and a lower reoperation rate than with suture annuloplasty. Patients, who require tricuspid valve surgery either as an isolated or a combined procedure, still constitute a high-risk group. The long-term survival is poor.

Minimally invasive concomitant aortic and mitral valve surgery: the "Miami Method".

Valve surgery via a median sternotomy has historically been the standard of care, but in the past decade various minimally invasive approaches have gained increasing acceptance. Most data available on minimally invasive valve surgery has generally involved single valve surgery. Therefore, robust data addressing surgical techniques in patients undergoing double valve surgery is lacking. For patients undergoing combined aortic and mitral valve surgery, a minimally invasive approach, performed via a right lateral thoracotomy (the "Miami Method"), is the preferred method at our institution. This method is safe and effective and leads to an enhanced recovery in our patients given the reduction in surgical trauma. The following perspective details our surgical approach, concepts and results for combined aortic and mitral valve surgery.

EFFECT OF PRIMARY PERCUTANEOUS CORONARY INTERVENTION ON THE INCIDENCE AND SEVERITY OF ISCHEMIC MITRAL REGURGITATION IN PATIENTS WITH ACUTE ST-ELEVATION MYOCARDIAL INFARCTION.

Ischemic mitral regurgitation (IMR) is mitral incompetence resulting from coronary artery disease in the absence of intrinsic valve lesions. This common complication of acute myocardial infarction (AMI) (1) occurs in 15–64% of patients after this event, (2) and is an independent predictor of future cardiovascular mortality(3). The pathophysiology of ischemic MR is complex, and its presence may be related to several underlying processes that are often difficult to separate in a given patient(4). It may result from altered ventricular geometry(5,6,7), incomplete mitral leaflet coaptation, papillary muscle dysfunction and regional wall motion abnormalities (8). IMR severity is positively associated with development of heart failure after AMI.(9).Because of its complex pathophysiology and heterogeneous clinical presentation, the proper treatment of ischemic MR is often debated, and the relative utility of revascularization with and without concomitant mitral valve surgery is uncertain(4). Although primary percutaneous coronary intervention (PCI) for AMI is known to improve outcome(10,11,12), and that IMR after myocardial infarction (MI) worsens outcome, (13) the effect of primary PCI on IMR incidence has not been specifically studied. Aim of the work: To detect the impact of Primary PCI on the development and severity of ischemic mitral valve regurgitation in patients presenting with acute ST segment elevation myocardial infarction. Patients and methods: This study included 60 patients presenting for the first time with Acute ST segment elevation myocardial infarction The patients were divided into two groups group A: Included 30 patients who were treated with primary PCI group B included 30 patients who were treated by thrombolytic therapy..All patients had echocardiography after reperfusion , during the hospital stay then reevaluation after one month period. Results:. During hospital stay the mean LV EF in the PCI group was 46.17± 7.51 % while in the SK group the mean EF was 41.67±6.06 %.In the PCI group the mean wall motion score index during the hospital stay was 1.25± 0.15 while in the SK group it was 1.39 ±0.14 with P value less than 0.001.At one month follow up. In the PCI group there were 6 patients with mitral regurgitation the mean jet area was (1.33±0.63) cm2, while in the SK group there were 25 patients with mitral regurgitation the mean jet area was( 4.45 ±2.17) cm2 with P value <0.0001In the PCI group the severity of mitral regurge was positively correlated with the age of the patient P value less than 0.01,door to needle P value less than 0.01 and pain to hospital times P value 0.04.In the streptokinase group, the severity of mitral regurgitation was positively correlated with door to needle time delay with P value of 0.03. Conclusion: Primary PCI decreased the incidence and severity of chronic ischemic mitral regurgitation when compared with medical reperfusion in patients with acute ST segment elevation myocardial infarction. Key words : Ischemic mitral regurgitation, Acute ST elevation myocardial infarction, Primary PCI. * Corresponding author : Email address :Dr_Ahmedkamel@hotmail.com (Ahmed Kamel) Cardiology department,National heart institute,Cairo, Egypt

Outcomes of patients undergoing concomitant mitral and aortic valve surgery: results from an Italian regional cardiac surgery registry.

There are limited reliable data on the long-term survival of patients operated upon with double-valve surgery (DVS) in the literature. In this study, in-hospital mortality and 5-year survival were determined and the potential risk factors for increased mortality were identified and discussed. This is a report of an observational retrospective study of 1167 patients undergoing concomitant aortic and mitral valve surgery from 2002 to 2011. Data were prospectively collected in a regional database from Emilia-Romagna (Italy). The overall in-hospital mortality rate for DVS was 6.9%. Both in-hospital and 1-year mortality were statistically significant between age groups. In-hospital mortality was significantly higher for patients with a smaller body mass index (BMI), for those who had concomitant coronary artery bypass grafting (CABG) and those who received mitral valve replacement (MVR) instead of plasty (MVP). In-hospital and 1-year mortality were highest in patients ≥70 who had implantation of mitral and aortic mechanical valves. There were significant differences in 5-year follow-up survival according to age, BMI and concomitant CABG. The choice of MVR and MVP did not affect 5-year survival. Multivariable analysis showed that patient-related factors appear to be the major determinant of late survival, irrespective of the type of operation or other intraoperative variables. Advanced age, smaller BMI and concomitant CABG are significant risk factors for mortality in DVS. MVP provided comparable 5-year outcomes with MVR. Multivariable analysis demonstrates that preoperative and clinical patient-related factors are the real burden in the successful treatment of patients undergoing double-valve procedures.

Long-term Survival after Isolated Tricuspid Valve Replacement

Isolated replacement of the tricuspid valve is rare, and the decision to operate is difficult. This study reviews the in-hospital mortality and long-term survival after tricuspid valve replacement in the absence of concomitant left sided valve surgery. It identifies predictors of poor outcome. All patients who underwent tricuspid valve replacement between January 1995 and December 2011 were retrospectively reviewed. Patients having concomitant mitral or aortic valve surgery were excluded. Logistic regression was used to identify predictors of early and late death. Twenty-nine cases were identified. There were six in-hospital deaths (20.6%), and eight late deaths. Ascites was associated with in-hospital death (hazard ratio 16.96; p=0.0052). Higher dose of Frusemide was associated with late mortality (hazard ratio 1.157 per 20mg increase; p=0.0155). Frusemide dose and ascites were both significantly associated with death overall (p<0.01). Survival analysis estimated a 50% probability of surviving to 12.45 years. Isolated tricuspid valve replacement has a high peri-operative risk. Long-term survival in this study was consistent with other reports. Ascites and higher doses of Frusemide were associated with poor outcomes.

Expanding the indication for sutureless aortic valve replacement to patients with mitral disease

To review our experience with sutureless aortic valve replacement (AVR) in the setting of concomitant mitral valve (MV) surgery and discuss the technical considerations. Between January 2012 and March 2013, 10 patients underwent sutureless AVR with the Perceval prosthesis in the setting of concomitant mitral disease. Five patients underwent MV repair, 4 underwent MV replacement, and 1 had a previously implanted mechanical mitral prosthesis. The median age was 79 years and 7 patients (70%) were male. Median logistic EuroSCORE II was 6.2%. All valves were successfully implanted with no 30-day mortality. There was no residual aortic paravalvular leak. Two patients had from third-degree atrioventricular block requiring permanent pacemaker implantation. At a mean follow-up of 8±4 months (range, 2-16 months), the overall survival was 80% with 2 non-valve-related deaths and the mean transaortic gradient and aortic valve area had improved to 11.1±4.6 mm Hg and 1.5±0.3 cm2, respectively. There was no evidence of mitral dysfunction in any patient. In our experience, sutureless AVR in the setting of concomitant mitral surgery is a feasible and reproducible procedure. Elderly patients undergoing multiple valve surgery present a higher operative risk, therefore extending the indication for sutureless AVR to patients with concomitant mitral disease could greatly benefit this specific population.

Concomitant aortic and mitral surgery: To replace or repair the mitral valve?

The study objectives were to evaluate the perioperative outcomes of concomitant mitral and aortic valve surgery and to determine the influence of mitral valve repair versus replacement on survival and adverse events. The study population comprised 261 patients with a mean age of 61.3±11.2 (19-82) years; 57.5% were male, and 73% were in New York Heart Association class III or IV. Mitral valve repair was performed in 209 patients (80%), and mitral valve replacement was performed in 52 patients (20%). Follow-up was complete for 95% of the patients (1395 patient-years). We specifically examined the impact of mitral valve repair versus replacement by comparing 2 propensity-matched subgroups. Degenerative and functional mitral regurgitation, and left ventricular dilation and dysfunction were associated with mitral valve repair (P<.05). Rheumatic disease, chronic obstructive pulmonary disease, redo surgery, mitral calcification, and atrial fibrillation were more frequently related to mitral valve replacement (P<.05). Overall 30-day mortality was 1.1% (3 patients). Overall 1-, 5-, and 8-year survival were 98.0%±2.0%, 85.9%±6.1%, and 79.8%±8.2%, respectively, for the mitral valve replacement group and 95.3%±1.5%, 87.4%±2.6%, and 75.2%±4.0%, respectively, for the mitral valve repair group (P=.906). This was confirmed by comparable survival in propensity-matched analyses. Mitral valve repair showed a survival advantage in older patients (aged ≥65 years) and patients with nonrheumatic mitral valves (P=.017 and P=.034, respectively). Bleeding events (83% vs 60%), endocarditis (97.6% vs 84.6%), and reoperation (97.6% vs 86.9%) were higher in those undergoing mitral valve replacement. Freedom from major adverse valve-related events was higher for the mitral valve repair group (P=.002). Mitral valve replacement was identified as an independent risk factor for major adverse valve-related events (hazard ratio, 1.99; P=.018). Concomitant mitral and aortic valve surgery carries a low surgical risk. The choice of the mitral procedure did not significantly affect survival. However, mitral valve replacement was associated with an increased incidence of adverse events. Thus, valve repair, whenever feasible, is a better option.