Leaflet Procedures Research Articles

A novel approach of tricuspid valve repair: mitralization of tricuspid valve

OBJECTIVESThis study presents the mid-term results of a novel tricuspid valve (TV) repair strategy defined as ‘mitralization of TV’ (resection and plication of the posterior leaflet, ring implantation, optional leaflet procedures) applied for the correction of tricuspid regurgitation (TR).METHODSBetween 2017 and 2020, a total of 22 patients underwent concomitant TV repair using mitralization of the TV. Fourteen of the patients had functional TR (2 of them had severe tethering), 5 patients had prolapse and 3 patients had rheumatic involvement.RESULTSThere was no in-hospital mortality. Moderate or severe TR was not observed in any patient in echocardiographic evaluations before discharge. The mean follow-up duration was 30.9 + 6.2 months. Moderate-to-severe TR-free survival was 100% in the second year and 94.7% in the third year.CONCLUSIONSMitralization of the TV is a safe and effective treatment modality in terms of its mid-term results. This new technique provides an innovative perspective for the treatment of TR, especially in complex TV pathologies.

Minimally invasive aortic valve repair using geometric ring annuloplasty.

As aortic valve repair (AVr) for aortic insufficiency (AI) expands, minimally invasive (Mi) approaches are increasingly being applied. Cardiac surgical techniques can be more difficult through small incisions, and this report analyzes medium-term outcomes for MiAVr facilitated by geometric ring annuloplasty. Since 2013, 58 patients were selected for AVr through upper sternotomy third-interspace incisions. The average age was 58.9 ± 15.4 (mean ± SD) years, 71% were male, and preoperative AI grade was 3.6 ± 0.8. Sixty-two percent (36/58) had a proximal aortic replacement for ascending aortic aneurysms (n = 26) and/or remodeling grafts for aortic root aneurysms (n = 10). Annuloplasty rings were placed subannularly (69% trileaflet; 31% bicuspid), and leaflet procedures were performed in 70%. The average ring diameter was 21.6 ± 1.4 mm, and the average aortic clamp time was 113 ± 35 min. After repair, AI grade fell to an average of 0.5 ± 0.6 (p < .0001), with a mean valve gradient of 12.5 ± 7.1 mmHg. No operative mortalities or major complications occurred. Three patients required reoperations for bleeding, and two had pacemakers. At an average follow-up of 38 months (maximal 88 months), three late deaths and no valve-related complications were observed. Four patients required reoperative aortic valve replacement over follow-up, and Kaplan-Meier survival and freedom from reoperation both exceeded 80% at 88 months. At the last follow-up, the average AI grade was 0.7 ± 0.7, and the mean valve gradient was 12.7 ± 6.3 mmHg. Geometric ring annuloplasty was safe and seemed to facilitate performing AVr ± proximal aortic replacement through Mi incisions. Hemodynamic improvements were significant, medium-term clinical outcomes were acceptable, and results could improve further with experience.

Reparación valvular aórtica bicúspide. Resultados

Introduction and objectivesThe clinical practice guidelines do not specifically mention valve repair in patients with aortic regurgitation and bicuspid aortic valve as an alternative to prosthesis implantation. Bicuspid repair may require complex techniques such as the use of pericardium. We intend to analyze the long-term evolution of bicuspid and tricuspid repair. Methodsprospective, non-randomized, analysis of 138 patients with aortic valve repair (2011-2019). Two groups: bicuspid valve 55 (40%) and tricuspid valve 83 (60%). ResultsBicuspid-group: mean age 51.1 ± 13.8 years, 12 (21.8%) women; EuroSCORE-Logistic 6.7 ± 4; preoperative-regurgitation: I-II (25.4%), III-IV (74.6%). Tricuspid-group: mean age 62.7 ± 12.6 years, 21 (25.3%) women; 8 (9.6%) emerging; EuroSCORE-Logistic 10.9 ± 8.1; preoperative-regurgitation: I-II (13.2%), III-IV (86.8%). Procedures performed: bicuspid-group: valve-reimplantation (DAVID) 24 (43.6%); aortic-remodeling (Yacoub) 18 (32.7%); supracoronary-tube + aortic-plasty-4 (7.3%); aortic-plasty 9 (16.4%). Tricuspid-group: DAVID 54 (65.1%); Yacoub 4 (4.8%); supracoronary-tube + aortic-plasty 11 (13.3%); aortic-plasty 14 (16.9%). Leaflet procedures: 56.6% (tricuspid-group) and 97.3% (bicuspid-group) p < 0.0001.There was conversion to intraoperative prosthesis: 15 (18.1%) tricuspid-group and 1(1.8%) bicuspid-group. Eight (5.8%) patients died in the immediate postoperative period (3.9% of electives).The median follow-up was 42.5 months. The peak gradient (mmHg) in follow-up: bicuspid-group 16.3 ± 5.4 vs. tricuspid-goup 8.3 ± 1.4 (p < 0.0001).At 9 years, they are free of aortic regurgitation ≥ III: 83.5% (whole-series); 90.4% (tricuspid-group) vs. 73.9% (bicuspid-group), p = 0.07; 100% (tricuspid-group-without-pericardium-plasty) vs. 70.5% (tricuspid-group-with-pericardium-plasty), p = 0.001; 92.9%(bicuspid-group-without-pericardium-plasty) vs. 57.7% (bicuspid-group-with-pericardium-plasty), p = 0.009. Free of re-operation: 88.4% (whole-series), 94.2% (tricuspid-group) vs. 80.1% (bicuspid-group), p = 0.086; 100%(tricuspid-group-without-pericardium-plasty) vs. 82.1% (tricuspid-group-with-pericardium-plasty), p = 0.01; 100% (bicuspid-group-without-pericardium-plasty) vs. 62.7% (bicuspid-group-with-pericardium-plasty), p = 0.007. ConclusionsThe bicuspid valve requires complex repairs, but less conversion to an intraoperative prosthesis; bicuspid repair offers results not inferior to tricuspid repair, with good durability and hemodynamics; the use of pericardium, more frequent in bicuspid valves, reduces durability.

Current Status of Mitral Valve Repair

AbstractBackground: Techniques of MV repair have undergone many modifications and improvements in the last three decades, which have made it a more predictable and reproducible method either in rheumatic or degenerative mitral valve repair.Aim of Study: 1- Comparing the results of repairing degenerative mitral valve versus the rheumatic pathology. 2- Assessment the results of resectional technique (excising part of valve leaflet) and the respect one (preserving the valve leaflet without excision any part of it) for posterior leaflet prolapse during the degenerative mitral valve repair.Patients and Methods: This prospective study was con-ducted in the Department of Cardiac Surgery, National Heart Institute (NHI) from July 2014 to December 2017 including postoperative follow-up at 6 months. One hundred cases with severe mitral valve regurgitation underwent mitral valve repair divided into two groups: Group “D” where 50 cases had degenerative mitral valve pathology with a predominant mitral regurgitation and Group “R” where 50 cases had rheumatic valve disease with a predominant mitral regurgitation and high likelihood of repair. Techniques used for repair of prolapsed degenerative PML divided into resection technique and respect one.Results: As regards comparison between Group “D” versus Group “R” there was significant increase in MV area, MPAP and mean diastolic gradient of MV in group “D” than group “R” at 6 months of post-operative follow-up. Five cases in Group “R” had a mean diastolic mitral gradient more than 10mmHg that needed mitral valve replacement, four cases of them were post leaflets' shaving and decalcification. Degree of residual mitral regurgitation in Group “D” included 41 (82%) cases with no or trivial regurgitation while 9 (18%) cases were mild, whereas in group “R” 37 (74%) cases had no or trivial regurgitation, 9 (18%) had mild mitral regurgita-tion, 2 (4%) was mild to moderate and 2 (4%) cases had moderate mitral regurgitation that needed further follow-up with echocardiography every 6 months. Comparison between resection technique versus respect one revealed a significance difference between both groups as regards MVA and size of the ring annuloplasty but no significance difference was found between both groups as regards degree of residual MV regurgitation or mean diastolic MV gradient after 6 months of follow-up.Conclusions: The early postoperative results for posterior mitral leaflet repair with respect technique using Uniscalloping of posterior leaflet or artificial chordae-ePTFE-is very accept-able and recommended. Using of artificial chordae to AML is very effective and safe to solve the problem of leaflet prolapse. Rheumatic valve repair appears to be possible in selected cases with rheumatic mitral valve dysfunction. Leaflet procedures in rheumatic valve repair may be associated with reduced durability of rheumatic MV repair.

Comparative long-term results of mitral valve repair in adults with chronic rheumatic disease and degenerative disease: Is repair for “burnt-out” rheumatic disease still inferior to repair for degenerative disease in the current era?

Mitral valve repair is perceived to be of limited durability for advanced rheumatic disease in adults. We aim to examine the long-term outcomes of repair for rheumatic disease, identify predictors of durability, and compare with repair for degenerative disease. Rheumatic and degenerative mitral valve repairs in patients aged 40 years or more were prospectively analyzed. The primary outcomes investigated were mortality, freedom from reoperation, and valve failure. Logistic regression analysis was performed to define predictors of poor outcome. Between 1997 and 2011, 253 rheumatic and 148 degenerative mitral valves were repaired. The age of patients in both groups was similar, with a mean of 54.1 ± 8.4 years versus 55.6 ± 7.3 years (P = .49). Freedom from reoperation for rheumatic valves at 5 and 10 years was 98.4%, comparable to 95.3% (P = .12) for degenerative valves. Freedom from valve failure at 5 and 10 years was 91.4% and 81.5% for rheumatic repairs and 82.5% and 75.4% for degenerative repairs, respectively (P = .15). The presence of residual mitral regurgitation greater than 2+ before discharge was the only significant independent predictor of reoperation, whereas residual mitral regurgitation greater than 2+ and leaflet procedures were significant risk factors for valve failure. The durability of rheumatic mitral valve repair in the current era has improved and is comparable to the outstanding durability of repairs for degenerative disease, even in the adult rheumatic population. Modifications of standard repair techniques, adherence to the importance of good leaflet coaptation, and strict quality control with stringent use of intraoperative transesophageal echocardiography have all contributed to the improved long-term results.

Valve-sparing aortic root replacement and remodeling with complex aortic valve reconstruction in children and young adults with moderate or severe aortic regurgitation

The durability of valve-sparing aortic root procedures with aortic regurgitation due to leaflet disease is questioned. Here, we review our experience in combined aortic root and valve reconstruction in children and young adults. All valve-sparing aortic root procedures from 2000 to 2012 were reviewed, and patients with aortic valve repair beyond resuspension were included. Root procedures were classified as replacement with reimplantation, root remodeling, or aortic annular and sinotubular junction stabilization. The primary end point was structural valve deterioration, a composite of aortic valve reoperation and/or moderate or greater regurgitation at follow-up. Thirty-four patients were included during the study period. The surgery consisted of reimplantation in 13 patients, remodeling in 16 patients, and annular and sinotubular junction stabilization in 5 patients. Valve repair consisted of leaflet procedures in 26 patients and subannular reduction in 15 patients. During a median follow-up of 4.2 months (range, 2 weeks-8 years), there were 5 reoperations for aortic valve replacement due to aortic regurgitation, and 2 patients presented with moderate or greater regurgitation. Freedom from structural valve deterioration was 70.1% ± 10.3% at 1 year and remained stable thereafter, although it was significantly worse in the reimplantation group (P = .039). A more severe degree of preoperative aortic regurgitation (P = .001) and smaller graft to aortic annulus ratio (P = .003) were predictors of structural valve deterioration. Valve-sparing root and valve reconstruction can be done with low operative risk and allows valve preservation in most patients. These data should question the assumption that reimplantation is superior when associated with complex valve reconstruction.

Early results of a novel technique for ring-reinforced aortic valve and root restoration†

Surgery for aortic root aneurysm without valve stenosis is increasingly being transformed from the Bentall procedure to valve-sparing aortic root remodelling or reimplantation. In this report, a new repair option is explored, with full functional 'restoration' of the aortic root complex using a geometric annuloplasty ring, leaflet repair, and sinus/ascending aortic replacement with a Valsalva graft. The geometric annuloplasty ring restores elliptical annular shape and size in patients with tri-leaflet aortic insufficiency (AI). The ring mounts the three valve commissures on 10° outwardly flaring posts, and facilitates required leaflet procedures. In clinical application, the device has been effective in achieving stable AI reduction with low valve gradients. In this report, 6 patients with aortic root aneurysms and moderate/severe AI were managed with valve repair using the annuloplasty device and leaflet reconstruction, and then concomitant sinus and ascending aortic graft replacement with coronary implantation. In the 6 initial root aneurysm patients, there were no in-hospital mortalities, procedural conversions, or valve-related complications. Preoperative AI grade was 2-4 and fell to 0-1 postoperatively. Post-repair mean systolic gradients ranged from 7 to 12 mmHg, and all patients had stable intermediate-term valve function. Aortic root restoration using a geometric annuloplasty ring and Valsalva graft may be the most physiological method of aortic valve repair and root replacement. Even with severe leaflet derangements, valve sparing can be achieved with good competence and potentially stable long-term results. This technique could assist in extending valve sparing into most categories of aortic root disease. Patients were managed as part of a Phase I (ClinicalTrials.gov Identifier: NCT01400841), supported by BioStable Science and Engineering (BSE), Austin, TX, USA; www.biostable-s-e.com.

Reply to Kestelli et al.

We thank Kestelli et al. [1] for their interest in our article [2] and appreciate the editor for the opportunity to reply. To begin with, we would like to stress on the importance of selecting patients who will be best benefited by repair in rheumatic mitral valve disease. Most important factors determining the reparability include the extent of subvalvular apparatus involvement, degree of calcification, and severity of leaflet retraction. If the continuity from papillary muscle to leaflet edge is not pliable enough, coaptation margin will not allow a competent valve function even though sufficient leaflet surface area is obtained through leaflet augmentation procedures. In such cases, valve replacement will be a better option because, as was shown from our previous report, long-term clinical outcomes of mechanical valve replacement were nearly comparable to those of valvuloplasty [2]. We believe ring annuloplasty should be performed even if the valve appears competent following leaflet procedures because the annulus has already been affected by the disease and therefore further annular dilatation is possible. In case of rheumatic mitral regurgitation, the maintenance of both annular dimension and its shape is known to play an important role to prevent mitral regurgitation recurrence [3]. Therefore, implantation of a complete rigid ring (or a semi-rigid ring) is preferred over flexible or partial rings. Generally, the selection of ring size is based on the measurement of anterior leaflet surface area. With adequate process of patient selection, ring annuloplasty can offer a sufficient coaptation margin even without leaflet extension or augmentation in many cases. For this, the restrictive motion of leaflet (type IIIa dysfunction) should be relieved by adequate release procedures such as commissurotomy, papillary muscle splitting, and leaflet mobilization according to the morphology of rheumatic involvement. In cases where leaflet edges are as pliable as to allow repair but leaflet surface area is insufficient to make adequate coaptation margin even after release procedures, leaflet augmentation or extension procedures are necessary to obtain a satisfactory coaptation surface. In these cases, a similar rule is applied in determining the ring size as for those cases without leaflet extension or augmentation. For example, when posterior leaflet is augmented, the adequate ring size is generally the same size as the size that covers the anterior leaflet surface area. When the anterior leaflet is augmented, the ring size should be the same size as the size that covers the entire anterior leaflet including the augmented area. If the sizing is equivocal, we believe choosing the larger size is advisable to prevent mitral stenosis. In our previous report, leaflet augmentation technique was not as frequently performed as in other reports [2]. This is perhaps because we had more cautious and conservative attitudes toward valve repair for patients with more severe leaflet pathology in that valve replacement was preferred in potential candidates for leaflet augmentation. Most importantly, intraoperative trans-esophageal echocardiography should be followed after pump weaning for confirmation of valve competence with adequate coaptation margin. If not satisfactory, re-repair or conversion to replacement should be followed.

Surgical management of secondary tricuspid valve regurgitation: Annulus, commissure, or leaflet procedure?

Techniques employed today concomitantly with left-sided heart valve surgery address secondary tricuspid valve regurgitation at 3 anatomic levels-annulus, commissure, and leaflet-although success of these alone or in combination in eliminating tricuspid regurgitation is uncertain. Our objective was to assess the comparative effectiveness of these techniques in reducing or eliminating secondary tricuspid regurgitation. From 1990 to 2008, 2277 patients underwent tricuspid valve procedures for secondary tricuspid regurgitation concomitantly with mitral (n = 1527, 67%), aortic (n = 180, 7.9%), or combined (n = 570, 25%) valve surgery. These included annulus (flexible prosthesis [n = 1052, 46%], rigid prosthesis [standard = 387, 3-dimensional = 197; 26%], Peri-Guard annuloplasty [Synovis Surgical Innovations, St Paul, Minn; n = 185, 8.1%], and De Vega suture [n = 129, 5.7%]), commissure (Kay [n = 248, 11%]), and leaflet (edge-to-edge suture [n = 79, 3.5%] +/- annulus or commissural) procedures. A total of 4745 postoperative transthoracic echocardiograms in 1965 patients were analyzed. By 3 months after surgery, only 32% of patients overall had no tricuspid regurgitation. However, by 5 years, this had decreased to 22%, and 3+/4+ tricuspid regurgitation had increased from 11% at 3 months to 17%. Patients with rigid ring annuloplasty alone, either standard or 3-dimensional, had the least increase of 3+/4+ tricuspid regurgitation (to 12% at 5 years) compared with either a commissural or leaflet procedure. Rigid prosthetic ring annuloplasty, standard or 3-dimensional, provides early and sustained reduction of tricuspid regurgitation secondary to left-sided valve disease without need for an additional leaflet procedure. However, results are imperfect, possibly because other anatomic levels (subvalvular, papillary muscle, and right ventricular) contributing to its pathophysiology are unaddressed.

Outcomes After Repair of the Anterior Mitral Leaflet for Degenerative Disease

Repair of anterior mitral disease is challenging. Objectives of this study were to (1) compare patients with anterior versus posterior disease, (2) identify factors predisposing to replacement rather than repair in anterior disease, (3) determine durability of, and survival after, repair, and (4) compare outcomes with those after posterior repair. From January 1985 to January 2006, 3,544 patients underwent primary isolated mitral valve surgery for degenerative disease, including 307 isolated anterior (252 repairs, 82%) and 2,754 isolated posterior (2,650 repairs, 96%) leaflet procedures. Logistic regression analysis was used to identify predictors of valve replacement and to generate propensity scores for risk-adjusted comparisons. Durability was assessed by reoperation and return of mitral regurgitation. Patients with anterior disease were older and more symptomatic, with more chordal elongation and greater changes in cardiac morphology and function; advanced age was associated with replacement (p < 0.0001). Unadjusted freedom from reoperation was 89% at 10 years, worse than after posterior repair (p < 0.0001). Return of 3+ to 4+ mitral regurgitation was more common in those with anterior than posterior repair (11% versus 4% at 1 year; p = 0.03). Unadjusted survival was 83% versus 88% 10 years after posterior repair, but propensity-adjusted survival was similar (p >or= 0.5). Patients with anterior disease have more symptoms and greater changes in cardiac structure and function than do patients with posterior disease. Anterior repair is less durable than posterior, but is associated with comparable, excellent long-term survival. More durable repair techniques, applicable to the broader spectrum of anterior disease, are needed.

Percutaneous Treatment for Mitral Regurgitation: The QuantumCor System

Percutaneous edge-to-edge techniques and annuloplasty have been used to treat mitral regurgitation (MR). However, neither intervention can be performed reliably a second time and, with annuloplasty, a foreign body is left behind. The mitral and tricuspid annuli are areas of dense collagen (Fig. 1); treatment with radiofrequency (RF) energy in sheep reduces their size, and can be repeated without affecting the coronary sinus. RF energy may also be used in leaflet procedures. Our aim was to improve mitral valve competence using techniques that can be incorporated into a minimally invasive approach. In open-heart procedures in 16 healthy sheep (6 with naturally occurring MR), we used a malleable probe (QuantumCor, Inc., Lake Forest, CA) that conforms to the annular shape to deliver RF energy via a standard generator to replicate a surgical mitral annular ring. Four segments of the posterior mitral valve annulus were treated while on cardiopulmonary support via a left thoracotomy with access via the atrial appendage. Seven sheep were followed chronically. All sheep underwent intracardiac echocardiography (ICE) or direct circumferential measurement of the mitral annulus before and after RF therapy. RF therapy was administered in less than 4 minutes in each case, and the mean anteroposterior (AP) annular distance was reduced by a mean of 5.75 +/- 0.86 mm (23.8% reduction, P< 0.001). In the 6 sheep with nonischemic MR, regurgitation was eliminated. Acute histopathology (HP) demonstrated no damage to the leaflets, coronary sinuses, or coronary arteries. At 30 days, the AP distance continued to be reduced in the 7 surviving sheep (mean 5.0 +/- .6 mm, 21.4% reduction, P< 0.001). In a sheep model, RF energy applied for less than 4 minutes per case at subablative temperatures in four quadrants of the posterior mitral valve annulus reduced the AP and circumferential annular distances significantly, and eliminated nonischemic MR. Results will need to be confirmed in follow-up studies to determine safety and efficacy. RF energy administered as a novel, percutaneous method of mitral valve annuloplasty may have the potential to reduce morbidity and mortality associated with current surgical techniques.

Anterior leaflet procedures during mitral valve repair do not adversely influence long-term outcome

Objectives. This study was done to assess the impact of anterior mitral leaflet reconstructive procedures on initial and long-term results of mitral valve repair.Background. It has been suggested that involvement of the anterior leaflet in mitral valve disease adversely affects the long-term outcome of mitral valve repair. Our policy has been to aggressively repair such anterior leaflets with procedures that include triangular resections in some cases.Methods. From June 1979 through June 1993, 558 consecutive Carpentier-type mitral valve repairs were performed. The anterior mitral leaflet and chordae tendineae were repaired in 156 patients (mean age 58 years). The procedures included anterior chordal shortening in 78 patients (50%), anterior leaflet resections in 44 (28%), resuspension of the anterior leaflet to secondary chordae in 42 (27%) and anterior chordal transposition in 27 (17%). Concomitant cardiac surgical procedures were performed in 75 patients (48%).Results. The operative mortality rate was 2.5% (2 of 81) for isolated mitral valve anterior leaflet repair and 3.8% (6 of 156) for all mitral valve anterior leaflet repair. Freedom from reoperation at 5 and 10 years was, respectively, 89.7% (n = 160) and 83.4% (n = 24) for the entire series of 558 patients, 91.9% (n = 51) and 81.2% (n = 10) for patients with anterior leaflet procedures, 88.8% (n = 109) and 84.4% (n = 14) for patients without anterior leaflet procedures and 91.7% (n = 118) and 88.9% (n = 18) for patients without rheumatic disease. Logistic regression showed that rheumatic origin of disease (odds ratio 2.99), but not anterior leaflet repair, increased the risk for reoperation.Conclusions. These results demonstrate that expansion of mitral valve techniques to include anterior leaflet disease yields immediate and long-term results equal to those seen in patients with posterior leaflet disease.