Durability Of Mitral Valve Repair Research Articles

HOW TO MANAGE MITRAL VALVE POSTERIOR LEAFLET HYPOPLASIA

Abstract Background Mitral valve posterior leaflet hypoplasia is a relatively rare and often congenital anatomical malformation. In this condition, achieving a good and durable mitral valve repair still represents a challenge for surgeons. Methods We present the case of a 43 years old man presenting with exertional dyspnoea due to severe mitral regurgitation. Transthoracic and transesophageal echocardiograms revealed a severe hypoplasia of the posterior mitral leaflet with an significant prolapse of the anterior leaflet (particularly A2–A3), which determined massive regurgitation. The anteroposterior annular diameter was 38 mm with a 4 mm mitro–anular disjunction, left ventricular telediastolic diameter was 59 mm and ejection fraction 68%. No other cardiac malformations were evident; in particular tricuspid valve was normal. Results Surgery was performed through a right mini–thoracotomy with femoral cannulation, using three–dimensional video–assisted technology. The mitral valve was approached from the left atrium, behind the interatrial groove. Surgical inspection revealed a severely hypoplasic posterior leaflet and a wide anterior leaflet prolapsing near the postero–medial commissure (A2–A3) (Figure 1). Based on our previous experience, we decided to repair the valve performing a posterior para–commissural edge–to–edge (A3–P3) followed by an atypical annuloplasty using a bovine pericardium band, shaped on a 40 mm ring sizer, only in the postero–medial portion of the mitral annulus (Figure 2). On the hydrostatic test, the valve showed a satisfactory continence, that was confirmed on the intraoperative TEE. Postoperative course was uneventful and the patient was discharged home on postoperative day 7. Transthoracic echocardiography at discharge showed a good result of the mitral valve repair with no residual regurgitation a medium gradient across the mitral valve of 3 mmHg. Conclusions In our experience, reductive annuloplasty isn’t the optimal treatment for hypoplasic mitral valve posterior leaflet because it lowers the already small posterior leaflet, thus reducing the coaptation surface. To avoid this, we introduced this technique that improved our surgical outcomes.

Coaptation Length as Predictor of Recurrent Mitral Regurgitation After Surgical Repair for Degenerative Mitral Valve Disease: Meta-Analysis of Reconstructed Time-to-Event Data

Coaptation Length as Predictor of Recurrent Mitral Regurgitation After Surgical Repair for Degenerative Mitral Valve Disease: Meta-Analysis of Reconstructed Time-to-Event Data

Predictability and durability of mitral valve repair in patients with severe degenerative mitral regurgitation in medium sized centres.

Mitral valve repair (MVr) is now the treatment of choice to correct severe degenerative mitral regurgitation (MR). Repair rates vary greatly from centre to centre, and the concept of heart valve centres of excellence has been established. The purpose of this study was to see whether large international centre repair rates, and outcomes, are transferrable to medium-sized centres with an interest in mitral repair. Between 2011 and 2018, a total of 346 patients underwent mitral valve surgery by a single surgeon. Of these, 238 consecutive patients had repairs, or attempted repairs for degenerative MR, and are included in this study. The study sample consisted of 71% male patients and had a mean age of 64.4 ± 12.3 years; 66% of the study population had concomitant procedures. The overall repair rate in this cohort is 99%. Mean follow up was 3.7 ± 1.9 years. At 5 years, the freedom from MR ≥ 3+ was 95.9 ± 1.9% and at 7 years 91.1 ± 3.8%. Freedom from reoperation at 5 years was 92.9 ± 3.7%, while the 5 years actuarial survival was 89.1 ± 3.7%. On a multivariate analysis, predischarge echo grade was associated with higher risk of future reoperation (odds ratio (OR) = 21.82, p = 0.05). Only age (OR = 1.3, p = 0.03) was predictive of long-term survival. In specialised medium-sized heart centres, where the surgical team have undergone specialist mitral training, favourable short- and long-term outcomes are achievable with mitral repair rates similar to those from large international centres of excellence. In these heart centres, early surgery should be considered for all patients with severe degenerative MR.

Artificial chordae for mitral valve repair.

Mitral valve repair using expanded polytetrafluoroethylene sutures to replace mitral chordae tendineae is a well-established procedure. However, the incidence of neo-chordae failure causing recurrent mitral regurgitation is not well defined. We have reviewed the reported cases of complications after mitral valve repair related to the use of neo-chordae. This study was mainly carried out through PubMed, Medline, and Google Chrome websites. We have identified a total of 26 patients presenting with rupture of polytetrafluoroethylene neo-chordae, mostly being described as isolated cases. Few other cases of recurrent mitral regurgitation with hemolysis were found, where reoperation was not caused by neo-chordal failure but most likely by technical errors. At pathological investigation the findings were substantially similar in all reported cases. The neo-chordae retained their length and pliability, became covered with host tissue and rupture was mainly related to suture size. Mild calcification was observed not interfering with chordal function; chordal infection did never occur. The use of artificial neo-chordae provides excellent late results with durable mitral valve repair stability. Chordal rupture may occur late postoperatively leading to reoperation because of recurrent mitral regurgitation. Despite its rarity, this potential complication should not be overlooked during follow-up of patients after mitral valve repair using artificial neo-chordae.

Institution representation in publications reporting mitral valve repair durability: A scoping review.

Mitral valve repair durability currently plays a key role in operative decision making and in defining optimal surgical practice. However, mitral valve durability outcomes measures are not captured by national registries and limited to centers that publish their outcomes. In this study, we aim to describe the scope of institutions represented by reports describing durability outcomes after mitral valve repair within the contemporary literature. A scoping review of the literature was performed to extract abstracts potentially reporting mitral valve operation outcomes published between 2000-2019. 370 full text articles reporting mitral valve durability outcomes by either reoperation rate or rate of recurrent mitral regurgitation met criteria for analysis. Study characteristics including case volume, country and institution of origin, and surgeon volume were extracted and used to calculate the proportion of total cases in the top 3, 5, and 10 represented countries and institutions by the sum of reported mitral valve repairs described. The top 5 of 21 countries represented 78.9% of the mitral valve repair cases described. The top 3 most represented institutions described 20,120 (37.3%) of all mitral valve repairs in 58 (33.9%) single-center studies. Published mitral valve repair durability data must be interpreted with caution when used to derive policies and practice recommendations that govern the cardiovascular community at large.

Mitral valve repair with a device for artificial chordal implantation at 2 years

ObjectivesThis study examines the early and midterm safety, efficacy, and durability of mitral valve repair for primary mitral regurgitation (MR) using the ChordArt device (CoreMedic) for chordal replacement. MethodsFive patients with symptomatic severe primary degenerative MR due to isolated central posterior leaflet prolapse/flail were treated with the ChordArt device in a transseptal surgical approach and followed prospectively with periodical clinical and echocardiographic assessments for 2 years. ResultsReduction of MR immediately after the implantation of artificial chords was achieved in all patients showing no or trace MR (<1+/4+). In all patients, MR <1+ was maintained during 24 months of follow-up. No dehiscence, detachment, or dislocation of the implanted ChordArt devices was observed. Transthoracic echocardiography showed that left ventricle end diastolic diameter significantly decreased during the whole follow-up period in comparison to baseline condition, especially at discharge and 1-month follow-up. Left ventricle end systolic diameter also significantly decreased during the whole follow-up period in comparison to baseline condition. Left atrial volume significantly decreased during the follow-up period in comparison to discharge. No major adverse events, as defined per protocol, were observed during the intervention or during the follow-up period. ConclusionsThe ChordArt device allows successful treatment of primary degenerative MR due to posterior mitral leaflet prolapse or flail, with a good safety profile and promising immediate clinical and echocardiographic benefits that are confirmed up to 24 months.

Clinical Outcomes After Durable Mitral Valve Repair for Ischemic Mitral Regurgitation

BackgroundThis study aimed to clarify the incidence and determinants of postoperative adverse events in patients with ischemic cardiomyopathy who achieved long-term durable mitral valve repair. MethodsBetween 1999 and 2015, 166 patients with chronic ischemic mitral regurgitation (MR) and a left ventricular ejection fraction ≤40% underwent restrictive mitral annuloplasty. During follow-up (65 ± 34 months), echocardiographic assessments were performed 809 times (mean, 4.9 ± 2.4 times), and 20 patients who had postoperative recurrent MR (moderate or severe) were excluded. Finally, 146 patients (aged 68 [63-75] years) whose MR was well controlled over time were included. ResultsA total of 61 deaths or 27 readmissions for heart failure were observed in 76 patients (52%). Among hospital survivors, age (adjusted hazard ratio, 1.05; P = .001) and estimated glomerular filtration rate (adjusted hazard ratio, 0.61; P = .001) were identified as independent predictors of long-term mortality or readmission for heart failure. The degree of postoperative left ventricular function recovery was comparable between patients with and without adverse events. However, the former group showed greater values for systolic pulmonary artery pressure, tricuspid regurgitation severity, inferior vena cava dimension, and plasma brain natriuretic peptide level throughout the follow-up period (group effect P < .05 for all). ConclusionsApproximately 50% of patients died or were hospitalized for heart failure even in the absence of recurrent MR during the 5-year follow-up, a finding indicating that durable mitral repair does not always lead to favorable clinical outcomes. The adverse events may have been related to volume overload secondary to impaired renal function and less favorable pulmonary hemodynamics.

Current Perspectives on Contemporary Rheumatic Mitral Valve Repair.

The surgical management of rheumatic mitral valve disease remains a challenge for cardiac surgeons. Durability of mitral valve repair (MVr) is likely compromised not simply due to high technical demand, but surgeon reluctance, despite boasting copious advantages over MV replacement. This comprehensive review aims to evoke a deeper understanding of MVr concepts necessary to abate these limitations and shift mindset towards a more holistic approach to repair. Details of commonly utilized techniques in contemporary MVr for rheumatic heart disease will be discussed. Of importance, the reparative procedures will be mapped to an in-depth physiological exploration of the mitral complex-dynamism and rheumatic interplay. This is further emphasized by outlining the current “aggressive” resection strategy in contemporary rheumatic MVr.

Lessons from reoperations for mitral stenosis after mitral valve repair

BackgroundThe durability of mitral valve repair (MVr) is usually defined by the absence of recurrent significant mitral regurgitation. Postrepair mitral stenosis (MS) is a less frequent and less studied mode of failure of MVr. We analyzed our experience in patients who underwent reoperation for postrepair MS to characterize mechanisms resulting in MS and to summarize reoperative surgical strategies and mid-term outcomes. MethodsUsing a prospective database, we retrospectively analyzed data on 35 consecutive patients who underwent reoperation for symptomatic moderate to severe MS between January 1, 2011, and February 1, 2020. ResultsThe mean patient age was 61.4 ± 11.4 years, and 69% were female. The median annuloplasty ring size used at the initial repair was 28 mm (interquartile range, 26-30 mm). Additional repair techniques at the initial operation included leaflet resection in 12 patients (34%) and commissuroplasty or edge-to-edge repair in 6 patients (18%). At reoperation, the most common mechanism of MS was pannus ingrowth in 20 patients (57%), leaflet calcification in 12 (34%), commissural fusion in 5 (14%), and tunnel effect (functional MS) in 3 (9%). Twenty-two patients (63%) underwent valve replacement, and 13 (37%) underwent valve re-repair. In patients who underwent re-repair, annuloplasty revision was performed in all patients, with 6 patients (46%) converted from complete ring to band, 4 (11%) converted from ring to pericardial annuloplasty, 2 (6%) converted to no annuloplasty, and 1 (8%) with annuloplasty ring upsizing. There were no in-hospital or 1-year mortalities. Survival at the 5-year follow-up was 93.9%. ConclusionsMS causing late failure of MVr is frequently associated with smaller ring sizes and inflammatory or calcific changes in the valve. Highly selected patients may be good candidates for mitral valve re-repair.

Abstract 16801: Papillary Muscle Tip Approximation in Repair of Ischemic Mitral Regurgitation in a Chronic Swine Model

Introduction: Mitral valve (MV) repair with undersized annuloplasty (UMA) for ischemic mitral regurgitation (IMR) is being abandoned in favor of valve replacement (MVR) following CTSN trial results. However, in patients with durable repair, survival and left ventricular function (LVF) were significantly better than MVR. Achieving a durable repair with UMA is challenging as it draws leaflets away from papillary muscle (PM) insertions, causing unphysiological tethering and unicuspid configuration that fails (FigA-B). Hypothesis: Drawing PM tips together with an approximating stitch (PMT-A) can relieve leaflet tethering and enable better repair (FigC). A chronic swine model of IMR was used to compare effects of isolated PMT-A, UMA and PMT-A+UMA on MV and LV at 3 months post surgery. Methods: Twenty-five farm swine underwent catheterization and occlusion of left circumflex artery, resulting in postero-lateral myocardial infarction (MI). Two months after MI, IMR severity of &gt;2+ was confirmed on echo, and animals underwent one of the 3 repairs: PMT-A (n=6), UMA (n=8), PMT-A+UMA (n=11). Echo was performed postoperatively and repeated with MRI at 3 months (FigD). MV kinematics, coaptation geometry, and LVF were assessed. Results: IMR was eliminated after all repairs and did not recur through the study. Annulus continued to grow after PMT-A, but not in UMA or PMT-A+UMA group (FigE1) without increasing severity of IMR. Compared to prerepair, tenting depth was significantly reduced only in PMT-A and PMT-A+UMA groups (FigE2). Both leaflet excursion angles (diastolic minus systolic angles) increased after PMT-A, but not in other groups (FigE3-4). LV size and LVF was similar between groups, confirming that PMT-A did not perturb diastolic filling. Conclusions: In this model of IMR, PMT-A improved leaflet mobility, compared to isolated UMA or PMT-A+UMA. PMT-A is a simple technique that can potentially improve durability of MV repair by restoring valvular kinematics.

The Length of the Neochords for Correction of Mitral Valve Leaflet Prolapse

Chordal replacement with expanded tetrafluoroethylene (ePTFE) sutures is commonly used to correct leaflet prolapse in degenerative mitral and tricuspid valve disease. The concept of “respect rather than resect” the posterior leaflet was introduced by Perier and colleagues1 and has become the motto of many mitral valve repair surgeons. I continue to use Carpentier’s classical techniques of leaflet resection in some patients, but the introduction of chordal replacement with ePTFE sutures increased the probability of mitral valve for leaflet prolapse close to 100% and also enhanced the durability of mitral valve repair in my practice.

Sex-based differences in mitral valve Re-operation after mitral valve repair: Truth or myth?

BackgroundOutcomes after mitral valve (MV) repair are known to be worse in women. Less is known about sex-based differences in MV repair durability. MethodsAll adult patients undergoing MV repair from 2002 to 2016 were reviewed. Of 2463 cases, 947 (39%) were women. Re-operation risk was defined as any intervention for repair failure or MV disease progression. Median follow-up was 8.2 years. ResultsWomen were older with higher STS-risk scores and were more likely to have rheumatic disease (RHD). Operative mortality was clinically higher in women (2.7% vs 1.7%; P = 0.09). Although women had significantly higher 10-year re-operation risk (7% vs 4%), adjusted longitudinal analysis showed that this was associated with RHD in women (HR 4.04; P = 0.001). Female sex alone was not a significant predictor (P = 0.21). ConclusionsRe-operation following MV repair was infrequent. Women had increased re-operation risk that was largely attributable to their worse preoperative profiles rather than female sex alone.

Development of a Reproducible Swine Model of Chronic Ischemic Mitral Regurgitation: Lessons Learned

Durability of mitral valve repair for ischemic mitral regurgitation (IMR) remains poor. We established a swine model of chronic IMR, and describe the methods and lessons learned from this model. Thirty-five swine underwent percutaneous myocardial infarction with ethanol ablation of the circumflex or obtuse marginal (OM) arteries. Swine were followed with routine echocardiography for the development of severe IMR. Once severe IMR was established, swine underwent mitral valve operations on cardiopulmonary bypass. After operation, swine were survived up to 7 weeks. Angiographic and echocardiographic features of swine who developed severe IMR (IMR swine) and those who did not (non-IMR swine) were compared. The median number of OM arteries was 3, with2 OM arteries infarcted. Acute survival after the myocardial infarction was 74% (26 of 35) with 3 (9%) early,postoperative deaths. Among the 23 swine with follow-up todetermine IMR status, 14 of 23 (61%) developed significant IMR. Among IMR pigs, left ventricular (LV) ejection fraction decreased from 65% pre-myocardial infarction to 45% pre-mitral valve intervention (P < .001). Among non-IMR swine, LV ejection fraction decreased nonsignificantly from baseline (60%) to latest follow-up (55%) (P= .443). LV end-diastolic dimension (P= .039), wall motion score (P= .027), global circumferential strain (P= .014), and global longitudinal strain (P= .023) were significantly worse in IMR compared with non-IMR swine. A reproducible percutaneous model ofsevere IMR in swine is feasible with a guided anesthetic and perioperative approach. This model canserve as a platform to better understand the mechanism of IMR and subsequently to test novel repair techniques.

Recurrent mitral regurgitation after mitral valve repair for bileaflet lesions in the modern era

BackgroundGood mid-term durability of mitral valve repair of bileaflet lesions has been reported; however, patients may develop failure during follow-up. This study assessed late outcomes and mechanisms of failure associated with mitral valve repair of bileaflet lesions.MethodsFifty-six patients (mean age 67 ± 12 years) underwent mitral valve repair of bileaflet lesions due to degenerative disease in 2011–2018. Mitral annuloplasty was added to all procedures except for 1 patient with annular calcification. Mitral valve lesions were identified by surgical inspection. Mean clinical and echocardiography follow-up occurred at 2.7 ± 2.1 and 2.5 ± 1.9 years, respectively.ResultsAdditional mitral valve repair techniques involved triangular resection (n = 15 patients), quadrangular resection with sliding plasty (n = 12), neochordoplasty (n = 52), and commissural plication (n = 26). Prolapse of ≥2 anterior and posterior leaflet scallops occurred in 22 (39%) and 30 (54%) patients, respectively. During follow-up, 10 (17.8%) patients developed moderate or severe mitral regurgitation. Whereas prolapse or tethering was observed early after neochordoplasty or quadrangular resection, recurrent regurgitation occurred late after commissural repair. Five-year freedom from recurrent moderate or severe mitral regurgitation rates was 71.1 ± 11.0%.ConclusionsSeventeen percent of patients developed recurrent mitral regurgitation during follow-up. Repair failure in the early phase occurred owing to aggressive resection of the posterior mitral leaflet or maladjustment of the artificial neochordae. Recurrent mitral regurgitation might occur in the late phase even after acceptable commissural repair. A sequential approach may be useful to improve the quality of mitral valve repair in bileaflet lesions.

Impact of Lesion Localization on Durability of Mitral Valve Repair in Infective Endocarditis

Mitral valve (MV) repair for infective endocarditis (IE) is sometimes challenging. We investigated the durability of repair associated with the location of the infected lesion. The study comprised 83 patients (55 ± 18 years; active, 66; healed, 17) who underwent MV repair at our institution. Patients were categorized into 5 types based on the location of the main lesion: type I, posterior leaflet (n= 36); type IIC, clear zone of anterior leaflet (n= 12); type IIR, rough zone of anterior leaflet (n= 28); and type III, annulus (n= 7). Type IIR was divided into 2 subgroups: IIR-large (>1 segment involvement, n= 9) and IIR-small (1 segment, n= 19). Follow-up was 95.2% completed for 7.2 ± 5.2 years. The rate of recurrent moderate or severe mitral regurgitation (MR) was 2.8% in type I, 0% in type IIC, 28.6% in type IIR, and 14.3% in type III. The freedom from recurrent moderate or severe MR was significantly lower in type IIR compared with the other types (63.1% ± 10.6% vs 96.8 ± 3.2% at 5 years, P< .001). Moreover, the recurrence rate was higher in type IIR-large (55.6%) than in type IIR-small (15.8%, P= .068). Type IIRwasan independent predictor of recurrent MR (hazard ratio, 11.1, 95% confidence interval, 2.52-78.2; P= .001). The durability of MV repair for IE was satisfactory in posterior leaflet infection without annulus invasion and in clear zone infection of the anterior leaflet. However, rough zone infection of the anterior leaflet, especially with more than 1 segment involvement, was associated with a high risk of recurrent MR.

Durability of mitral valve repair: A single center experience.

This study aims to present clinical outcomes of mitral valve repair in patients with different etiologies. Between June 2006 and August 2017, a total of 421 consecutive patients (266 males, 155 females; mean age 53.1±15.6 years; range, 5 to 89 years) who underwent mitral valve repair with or without concomitant cardiac procedures were retrospectively analyzed. All pre-, intra-, and postoperative data were collected. Echocardiographic examinations were performed at discharge and during follow-up. Kaplan-Meier analysis was used to estimate overall survival and from residual severe mitral regurgitation, endocarditis and reoperation-free survival rates. The mean follow-up was 58.9±35.1 months. Of the patients, 12 (2.8%) had previous cardiac operations. The most predominant pathology was degenerative disease in 265 patients (62.9%). Repair techniques included ring annuloplasty (n=366, 86.9%), artificial chordae implantation (n=185, 44%), and commissurotomy (n=38, 9%). Overall in-hospital mortality rate was 1.2% (n=5). Echocardiography before discharge showed no/trivial mitral regurgitation in 64.9% (n=270) and mild mitral regurgitation in 34.85% (n=145) of the patients. At the late postoperative period, transthoracic echocardiography revealed moderate mitral regurgitation in 23 patients (5.7%) and severe in 11 patients (2.7%). The mean late survival and freedom from endocarditis, reoperation, and recurrent severe mitral regurgitation rates were 92±0.03%, 98.5±0.07%, 98.1±0.01%, and 94.7±0.02%, respectively. Our study results suggest that mitral valve repair is a safe and effective procedure associated with favorable longterm outcomes in experienced centers.

Leaflet Resection versus Chordal Replacement for Degenerative Mitral Regurgitation: Long-term Outcomes According to the Technique Used

Background: Mitral valve repair (MVR) is the technique of choice for the treatment of degenerative mitral regurgitation (MR). Leafletresection has demonstrated excellent mid-term and long-term outcomes, but there are still disagreements in the literature at themoment of choosing between resection or conservative techniques.Objective: The primary outcome was to compare the durability of MVR and freedom from reoperation of the quadrangular andtriangular leaflet resection techniques versus chordal replacement in degenerative MR. The secondary outcome was to analyze theresults of the surgical techniques, the incidence of early postoperative complications and a composite outcome of mortality, reoperationor progression to significant MR in this population.Methods: We conducted a retrospective cohort study in patients with degenerative MR undergoing MVR (leaflet resection or chordalreplacement) between January 2005 and December 2017. A total of 154 patients were included: 78 in the leaflet resection group and76 in the chordal replacement group. Ten patients underwent both procedures and were excluded from the analysis.Results: Mean age was 66.4±13.9 years (p=0.3) A minimally invasive approach was used in 29.8% of cases. Mortality at 30 days was1.2% in the leaflet resection group vs. 1.3% in the chordal replacement group (p=0.31), and it was 2.4% vs. 1.3%, respectively, in thelong-term follow up (p=0.62). Cardiopulmonary bypass time was longer in the chordal replacement group (160.3±51.3 minutes vs.130.4±42.4 minutes, p<0.001), as well as the number of anterior leaflet (17.1% vs. 3.8%, p=0.007) and both leaflet repairs (17.1%vs. 3.8%, p<0.001). At the long-term follow-up, freedom from reoperation was 97.4%, freedom from significant MR was over 90% andsurvival at 7 years was 97.4% in the entire cohort. Atrial fibrillation was the most common complication (5.8%).Conclusions: Both techniques had excellent and similar results in terms of mortality, freedom from reoperation and freedom fromsignificant MR.

2019 AATS/ACC/ASE/SCAI/STS expert consensus systems of care document: A proposal to optimize care for patients with valvular heart disease: A Joint Report of the American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.

This statement was commissioned as a Multisociety Expert Consensus Systems of Care Document by the American Association for Thoracic Surgery (AATS), American College of Cardiology (ACC), American Society of Echocardiography (ASE), Society for Cardiovascular Angiography and Interventions (SCAI), and

Strategy-specific durability of mitral valve repair through the video-assisted right minithoracotomy approach.

We sought to analyze the early and follow-up results of minimally invasive video-assisted mitral valve repair. With particular focus on degenerative disease, results were stratified according to type of lesion, strategy of repair and surgical technique. We retrospectively built a database over 241 patients who received mitral repair for severe regurgitation through right minithoracotomy in the 2009-17 period. Cause was degenerative in 92.1%, restrictive in 5.8% and mixed in the remainders. Clinical and echocardiographic follow-up (98.7% complete, average duration 2.9 years ± 1.4) was obtained through contact of in-house and territorial cardiologists. Recurrent mitral regurgitation at follow-up was defined as being at least mild-to-moderate (2+). Operative mortality was 1.7%, and related to the technique in one case. Five-year actuarial survival was 95% ± 2; there was no valve-related death and one reoperation. At follow-up, we observed eight cases of 2+ regurgitation and one instance of 4+ regurgitation (4-year actuarial freedom: 92% ± 4). Freedom from recurrent regurgitation was significantly lower in the 'restrictive' subgroup vs. the 'degenerative' subgroup (P = 0.02); no statistically significant difference in freedom from recurrence was observed among patients who received mitral repair using a 'resect' vs. 'nonresection' strategy (P = 0.46), and in those who received the Totally Endoscopic technique (endoaortic balloon occlusion, no costal spreading) vs. controls (external aortic clamp, costal spreading) (P = 0.98). Durability of minimally invasive mitral repair is optimal. Nonresection repair techniques are at least noninferior to previous approaches based on leaflet resection.

Reconstructive surgery of an extremely calcified mitral valve in Barlow disease patient: A case report

Introduction: Mitral valve calcifications are frequent finding in the Barlow disease. This is makinkg mitral repair surgery even more demanding in already complex valve pathology. Case report: Fifty-five year old Barlow disease patient underwent mitral repair surgery due to posterior leaflet prolapse at P2 level and extensive posterior leaflet and annular calcifications as well. Prolapsed scalop was resected, while P1 and P3 scalops were detached from the annulus. After complete posterior annulus decalcification, so formedlarge atrio-ventricular defect was reconstructed with autologous pericardial patch and double suture line technique.P1 and P3 segments were reatched thereafter by sliding technique, and sutured with no strain. Annuloplasty was performed with saddle rigid ring No 36. Patient was discharged nine days after the surgery with just a trace of mitral reguritation. Conclusion: Annular decalcificaion and reconstruction in patients with calcified Barlow mitral disease is neccessary for safe and durable mitral valve repair surgery.