Minimally Invasive Mitral Valve Repair Research Articles

Serial Cardiac Magnetic Resonance Imaging in Patients with Mitral Valve Prolapse-A Single-Center Retrospective Registry.

Background: Mitral valve prolapse (MVP) and mitral annular disjunction (MAD) are common valvular abnormalities that have been associated with ventricular arrhythmias (VA). Cardiac magnetic resonance imaging (CMR) has a key role in risk stratification of VA, including assessment of late gadolinium enhancement (LGE). Methods: Single-center retrospective analysis of patients with MVP or MAD who had >1 CMR and >1 24 h Holter registration available. Data are presented in detail, including evolution of VA and presence of LGE over time. Results: A total of twelve patients had repeated CMR and Holter registrations available, of which in four (33%) patients, it was conducted before and after minimal invasive mitral valve repair (MVR). After a median of 4.7 years, four out of eight (50%) patients without surgical intervention had new areas of LGE. New LGE was observed in the papillary muscles and the mid to basal inferolateral wall. In four patients, presenting with syncope or high-risk non-sustained ventricular tachycardia (VT), programmed ventricular stimulation was performed and in two (50%), sustained monomorphic VT was easily inducible. In two patients who underwent MVR, new LGE was observed in the basal inferolateral wall of which one presented with an increased burden of VA. Conclusions: In patients with MVP and MAD, repeat CMR may show new LGE in a small subset of patients, even shortly after MVR. A subgroup of patients who presented with an increase in VA burden showed new LGE upon repeat CMR. VA in patients with MVP and MAD are part of a heterogeneous spectrum that requires further investigation to establish risk stratification strategies.

Alternative minimally invasive surgical explantation techniques for failed transcatheter mitral valve repair devices.

The use of transcatheter mitral valve repair (TMVr) devices is increasing in elderly and high-risk patients. However, the increasing number of patients with recurrent mitral regurgitation (MR) has confronted surgeons with the issue of how to explant the devices and whether the mitral valve should be repaired or replaced. The aim of the study is to summarize our clinical experience with the explantation of different TMVr devices and to provide alternative surgical techniques that can be performed in different clinical scenarios. A simulator system including a dummy valve representing native valves was used to create video documentation and to develop alternative surgical methods for clip explantation. Moreover, the clip explantation techniques were shown in 2 patients undergoing minimally-invasive mitral valve repair after a failed TMVr. Alternative explantation techniques were described for each TMVr device; 2 techniques for MitraClip and 3 techniques for PASCAL (Precision Transcatheter Valve Repair System), which may be adjusted for each individual according to the underlying valve pathology and the degree of device encapsulation. The patients were discharged without residual MR and remained MR free at the follow-up. Transcatheter edge-to-edge repair devices can be surgically explanted without damaging the MV leaflets. Removal of each device may require a different technique tailored to the degree of device encapsulation and valve pathology. Increasing experience may facilitate repair in patients with recurrent MR after TMVr.

Selecting the Access and Approach: Resect Versus Respect

Since the late 90s, minimally invasive mitral valve repair (MIMVR) has become a routine technique in cardiac surgery. It is generally defined as a small surgical chest wall incision, which does not involve a complete sternotomy. Using this approach, nearly every surgical technique for mitral valve repair that is performed via full sternotomy can and should also be performed using a mini access approach, as MIMV surgery does not mean accepting compromises.

Continuous field flooding versus final one-shot CO2 insufflation in minimally invasive mitral valve repair

BackgroundInsufflation of carbon dioxide (CO2) into the operative field to prevent cerebral or myocardial damage by air embolism is a well known strategy in open-heart surgery. However, here is no general consensus on the best delivery approach.MethodsFrom January 2018 to November 2021, we retrospectively collected data of one hundred consecutive patients undergoing minimally invasive mitral valve repair (MIMVR). Of these, fifty patients were insufflated with continuous CO2 1 min before opening the left atrium and ended after its closure, and fifty patients were insufflated with one shot CO2 10 min before the start of left atrium closure. The primary outcome of the study was the incidence of transient post-operative cognitive disorder, in particular agitation and delirium at discontinuation of anesthesia, mechanical ventilation (MV) duration and intensive care unit (ICU) length of stay.ResultsIn all patients that received continuous field flooding CO2, correction of ventilation for hypercapnia during cardiopulmonary bypass (CPB) was applied with an increase of mean sweep gas air (2.5 L) and monitoring of VCO2 changes. One patient vs. 9 patients of control group reported agitation at discontinuation of anesthesia (p = 0.022). MV duration was 14 ± 3 h vs. 27 ± 4 h (p = 0.016) and ICU length of stay was 33 ± 4 h vs. 42 ± 5 h (p = 0.029). A significant difference was found in the median number of total micro-emboli recorded from release of cross-clamp until 20 min after end of CPB (154 in the continuous CO2 group vs. 261 in the one-shot CO2 control group; p < 0.001). Total micro-emboli from the first 15 min after the release of cross-clamp was 113 in the continuous CO2 group vs. 310 in the control group (p < 0.001). In the continuous CO2 group, the median number of detectable micro-emboli after CPB fell to zero 9 ± 5 min after CPB vs. 19 ± 3 min in the control group (p = 0.85).ConclusionContinuous field flooding insufflation of CO2 in MIMVR is associated with a lower incidence of micro-emboli and of agitation at discontinuation of anesthesia, along with improved MV duration and ICU length of stay.

Minimally invasive mitral valve repair for degenerative etiology: a comparative study

BackgroundThere is a paucity of data comparing the minimally invasive mitral valve repair (MiMVr) to the conventional approach in patients with degenerative disease. Our objective was to compare the outcomes of MiMVr to the traditional mitral valve repair through median sternotomy in patients with degenerative mitral valve disease. We conducted a retrospective study on 215 patients classified into two groups. Group 1 (n = 80) included those who had mitral valve repair through a right anterolateral video-assisted mini-thoracotomy, and group 2 (n = 135) was approached through a conventional median sternotomy. We compared the preoperative, operative, and postoperative data between groups. Both groups had echocardiographic follow-ups after 6 and 12 months.ResultsThere was no difference in gender distribution between both groups, and patients who had median sternotomy were significantly older (median 37 (Q1-Q3, 29-44) vs. 54 (48-60) years; P < 0.001). Cardiopulmonary bypass (134.5 (130-138.5) vs. 99 (97-104) min; P < 0.001) and ischemic times (99 (95-105.5) vs. 78 (75-81) min; P < 0.001) were significantly shorter in patients who had median sternotomy. Patients with MiMVr had significantly lower blood loss (370 (315-390) vs. 550 (490-600) ml; P < 0.001) and ICU stay (5 (4.5-6) vs. 7 (7-8) days; P < 0.001). There was no difference between both groups regarding re-exploration for bleeding, postoperative stroke, wound infection, renal failure, and mortality. As regards postoperative echocardiography follow-up at 6 and 12 months after the operation, there were no significant changes in the mean mitral valve gradient within each group; however, the mean gradient was lower in the MiMVr group (3 (3-3.5) vs. 4 (3-5) mmHg; P < 0.001). There was no significant difference between both groups regarding mitral regurgitation severity during 6 and 12 months follow-up.ConclusionMinimally invasive mitral valve repair in patients with degenerative pathology could be an alternative to conventional mitral valve surgery with comparable short-term and long-term outcomes.

Minimally-invasive mitral valve repair of symmetric and asymmetric Barlow\xb4s disease

ObjectivesBarlow´s disease represents a wide spectrum of mitral valve pathologies associated with regurgitation (MR), excess leaflet tissue, and prolapse. Repair strategies range from complex repairs with annuloplasty plus neochords through resection to annuloplasty-only. The latter requires symmetric prolapse patterns and central regurgitant jets. We aimed to assess repair success and durability, survival, and intraoperative outcomes with symmetric and asymmetric Barlow’s disease.MethodsBetween 09/10 and 03/20, 103 patients (of 1939 with mitral valve surgery) presented with Barlow´s disease. All received surgery through mini-thoracotomy with annuloplasty plus neochords (n = 71) or annuloplasty-only (n = 31). One valve was replaced for endocarditis (repair rate: 99%).ResultsAnnuloplasty-only patients were older (64 ± 16 vs. 55 ± 11 years, p = 0.008) and presented with higher risk (EuroSCORE II: 4.2 ± 4.9 vs. 1.6 ± 1.7, p = 0.007). Annuloplasty-only patients had shorter cross-clamp times (53 ± 18 min vs. 76 ± 23 min, p < 0.001) and received more tricuspid annuloplasty (15.5% vs. 48.4%, p < 0.001). Operating times were similar (170 ± 41 min vs. 164 ± 35, p = 0.455). In three patients, annuloplasty-only caused intraoperative systolic anterior motion (SAM), which was fully resolved by neochords to the posterior leaflet. There were no conversions to sternotomy or deaths at 30-days. Three patients required reoperation for recurrent MR (at 25 days, 2.8 and 7.8 years). At the latest follow-up, there was no MR in 81.4%, mild in 14.7%, and moderate in 2.9%. Three patients died due to non-cardiac reasons. Surviving patients report the absence of relevant symptoms.ConclusionsMinimally-invasive Barlow’s repair is safe with good durability. Annuloplasty-only may be a simple solution for complex but symmetric pathologies. However, it may carry an increased risk of intraoperative SAM.

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

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

Early and mid-term outcomes of minimally invasive mitral valve repair via right mini-thoracotomy: 5-year experience with 129 consecutive patients

ObjectivesThis study analyzed the experience of a single institution with minimally invasive mitral valve repair (MIMVr) via a right mini-thoracotomy (RT), including short and mid-term morbidity and mortality as surgical outcomes, and rates of reoperation. Late follow-up findings regarding mitral regurgitation (MR) were also assessed.MethodsBetween January 2014 and January 2020, a total of 141 consecutive patients underwent MIMVr for mitral regurgitation at our institution via an RT, with late follow-up results (median 35 ± 15 months) available for 129 (91.4%). Findings regarding surgical approach, complications, reoperations, and late survival were examined. Late echocardiographic results showing recurrence of MR after mitral repair were also noted. Survival, freedom from reoperation, and recurrent MR (grade > 2) were evaluated by Kaplan–Meier analysis.ResultsMean age was 63.9 ± 14.3 years, mean ejection fraction was 66.9 ± 10.4%, and 2 patients (1.6%) underwent a reoperation. Concomitant procedures included atrial fibrillation ablation (18%), tricuspid valve surgery (16%). None (0%) experienced intraoperative conversion to sternotomy. A learning curve was observed as the number of cases increased. Overall in-hospital mortality and stroke incidence were both 0%. Freedom from recurrent MR (grade > 2) at 1, 3, and 5 years was 99.2, 94.9, and 94.9%, respectively, while freedom from reoperation at 1, 3, and 5 years after mitral valve repair was 98.4, 98.4, and 98.4%, respectively.ConclusionsEarly and mid-term results of MIMVr were satisfactory, with low rates of perioperative morbidity and recurrent MR, as well as reoperation and death. Furthermore, the protocols for patient selection and surgical approach were considered to be appropriate.

Resurgence of the edge-to-edge repair of the mitral valve.

To provide a critical review of the application and outcomes of surgical edge-to-edge (E2E) or Alfieri repair for mitral valvulopathy. The E2E repair is a surgical technique to address mitral regurgitation, particularly suited when the responsible mechanism is bileaflet prolapse combined with enlarged annular area. It can also be used for a range of mitral valve pathologies. Surgically, the technique has been employed as a bailout for unsuccessful repair including residual mitral regurgitation because of systolic anterior motion (SAM). E2E repair should be accompanied by a ring annuloplasty for long-term repair durability. The simplicity of this approach makes it an ideal strategy during minimally-invasive mitral valve repair. It may also be performed via a transaortic approach at the time of aortic valve surgery to address less-than-severe mitral regurgitation or to address residual SAM following myectomy for hypertrophic obstructive cardiomyopathy. We review the surgical indication, potential complications including risk of mitral stenosis and the long-term outcomes of E2E repair. The E2E surgical repair is a simple and effective surgical strategy to address a wide range of mitral regurgitation. This is an important technique in the surgical armamentarium especially in cases of minimally-invasive mitral valve surgery.

603 Comparison of Surgical and Transcatheter Edge-to-Edge Mitral Valve Repair in Patients With Left Ventricular Dysfunction

A comparison of minimally invasive mitral valve repair (MIMVR) and transcatheter edge-to-edge repair (TMVR) on ventricular remodelling in patients with pre-existing left ventricular systolic dysfunction (LVEF≤50%) has not previously been reported. This study compares the immediate and short-term echocardiographic outcomes of MIMVR and TMVR. This is a single-center, retrospective, observational cohort study of patients with an LVEF≤50% who underwent MIMVR or TMVR between February 2008-August 2018. Baseline and postoperative TTE’s (pre-discharge; 3 months) were analysed by two-blinded independent investigators. Eighty-three patients (33 MIMVR; 50 TMVR; 76 [19] years) with grade 3-4 MR and an LVEF≤50% underwent MIMVR or TMVR. Less than 2+MR was achieved in 97% of MIMVR patients with a corresponding reduction in LVEDVI (Pre-70±23mLs/m2; Post-53mLs±17mLs/m2; p<0.01). Ninety-two percent of TMVR patients had ≤2+MR pre-discharge, albeit with no significant post-procedural reduction in LVEDVI (Pre-81±43mLs/m2; Post-81±42mLs/m2; p=0.52). At 3-months in the TMVR cohort, ≤1+MR remained in 71% of patients whilst 10% had ≥3+MR. There was a transient decline in LVEF in both cohorts, however this recovered to baseline at 3-months. Both cohorts demonstrated a reduction in pulmonary artery systolic pressure at 3-months (MIMVR post-28±7mmHg, p=0.13; TMVR post-41±16mmHg, p<0.01) and a trend towards improved RVFAC albeit not statistically significant. Surgical MIMVR is more effective than TMVR in correcting MR and reducing LV volumes in patients with pre-existing LV dysfunction. These findings raise the possibility that valve annuloplasty, in addition to repair, is an important component of remodelling and may help to guide future transcatheter device selection.

Transfer of a minimally invasive mitral valve repair program from a high-volume center to a very low volume center: how many cases are necessary to maintain acceptable results?

To investigate whether minimally invasive mitral valve repair (MIMVR) can be transferred from a high-volume center into a very small volume center and to clarify how many cases are necessary for maintenance of this program, early outcomes of MIMVR in Asahikawa Medical University were compared with those results in patients operated by a single surgeon in Duesseldorf University Hospital. Sixty-five patients who underwent MIMVR in Asahikawa Medical University (group A) between May 2014 and July 2018 and 134 patients who underwent MIMVR in Duesseldorf University Hospital (group D) between September 2009 and January 2014 by a surgeon who started MIMVS later in Asahikawa were retrospectively analyzed. In group D, there were more patients with ischemic mitral valve regurgitation and with annular calcification than in group A. Survival rate at 6months and 1year was 98.5% and 98.5% in group A and 92.9% and 91.3% in group D, respectively. EuroSCORE II was significantly higher in patients dead within 30days and within the first year. The present study demonstrated that MIMVR programs can be transferred with acceptable early results into very low volume centers, if the team is developed by surgeons who are well trained and experienced in MIMVR. Moreover, the present study suggested that case number for maintenance of acceptable results may be obviously less than the previous recognition that this kind of specialized surgery could be maintained with at least 50 cases annually. However, meticulous preparations for surgery are essential for satisfactory surgical outcomes.

The "Paper Roll": A Simple but Useful Tool for Minimal Invasive Mitral Valve Repair Surgery.

During minimal invasive mitral valve repair, excessive valve tissue, as in myxomatous or Barlow disease, might be cumbersome to analyze and treat the subvalvular mitral valve apparatus. We developed a new, adaptive, flexible, and easy-to-use technique for better visualization of the subvalvular apparatus. After visualization of the mitral valve, a simple sterile paper ruler was curled up to a roll 1 cm in diameter and inserted through the mitral valve. By means of two endo forceps, the paper roll was uncurled to the desired diameter, thus pushing the valve leaflets away, allowing for a direct view onto the subvalvular apparatus. This technique was successfully used in 34 consecutive patients (mean ± SD age = 57.2 ± 11.5 years; 22 male). The calculated risk score for additive EuroScore, logistic EuroScore, and EuroScore II was 4 ± 2, 3.2 ± 2.1, and 2.5 ± 5.4, respectively. No patient died within the first 30 days. All patients presented mitral valve insufficiency grade 0 to 1 postoperatively. Artificial chords were implanted in all patients (3.6 ± 1.8 chords per patient). This simple, adaptive, and cheap technique facilitates the approach to the subvalvular apparatus, especially in patients with myxomatous or Barlow disease. The ease of use allows for prompt approach to the papillary muscles and quick removal.

Minimally Invasive Mitral Valve Repair Through Right Minithoracotomy - 11-Year Single Institute Experience.

Although minimally invasive mitral valve repair (MIMVR) is increasingly being performed, only a few clinical studies from Japanese institutions have been reported.Methods and Results:From 2006 to 2017, 387 consecutive patients (135 females, mean age 56±13 years) underwent an initial isolated MIMVR through a right minithoracotomy. The mitral etiology was degenerative in 348, functional in 22, and endocarditis in 13 cases. Repair techniques included leaflet resection/plication in 280, chordal reconstruction in 109, and annuloplasty alone in 24 patients, and concomitant procedures included tricuspid valve repair and atrial fibrillation ablation in 70 (18.1%) and 78 (20.2%), respectively. Hospital mortality rate was 0.26%; 2 patients (0.5%) required intraoperative conversion to a median sternotomy. Perioperative morbidity included stroke (1.3%), reoperation for bleeding (0.8%), prolonged ventilation (0.5%), and permanent pacemaker implantation (2.1%). The transfusion rate was 14.7% and median ventilation time was 4 hours. Overall 5-year survival was 96.9%. For patients with degenerative mitral regurgitation (MR), the 5-year freedom from reoperation or severe recurrent MR, and freedom from ≥moderate MR were 94.7% and 82.2%, respectively. Repair for anterior mitral leaflet prolapse and the initial 30 cases were associated with higher occurrence of recurrent MR. MIMVR can be performed safely with low levels of mortality and morbidity, and provides sufficient repair durability. A learning curve exists in terms of repair durability, especially for anterior mitral leaflet repair.

Long-Term Outcomes Comparing Minimally Invasive Mitral Valve Repair versus Conventional Mitral Valve Surgery

Objectives: To compare the long term outcomes between minimally invasive mitral valve repair (MiMVR) and conventional surgery. Current retrospective comparisons between the techniques frequently report echocardiographical (echo) outcomes early after surgery and rarely report them later. Methods: Patients were selected for MiMVR by the surgical multi-disciplinary meeting from June 2008-March 2013. Patients included had at least two transthoracic post-operative echocardiograms. Echocardiographic parameters including left ventricular size and systolic function, degree of mitral regurgitation (MR) and mean mitral valve gradient were recorded. Clinical outcomes including all-cause mortality, re-operation, recurrence of at least moderate MR and elevated mean mitral valve gradients > 5 mmHg were recorded and compared using Kaplan-Meier survival analysis. Results: 223 patients were screened, 96 (43%) met the criteria and were included. Thirty-seven patients underwent conventional surgery and 59 underwent MiMVR. Mean clinical follow-up was 6.3 years and echo follow up was 3.2 years. There was a significantly higher recurrence of moderate MR in the conventional group (38% (n = 19) versus 17% (n = 10)). The mean LV end-diastolic diameter was 4.8 cm (conventional) versus 5.0 cm (MiMVR). The incidence of elevated PG was 26% (n = 13, conventional) and 23% (n = 14, MiMVR). There was no significant difference in incidence in re-operation (conventional 12% (n = 6), MiMVR 8.3% (n = 5)). Long-term mortality was higher in the conventional group (1.7% vs. 18% p = 0.004) although the logistic Euroscore was significantly higher 6.8% ± 5.4 vs. 3.6% ± 1.6. Conclusions: Minimally invasive mitral valve surgery is safe and feasible in selected patients with good medium and long-term echocardiographic follow-up.

094 * OFF-PUMP TRANSAPICAL MITRAL VALVE REPAIR WITH NEOCHORDAE

Objectives: On-pump mitral valve repair is well established and currently the gold standard. Off-pump mitral valve repair has so far not been feasible. Based on improved online cardiac imaging techniques such as 3D echocardiography, a closed application technique of neochordae in prolapsed leaflet segments with a newly developed device, Neochord DS 1000, has been developed. We present our experience with this technique in 8 patients with mitral valve prolapse. Methods: Eight patients, age 60 ± 12.8 years, 5 male, presented with severe mitral regurgitation with mitral valve (MV) prolapse of the posterior mitral leaflet, left ventricular ejection fraction 51.6 ± 7.4%, pulmonary arterial pressure 52.5 ± 20.3 (40–100) mmHg, atrial fibrillation in 2 patients, left atrial diameter 47.1 ± 3.3 mm, left ventricular end diastolic diameter 61.9 ± 8.3 mm, AP diameter (MV) 41.9 ± 1.45 mm. Surgery was performed via left mini-thoracotomy (5th intercostal space, medioclavicular line). The chordal implantation tool was inserted 2D/3D guided under heparin (activated clotting time >300 s) through the ventricular apex laterally on beating heart. Under sophisticated 2D/3D echo-guidance, the artificial chordae (GoreTex 4-0) were placed with the Neochord DS 1000 System; the number of neochordae was 3 in 6 patients and 4 in 2 patients. Adjustment was done under continuous 2D/3D echo-control. Results: There were no operative complications and no blood transfusions. Residual MI was zero in 5, trace in 2 and I–II in 1 patient. All patients were extubated within 3 h. Echo at discharge as well as at follow-up (4.1 ± 1.9 months) was stable except for one patient with increase of MI due to ventricular remodelling. Conclusion: Off-pump minimal invasive mitral valve repair with artificial chordae is feasible with excellent short-term results. Long-term observation is neccessary to confirm durability.

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Introduction: Right ventricular (RV) dysfunction can occur after cardiac surgery. Although the exact mechanism is not well understood, it has been suggested to be associated with pericardial incision as well as other factors related to cardiac surgery. Speckle Tracking Echocardiography was performed to assess RV systolic and diastolic function before and after cardiac surgery. Methods: RV speckle tracking was performed by transthoracic echocardiography before (mean 20.4hrs ±27) and after surgery (mean 47hrs ±33) in 50 patients (mean age 67.2 years ±12, 64% male) undergoing a variety of cardiac operations: 3 coronary artery bypass grafts, 12 aortic valve replacement, 3 mitral or aortic valve mass removal, 16 open and 16 robotic-assisted minimally-invasive mitral valve repair. The following strain parameters were measured: systolic function parameters include RV free wall longitudinal strain (RV LS) and strain rate (RV LSR), and diastolic function parameter RV free wall longitudinal early strain rate relaxation (RV LSRe). Results: RV systolic function assessed by speckle tracking was significantly reduced after cardiac surgery: RV longitudinal strain -25.3% to -15.5% (p<0.001), RV longitudinal strain rate -1.5 to -0.94 (p<0.001). RV diastolic function assessed by speckle tracking was similarly reduced: RV longitudinal strain rate early relaxation 1.4 to 0.92 (p<0.001). Conventional assessment methods of RV function also showed significant reductions: TAPSE 24.7mm to 13.4mm (p<0.001), Tricuspid valve S’ 0.14m/s to 0.08m/s (p<0.001), RIMP 0.39 to 0.54 (p<0.001), RV E:e’ 4.3 to 7.2 (p<0.001). RV fractional area change, E:A ratio and RV systolic pressure estimation did not significantly change. There was no significant association for the reduction in RV systolic or diastolic function assessed by speckle tracking (RV LS, RV LSR, RV LSRe) with echo-based RV peak systolic pulmonary artery pressures, cross clamp or bypass time, time to extubation, vasoactive requirement or number of days in hospital. The association between the reduction in RV longitudinal strain and whether surgery was minimally invasive approached significance (p=0.055), with minimally invasive surgery having a smaller reduction in strain values. Conclusions: RV systolic and diastolic function decreases significantly after cardiac surgery. This reduction is independent of echo-based RV peak systolic artery pressure estimation, cross-clamp or bypass time, vasoactive requirements, intubation time or number of days in hospital. RV longitudinal strain reduction may be smaller if surgery is minimally invasive supporting the concept that RV dysfunction is associated with the size of pericardial incision. Larger studies are warranted to extend this finding.

A meta-analysis of minimally invasive versus conventional mitral valve repair for patients with degenerative mitral disease.

Minimally invasive mitral valve surgery through a mini-thoracotomy approach was developed in the mid-1990s as an alternative to conventional sternotomy, but with reduced trauma and quicker recovery. However, technical demands and a paucity of comparative data have thus far limited the widespread adoption of minimally invasive mitral valve repair (MIMVR). Previous meta-analyses have grouped various surgical techniques and underlying valvular disease aetiologies together for comparison. The present study aimed to compare the clinical outcomes of MIMVR versus conventional mitral valve repair in patients with degenerative mitral valve disease. A systematic review of the current literature was performed through nine electronic databases from January 1995 to July 2013 to identify all relevant studies with comparative data on MIMVR versus conventional mitral valve surgery. Measured endpoints included mortality, stroke, renal failure, wound infection, reoperation for bleeding, aortic dissection, myocardial infarction, atrial fibrillation, readmission within 30 days, cross clamp time, cardiopulmonary bypass time and durations of intensive care unit (ICU) stay and overall hospitalization. Echocardiographic outcomes were also assessed when possible. Seven relevant studies were identified according to the predefined study selection criteria, including one randomized controlled trial and six retrospective studies. Meta-analysis of clinical outcomes did not identify any statistically significant differences between MIMVR and conventional mitral valve repair. The duration of ICU stay was significantly shorter for patients who underwent MIMVR, but this did not translate to a shorter hospitalization period. Patients who underwent MIMVR required longer cross clamp time as well as cardiopulmonary bypass time. Both surgical techniques appeared to achieve satisfactory echocardiographic outcomes. Pain-related outcomes was assessed in one study and reported significantly less pain for patients who underwent MIMVR. However, this limited data was not suitable for meta-analysis. The existing literature has limited data on comparative outcomes after MIMVR versus conventional mitral valve repair for patients with degenerative disease. From the available evidence, there are no significant differences between the two surgical techniques in regards to clinical outcomes. Patients who underwent MIMVR required longer cardiopulmonary bypass and cross clamp times, but the duration of stay in the ICU was significantly shorter than conventional mitral valve repair.

Minimal invasive mitral valve repair for Barlow syndrome: Early and long-term results

Minimal invasive mitral valve repair for Barlow syndrome: Early and long-term results

Severe hemolysis after minimally-invasive mitral valve repair

Introduction: Hemolytic anemia is known to be a rare complication after prosthetic replacement of the mitral valve, especially in the presence of perivalvular leaks, and even less frequent after mitral valve repair.

Transvalvular intramyocardial bone marrow stem cell transplantation in combination with videoscopic mitral valve repair

In the last years both minimally-invasive therapy approaches as well as intramyocardial cell therapy have entered clinical practice in cardiac surgery. Stem cell therapy has been combined in most cases with coronary artery bypass grafting (CABG) for chronic ischemic heart disease. Here, we report the first case of a patient with ischemic mitral regurgitation treated by videoscopic, transvalvular, intramyocardial bone marrow stem cell injection, while undergoing minimally-invasive mitral valve repair.