Failure Of Mitral Valve Repair Research Articles

Mitral valve leaflet response to ischaemic mitral regurgitation: from gene expression to tissue remodelling.

Ischaemic mitral regurgitation (IMR), a frequent complication following myocardial infarction (MI), leads to higher mortality and poor clinical prognosis if untreated. Accumulating evidence suggests that mitral valve (MV) leaflets actively remodel post MI, and this remodelling increases both the severity of IMR and the occurrence of MV repair failures. However, the mechanisms of extracellular matrix maintenance and modulation by MV interstitial cells (MVICs) and their impact on MV leaflet tissue integrity and repair failure remain largely unknown. Herein, we sought to elucidate the multiscale behaviour of IMR-induced MV remodelling using an established ovine model. Leaflet tissue at eight weeks post MI exhibited significant permanent plastic radial deformation, eliminating mechanical anisotropy, accompanied by altered leaflet composition. Interestingly, no changes in effective collagen fibre modulus were observed, with MVICs slightly rounder, at eight weeks post MI. RNA sequencing indicated that YAP-induced genes were elevated at four weeks post MI, indicating elevated mechanotransduction. Genes related to extracellular matrix organization were downregulated at four weeks post MI when IMR occurred. Transcriptomic changes returned to baseline by eight weeks post MI. This multiscale study suggests that IMR induces plastic deformation of the MV with no functional damage to the collagen fibres, providing crucial information for computational simulations of the MV in IMR.

Use of Suture tightening automated device COR-KNOT® for minimally invasive heart valve surgery: Our initial experience in Bangladesh

Background: COR-KNOT® (LSI Solutions, New York, NY, USA) is an automated suture securing device has not been well known. We report a case series for first automated knotting device used for minimally invasive heart valve surgery in Bangladesh. Method and
 Results: To overcome the challenge of knot securing via a Key-Hole surgery we have used CORKNOT ®. The newest device is capable of remotely and automatically secure sutures and simultaneously can cut and remove the excess suture tails. We covered the spectrum of heart valve surgery: There was one case of bioprosthetic aortic valve replacement, one case of mitral valve repair, one case of bioprosthetic mitral valve replacement, one case of failed mitral valve repair with COR-KNOT® explantation followed by mechanical mitral valve replacement and one case of redo-mitral valve replacement. Average length of hospital stays was 5 ± 1days. There was one reopening, one post-operative atrial fibrillation. No wound infection and no 30day mortality.
 Conclusion: We conclude, COR-KNOT® is a safe and effective tool to reduce the duration of operation. Clinical outcome of heart valve surgery with COR-KNOT® is comparable with other methods of suture tying methods.
 Bangladesh Heart Journal 2019; 34(2) : 127-131

Can We Predict Failure of Mitral Valve Repair?

Objective: To identify echocardiographic and surgical risk factors for failure after mitral valve repair. Methods: We identified a total of 77 consecutive patients from our institutional mitral valve surgery database who required redo mitral valve surgery due to recurrence of mitral regurgitation after primary mitral valve repair. A control group of 138 patients who had a stable echocardiographic long-term result was included based on propensity score matching. Systematic analysis of echocardiographic parameters was performed before primary surgery; after mitral valve repair and prior to redo surgery. Risk factor analysis was performed using multivariate Cox regression model. Results: Redo surgery was associated with the presence of pulmonary hypertension ≥ 50 mmHg (p = 0.02), a mean transmitral gradient > 5 mmHg (p = 0.001), left ventricular ejection fraction ≤ 45% (p = 0.05) before surgery and mitral regurgitation ≥moderate at time of discharge (p = 0.002) in the whole cohort. Patients with functional mitral valve regurgitation had a higher tendency to undergo redo surgery if preoperative left ventricular end-diastolic diameter exceeded 65 mm (p = 0.043) and if postoperative tenting height exceeded 6 mm (p = 0.018). Low ejection fraction was not significantly associated with the need for redo mitral valve surgery in the functional subgroup. Conclusions: Recurrent mitral regurgitation is still a valuable problem and is associated with relevant perioperative mortality. Patients with severe mitral regurgitation should undergo early mitral valve repair surgery as long as systolic pulmonary artery pressure is low, left ventricular ejection fraction is preserved, and LVEED is deceeds 65 mm.

Redo mitral valve surgery following prior mitral valve repair.

The optimal treatment strategy following a failed mitral valve repair remains unclear. This study evaluated early and long-term outcomes of redo mitral valve repair (MVr) and replacement (MVR) after prior mitral valve repair. Patients undergoing redo mitral valve surgery after prior mitral valve repair at a single institution between 2002 and 2014 were reviewed. Primary outcomes included operative mortality (30-day or in-hospital mortality) and long-term freedom from mitral valve reoperation and death. Secondary outcomes included postoperative complications. 305 patients underwent redo MVr (n = 48) or MVR (n = 257) after prior mitral valve repair. Concomitant procedures included tricuspid valve repair or replacement (23%), aortic valve replacement (6%), and coronary artery bypass grafting (4%), with no differences between cohorts. 18% were performed via right mini-thoracotomy (24% MVr vs 18% MVR, P = 0.31). Unadjusted and risk-adjusted operative mortality were lower with MVr (0% vs 8%, P = 0.04). Rates of postoperative complications were similar except for blood product transfusion (35% MVr vs 59% MVR, P = 0.003) and prolonged mechanical ventilation (8% MVr vs 29% MVR, P = 0.003). Long-term freedom from mortality was comparable: 96% MVr versus 86% MVR at 1 year and 78% MVr versus 68% MVR at 5 years (P = 0.29). When technically feasible, mitral valve re-repair can be safely performed with outcomes comparable to MVR.

Percutaneous Techniques, Limitations and Challenges for the Failed Surgical Mitral Intervention.

The advent of percutaneous therapies has significantly altered therapeutic options for patients with valvular heart disease. Building on the success of transcatheter aortic valve replacement, both expanded indications and purpose-built devices are now being used to address percutaneous approaches for mitral valve pathology. While surgical mitral valve repair remains the gold standard for addressing significant mitral valve pathology, there has been a progressive increase in the utilization of bioprosthetic valves despite their limited lifespan. The risks of reoperation to address mitral valve repair failure or bioprosthetic valve dysfunction is not insignificant. In light of the aging population and the potential for significant associated comorbidities, less invasive alternative techniques hold particular appeal. Utilization of commercially available transcatheter aortic valve replacement valves for failed surgical valves has been shown to have better short-term mortality than would be predicted for open reoperation. As a result, the US Food and Drug Administration approved the utilization of transcatheter mitral valve-in-valve replacement for the failed bioprosthetic valve in high surgical risk patients. Despite the favorable outcomes, transcatheter mitral valve-in-valve is not without procedural challenges and potential complications including malpositioning, embolization, paravalvular leak, and outflow tract obstruction. Awareness of these challenges, mitigation strategies, and therapeutic options is imperative to optimizing outcomes in this high-risk patient population.

A retrospective audit of mitral valve repair surgery at Tygerberg Hospital

Background: Mitral valve repair is well established as the preferred treatment modality for the majority of patients with degenerative mitral valve disease requiring intervention. Valve repair offers a distinct event-free survival advantage compared with replacement with either a bioprosthetic or mechanical valve. At present, there are little data available on the management and outcome of mitral valve repair in South Africa. The aim of this study is to describe and compare the indications, specific pathology and outcomes of patients accepted for mitral valve repair. Internationally published figures for peri-operative mortality are less than 2% for degenerative mitral regurgitation, with a freedom from mitral valve reoperation of 94% at 10 years. Methods: All patients referred for mitral valve repair at Tygerberg Hospital, Cape Town, South Africa, between 1 December 2010 and 30 June 2015, were retrospectively included. Demographic characteristics, cardiovascular risk factors, pre-operative (NYHA) functional class, the pre- and post-operative transthoracic and transoesophageal echocardiograms, immediate in hospital mortality and 6-month post-surgical mortality and functional class were analysed. Repair failure was defined as either intra-operative conversion to MVR or need for reoperation at 6 months. Results: A total of 147 patients were referred for mitral valve repair, of which 114 patients were accepted for mitral valve repair by the local heart team. In total, 106 of the 114 patients underwent surgical intervention, 6 defaulted their surgical dates, and 2 refused surgery. Of those accepted for surgery, 57.9% were males, 42.1% were females, with a mean age of 47.7 years in both groups combined, 44.7% had hypertension, 43.9% were smokers and 21.1% had concomitant IHD; 56.1% were pre-operative NYHA functional class III, 29.8% were class II, 7% class IV, and 7% were class I; 60.2% had a 6-month post-operative NYHA functional class I, 32.3% had class II, 5.4% class III, and 2.2% had class IV. Mitral valve prolapse (MVP) with flail segment due to chord rupture was the predominant etiology (29%); P2 was the most common segment involved (36%), followed by A2 (29.8%). For MVP, including patients with infective endocarditis, the mortality rate was 4.8% at 30 days and 6 months. The overall mortality rates for all patients accepted for mitral valve repair were 4.7% and 6.6% at 30 days and 6 months respectively. Freedom from reoperation was 98% at 6 months. There was a significant association between bileaflet involvement and mitral valve repair failure (p=0.006). Chordal insertion with annuloplasty was the most common intervention used (45.5%). Conclusion: Mitral valve prolapse was the predominant etiology in patients referred for mitral valve repair. The mortality rate for mitral valve repair in the prolapse group was 4.8% at 6 months. Chordal insertion with annuloplasty was the most common intervention used. Bileaflet involvement was found to be an independent risk factor for repair failure. The mortality rate for all patients accepted for mitral valve repair was 6.6% at 6 months.

Causes of repair failure for degenerative mitral valve disease and reoperation outcomes.

This study aimed to evaluate the causes of initial mitral valve (MV) repair failure, the details of reoperation and the long-term outcomes of mitral valve re-repair (Re-MVP). We retrospectively reviewed 86 patients who underwent reoperation after MV repair for MR due to degenerative disease from October 1991 to December 2015. First, we analysed the initial MV repair data, causes of MV repair failure, reoperation data and long-term outcomes including survival. Second, the patients were classified into 2 groups based on valve related failure or procedure related failure , and the differences between the groups were analysed. Leaflet prolapse at the initial operation affected the bilateral leaflets in 37 (43%) patients, the anterior leaflet in 30 (35%) patients and the posterior leaftlet in 19 (22%) patients. Median duration from first operation to reoperation was 47.5 (interquartile range 4.8-85.8) months. Reoperation indication included recurrent mitral regurgitation alone in 59 patients, haemolysis combined with recurrent mitral regurgitation in 15 patients, infectious endocarditis combined with recurrent mitral regurgitation in 8 patients, mitral stenosis in 2 patients and left ventricular pseudoaneurysm in 2 patients. The cause of MV repair failure was valve-related in 61 (71%) patients, procedure-related in 20 (23%) patients and both in 5 (6%) patients. Re-MVP was successful in 23 (27%) patients. Re-MVP was more common in patients with procedure-related failure, which occurred earlier than valve-related failure. Freedom from all-cause death was significantly better after Re-MVP. The 5-year freedom from reoperation after Re-MVP was 95.7%. Re-MVP was more common in patients with procedure-related failure, which occurred earlier than valve-related failure. Durability of re-repaired MVs and survival of re-repaired patients were acceptable.

Comparative study of mitral valve repair in ischemic and rheumatic mitral regurge

BackgroundRheumatic affection is still a significant aetiology of mitral valve disease (MVD) in Egypt. Some of these patients with rheumatic predominant mitral regurge indicated for mitral repair may need a concomitant coronary artery bypass grafting (CABG). We aimed to compare the short-term outcomes of mitral valve (MV) repair in rheumatic and ischemic mitral regurge in patients undergoing CABG. MethodsBetween January 2014 and December 2015, we operated 71 patients of combined CABG and mitral valve repair surgery (with either ischemic or rheumatic mitral pathology).These patients were divided into two groups, group I: included 35 patients of rheumatic pathology, group II: included 36 patients of ischemic pathology. We compared the two groups regarding the operative, postoperative and 6 months follow up results. ResultsThere was no significant difference between the two study groups regarding preoperative data with exception of age and diabetes mellitus (DM). Ischemic cases had significantly higher mean age (54.1 ± 5.2 versus 49.77 ± 6.3, P value = 0.002) and significantly higher incidence of DM (44% versus 17.1, P value = 0.013). Rheumatic MV disease group had 6 cases of MV repair failure (17.1% versus 0.0% in group II). Regarding postoperative data ischemic valve group had a higher percentage of low cardiac output (COP) (86.1% versus 60%, statistically significant, P > 0.013). Ischemic group had higher mortality (13.9% versus 2.9% in group I). There was no significant difference between the two studied groups regarding 6 months follow up data. ConclusionsPatients with ischemic MVD were in a worse cardiac condition with higher hospital mortality than patients with combined rheumatic MVD and coronary artery bypass grafting. Patients with rheumatic MVD were usually having very complex pathology and in need modifications of standard repair techniques. Once discharged from hospital, both groups had comparable short and mid-term outcomes.

Impact of failed mitral valve repair on hospital outcome of redo mitral valve procedures.

The prognostic impact of failed mitral valve repair (FMR) on in-hospital outcome after redo mitral valve surgery has not been thoroughly investigated. Hospital outcomes after redo mitral valve surgery because of an FMR in patients from nine European centres were reported. Logistic regressions identified predictors of mortality in combined or isolated redo mitral valve operations. Hospital outcome was compared between propensity-matched cohorts with FMR and native mitral valves in the context of redo surgery and FMR versus failed prostheses. A total of 246 patients with FMR yielded a 6.5% mortality rate at redo surgery. FMR per se did not impact mortality at multivariable analysis ( P = 0.64). A preoperative Global Initiative for Chronic Obstructive Lung Disease (GOLD) score ≥2 chronic obstructive lung disease (COPD) (OR 15.2, P < 0.01), left ventricular ejection fraction <30% (odds ratio (OR) 21.5, P = 0.005), major injury to cardiovascular structures at re-entry (OR 27.2, P < 0.01) or injury to patent left internal mammary artery-coronary artery bypass graft (OR 7.6, P = 0.03) predicted mortality in the whole FMR population. GOLD ≥ 2 COPD (OR 12.3, P = 0.049), age at surgery (OR 1.15 for each incremental year, P = 0.049) and cardiopulmonary bypass duration (OR 1.02, P = 0.022) predicted mortality in isolated redo mitral valve surgery for FMR. The fourth (> 68 years = 13.8% mortality) and the fifth quintiles of age (≥73.4 years = 14.8%) reported the highest mortality (OR 3.8 and 4.2 respectively, P = 0.002) in this subgroup. Propensity-matched cohorts of FMR and native mitral valves in the context of redo surgery showed no differences in terms of mortality ( P = 0.69) and major morbidity (acute myocardial infarction P = 0.31, stroke P = 0.65, acute kidney injury P = 1.0), whereas more perioperative dialysis ( P = 0.04) and transfusions ( P = 0.02) were noted in propensity-matched failed prostheses compared to FMR. A failed mitral repair does not impact hospital outcome of redo surgery. Given the role of severe left ventricular dysfunction and advanced age on hospital mortality rates, an early indication for redo surgery may improve outcome.

Invited Commentary

Mitral annuloplasty ring dehiscence may occur in 1% to 10% of all mitral surgeries, but can have severe and potentially fatal consequences when it does. In this issue of The Annals, Pierce and colleagues [1Pierce E.L. Siefert A.W. Paul D.M. et al.How local annular force and collagen density govern mitral annuloplasty ring dehiscence risk.Ann Thorac Surg. 2016; 102: 518-526Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar] examine the mechanisms underlying mitral annuloplasty ring dehiscence. In this manuscript, “How Local Annular Force and Collagen Density Govern Mitral Annuloplasty Ring Dehiscence Risk,” Pierce and colleagues examine causative factors governing mitral annular ring suture dehiscence in a sheep model. Possible mechanisms contributing to dehiscence such as cyclic force, loading, annular flexion, and left ventricular pressures, among others, were quantified and correlated with relative collagen density differences at multiple points around the mitral ovine annulus. From this data, a propensity for mitral annular suture pull out and force margins of safety was developed. The results showed that the anterior annular holding strength exceeded posterior annular holding strength and that the overall pullout force required exhibited a strong correlation to local collagen density. Surprisingly, trigonal sutures were less secure (less resistant to pullout) than would have been predicted or thought by the authors, due to a combination of reduced collagen in the trigonal area and higher overall annular rigidity. This goes against popular belief that the trigones are the most secure area. This finding reinforces their finding that the inter-trigonal anterior annular tissue may be a superior anchor for a mitral annular ring. This fact may help guide clinicians in selection of type of ring (complete versus partial) and for future rings and mitral prostheses. Furthermore, this manuscript is also important as it brings up more questions to be considered. For example, ring dehiscence appears to be more common in the tricuspid annular position than mitral. What are the corresponding pullout forces in the tricuspid position? Are there significant differences between the ovine and the human annulus? What happens to pullout force when the annulus is overdistended and dilated, as is often seen in human congestive heart failure. All of these questions should be examined carefully as our field moves forward to possible percutaneous therapy for mitral and tricuspid disease. Data such as in the present manuscript will help with the technology of percutaneous implantations of mitral and tricuspid rings when annular ring implantation technique no longer includes direct visualization. The scientific quantitation of long-held popular beliefs in cardiac surgery is well warranted. The questioning and validation or abandonment of our standard practice should be a continual quality process. It is in this manner that we will best serve our future mitral patients. How Local Annular Force and Collagen Density Govern Mitral Annuloplasty Ring Dehiscence RiskThe Annals of Thoracic SurgeryVol. 102Issue 2PreviewAnnuloplasty ring dehiscence is a well described mode of mitral valve repair failure. Defining the mechanisms underlying dehiscence may facilitate its prevention. Full-Text PDF

How Local Annular Force and Collagen Density Govern Mitral Annuloplasty Ring Dehiscence Risk

Annuloplasty ring dehiscence is a well described mode of mitral valve repair failure. Defining the mechanisms underlying dehiscence may facilitate itsprevention. Factors that govern suture dehiscence were examined with an ovine model. After undersized ring annuloplasty in live animals (n= 5), cyclic force (FC) that acts on sutures during cardiac contraction was measured with custom transducers. FC was measured at ten suture positions, throughout cardiac cycles with peak left ventricular pressure (LVPmax) of 100, 125, and 150 mm Hg. Suture pullout testing was conducted on explanted mitral annuli (n= 12) to determine suture holding strength at each position. Finally, relative collagen density differences at suture sites around the annulus were assessed by two-photon excitation fluoroscopy. Anterior FC exceeded posterior FC at each LVPmax (eg, 2.8 ± 1.3 N versus 1.8 ± 1.2 N atLVPmax= 125 mm Hg, p < 0.01). Anterior holding strength exceeded posterior holding strength (6.4 ± 3.6 N versus 3.9 ± 1.6 N, p<0.0001). On the basis of FC at LVPmax of 150 mm Hg, margin of safety before suture pullout was vastly higher between the trigones (exclusive) versus elsewhere (4.8 ± 0.9N versus 1.9± 0.5 N, p < 0.001). Margin of safety exhibited strong correlation to collagen density (R(2)= 0.947). Despite lower cyclic loading on posterior sutures, the weaker posterior mitral annular tissue creates higher risk of dehiscence, apparently because of reduced collagen content. Sutures placed atop the trigones are less secure than predicted, because of a combination of reduced collagen and higher overall rigidity in this region. These findings highlight the inter-trigonal tissue as the superior anchor and have implications on the design and implantation techniques for next-generation mitral prostheses.

Surgical techniques in mitral valve diseases. Reconstruction and/or replacement

Mitral valve (MV) disease is one of the most common heart valve diseases. The surgical and interventional treatment for MV disease requires a multidisciplinary approach. For primary mitral valve regurgitation (MVR) surgical MV repair is the treatment of choice, which can be performed with an excellent outcome and long-term survival in reference centers. The surgical technique used for MV repair depends on the pathological mechanism, the morphological dimensions of the MV, the operative risk and the expertise of the cardiac surgeon. The surgical and interventional treatment of secondary MVVR is the subject of on-going discussions. In patients with moderate secondary MVR undergoing coronary artery bypass grafting, concomitant MV repair should be performed. In the presence of severe secondary MR with risk factors for failure of MV repair, patients should consider having MV replacement. In the rare cases of patients presenting with mitral valve stenosis (MVS) MV repair can be considered in young patients and who are most often treated with MV replacement. The choice between biological or mechanical MV replacement depends on the pathophysiology, the comorbidities, the amount of anticoagulation necessary and the age of the patient. New percutaneous techniques for MV replacement offer new treatment options for reoperation in high-risk patients.

Abstract 13699: A True World Picture - Surgical Revision After Percutaneous Mitral Valve Repair With the Mitraclip Device

Background: Transcatheter mitral valve (MV) repair is of increasing interest facing however questionable mid term results. We herein report MV reference center experience of 18 patients who underwent MV surgery after failed percutaneous MV repair with MitraClip device (Evalve, Menlo Park, CA). Methods: Between June 2010 and October 2013, a total of 141 patients with severe mitral regurgitation (MR) underwent MitraClip procedure at Heart Center Leipzig. 11 patients (7.8%) needed surgical treatment for failed MV repair with the MitraClip device. For the same reasons we admitted 7 patients who underwent MitraClip procedure in other cardiac surgery centers. Mean EuroScore II of the patients was 23,51 (5,17-60,14). Results: From the group of 18 patients undergoing surgical treatment after MitraClip repair, 14 patients (77.7%) received one or more clip-implants and 4 patients (22.2%) suffered from failed MitraClip implantation. All patient were symptomatic (n=9, 50% - NYHA III; n=9, 50% - NYHA IV). The primary indications for surgery were: partial clip detachment (n=11, 61.1%), failed MitraClip implantation (n=4, 22.2%), recurrent MR greater than moderate (2+) (n=3, 16.6%), acute mitral valve endocarditis (n=1, 5.5%), mitral ring and clip detachment (n=1, 5.5%). 13 patients (72.2%) underwent MV replacement, 3 patients (16.6%) received left-ventricular assist device (LVAD), 2 patients (11.1%) underwent MV repair. One-month mortality reached 27,8% (n=5), and the overall mortality reached 50% (n=9). Conclusions: MV repair was feasible in only 2 cases (11.1%). Despite the high operative risk, surgical treatment after percutaneous MV repair failure with the MitraClip device is an option to be considered.

3D Echocardiography in Cardiac Surgery

Herein, we present a patient who underwent successful repair of failed mitral valve repair in whom intraoperative 3D transesophageal echocardiography provided accurate assessment of the mechanism of mitral regurgitation. In addition, we review the potential advantages and limitations of 3D echocardiography and its role in cardiac surgery.

Re-repair of the mitral valve as a primary strategy for early and late failures of mitral valve repair

With the expanding uptake of mitral valve repair as the primary therapy for mitral valve regurgitation, an increasing cohort of patients are presenting with failures following valve repair. These patients have traditionally been treated by mitral valve replacement. We have adopted an aggressive strategy of valve re-repair for failures of mitral valve repair and present our mid-term results. Fifty-three consecutive adults underwent reoperation by a single surgical team for failed non-rheumatic mitral valve repair. Primary valve repair had been done for degenerative (n=38), congenital (n=6), infective (n=3), functional (n=1) or unknown (n=5) mitral disease. The reoperative mitral procedure occurred at a median interval of 3 (interquartile range 0.9-6.5) years from the primary mitral valve repair. Valve re-repair was attempted if the anterior leaflet was sufficiently pliable, and lesions causing recurrence were identifiable and deemed treatable. Standard repair techniques were employed in re-repair procedures. Valve analysis showed that the mode of failure was progression of original disease in 19 (36%), technical failure in 20 (38%) and new disease in 14 (26%) patients. Valve re-repair was successfully accomplished in 45 (85%) patients. Re-repair was most frequent when the prior aetiology was degenerative (34 of 38, 90%) as opposed to non-degenerative (11 of 15, 73%). There were no hospital deaths. Four-year patient survival was 97%. Freedoms from moderate mitral regurgitation were 100, 95, 88 and 80% at discharge and at 1, 3, and 4 years, respectively. There were no reoperations in the follow-up period. Re-repair of the mitral valve is feasible in most of the cases of failed mitral valve repair of non-rheumatic aetiology and has acceptable mid-term outcomes. The relatively high prevalence of technical failures as the mechanism of failure of the primary mitral valve repair suggests the need for ongoing surgical education and continuing development and refinement of repair techniques.

Transapical Valve-in-Valve-in-Ring for Stenotic Mitral Valve Repair

A 53-year-old woman, previously treated with irradiation and chemotherapy for Hodgkin lymphoma, was referred for redo valve surgery. She had had a pacemaker implantation and undergone coronary bypass surgery, mitral valve repair with a Carpentier-Edwards 28-mm Physio-annuloplasty ring, as well as a mechanical tricuspid valve replacement and a transfemoral CoreValve 26-mm implantation. She had cardiac cachexia, pleura effusion, and a failed mitral valve repair with stenosis. She was judged inoperable for open surgery but suitable for a transapical valve-in-valve implantation on partial femorofemoral bypass. A 26-mm Edwards SAPIEN XT aortic valve inversely mounted on the Ascendra + delivery catheter was balloon expanded into the Physio ring. During expansion, the introducer sheath remained too deep into the left ventricle and rotated the SAPIEN valve upward to the left atrium, creating the onset of a new mitral regurgitation and retaining the stenosis. Another Edwards SAPIEN XT 26-mm valve was then positioned into the first valve in a "valve-in-valve-in-ring" tandem configuration. Both valves were supported by the Physio ring. The stenosis and the regurgitation were thereafter eliminated.

Transcatheter valve-in-ring implantation after failure of surgical mitral repair

Redo surgery after failed mitral valve repair may be high risk, or contraindicated in patients with comorbidities. Because of this high risk, other interventional possibilities like transcatheter valve implantation might be of benefit. We report our experience with transcatheter mitral valve-in-ring implantation (TVIR) in high-risk patients after failure of surgical ring annuloplasty. From January 2010 to February 2012, following a multidisciplinary discussion, 17 high-risk patients underwent TVIR using Edwards SAPIEN XT prostheses, via either a transvenous transseptal (n = 8), or a transapical approach (n = 9). Patients were aged 70 ± 16 years, in New York Association classes III/IV. Their mean logistic EuroSCORE was 36 ± 17% and mean Society of Thoracic Surgeons risk score 13 ± 9%. The mean time interval between surgery and repair failure was 7 ± 3 years. Annuloplasty rings were semi-rigid in 14 cases, flexible in 2, and rigid in 1. Manufacturers ring diameters were 26 mm in 4 patients, 27 mm in 1, 28 mm in 9, 30 mm, 31 mm and 34 mm in 1. The predominant failure mode was regurgitation in 12 cases and stenosis in 5. SAPIEN XT diameters were 26 mm in 15 patients, 23 mm and 29 mm in 1. Procedural success rate was 88% (15/17). Emergency surgery was needed in 1 patient due to acute dislodgement of the ring. The degree of mitral regurgitation was reduced to none or mild in all but 2 patients; final mean gradient was 7 ± 3 mmHg. Thirty-day survival was 82% (14/17 patients). At last follow-up (13 ± 5 months), survival rate was 71% (12/17). These preliminary results suggest that TVIR is feasible, with low operative risk, and may provide short-term clinical and haemodynamic improvement in selected high-risk patients with failure of mitral ring annuloplasty.

Hemolysis after Mitral Valve Repair

Hemolysis is a potential complication of mitral valve repair. We report a case of hemolytic anemia after mitral valve repair successfully treated with re-repair, and review the literature on reoperation after failure of mitral valve repair with associated hemolysis.

The prevalence and impact of deep clefts in the mitral leaflets in mitral valve prolapse

Deep clefts are a cause of early failure of mitral valve repair, but it is not known whether clefts represent normal morphology, or whether they occur more frequently in mitral valve prolapse (MVP). Deep clefts were defined as indentations extending ≥ 50% of the depth of the mitral valve leaflet. Using trans-oesophageal echo (TOE), 3D zoom images were acquired of the mitral valve in 176 patients: 76 patients with MVP, 43 patients with alternative causes of mitral regurgitation (MR), and 57 controls. Three-dimensional TOE results were corroborated with findings made at surgery for a subset of patients who subsequently underwent mitral valve surgery. An assessment of the proportion of the valve that was prolapsing was documented, and correlated to the number of clefts. The relationship of clefts to the region of prolapse or flail was recorded. Three-dimensional TOE was 93% sensitive and 92% specific for detecting clefts. Clefts were documented in 84% of patients with MVP, but significantly less frequently in patients with alternative MR (16%; P < 0.001) and controls (12%, P < 0.001). Clefts always appear in prolapsing regions or framing them, and the number of clefts increased in patients with more extensive prolapse. Clefts are frequently seen in MVP, but are uncommon in patients without this diagnosis. They occur in greater numbers as a larger proportion of the valve prolapses. They may play an important role in the development of MVP.

CARDIAC SURGERY Clinical and echocardiographic predictors of recurrent mitral regurgitation following restrictive mitral annuloplasty. Evaluation in patients with chronic ischemic mitral regurgitation

Aim of the study: The aim of this study was to determine the clinical and echocardiographic predictors of recurrent mitral regurgitation after undersized ring implantation for ischemic mitral regurgitation (MR). Recurrent MR occurs in up to 30% of patients after undersized ring implantation. Understanding the causes of recurrent MR should improve the results of this kind of surgery. Material and methods: The pre- and postoperative echocardiograms of 134 patients operated on for ischemic mitral regurgitation using ring implantation were analyzed. The median follow-up period was 13 months. Results: The strongest influence on MR recurrence was exerted by coaptation length (OR 0.022; p = 0.001), effective regurgitant orifice area (EROA) (OR 1.85; p < 0.002), and vena contracta measured preoperatively (OR 1.42; p = 0.007). The independent predictors of recurrent MR included: the postoperative length of leaflet coaptation, preoperative left ventricular ejection fraction, the severity of regurgitation, and body surface area (BSA). The coaptation length cut-off value of < 6.2 mm was associated with 94% sensitivity and 85% specificity in the prediction of recurrent MR. Conclusions: This study showed that the recurrence of MR after undersized mitral ring implantation is low. The measure of coaptation length is superior to other echocardiographic parameters in the prediction of MR recurrence. Our model of risk stratification may predict mitral valve repair failure after restrictive annuloplasty.