Concomitant Mitral Valve Research Articles

Health status analysis is comparable in HM3 patients with different preoperative grades of mitral regurgitation

BackgroundThe guidelines for mechanical circulatory support of the International Society for Heart and Lung Transplantation do not recommend the routine replacement or repair of the mitral valve at the time point of left ventricular assist device (LVAD) implantation. We investigated different parameters of health status including exercise capacity, anxiety and depression after LVAD implantation in patients with different preoperative grades of mitral regurgitation (MR).MethodsA single-center analysis of health status was performed including 45 patients with HeartMate 3 (HM 3) implantation using the 12-items Short Form Health Survey (SF-12) and the Hospital Anxiety and Depression Score (HADS) questionnaires. The study groups were classified according to echocardiographically defined preoperative grade of MR. The group without severe MR comprised 33 patients; the group with severe MR comprised 12 patients.ResultsDemographic and preclinical characteristics as well as LVAD complications such as thrombosis and bleeding events were comparable between LVAD patients with severe and not severe MR (p > 0.05). Severe MR resolved in all patients after LVAD implantation and improved to moderate, mild or no MR in both groups in a period ranging from 6 months until 2 years. The analyses of SF-12 questionnaire revealed that the physical (p = 0.44) and mental health (p = 0.64) was comparable. The grade of anxiety (p = 0.34) and depression (p = 0.44) was comparable between the groups. Exercise capacity measured by the 6 min walk test correlated positively with the SF-12-determined physical health (p < 0.01, r = 0.518) and negatively with the HADS anxiety (p = 0.01, r = −0.399) and depression (p < 0.01, r = −0.570) scores.ConclusionsOur data showed that the health status is comparable in HM 3 patients with different preoperative MR severities in the post-LVAD period. Preoperative severe MR resolves in the majority of patients early after LVAD implantation and is not associated with concomitant mitral valve repair or replacement at the time of LVAD implantation.

Surgical Outcomes of Septal Myectomy With and Without Mitral Valve Surgeries in Hypertrophic Cardiomyopathy: a National Propensity-Matched Analysis (2005 to 2020)

The management of concomitant mitral valve (MV) disease in patients with hypertrophic cardiomyopathy (HCM) remains controversial. The 2020 American Heart Association/American College of Cardiology HCM guidelines recommend that MV replacement (MVR) at the time of myectomy should not be performed for the sole purpose of relieving outflow obstruction. At the national level, limited data exist on the surgical outcomes of MV repair/replacement in patients with HCM who underwent septal myectomy (SM). Hospitalizations of patients with HCM who underwent SM between 2005 and 2020 were identified using International Classification of Diseases, Ninth and Tenth Revision codes (International Classification of Diseases, Ninth and Tenth Revision Clinical Modification/ProcedureCoding System). The 3 comparison cohorts were SM alone, MV repair, and MVR with concomitant SM. After propensity matching, 2 cohorts, SM+MVR versus SM+MV repair, were studied for surgical outcomes. Demographic characteristics, baseline co-morbidities, procedural complications, inpatient mortality, length of stay, and cost of hospitalization were compared between the propensity-matched cohorts. A total of 16,797 SM procedures were identified from 2005 to 2020. Among them, 11,470 hospitalizations had SM alone (68.2%), SM+MVR was seen in 3,101 (18.4%), and SM+MV repair comprised 2,226 (13.2%). After propensity matching, the MVR and MV repair formed the matched cohorts of 1,857. There were no significant differences in the odds of cardiogenic shock (adjusted odds ratio [aOR] 0.88, 95% confidence interval [CI] 0.63 to 1.24, p=0.49), mechanical circulatory support requirement (aOR 0.58, 95% CI 0.37 to 0.90, p=0.015), stroke (aOR 1.27, 95% CI 0.81 to 1.99, p=0.29), and major bleeding (aOR 0.52, 95% CI 0.34 to 0.79, p=0.0026) between the comparison groups. MVR, compared with MV repair, was associated with a higher risk of procedural mortality (8.02% vs 3.18%, aOR 2.98, 95% CI 2.05 to 4.33, p <0.0001), complete heart block (16.36% vs 12.15%, aOR 1.76, 95% CI 1.44 to 2.12, p <0.0001), and the need for permanent pacemaker (16.39% vs 10.62%, aOR 1.83, 95% CI 1.41 to 2.38, p <0.0001). The total length of hospital stay and median hospitalization cost was higher in the MVR group. SM in HCM concomitant with MVR is associated with higher procedural mortality and in-hospital complication risk. These real-world data support the 2020 American Heart Association/American College of Cardiology guidelines that in patients who are candidates for surgical myectomy, MVR should not be performed as part of the operative strategy for relieving outflow obstruction in HCM.

Mitral Valve Repair Is Effective When Performed With Valve-Sparing Aortic Root Replacement

BackgroundConcurrent aortic and mitral valve repair presents specific technical challenges to surgeons. Here we evaluate the outcomes of patients undergoing combined valve-sparing aortic root reimplantation and mitral valve repair. MethodsWe performed a retrospective review of patients at our center between 2006 and 2021 who underwent concomitant valve-sparing aortic root replacement and mitral valve repair. Patient characteristics, including preoperative and postoperative valve function, and operative outcomes were analyzed. ResultsBetween 2006 and 2021, 14 patients underwent valve-sparing aortic root replacement with concurrent mitral valve repair. Mean age of the patients at operation was 39 ± 20 years. Almost half of the patients (6/14) had Marfan disease. The primary indication for operation in all patients was aortic root dilation. Preoperatively, all patients (14/14) had moderate to severe mitral regurgitation, and half (7/14) had moderate to severe aortic regurgitation. Patients underwent mitral annuloplasty alone (9/14) or had concurrent leaflet repair (5/14). The median length of intubation was 0 day (interquartile range, 0-1 day), and median length of stay was 7 days (interquartile range, 6-10 days). At average follow-up of 6.8 ± 4.2 years, 13 of 14 patients had none to trace aortic and mitral regurgitation. One patient required reoperation for late recurrence of aortic and mitral regurgitation. There was no early or late cardiovascular mortality. ConclusionsMitral valve repair can be performed safely with excellent short-term and long-term results in selected patients undergoing valve-sparing aortic root reimplantation. For durable bivalvular repair to be achieved, specific technical considerations should be adhered to.

Robotic endoscopic transmitral septal myectomy and concomitant mitral valve repair for hypertrophic obstructive cardiomyopathy

Hypertrophic obstructive cardiomyopathy is a disease of the heart in which the patient develops left ventricular outflow tract obstruction due to the interaction of the mitral valve and the intraventricular septum. Although septal myectomy remains the gold standard treatment for hypertrophic obstructive cardiomyopathy, several other approaches have been described in the literature, such as a transaortic, transapical or transmitral approach via a sternotomy. All of these approaches have been shown to produce reliable reduction in left ventricular outflow tract gradients. Robotic-assisted cardiac surgery has recently become a safe and effective alternative approach to a sternotomy for several intracardiac procedures, especially mitral valve repair and, in experienced centres, septal myectomy.

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.

Predictors and clinical implications of residual mitral regurgitation following left ventricular assist device therapy

BackgroundCorrection of mitral regurgitation (MR) at the time of left ventricular assist device (LVAD) implantation remains controversial. There is conflicting evidence regarding the clinical impact of residual MR, and studies...

Concomitant transapical aortic and mitral valve transcatheter implantation in a patient with aortic stenosis and ischemic mitral regurgitation

Concomitant transapical aortic and mitral valve transcatheter implantation in a patient with aortic stenosis and ischemic mitral regurgitation

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.

Conventional Biological versus Sutureless Aortic Valve Prostheses in Combined Aortic and Mitral Valve Replacement.

Sutureless aortic valve prostheses have proven to provide a significant decrease in procedural, cardiopulmonary bypass and cross-clamp time, leading to a significant reduction in mortality risk in elderly high-risk cohorts. In this study, we sought to review our institutional experience on the sutureless aortic valve replacement (SU-AVR) and the concomitant mitral valve replacement (SMVR), comparing the combined conventional surgical aortic valve replacement (SAVR) with SMVR. Between March 2018 and July 2022, 114 consecutive patients underwent a combined aortic and mitral valve replacement at our institution. We stratified the patients according to the operative procedures into two groups and matched them 1:2: Group 1 underwent a combined conventional SAVR and SMVR (n = 46), and Group 2 included combined SU-AVR with Perceval prosthesis and SMVR (n = 23). No significant differences in the preoperative characteristics were present. SU-AVR combined with SMVR demonstrated excellent haemodynamic performance, comparable to that of SAVR plus SMVR, with median postoperative gradients over the aortic valve of 4 mmHg (IQR 3.0-4.0) in Group 1 and 4 mmHg (IQR 3.0-4.0) in Group 2 (p = 0.67). There was no significant difference in the occurrence of postoperative major adverse events such as death, stroke, myocardial infarction and kidney failure between the groups. There was also no significant difference in the permanent pacemaker implantation rate, paravalvular leakage or valve dislocation. We also could not detect any significant difference in postoperative mortality between the groups. SU-AVR has proven to be a reliable alternative to conventional valve prostheses in patients with multivalve disease undergoing combined aortic and mitral valve replacement, offering shorter procedural time and outstanding hemodynamic performance compared to the conventional surgical method.

Giant Partial Endocardial Cushion Defect Challenging Mitral Valve Replacement in Adults: Surgical Approach.

Atrial septal defect (ASD) is one of the most common congenital heart diseases diagnosed in children and adults [ [1] Steele P.M. Fuster V. Cohen M. Ritter D.G. McGoon D. Isolated atrial septal defect with pulmonary vascular obstructive disease – long-term follow-up and prediction of outcome after surgical correction. Circulation. 1987; 76: 1037-1042 Crossref PubMed Scopus (236) Google Scholar ]. Interventional closure devices or surgical patch closure are potential treatment options in haemodynamically relevant ASD. Concomitant severe mitral valve regurgitation is impeded by persisting type I ASD, as a congenital partial endocardial cushion defect (PECD) might be present. Partial endocardial cushion defect is a rare form of congenital heart failure, accounting for about 3% of the overall incidence [ [2] Robinson C.L. Merriman J.E. Kilduff C.J. Partial endocardial cushion defects. Can Med Assoc J. 1963; 88: 1147-1154 Google Scholar ].

Reverse cardiac remodeling in patients undergoing combination therapy of transcatheter mitral valve repair.

For patients with severe mitral valve regurgitation (MR), different kinds of transcatheter mitral valve repair (TMVr) exist, targeting the leaflets, annulus, and chordae. The concomitant combination (COMBO) therapy of TMVrs is rarely used as treatment, and there are very few publications about this therapeutic strategy. We evaluated the effect of COMBO-TMVr on the cardiac left chambers and clinical data, including survival. We included 35 patients at high risk who underwent concomitant sequential transcatheter mitral valve edge-to-edge repair (M-TEER) and another TMVr for severe MR in our hospital between March 2015 and April 2018. Of these, 13 had adequate follow-up transthoracic echocardiography (TTE) up to around 1 year after the procedure. Survival for all patients was 83% at 1 year, 71% at 2 years, and 63% at 3 years, respectively. In the 13 patients with adequate TTE follow-up, M-TEER plus either Cardioband (n = 4), Carillon Mitral Contour System (n = 7), or Neochord (n = 2) were used, respectively. Ten patients had secondary, and three patients primary MR. After 1 year, changes [median (Q1, Q3)] of left ventricular (LV) end-systolic diameter of -9.9 cm (-11.1, 0.4), LV end-diastolic diameter of -3.3 cm (-8.5, 0.0), LV end-systolic volume (LVESV) of -17.4 mL (-32.6, -0.4), LV end-diastolic volume (LVEDV) of -13.5 mL (-15.9, -3.2), LV mass of -19.5 g (-24.2, -7.6), and left atrial volume (LAV) index (LAVi) of -16.4 mL (-23.3, -11.3) were observed. A significant reduction was also seen in the change ratios of LVESV, LVEDV, LV mass, and LAVi, respectively. We found that COMBO therapy of TMVr seems feasible and may support reverse remodeling of left cardiac chambers during 1 year after the procedure in a cohort of patients at high risk.

Transcatheter Valve Implantation in Patients with Multivalvular Heart Disease

Transcatheter Valve Implantation in Patients with Multivalvular Heart Disease

Concomitant Mitral Valve Repair vs Replacement During Surgical Ventricular Restoration for Ischemic Cardiomyopathy.

There is no consensus regarding mitral valve management during surgical ventricular restoration (SVR) for ischemic cardiomyopathy. We compared the impact of SVR with mitral valve repair (MVr) vs replacement (MVR) on postoperative outcomes and long-term survival in ischemic cardiomyopathy and mitral regurgitation patients. This study included 112 patients who underwent SVR from 2009 to 2018 with MVr (n = 75) or MVR (n = 37). Patients who had MVR had higher Euro SCORE II, dyspnea class, a lower ejection fraction, higher pulmonary artery systolic pressure, higher grade of preoperative mitral and tricuspid regurgitation, and higher end-diastolic and end-systolic diameters. Intra-aortic balloon pump was more commonly used in patients with MVR. Hospital mortality occurred in 7 (9.33%) patients in the MVr group vs 3 (8.11%) in the MVR group (P > .99). Freedom from rehospitalization at 1, 5, and 7 years was 87%, 76%, and 70% in the MVr group and 83%, 61%, and 52% in the MVR group (P = .191). Survival at 1, 5, and 7 years was 88%, 78%, and 74% in the MVr group and 88%, 56%, and 56% in the MVR group (P = .027). Adjusted survival did not differ between groups.MVr or MVR are valid options in patients undergoing SVR, with good long-term outcomes.

Clinical Effects of Surgical Left Atrial Reduction and Concomitant Mitral Valve Replacement in Patients with Giant Left Atrium.

A giant left atrium may cause respiratory dysfunction and hemodynamic disturbance postoperatively. This retrospective study aimed to evaluate clinical effects of surgical left atrial reduction in concomitant cardiac valves operations. One hundred and thirty-five patients with heart valve diseases and giant left atriums from January 2004 to July 2021 were enrolled into this research. They were divided into the folded group (n=63) and the unfolded group (n=72). Patients in the folded group had undergone cardiac valve operations concomitantly with left atrial reductions. The perioperative characteristics were compared between both groups, and subgroup analysis was performed. There were five deaths in the folded group and 25 deaths in the unfolded group (P<0.001). Complications including pneumonia, sepsis, multiple organs dysfunction syndrome, low cardiac output syndrome, and the use of continuous renal replacement therapy were significantly fewer in the folded group. The receiver operating characteristic curve of left atrial max. diameter predicting mortality was significant (area under the curve=0.878, P=0.005), and the cutoff point was 96.5 mm. The stratified analysis for sex showed that more female patients died in the unfolded group. Logistic regression for mortality showed that the left atrium unfolded, left atrial max. diameter, cardiopulmonary bypass time, and mechanical ventilation time increased the risk of death. Surgical left atrial reduction concomitantly with valves replacement could decrease mortality and was safe and effective in giant left atrium patients.

Surgical concepts for atrial fibrillation in patients with concomitant mitral valve disease

Surgical concepts for atrial fibrillation in patients with concomitant mitral valve disease

Surgical Outcomes After Reconstruction of the Aortomitral Curtain

Repair of concomitant aortic and mitral valvular disease with involvement of the aortomitral curtain requires a technically complex operation colloquially termed the commando procedure. Surgical outcomes of this procedure are not well described. The objective of this study was to examine outcomes of the commando procedure at our center. We identified all patients undergoing concomitant aortic and mitral valve replacements from 2004-2021. Of 363 patients, 41 underwent reconstruction of the aortomitral curtain. Survival analysis and multivariable modeling were used to examine outcomes and risk factors for mortality. The median age was 52 (IQR 44-71) years. Preoperatively, 4 of 41 (9.8%) patients had renal failure, and 10 of 41 (24.4%) had a stroke. The most common surgical indication was endocarditis in 25 of 41 (61.0%) patients. 25 of 41 (61.0%) patients underwent redo sternotomy, and 23 of 41 (56.1%) had previous prosthetic valves. Operative mortality was 14 of 41 (34.1%), and 8 of 41 (9.5%) patients received a permanent pacemaker. Survival at 1, 3, and 5 years was 55.4% (95% confidence interval (CI), 40.6-75.5%), 50.3% (35.0-72.3%), and 37.7% (19.3-73.9%) respectively. Cox proportional hazards regression identified previous sternotomy (HR 4.76, 95% CI 1.21-18.73), and female gender (HR 1.39, 95% CI 1.17-13.82) as risk factors for mortality. Patients undergoing reconstruction of the aortomitral curtain represent a high-risk population with complex surgical indications. Due to high perioperative morbidity and mortality, this procedure should be performed only when necessary. Despite a high up front morbidity burden, outcomes remain favorable for patients who survive the initial hospitalization.

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.

Successful coronary artery bypass grafting with concomitant septal myomectomy and mitral valve annuloplasty for severe coronary artery disease with hypertrophic obstructive cardiomyopathy and obstructive sleep apnoea

Obstructive sleep apnoea (OSA) is associated with a spectrum of cardiovascular diseases such as hypertension and coronary artery disease (CAD), and may worsen the haemodynamics of patients with hypertrophic cardiomyopathy due to nocturnal hypoxia-induced sympathetic activation.

Prevalence and Hemodynamic Consequences of Mitral Valve Abnormalities in Atrial Septal Defect

Background: Atrial septal defect (ASD) is a common congenital heart disease in adults. Concomitant mitral valve disease in patients with ASD could have significant hemodynamic effects whit a great impact on managing this congenital defect. Objectives: This study evaluated the prevalence of mitral valve abnormalities and the hemodynamic burden associated with different types of ASD. Methods: This retrospective study reanalyzed 1,006 consecutive patients referred to Rajaie Heart Center in Tehran from March 2019 to February 2022. We evaluated adult patients with the diagnosis of a shunt at the atrial level. Diagnoses were made with 2D and 3D transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE). 3D analysis was performed with 3D zoom, mitral valve navigation (MVN), and full-volume and multi-planar reconstruction (MPR) modalities. We performed statistical analysis by SPSS version 22.0. The qualitative data were expressed as frequency and percentage. Data were compared between subgroups via Mann-Whitney U/Kruskal-Wallis tests for the interval variables, Pearson's chi-square test for nominal variables, and chi-square for trends test for ordinal variables. Results: The distribution of different ASD types was ostium secundum in 88.8% of cases, primum ASD in 0.9%, SVC-type sinus venosus ASD in 9%, IVC-type sinus venosus in 0.4%, and unroofed coronary sinus in 0.9%. We found mitral valve abnormalities in 21.1% of cases, and the most common mitral valve abnormality were prolaptic lesions (17.4%). Conclusions: Age, ASD size, estimated Systolic Pulmonary Artery Pressure (SPAP), and severity of mitral regurgitation (MR) were markedly higher were markedly higher among patients with MV anomalies, more over left ventricular ejection fraction (LVEF) was significantly lower among this group (P-value &lt; 0.05).

Residual mitral regurgitation in patients with left ventricular assist device support - An INTERMACS analysis.

Left ventricular assist device (LVAD) placement frequently leads to a reduction in the severity of functional mitral regurgitation (MR). However, a significant number of LVAD supported patients have residual MR. We sought to assess the impact of residual MR in LVAD patient outcomes. Patients in the INTERMACS registry who received a continuous flow LVAD between 2006 and 2017 without a prior mitral valve repair were included for analysis. Residual MR was defined as moderate or severe MR within the first 3 months device support. Baseline characteristics, echocardiographic and hemodynamic variables, and clinical outcomes were comparatively analyzed between those with or without residual MR. A total of 8,364 patients were included in the study, of which 18.8% demonstrated residual MR. Younger age, female gender, and non-ischemic heart failure were predictors of residual MR, as were increased LVEDD, RV dysfunction, severe baseline MR or TR, and elevated right heart pressures. Concomitant mitral valve repair reduced the risk of residual MR. Those with residual MR demonstrated worse LV remodeling, more right ventricular dysfunction, and higher right heart pressures at almost all time points analyzed. Residual MR was associated with increased risk of right heart failure and renal failure, and a trend toward increased mortality on LVAD support. Residual MR is associated with worse clinical outcomes on LVAD support. Strategies to minimize MR including medical and device optimization as well as valve repair should be considered in LVAD patients with residual MR.