Conventional Mitral Valve Repair Research Articles

Abstract 15582: Robotic-Assisted versus Conventional Mitral Valve Repair: An Updated Meta-Analysis of Operative and Post-Operative Outcomes

Introduction: Cardiac surgery has seen notable advancements, especially in mitral valve repair, with the emergence of robotic-assisted mitral valve repair (RAMVR). Amid ongoing debates about RAMVR's efficacy and safety versus conventional mitral valve repair (CMVR), this updated meta-analysis offers a comprehensive comparison based on recently published data. Aim: The study aims to provide a comparison of RAMVR and CMVR, focusing on key operative and postoperative outcomes. Methods: A systematic search was conducted utilizing databases such as PubMed, EMBASE, and the Cochrane Library, until January 2023. The inclusion criteria included studies that compared RAMVR with CMVR. The meta-analysis incorporated a random-effects model to calculate pooled mean differences (MD) and relative risks (RR). All statistical analyses were carried out using R software (version 4.0.3), by metafor and meta packages. Results: Ten studies with a total of 54,235 patients (5,092 in the RAMVR group and 49,143 in the CMVR group) were included. The meta-analysis showed that RAMVR was associated with a significantly shorter hospital stay (MD -1.79 days; 95% CI -2.77 to -0.83, P=<0.01, I2=100%) and ICU length of stay (MD -16.76 days; 95% CI -29.34 to -4.19, P=<0.01, I2=98%). However, RAMVR was associated with significantly longer cardiopulmonary bypass time (MD 42.90 minutes; 95% CI 29.58 to 56.22, P<0.01, I2=98%) and cross-clamp time (MD 29.67 minutes; 95% CI 19.84 to 39.51, P<0.01, I2=98%). In terms of relative risks, RAMVR had a lower rate of overall mortality (RR 0.55; 95% CI 0.42 to 0.74, P<0.01, I2=0%) and rate of infection (RR 0.62; 95% CI 0.52 to 0.74, P<0.01, I2=0%). However, there was no statistically significant difference in the rate of blood transfusion, stroke rate, atrial fibrillation, and transient ischemic attack. Conclusions: This study suggests that RAMVR may offer benefits such as shorter hospital and ICU stays and lower overall mortality and infection rates, but it also involves longer cardiopulmonary bypass and cross-clamp times. Given the high heterogeneity across the included studies, this underlines the importance of further high-quality randomized controlled trials to optimize RAMVR techniques for improving patient outcomes in mitral valve repair.

Surgical Rehearsal for Mitral Valve Repair: Personalizing Surgical Simulation by 3D Printing

PurposeThe goal of this study was to show possible effects of performing the actual procedure of mitral valve repair (MVR) on personalized silicone models 1 day before operation. DescriptionBased on preoperative 3-dimensional echocardiography recordings, flexible 3-dimensional replicas of the depicted pathologic mitral valves could be produced and used for a simulation of reconstructive techniques analogous to the upcoming MVR procedure. We integrated this step of personalized surgical planning into the clinical routine of 6 MVR cases with 3 different surgeons. This pilot study was assessed by evaluating questionnaires and by comparing isolated surgical steps with conventional MVRs. EvaluationThis approach was considered a better preparation for MVRs with overall positive responses from the surgeons. Simulation helped reduce the time of initial inspection of the valve because of better understanding of the valve’s pathomorphologic features. Annuloplasty benefited from preoperative sizing by reducing the number of sizing attempts. ConclusionsThese initial findings suggest that simulation-based surgical planning can be implemented into patients’ and physicians’ clinical workflow as a major technologic advancement for future MVR preparation.

Midterm results after seamless patch mitral reconstruction.

Some pathologies, including infective endocarditis or sclerotic changes of the mitral leaflet, make the conventional mitral valve repair challenging. Our previously described technique for reconstruction with a seamless pericardial patch makes the repair feasible in some of such difficult pathologies. However, the extent of mitral leaflet segments that could be safely repaired using this technique remains unknown. We investigated the association between the midterm outcome and the extent of mitral leaflet segments replaced by a pericardial patch. From January 2009 to January 2022, patients who underwent mitral valve repair with the seamless 1-patch reconstruction technique were included. The glutaraldehyde-treated pericardium was trimmed and anchored at the papillary muscle. The edge was sewn to the leaflet and the annulus. A total of 49 patients (aged 60±15years) underwent mitral valve repair with this technique. The totally endoscopic approach was used in 27 patients (55%). No patient's repair was converted to valve replacement. No operative mortality or disabling stroke was observed during the early postoperative period. In the midterm follow-up, redo surgery was required in 9 patients (18%). Freedom from mitral valve reintervention rates at 1, 5, and 10years were 84%, 82%, and 82% for all patients, respectively. Freedom from reoperation at 5years was 100%, 92%, and 46% for commissural lesion, 1- to 2-segment involvement, and 3-segment involvement, respectively. There was a significant difference among the 3 groups with regard to mitral valve reoperation rate (P=.002). Mitral valve seamless patch reconstruction provides excellent midterm results if applied to commissural lesions or lesions involving up to 2 segments.

Edge-to-Edge Technique Used as a Bailout for Suboptimal Mitral Repair: Long-term Results

BackgroundFor cases of initial suboptimal mitral valve repair, the edge-to-edge (EE) technique has been used as a bailout procedure. However the long-term durability of those rescued mitral valves is currently unknown. With this study we aim to evaluate the long-term clinical and echocardiographic results of the EE technique used to rescue patients with initial suboptimal conventional mitral valve repair. MethodsA retrospective review of our institutional database was done to query for patients who had undergone mitral valve repair with the EE technique used as a bailout procedure. The cumulative incidence function using death as a competing event was used to estimate cardiac death and redo for mitral valve replacement. To describe the time course of mitral regurgitation, we performed a longitudinal analysis using generalized estimating equations with random intercept for correlated data. ResultsEighty-one patients were selected. The median follow-up was 9.1 years (interquartile range, 6.7-12.1; maximum, 22.6 years). At 15 years the estimated Kaplan-Meier overall survival was 63.2% ± 8.69% (95% confidence interval, 43.76-77.46) and the predicted rate of moderate to severe mitral regurgitation recurrence was 16.67%. At 15 years the cumulative incidence function for redo for mitral valve replacement with death as a competing event was 2.5% (95% confidence interval, 0.48-7.84). No case of more than mild mitral stenosis was detected. ConclusionsThe EE technique can be effectively used as a bailout procedure in patients with suboptimal conventional mitral valve repair with satisfactory long-term results.

Time independent myocardial protection of single dose HTK cardioplegia: Comparison of conventional and minimally invasive mitral valve repair

Minimally invasive mitral valve surgery may require a prolonged period of myocardial ischemia. Cardioplegic solutions that necessitate a single dose for adequate myocardial protection are evoked to simplify surgery and result to be appealing in this setting. The aim of this study was to assess early outcomes after minimally invasive versus conventional mitral valve repair using one single dose of histidine-tryptophan-ketoglutarate solution (HTK; Custodiol) for myocardial protection. A retrospective analysis of prospectively collected data of patients who underwent primary isolated mitral valve repair between 2015–December 2021 was undertaken. Primary end-point was peak creatine kinase (CK)-MB within the first 24 hours after surgery. Secondary endpoints included operation and aortic cross-clamp times, in-hospital mortality, hospital and ICU stay, postoperative bleeding and rethoracotomy, and cumulative blood transfusion. All values are given as mean ± SD, P < 0.05 was considered as statistically significant. Analysis was performed by using the SPSS statistic software. 276 patients were included in the study (64 conventional vs. 272 minimally invasive procedure). Baseline patient characteristics did not differ between the groups except gender distribution (43.7% vs. 22.2% female, P = 0.02). There were no in-hospital death in the whole cohort. Operation and aortic cross-clamp times were significantly lower in the conventional group (208 ± 5 vs. 277 ± 4 min, P = 0.001 76 ± 20 vs 107 ± 26 min, P = 0.001, respectively). Peak CK-MB showed no significant differences between the groups (81 ± 53 vs. 76 ± 55 U/l). Postoperative measures did not differ between the groups. The present data confirms similar outcomes between conventional and minimally invasive mitral valve repair. Despite longer operation and aortic cross-clamp times, single dose cardioplegia with HTK solution provides a time independent excellent myocardial protection during minimally invasive surgery.

Initial experiences of transapical beating-heart mitral valve repair with a novel artificial chordal implantation device.

BackgroundSevere mitral regurgitation (MR) is associated with progressive heart failure and impairment of survival. Degenerative MR accounts for most MV repair surgeries. Conventional mitral valve repair surgery requires cardiopulmonary bypass and is associated with significant morbidity and risks. Transapical beating‐heart mitral valve repair by artificial chordae implantation with transesophageal echocardiography (TEE) guidance has the potential to significantly reduce surgical morbidity. We report the first‐in‐human experience of degenerative MR repair using a novel artificial chordae implantation device (MitralstitchTM system).MethodsTen patients with severe MR underwent transapical artificial chordae implantation using MitralstitchTM system. The procedure was performed through a small left thoracotomy under general anesthesia and TEE guidance. Patients underwent transthoracic echocardiography and other assessments during the follow‐up.ResultsAll 10 patients with an average age of 63.7 ± 9.6 years successfully received transapical artificial chordae implantation. Their MR reduced from severe to none or trace in five patients, mild in five patients before discharge. Five patients received one artificial chordal implantation, four patients received two, and one patient received three and edge‐to‐edge repair by locking two of them. The safety and efficacy endpoint were achieved in all patients at 1‐month follow‐up. At 1‐year follow‐up, six patients had mild MR, three patients had moderate MR, one patient had recurrence of severe MR and underwent surgical repair.ConclusionsThe results of this first‐in‐human study show safety and feasibility of transapical mitral valve repair using MitralStitch system. Patient selection and technical refinement are crucial to improve the outcomes.

Transcatheter Mitral Edge-to-Edge Repair in Patients with Primary or Secondary Mitral Regurgitation

&#x0D; Four systematic reviews (SRs) and 6 retrospective cohort studies provided evidence for the clinical effectiveness of transcatheter mitral valve repair (TMVR) versus open heart conventional surgical mitral valve repair or replacement (SMVR) in patients with primary or secondary mitral regurgitation (MR). No relevant evidence regarding the cost-effectiveness of TMVR versus SMVR in patients with primary or secondary MR was identified; therefore, no summary can be provided.&#x0D; There was evidence indicating a statistically significant difference in favour of TMVR over SMVR regarding the odds of post-procedure bleeding, need for permanent pacemaker implantation, 30-day readmission, and a shorter duration of hospitalization.&#x0D; There was evidence suggesting a statistically significant difference in favour of SMVR over TMVR regarding the odds of recurrent MR, the need for reoperation, and mortality rate (i.e., during hospitalization, at 1 year, and &gt; 3 years). Also, compared with TMVR, the likelihood of residual MR grade &gt; 2 or freedom from MR grade ≥ 2 or ≥ 3 at 4 years was statistically significantly lower or higher, respectively, with SMVR.&#x0D; Evidence regarding the comparative clinical effectiveness of TMVR versus SMVR concerning stroke, acute kidney injury (AKI), cardiogenic shock, and death during hospitalization was conflicting and inconclusive.&#x0D; There was no evidence of a significant difference between the 2 interventions regarding overall mortality or mortality at 5 years, overall survival, freedom from cardiac death at 4 years, cardiac arrest, acute myocardial infarction (MI), and respiratory or vascular complications.&#x0D; A major limitation of the evidence was that it derives from studies of low or unknown quality and risk of bias, Furthermore, all the findings are confounded by differences in patient selection, which reflect the approved indications for the interventions but prevent a direct comparison between the TMVR and SMVR groups.&#x0D;

Postoperative Outcomes of Minimally Invasive versus Conventional Mitral Valve Repair; A Randomized Study

Background: Minimally invasive mitral valve surgery (MIMVS) is associated with less surgical trauma. However, its advantages over the conventional approach are controversial. This study aims to compare the early postoperative pain, hospital stay, and pulmonary function between minimally invasive and conventional mitral repair.&#x0D; Methods: Fifty patients with non-ischemic mitral valve disease who had mitral valve repair between 2017 and 2019 were included in the study. Patients were randomly divided into two equal groups. Group A (n=25) included patients who had minimally invasive mitral valve repair via anterolateral mini-thoracotomy with video assistance, and Group B (n=25) included patients who had mitral valve repair via median sternotomy.&#x0D; Results: The cross-clamp (99.45±16.01 vs. 87. 5±19.16 min; p= 0.058) and the total bypass times (134.08±27.38 vs. 120.71±22.18 min; p= 0.35) were nonsignificantly longer in Group A. Operative time was significantly longer in Group A (207.08±44.31 vs. 173.54±28.25 min; p= 0.001). The ICU stay in Group (A) was 2.58±1.44 days, and in Group (B), the ICU stay was 3.75±1.77 days (p= 0.001). The hospital stay was 7.87±1.59 days in Group A, and 14.5 ±5.05 days in Group B (P&lt;0.001). Postoperative FEV1 was 2.06±0.63 L in Group A and 1.39±0.43 L in Group B (p= 0.001). There was no difference in postoperative ejection fraction between both groups (p= 0.9).&#x0D; Conclusion: Minimal invasive mitral valve repair could reduce postoperative pain, length of ICU, and hospital stay and improve the postoperative respiratory function when compared to the conventional approach.

Analyzing and comparing the impacts and outcomes of two different types of surgeries - Minimally Invasive Surgeries (MIS) and Conventional Surgeries (CVS) on patients suffering from Degenerative Mitral Valve Diseases

Background: Degenerative Mitral Valve Disease (DMVD) is the most common cause of Mitral Regurgitation (MR) and the main reason for surgical intervention in patients with heart diseases. Traditionally, open-heart surgery or else sternotomy was the main surgical approach used until a few decades ago when Minimally Invasive Surgical (MIS) approaches came into existence. MIS approach is thought to have superior clinical outcomes while minimizing hospital and ICU stay; blood loss translating to fewer blood transfusions, and lower incidence of complications. Despite many promising institutional and regional results of benefits of MIS over the conventional surgery, the adoption of MIS worldwide in Mitral Valve Repair (MVR) has been so poor. There are still arguments on the surgical and clinical benefits of MIS and more importantly the cost and the expertise involved in conducting MIS. Objective: This study aimed at comparing the costs, clinical and surgical outcomes of MIS with conventional sternotomy MVR surgeries in patients with DMVD. Methods: Electronic databases such as MEDLINE, PubMed, Science Direct, and Google Scholar were searched for relevant peer-reviewed articles comparing costs and clinical outcomes of MIS with the conventional surgery/sternotomy in DMVD from January 2013 to November 2020. A total of 7 articles were identified as most relevant and therefore included in the meta-analysis. Results: Findings from the meta-analysis pointed out that repair of the mitral valve using MIS patients with DMVD has benefits such as short ICU, intubation and hospital duration; less loss of blood and therefore less need of blood transfusion; low postoperative infection rates; smaller incisions; early ambulation and return to activities of daily living over conventional surgery while maintaining similar costs of care and clinical outcomes as a sternotomy. Conclusions: Given the added advantages of MIS in mitral valve surgeries, cardiac surgeons should consider it over the conventional open surgeries in patients with DMVD. In this regard, more surgeons and nurses need to gain competency in conducting MIS through training and fellowships; hospitals need to acquire the needed infrastructure to enable the adoption of MIS.

The Neochord Procedure After Failed Surgical Mitral Valve Repair

Surgical mitral valve reintervention is associated with significant morbidity and mortality, and repeat repair is not always feasible. We examine the clinical outcomes of the NeoChord procedure after failed conventional mitral valve repair. A total of 312 patients were treated with the NeoChord repair procedure between January 2014 and December 2018 at 5 European centers. Clinical and echocardiographic data were reviewed to identify patients who had a prior surgical mitral valve repair procedure. The primary endpoint (Patient Success) was a composite of placement of at least 2 neochordae and end-procedure mitral valve regurgitation (MR) ≤ mild, freedom from death, stroke, structural or functional procedure failure (MR > moderate), procedure or device-related unplanned procedures, cardiac-related rehospitalization, or worsening NYHA functional class at 1 and 2-year FU. Fifteen (15) patients were identified who required reoperation for failed surgical mitral valve repair. Mean time-to-reoperation was 2.7 years (2.2-6.1). Median intensive care unit stay was 24 hours and median hospitalization time was 7 days (6-8). No in-hospital deaths were observed. At discharge, mitral regurgitation was ≤ mild in 13 patients (86.7%). Patient success and freedom from more than mild MR were 92.3 ± 7.4% and 83.9 ± 10.4% at 1 and 2-year follow-up respectively. One high-risk patient presented with severe recurrent MR and died during surgical reintervention due to an acute aortic dissection. Selected patients can be successfully treated with the NeoChord procedure after failed surgical mitral valve repair. These results support a wider adoption of the NeoChord procedure as a first-line minimally invasive, alternative therapy to treat failed mitral valve repair.

Comparison of early postoperative results between conventional and transapical mitral valve repair

IntroductionConventional mitral valve repair (CMVR) is well-established, safe and effective treatment for degenerative mitral regurgitation (MR). Transapical off-pump implantation of artificial chordae (TA) has been introduced into practice and gained interest among surgeons. However, there are no publications comparing the results between TA and CMVR.AimTo compare early postoperative outcomes of CMVR with TA in patients with degenerative MR.Material and methodsThis was a retrospective cohort study. A total of 169 patients who underwent mitral valve repair between 2011 and 2018 were included in this analysis. Patients were divided into two groups: the TA group, n = 78 and CMVR group, n = 91. The groups were compared for early postoperative outcomes.ResultsPatients in the TA group were younger, 54.2 ±11.1 vs. 59.5 ±12.8 years (p = 0.005). Patients in the CMVR group had more complicated postoperative course with higher incidence of blood transfusion (42.9% vs. 7.8%, p = 0.001), atrial fibrillation (25.3% vs. 11.7%, p = 0.031), renal insufficiency (15.4% vs. 2.6%, p = 0.007) and stroke (2.1% vs. 0%). In the early postoperative period, one patient died in the TA group, and there were no deaths in the CMVR group (p = 0.277). Residual moderate to severe mitral regurgitation was present in nine (11.5%) TA patients, while none of the patients in the CMVR group had moderate or a higher degree of residual regurgitation (p = 0.001).ConclusionsOff-pump transapical MV repair is a feasible and safe procedure with low postoperative morbidity rates. Higher rates of mitral regurgitation reoccurrence would require a careful and thorough selection of the patients suitable for the TA approach.

The Application of Mitraclip in the Treatment of Mitral Regurgitation: A Clinical Policy

Context: The mitral valve conducts blood flow from the left atrium to the left ventricle. Mitral regurgitation occurs when the valve couldn’t be closed properly at the end of ventricular filling. Mitraclip, a catheter-based device that can reduce mitral regurgitation without requiring open surgery, is routinely used for patients with unacceptable risk of conventional mitral valve repair or replacement. The purpose of this study is assessing the safety, efficacy, and economic aspects of Mitraclip treatment for mitral regurgitation. Evidence Acquisition: The Cochrane Library, the TRIP database, and Google Scholar have been searched through appropriate strategies. Seven studies were included in the final phase based on the inclusion and exclusion criteria. Data collected from these studies were analyzed based on four main themes; applications, safety, efficacy, and economic evaluation. Results: The most potential side effects were related to an improper transfer of catheters and low durability of the device. One of the included studies showed that improved outcomes of the New York Heart Association (NYHA) was more in the clip group with better quality of life that were observed after 1 to 12 months in 192 patients and also one-year mortality rate after using clip ranged between 10% and 24%. This included study found that 72% to 100% of patients with Mitraclip have been successfully treated and the duration of hospital stays in these patients was between 5 to 10 days. The cost-effectiveness of the procedure still needs more robust evidence. Conclusions: Given the lack of high quality evidence and relatively high cost of Mitraclip, it seems that until further robust evidence is produced; it should be used in research and in high risk patients selected after detailed examination with strict indications and appropriate opinions of cardiologists.

Galectin-3 is associated with left ventricular reverse remodeling and outcome after percutaneous mitral valve repair

BackgroundPlasma Galectin-3 is a marker of myocardial inflammation and fibrosis, was associated with left ventricular (LV) reverse remodeling after conventional surgical mitral valve repair (MVR) and predicted clinical events in patients undergoing transcatheter aortic valve replacement (TAVR). We aimed to evaluate the association between pre-interventional Galectin-3 levels and (1) reverse LV remodeling and (2) major adverse cardiovascular events (MACE) in patients undergoing percutaneous MVR. MethodsForty-four consecutive patients (median age 79 years, LV ejection fraction 39.5 ± 11.4%, 91% in NYHA functional class ≥III) with symptomatic moderate to severe mitral regurgitation undergoing percutaneous MVR were prospectively included. Plasma Galectin-3 levels were measured before the procedure. Echocardiographic and clinical assessment was performed at baseline and after 3 months. LV reverse remodeling was prospectively defined as a ≥10% increase in global longitudinal strain. MACE included death, myocardial infarction, heart failure related rehospitalization and stroke and was assessed after a mean follow-up time of 2 years. Results72.7% of the patients showed LV reverse remodeling. Pre-interventional Galectin-3 < 10 ng/ml was an independent predictor of LV reverse remodeling (OR 10.3, 95% CI 1.2–83.9, p = 0.036). 25 patients (56.8%) experienced a MACE. Patients with Galectin-3 levels ≥ 10 ng/ml had significantly more MACE than patients with Galectin-3 levels < 10 ng/ml (100% vs. 45.5%, p = 0.003). Diabetes independently predicted MACE (HR 3.1, 95% CI 1.0–9.4, p = 0.049); Galectin-3 ≥ 10 ng/ml was of borderline significance (HR 2.2, 95% CI 0.9–5.4, p = 0.088). ConclusionsPre-interventional plasma Galectin-3 levels are associated with LV reverse remodeling and with clinical outcome after percutaneous MVR.

Short-term outcomes of minimally invasive mitral valve repair: a propensity-matched comparison.

We aimed to investigate the effect of minimally invasive mitral valve repair on early pulmonary function and haemodynamics, as well as its short-term efficacy. From March 2012 to July 2015, 78 cases of minimally invasive mitral valve repair and 89 cases of conventional mitral valve repair were included in this study, with 67 well-matched pairs of patients identified by a propensity score matching, who were divided into the conventional sternotomy group and the right minithoracotomy group (the RT group). The in-hospital mortality was similar between the 2 groups (3.0% vs 1.5%, P = 1.000). Both cross-clamp time and bypass time were higher in the RT group (P < 0.001), whereas drainage amount, blood transfusion and length of intensive care unit stay were higher in the conventional sternotomy group (P < 0.001). There was not much discrepancy in pulmonary function between the 2 groups, except that partial pressure of O2 in arterial blood (PaO2)/fraction of inspired oxygen (FiO2) in the RT group was significantly lower than that in the conventional sternotomy group 0, 4 and 8 h after surgery (P < 0.05), whereas the extravascular lung water index (ELWI), pulmonary vascular permeability index (PVPI) and alveolar-arterial PO2 difference (PA-aO2) of the RT group was higher (P < 0.05). We found no disparity in haemodynamics (P > 0.05), incidence of complications (P > 0.05) and short-term recurrence between the 2 groups (P = 0.7697). When compared with the median sternotomy approach, the RT approach shows comparable results in short-term efficacy and safety. On relatively increasing cardiopulmonary bypass time and operation time, the RT approach shortens the patient's intensive care unit stay and reduces the need for blood transfusion. Pulmonary function may be affected shortly post-surgery in the RT approach, with insignificant difference in haemodynamics.

Beating-Heart Mitral Valve Repair Using a Novel ePTFE Cordal Implantation Device: A Prospective Trial

BackgroundConventional mitral valve (MV) operations allow direct anatomic assessment and repair on an arrested heart, but require cardiopulmonary bypass, aortic cross-clamping, sternotomy or thoracotomy, and cardioplegic cardiac arrest, and are associated with significant perioperative disability, and risks of morbidity and mortality. ObjectivesThis study evaluated safety and performance of a transesophageal echocardiographic-guided device designed to implant artificial expanded polytetrafluoroethylene (ePTFE) cords on mitral leaflets in the beating heart. MethodsIn a prospective multicenter study, 30 consecutive patients with severe degenerative mitral regurgitation (MR) were treated with a mitral valve repair system (MVRS) via small left thoracotomy. The primary (30-day) endpoint was successful implantation of cords with MR reduction to moderate or less. ResultsThe primary endpoint was met in 27 of 30 patients (90%). Three patients required conversion to open mitral surgery. There were no deaths, strokes, or permanent pacemaker implantations. At 1 month, MR was mild or less in 89% (24 of 27) and was moderate in 11% (3 of 27). At 6 months, MR was mild or less in 85 % (22 of 26), moderate in 8% (2 of 26), and severe in 8% (2 of 26). Favorable cardiac remodeling at 6 months included decreases in end-diastolic (161 ± 36 ml to 122 ± 30 ml; p < 0.001) and left atrial volumes (106 ± 36 ml to 69 ± 24 ml; p < 0.001). The anterior-posterior mitral annular dimension decreased from 34.7 ± 5.8 mm to 28.2 ± 5.1 mm; p < 0.001 as did the mitral annular area (10.0 ± 2.7 cm2 vs. 6.9 ± 2.0 cm2; p < 0.0001). ConclusionsMVRS ePTFE cordal implantation can reduce the invasiveness and morbidity of conventional MV surgery. The device’s safety profile is promising and prospective trials comparing the outcomes of the MVRS to conventional MV repair surgery are warranted. (CE Mark Study for the Harpoon Medical Device [TRACER]; NCT02768870)

Transapical Off-pump Neochord Implantation for Mitral Regurgitation Recurrence

Recently, transapical off-pump mitral valve repair with Neochord implantation (TOP-MINI) using the NeoChord DS-1000 device (NeoChord, Eden Praire, United States, Figure 1) has been proposed to correct degenerative mitral regurgitation. The surgical procedure is illustrated step-by-step in Figure 2 and it is performed under 2and 3-dimensional transesophageal echocardiography guidance. We present the first TOP-MINI procedure in a symptomatic 58-year-old patient with reappearance of severe mitral regurgitation 4 years after conventional mitral valve repair with an annuloplasty band and implantation of 2 neochordae to treat a posterior mitral leaflet flail at P2 segment (Figures 3A and 3B, videos 1 and 2 of the supplementary material). The patient was enrolled in our institutional prospective registry approved by the local Ethics committee. The patient signed informed consent. A successful TOP-MINI procedure was performed with 5 Neochords implanted on the posterior mitral leaflet (Figures 3C-3F, videos 3 and 4 of the supplementary material). The patient was discharged home after 5 postoperative days. At 6 months, the patient was asymptomatic and transthoracic echocardiography showed the absence of any residual mitral regurgitation (Figures 3G-3H, videos 5 and 6 of the supplementary material). The TOP-MINI procedure is approved in Europe for patients with degenerative mitral valve disease independently of their risk profile. We proposed this therapeutic option because, in our experience, it is associated with extremely low complication rates and high success rates in patients with posterior mitral leaflet disease limited to P2 segment. In this specific case, the presence of a previously implanted annuloplasty band also provided an extra support for the repair by diminishing the stress on the repaired leaflet and possibly increasing durability.

Simple repair approach for mitral regurgitation in Barlow disease

ObjectiveMitral valve repair for myxomatous Barlow disease is a challenging procedure requiring complex surgery with less than optimal results. The use of ring-only repair has been previously reported but never analyzed or followed-up. We investigated this simple valve repair approach for patients with Barlow disease and multisegment involvement causing mainly central jet. MethodsOf 572 patients who underwent mitral valve repair for mitral regurgitation at our medical center, 24 with Barlow disease (aged 47 ± 14 years; 46% male) underwent ring-only repair. Patients were characterized by severely enlarged mitral valve annulus, multisegment prolapse involving both leaflets, and demonstrated mainly a central wide regurgitant jet. Surgical technique included only the implantation of a large mitral annuloplasty ring. Early and late outcome results were compared with those of the remaining patients who underwent conventional mitral valve repair for degenerative disease (controls). ResultsAll ring-only patients presented with moderate-severe/severe mitral regurgitation (vena contracta, 0.6 ± 0.1 cm; regurgitation volume, 52 ± 17 mL), with mainly a central jet and almost preserved ejection fraction (59% ± 6%). Cardiopulmonary bypass and crossclamp times were significantly shorter compared with controls (P < .0001). At follow-up (ring-only, 38 ± 36 months and controls, 36 ± 29 months), there were no late deaths in the ring-only group compared with 19 (4%) in the controls. Late follow-up revealed New York Heart Association functional class I or II in 95% of ring-only patients, compared with 90% of controls. Freedom from recurrent moderate or severe mitral regurgitation was 100% and 89% in the ring-only and control groups, respectively. ConclusionsMitral annuloplasty for Barlow disease patients with multisegment involvement and mainly central regurgitant jet is both simple and reproducible with excellent late outcomes.

Left ventricular remodeling following percutaneous edge-to-edge repair using Mitraclip

Background Percutaneous edge-to-edge repair with MitraClip has been recommended as an alternative to conventional mitral valve repair in symptomatic severe mitral regurgitation at very high surgical risk. Data on the impact of MitraClip on left ventricular volumes are scarce. Therefore we aimed to assess left ventricular remodeling following MitraClip. Methods Consecutive patients scheduled for MitraClip were prospectively studied. Patients with pacemaker or ICD were excluded. Transthoracic echocardiography and CMR at 1.5 Tesla were performed before and 6 months after MitraClip procedure. Left ventricular volumes were measured using transthoracic echocardiography (biplane Simpson’s method) and short-axis SSFP CMR images covering the left ventricle. Mitral insufficiency was graded using color Doppler flow mapping (grade 1-4). Results

Robotic-assisted mitral valve repair: surgical technique.

Robotic-assisted mitral valve repair represents the least invasive surgical approach currently available for anatomical mitral valve repair in patients with myxomatous mitral valve disease. Standard mitral valve repair techniques utilized during conventional sternotomy/right thoracotomy are exactly replicated with the robotic instrumentation through 1-2 cm port-like incisions with superior 3D visualization. This is performed on cardiopulmonary bypass by peripheral cannulation of the femoral vessels/right internal jugular vein. The ascending aorta is occluded with a transthoracic aortic cross-clamp. Antegrade cardioplegia is delivered centrally into the aortic root through a cardioplegia vent catheter. By replicating conventional mitral valve repair done via an open sternotomy approach, the quality of mitral valve repair is ensured while providing the patients with advantages of less invasive surgery including shorter hospital stay, rapid recovery and return to normal activities, less blood transfusion, superior cosmesis and complete elimination of sternotomy-related morbidities such as deep sternal wound infection and sternal dehiscence. We reviewed the first consecutive 200 patients undergoing robotic mitral valve repair at Mayo Clinic Rochester between 24 January 2008 and 28 January 2011. Successful mitral valve repair was completed in all patients. There were no early (30-day) deaths. One patient suffered a stroke (0.5%). One patient required reoperation for bleeding (0.5%). Two patients (1%) required reoperation for recurrent mitral regurgitation. Twelve patients (6%) required transfusion of allogeneic blood products. We have noted a significant reduction in operative times and resource utilization over time.

Percutaneous mitral valve repair in high-risk patients: initial experience with the Mitraclip® system in Belgium

Aims Treatment with percutaneous edge-to-edge mitral valve repair (Mitraclip®) has recently been recommended as an alternative to conventional mitral valve repair for high surgical risk patients with symptomatic severe mitral regurgitation (MR). In this study, we report the first use of Mitraclip® therapy in Belgium.Methods and results This prospective registry includes 41 consecutive patients treated with the Mitraclip® in two Belgian centres from October 2010 to June 2013. Acute procedural success, in-hospital safety end points and clinical status were analysed on an intention-to-treat basis up to one year after the procedure. In addition, determinants of major adverse cardiac events (MACE, death, surgical mitral valve intervention, and rehospitalization for heart failure) were analysed.Acute procedural success (successful clip placement and reduction of colour Doppler flow MR to ≤ 2) was obtained in 32 patients (78%) and 18 of these patients received two clips. The primary safety end point was reached in 36 pts (88%): one patient died due to intracranial bleeding, there were three urgent surgical interventions and one severe access site bleeding. The MACE rate after one year was 41% (17 patients). There were 11 deaths (27%), six surgical interventions (15%) and 10 rehospitalizations for heart failure (24%). Additional subgroup analysis revealed that the one-year MACE rate was particularly high in patients with left ventricular ejection fraction (LVEF) < 25%: 62% vs. 36% in patients with LVEF ≥ 25% (P = 0.05). At one year, MR ≤ 2+ and NYHA class ≤ 2 was present in 83% of the surviving patientsConclusion In high-risk patients with functional MR, treatment with the Mitraclip®-device is a feasible and safe option resulting in improvement of MR severity and clinical symptoms. However, as MACE is high in some subgroups (e.g. LVEF < 25%), careful patient selection is crucial to ensure the maximum benefit from this new technique.