Mitral Repair Research Articles

Incidence and factors associated with mitral valve reoperation in patients undergoing intervention for mitral regurgitation: a nationwide cohort study

Abstract Background When intervention is needed for the treatment of mitral regurgitation, the risk of reoperation is of concern for both patients and physicians. As such, contemporary and nationwide data on the incidence and factors associated with mitral reoperation can provide crucial information to support patient education and clinical follow-up after intervention. Purpose To examine the incidence of mitral reoperation in patients operated for mitral regurgitation. Second, to assess whether reoperation rates differed according to time since surgery and identify potential factors associated with reoperation. Methods Using Danish nationwide registries, patients undergoing first-time surgery for mitral regurgitation 1996–2021 were identified. Exclusion included first-time surgery due to endocarditis. According to index surgery, the population was categorized into 1) mitral repair; 2) mechanical prosthesis; 3) bioprosthesis. Patients were followed from date of discharge. Cumulative incidence of reoperation was examined using competing risk analysis during a maximum of 20-years follow-up. Crude incidence rates of reoperation were reported from 0-6 months and for overall study period. Multivariate Cox analysis was used to examine factors associated with reoperation. Results We identified 7,063 patients: 4,680 (66.3%) with repair (72% male, median age 66), 1,273 (18.0%) with mechanical prosthesis (52% male, median age 59), and 1,110 (15.7%) with bioprosthesis (57% male, median age 74). Median follow-up was 7.2 years, 10.7 years, and 4.5 years, respectively. At end of follow-up, cumulative incidences were 7.7% for repair, 6.8% for mechanical prostheses, and 7.5% for bioprostheses. Of these, reoperation was preceded by endocarditis in 8.0%, 21.5%, and 30.4% of the respective patient groups. The cumulative incidence function demonstrates that the highest proportion of reoperations occurred within first six months, Figure 1. From 0-6 months following surgery, incidence rates per 100 person-years were 9.1 for repair, 11.7 for mechanical prostheses, and 18.4 for bioprostheses, while this was 8.6, 9.4, and 17.0, respectively for the overall study period. Factors associated with increased rate of reoperation were heart failure (HR=1.80, 95% CI 1.40-2.32), chronic renal failure (HR=1.48, 95% CI 1.11-1.98) and chronic obstructive pulmonary disorder (COPD) (HR=1.34, 95% CI 1.01-1.77), Figure 2. Compared to mitral repair, mechanical prostheses were associated with lower rate of reoperation (HR=0.57, 95% CI 0.42-0.78), while there was no statistically significant difference between repair and bioprostheses (HR=1.10, 95% CI 0.81-1.50). Conclusion In patients operated for mitral regurgitation, cumulative incidences of reoperation with a maximum of 20-year follow-up were 7.7% for repair, 6.8% for mechanical prostheses, and 7.5% for bioprostheses. Comorbidities such as heart failure, renal failure and COPD were associated with increased risk of reoperation.Figure 1Figure 2

Incidence and factors associated with mitral valve reoperation in patients undergoing surgery for mitral regurgitation: A nationwide cohort study

BackgroundWhen patients undergo surgery for mitral regurgitation, risk of reoperation is of concern. AimsTo examine the incidence and factors associated with mitral reoperation following surgery for mitral regurgitation according to type of surgery. MethodsPatients undergoing first-time surgery for mitral regurgitation, 1996–2021, were identified from nationwide registries. According to index surgery, the population was categorized into 1) mitral repair; 2) mechanical prostheses; 3) bioprostheses. Patients were followed from discharge with a maximum of 15 years of follow-up and cumulative incidence of reoperation was examined. Multivariable Cox analysis was used to examine factors associated with reoperation. ResultsWe identified 6958 patients: 4624 with mitral repair (72 % male, median age 66), 1250 with mechanical prosthesis (52 % male, median age 59), and 1084 with bioprosthesis (57 % male, median age 74). Cumulative incidence of reoperation was 7.3 % for repair (median 7.2 years follow-up), 6.1 % for mechanical prostheses (median 10.9 years follow-up), and 7.1 % for bioprostheses (median 4.5 years follow-up). Within first year, 22.6 % of reoperations were preceded by infective endocarditis. In long-term follow-up, bioprosthetic replacement was associated with a higher reoperation rate, while increasing age, male sex and mechanical prosthesis were associated with lower reoperation rate. ConclusionsIn patients operated for mitral regurgitation, reoperation was infrequent at approximately 7 % for all intervention types during a maximum of 15-year follow-up. In adjusted analysis, bioprosthetic replacement was associated with a higher rate of reoperation, while increasing age, male sex and mechanical prosthesis was associated with a lower rate of reoperation.

Closed-chest robotic mitral repair using a semi-rigid ring inserted through a trocar.

There are several types of annuloplasty devices for mitral repair. We present a totally-thoracoscopic robotic mitral repair using a new semi-rigid ring with a nitinol core that makes it malleable so that it can be inserted through a trocar. This technique combines the advantages of semi-rigid rings and a totally-thoracoscopic approach, which may further expand this approach to other aetiologies.

Strategic Implementation of a New Robotic Mitral Repair Program: Early Experience and Outcomes

BackgroundDespite numerous reported benefits of robotic mitral repair, the absolute number of procedures performed remain low in part to uncertainties about the necessary steps to launch a program. In this report, we describe our early outcomes and strategy with launching a successful new robotic mitral repair program. MethodsOur multimodal strategic plan emphasized team education, hands-on technical preparation, stepwise advancement, and careful patient selection. Consultant service analytics and team debriefings allowed for iterative improvements. ResultsBetween March 2022 through February 2024, 50 patients underwent robotic mitral repair at our institution. Average age at time of operation was 62 with an STS risk score of 0.58. Successful repairs were performed in 98% of patients. There was one conversion to sternotomy. There were no deaths and minimal perioperative morbidity. On both predischarge and follow-up echocardiography, no patients had greater than mild mitral regurgitation. ConclusionsOur work provides a model for establishing a successful robotic mitral program. An upfront emphasis on team education, careful preparation, proper patient selection, and feedback-driven improvements can accelerate the attainment of standards set by high-volume centers.

TCT-634 Impact of Atrial Fibrillation on the Evolution of Mild-to-Moderate Tricuspid Regurgitation During Degenerative Mitral Repair

TCT-634 Impact of Atrial Fibrillation on the Evolution of Mild-to-Moderate Tricuspid Regurgitation During Degenerative Mitral Repair

Gender differences in 381 patients undergoing isolated mitral regurgitation repair.

Objectives To compare the gender differences in isolated mitral regurgitation (MR) repair. Methods Of 381 adults aged 54.8±12.3 years undergoing mitral valve repair (MVP) for isolated MR from 01/2019-12/2022, the baseline and operative data, and outcomes were compared between 161 women (42.3%) and 220 men (57.7%). Results Women tended to be non-smoker (98.1% vs 45%, P<0.001), and have more cerebrovascular accidents (38.5% vs 24.1%, P=0.004), lower creatinine (70.0±19.5 vs 86.3±19.9 µmol/dL, P<0.001), smaller LVEDD (54.4±6.7 vs 57.8±6.6 mm, P<0.001) and isolated annular dilatation (19.3% vs 9.1%, P=0.010). One female died of stroke at 2 days (0.3%). Another female (0.3%) underwent MV replacement for failed repair. Stroke occurred in 4 (1.0%). Two underwent re-exploration for bleeding (0.5%). Women were more likely to have less 24-hour drainage (290±143 vs 385±196 mL, P<0.001). Over a mean follow-up of 2.1±1.1 years (100% complete), one woman died, one man underwent a reoperation; 28 had moderate MR, and 9 had severe MR. Neither did early and late mortality and reoperation, nor freedom from late moderate/severe MR (71.6% vs 71.4% at 5 years; P=0.992) differ significantly between two genders. Predictors for late moderate/severe MR were anterior leaflet prolapse (hazard ratio [HR] 4.45; 95% confidence interval [CI] 1.18-16.72; P=0.027) and isolated annular dilation (HR 5.47, 95% CI 1.29-23.25; P=0.021). Conclusions Despite significant differences in smoking, cerebrovascular accidents, creatinine, LVEDD, and isolated annular dilatation at baseline, and 24-hour drainage, women and men did not show significant difference in early and late survival, reoperation and freedom from late moderate/severe MR.

Longitudinal Outcomes Following Mitral Valve Repair for Infective Endocarditis.

Mitral valve repair is the ideal approach in managing mitral valve infective endocarditis for patients requiring surgery. However, viable repair is influenced by the extent of valve destruction and there can be technical challenges in reconstruction following debridement. Overall, data describing long-term outcomes following mitral repair of infective endocarditis are scarce. We, therefore, assessed the late outcomes of 101 consecutive patients who underwent mitral valve repair for IE at the University of Ottawa Heart Institute from 2001 to 2021. The 5- and 10-year survival rate was 80.8 ± 4.7% and 61.2 ± 9.2%, respectively. Among these 101 patients, 7 ultimately required mitral valve reoperation at a median of 5 years after their initial operation. These patients were of a mean age of 35.9 ± 7.3 years (range 22-44 years) at the time of their initial operation. The 5- and 10-year freedom from mitral valve reoperation was 93.6 ± 3.4% and 87.7 ± 5.2%, respectively. Overall, mitral valve repair can be an effective method for treating infective endocarditis with a favourable freedom from reoperation and mortality over the long term.

The value of percutaneous transcatheter mitral valve regurgitation repair in the combination treatment of chronic heart failure patients: Results from a 6-month observational prospective study

Rationale: Surgical interventions have been recognized as the main method to repair of valvular disorders. Percutaneous transcatheter intervention with a clipping system is being actively introduced into the treatment of chronic heart failure (CHF) patients and mitral valve insufficiency (MVI) for correction of mitral regurgitation (MR), along with drug therapy. Aim: To establish the effect of the mitral valve leaflet clipping in the combination treatment of CHF patients on the clinical course of heart failure and the remodeling process. Methods: This single center prospective comparative study included 80 patients with CHF NYHA class II–IV and secondary MR grade 3–4. The patients were on optimal medical treatment (OMT) for CHF for at least 3 months before inclusion into the study. The main group included 55 patients who underwent transcatheter mitral valve repair with the use of MitraClip system, and the control group consisted of 25 patients in whom the surgery for MR was waived for various reasons (refusal of the surgery by the patient, some valve characteristics), and only OMT for CHF was used. At baseline, main clinical and demographic characteristics of the patients in the both groups were comparable. The duration of the follow-up was 6 months. Echocardiography (echoCG), a 6-minute walk test, and measurements of the brain natriuretic propeptide level were performed in all patients at baseline and at 6 months of the follow-up. Results: At 6 months, there was a significant reduction in CHF NYHA class and an increase in the 6-minute walk test distance and a decrease in diuretic requirements (converted to furosemide, from 58.4 ± 17.2 to 38.1 ± 20.7 mg daily, р = 0.02) in the group with the MitraClip implant, but not in the control group. In the OMT only group, there were no changes over 6 months in the diuretic requirements (48.1 ± 6.68 and 43.8 ± 27.15 mg daily, respectively, р = 0.8). The number of hospital readmissions due to CHF decompensation was 7 (12.7%) in the implanted MitraClip group and 4 (16%) in the OMT group (р = 0.69). EchoCG performed at 6 months after the surgical intervention identified no cases of MR grade 2. In the MitraClip implant group, there was a decrease in the size and volumes of the left atrium (р = 0.02 and р = 0.05, respectively), left ventricle (for end-diastolic diameter p = 0.002, end-diastolic volume p = 0.03), mean pulmonary artery pressure (p = 0.03), as well as an increase in cardiac output (р = 0.04). In the patients receiving OMT only, there were no significant changes in EchoCG parameters over time. Conclusion: Our study has shown benefits of the implantation of the mitral valve leaflet clipping system, compared to OMT only, in CHF. The clipping procedure promotes a significant improvement in clinical course of CHF, reverse myocardial remodeling, and reduction in diuretic requirements.

Incidence and Risk Factors for Permanent Pacemaker Implantation After Tricuspid Valve Repair

BackgroundAlthough the likelihood of needing a permanent pacemaker (PPM) after tricuspid valve (TV) repair has been thought to be low compared with TV replacement, the incidence and determinants are controversial. This study aimed to evaluate the incidence and risk factors for PPM implantation after TV repair. MethodsA total of 1237 consecutive patients undergoing TV repair from 1997 to 2019 were reviewed using a prospectively maintained database, and 1058 patients were enrolled. ResultsIncidence of PPM implantation was 10.3% (n = 109). Median time to PPM implantation was 7 (range, 6-9) days. Indications for PPM implantation were heart block (n = 62, 56.9%), junctional or sinus bradycardia (n = 21, 19.3%), and ventricular arrhythmia (n = 17, 15.6%). Likelihood of PPM varied with concurrent procedures: left ventricular assist device (3.4%), mitral repair (11.2%), mitral valve replacement (13.7%), aortic and mitral valve replacement (19.2%), and isolated tricuspid repair (6.5%). Older age (odds ratio [OR], 1.020; 95% CI, 1.003-1.036), prior mediastinal radiation (OR, 4.106; 95% CI, 1.598-10.554), and concomitant mitral and aortic valve replacement (OR, 1.963; 95% CI, 1.046-3.683) were risk factors, and concomitant left ventricular assist device implantation (OR, 0.325; 95% CI, 0.139-0.759) was a protective factor for PPM implantation. PPM implantation did not affect the early outcomes, overall survival (P =.287), or cumulative incidence of recurrent moderate or greater tricuspid regurgitation (P =.890) or TV reoperation (P =.602). ConclusionsThe likelihood of PPM implantation after TV repair is relatively high, but PPM implantation does not affect the early and long-term clinical outcomes. Older age, prior mediastinal radiation, and concomitant mitral and aortic valve replacement are risk factors, and concomitant left ventricular assist device implantation is a protective factor for PPM implantation after TV repair.

Outcomes of Leaflet Resection vs Chordal Replacement for Degenerative Mitral Regurgitation

BackgroundDebate persists regarding the outcomes of leaflet resection (RESECT) vs chordal replacement (CHORD) for degenerative mitral regurgitation. Our aim was to compare early and late outcomes of the RESECT vs CHORD techniques for degenerative mitral regurgitation. MethodsA total of 1066 consecutive patients undergoing mitral repair for degenerative regurgitation with the RESECT vs CHORD techniques were evaluated from a prospectively maintained database. Propensity score matching was used to compare outcomes in RESECT vs CHORD repairs. ResultsPatients who underwent CHORD had later operative dates, more flail leaflet, and more anterior leaflet disease. With the switch to predominant use of the CHORD technique in 2010, the percentage of repair for all degenerative valves improved significantly from 83% to 91% (P = .002). A total of 467 patients were matched for baseline characteristics. Patients in the CHORD group had larger rings (34 mm vs 32 mm; P < .001) and greater use of an Alfieri stitch (66% vs 22%; P < .001) in matched patients. The 10-year survival was similar for matched patients (RESECT vs CHORD, 86% ± 3% vs 84% ± 4%; P = .5).Patients in the RESECT group had a lower 10-year cumulative incidence of mitral reoperation (RESECT vs CHORD, 1% ± 1% vs 8% ± 3%; P = .002) and severe mitral regurgitation (RESECT vs CHORD, 1% ± 1% vs 9% ± 5%; P = .05) compared with matched patients in the CHORD group. The late ejection fraction and mitral gradient were not different between the 2 groups in matched patients, respectively (P = .9 and P = .2, respectively). ConclusionsThe use of the CHORD technique for degenerative mitral regurgitation increased the repair rates, but the CHORD technique had slightly lower repair durability at 10 years compared with the RESECT technique. These results could be related to more complex disease in CHORD group.

Comparisons between the Outcome of Mitral Repair versus Replacement in Patients with Ischemic Heart Disease with Severe Ischemic Mitral Regurgitation and Undergoing Coronary Artery Bypass Grafting (CABG) Surgery: Review Article

Comparisons between the Outcome of Mitral Repair versus Replacement in Patients with Ischemic Heart Disease with Severe Ischemic Mitral Regurgitation and Undergoing Coronary Artery Bypass Grafting (CABG) Surgery: Review Article

The Role of Microbes in Surgical Decision Making for Infective Endocarditis: Mitral Valve Repair or Replacement?

The benefits of mitral repair versus replacement for endocarditis are inconclusive. This study compares outcomes of patients with infective endocarditis undergoing mitral valve repair versus replacement and investigates the impact of microbial etiology. All 251 patients undergoing mitral valve surgery for active endocarditis between 2010 and 2023 were enrolled, 180 (71.7%) replacement and 71 (28.3%) repair. To adjust for imbalances, inverse probability of treatment weighting was applied and 187 patients were obtained. The analysis between groups, following the application of inverse probability of treatment weighting, showed no statistically significant differences across all considered outcomes. Early and late death was observed respectively in 6 (8.5%) and 11 (15.5%) patients in the repair group versus 24 (13.3%) and 45 (25.0%) in the replacement group without statistical significance (p = 0.221 and p = 0.446). Relapse occurred in six patients (8.5%) in the repair group after a median time of 4.0 months and in six (3.3%) in the replacement after 6.9 months (p = 0.071). Surgical strategy in mitral endocarditis has no effect on major postoperative complications, mortality, or medium/long-term survival. Staphylococcus aureus and Coagulase-negative Staphylococci represent a risk for early mortality and relapse. However, mitral valve repair for endocarditis can be pursued when it ensures the complete eradication of all infected tissue, particularly in cases caused by Streptococcus infection, in young patients, and after a minimum of 18 days of antibiotic therapy.

Eligibility to COAPT trial in the daily practice: A real-world experience.

The COAPT Trial was the first ever to demonstrate a survival benefit in treating functional mitral regurgitation (FMR). That was achieved through transcatheter mitral repair in selected patients. The exact proportion of patients fulfilling COAPT selection criteria in the real-world is unknown. To assess the applicability of COAPT criteria in real world and its impact on patients' survival. We assessed the clinical data and follow-up results of all consecutive patients admitted for FMR at our Department between January 2016 and May 2021 according to COAPT eligibility. COAPT eligibility was retrospectively assessed by a cardiac surgeon and a cardiologist. Among 394 patients, 56 (14%) were COAPT eligible. The most frequent reasons for exclusion were MR ≤ 2 (22%), LVEF < 20% or >50% (19%), and non-optimized GDMT (21.3%). Among Non-COAPT patients, weighted 4-year survival was higher in patients who received MitraClip compared to those who were left in optimized medical therapy (91.5% confidence interval [CI: 0.864, 0.96] vs. 71.8% [CI: 0.509, 0.926], respectively, p = 0.027). Only a minority (14%) of real-world patients with FMR referred to a tertiary hospital fulfilled the COAPT selection criteria. Among Non-COAPT patients, weighted 4-year survival was higher in patients who received MitraClip compared to those who were left in optimized medical therapy (91.5% [0.864, 0.96] vs. 71.8% [0.509, 0.926], respectively, p = 0.027).

Re-repair for mitral insufficiency

Mitral valve repair provides superior outcomes to replacement for primary MR. Whether this is true following previous repair is unknown. We present the results of a strategy of re-repair for failed mitral valve repair. We examine patients who were brought to the operating room for an intended mitral valve re-repair. We reviewed the last one decade of our institutional mitral valve databases at The University of Pennsylvania and Plano Heart Hospital and identified patients undergoing repeat mitral valve repair, in whom the index operation was mitral valve repair. We analyzed their operative details, clinical and echocardiographic outcomes. Between 2008 and 2021, 71 patients (aged 61.5 ±10.7 years, 20% female) underwent mitral valve reoperation at an mean of 6.24 ±7.62 years following index mitral repair. 20% of patients presented with NYHA class III/IV symptoms. At index operation, 34 (47.9%) had repair through a right mini-thoracotomy. 15 patients (21.1%) required the reoperation within one year. There were 0 early and 8 late deaths. One patient who underwent mitral replacement instead of repair, required reoperation for paravalvular leak during the follow-up period. Three patients required mitral valve replacement at an average of 2.28 ±2.03 years following initial mitral valve re-repair. Mitral re-repair can be performed with acceptable results at a valve reference center. Durability and functional advantages of this approach remain to be proven.

Superiority of 3D planimetry over pressure half-time method for the assessment of mitral valve area after percutaneous edge-to-edge mitral repair

Introduction and objectivesThere is limited evidence to identify the most accurate method for measuring the mitral valve area (MVA) after percutaneous edge-to-edge mitral repair. Our objective was to evaluate the optimal method in this context and its correlation with the mean transmitral gradient. MethodsA registry of patients undergoing percutaneous mitral repair was conducted, analyzing different methods of measuring MVA and their correlation with the mean gradient. ResultsWe analyzed data from 167 patients. The mean age was 76±10.3 years, 54% were men, and 46% were women. Etiology was degenerative in 45%, functional in 39%, and mixed in 16%. Postclip MVA measurements were 1.89±0.60 cm2 using pressure half-time (PHT), 2.87±0.83 cm2 using 3D planimetry, and the mean gradient was 3±1.19mmHg. MVA using 3D planimetry showed a stronger correlation with the mean gradient (r=0.46, P<.001) than MVA obtained by PHT (r=0.19, P=.048). Interobserver agreement was also higher with 3D planimetry than with PHT (intraclass correlation coefficient of 0.90 vs 0.81 and variation coefficient of 9.6 vs 19.7%, respectively). ConclusionsOur study demonstrates that the PHT method significantly underestimates MVA after clip implantation compared with direct measurement using transesophageal 3D planimetry. The latter method also correlates better with postimplantation gradients and has less interobserver variability. These results suggest that 3D planimetry is a more appropriate method for assessing postclip mitral stenosis.

HCM AT THE CROSSROAD

Abstract Introduction Treatment of oHCM frequently requires difficult choices, especially when it is superimposed on other urgent clinical conditions,such as AMI or mechanical complications. Clinical Case A 52–year–old man with known oHCM, who spontaneously quickly discontinued recommended therapy, presents to theED with a sudden episode of dyspnea and presyncope. A firstECG was essentially normal for pathology. After 1h, the patient experiences a sudden episode of chest pain with rapid hemodynamic deterioration and cardiogenic shock(CS). The ECG shows changes compatible with inferolateral MI. The TTE shows severe LVOTO, SAM, severe MR and a suspicious oval image attached to the anterior mitral leaflet. The patient underwent orotracheal intubation, coronary angiography and TEE. Coronary angiography shows a thrombotic occlusion of the proximal circumflex artery, treated with pPCI. TEE confirms a partial rupture of the papillary muscle head. Treatment:The patient‘s CS can be caused by 2different conditions that require treatments with opposing pathophysiological principles. SevereMR due to papillary muscle rupture, as mechanical complication of MI, requires afterload reduction, hemodynamic stabilization with IABP and emergency transfer to a cardiac surgery center. In contrast, the treatment of the underlying pathology(severe LVOTO and severe rMR due to SAM)requires pharmacological stabilization with depression of cardiac contractility and increase in afterload. In the context of cardiogenic shock a rapid choice was required. To help us make the right choice, an Esmolol test was performed. After iv administration of 2mg Esmolol, heart rate was reduced without reduction in BP. The patient was then treated with esmolol in continuous infusion and norepinephrine. In oHCM the ventriculo–arterial coupling is reduced, less than 1. This treatment favored better V–A coupling, ensuring an increase in afterload and a reduction in myocardial contractility. The patient‘s clinical condition rapidly improved, allowing extubation at48h and early mobilization at96h. Myectomy and mitral repair surgery was scheduled 1 month afterPCI. Conclusions Through the use of a short–lived drug such as Esmolol, it was possible to trace the prevailing mechanism of the patient‘s CS. Differently from other cases of CS, to rebalance the V–Acoupling, it was crucial to reduce myocardial contractility and increase afterload. A pathophysiological pharmacological approach ensured a good outcome.

MID–TERM OUTCOMES OF ENDOSCOPIC MITRAL VALVE REPAIR VIA RIGHT ANTERIOR MINI–THORACOTOMY

Abstract The adoption of less–invasive mitral repair (MVr) surgery is increasing, backed by evidence of satisfactory short–term results and lower major morbidity. We assessed mid–term follow–up results of our experience, and compared two techniques: isolated leaflet resection and neochord implantation for posterior leaflet (PML) prolapse. Between 2012–2021, 700+ operations were performed with a video–assisted right mini–thoracotomy (RMT) approach. We report 309 consecutive patients who had endoscopic MVr, including those receiving concomitant tricuspid repair, ablation for atrial fibrillation, closure of patent foramen ovale and/or left atrial appendage. The early and mid–term follow–up results were ascertained. Primary outcome was the incidence of mortality and significant mitral regurgitation (MR) during follow–up which were summarized by Kaplan–Meier estimator and compared between treatment arms via log–rank test. Secondary outcomes were the early–postoperative results including 30–days mortality and major complications. All patients had endoscopic MVr via RMT at the 3rd/4th intercostal space (IS). A soft–tissue retractor is used, accompanied or not by a rib spreader, and two ports in the fourth and sixth IS are used for 3D thoracoscopy and carbon dioxide insufflation. Femoral vessels exposure through a right groin incision and echo–guided cannulation sec. Seldinger is achieved post–heparinization. Thoracic fascia bisection is performed during single–lung ventilation using a double–lumen endotracheal tube, integral to our anesthetic management, including percutaneous right internal jugular vein cannulation. The pericardium is opened and an aortic root cannula for cardioplegia delivery and venting is placed via working incision. After establishing cardiopulmonary bypass, a Chitwood clamp is passed through the second IS and cardioplegia is delivered. Endoaortic balloon clamping is primarily used in redo cases. With ring annuloplasty, 136 (44%) patients received PML resection (122 isolated) and 97 (31%) PML chords implantation (88 isolated). Forty–nine patients had annuloplasty alone. In–hospital mortality was 1.0%. Mean follow–up was 29±22 months (max 8.3 years). Kaplan–Meier 5–year survival was 97.3±1.0%. MR (3/4+) free–survival at 5 years was 94.5±2.3%. Subgroup time–to–event analysis for the indexed outcomes showed no statistical significance between techniques. In conclusion, endoscopic MVr is safe with excellent mid–term outcomes.

Anomalous circumflex artery encircling the aortic annulus: implications for mitral valve repair

Injury to coronary arteries during mitral surgery is a rare but life-threatening procedural complication, an anomalous origin and course of the left circumflex artery (LCx) increase this risk. Recognizing the anomaly by the characteristic angiographic pattern and identifying its relationship with the surrounding anatomical structure using imaging techniques, mainly transesophageal echocardiography (TOE) or coronary computed tomography angiography (CCTA), is of crucial importance in setting up the best surgical strategy. We report a case of anomalous origin of a circumflex artery (LCx) from the proximal portion of the right coronary artery (RCA) with a pathway running retroaortically through the mitro-aortic space. An integrated diagnostic approach using a multidisciplinary team with a cardiologist and an imaging radiologist allowed us to decide the surgical strategy. We successfully performed a mitral valvular repair using a minimally invasive minithoracotomic approach and implanting a complete semirigid ring.

3-Year Outcomes for Degenerative Mitral Regurgitation Repair in a Medicare Population.

Mitral valve repair (MVr) has become the standard therapy for degenerative mitral regurgitation (DMR), but real-world late mortality, reintervention, and readmission data are lacking. This study estimates MVr outcomes for DMR to 3 years in the Medicare fee-for-service population. There were 4,219 DMR patients older than 65 years undergoing MVr within the Medicare 100% standard analytic file from October 2015 to December 2018 who were evaluated. Outcomes were analyzed for isolated MVr patients (n = 2,433) and patients undergoing MVr with certain concomitant procedures: MVr + tricuspid valve surgery (TVS; n = 619), MVr + cardiac ablation (CA; n = 540), and MVr + left atrial appendage closure (n = 627). Outcomes over a 3-year period included all-cause mortality, reintervention, rehospitalization, and common complications. All outcomes were modeled with adjustments for patient demographics and comorbid conditions. The average age for all patients was 71.9 ± 5.2 years. Adjusted all-cause mortality and MV reintervention (surgery or transcatheter) at 3 years for the primary cohort of isolated MVr was 3.5% and 1.6%, respectively. Directionally higher mortality at 3 years was observed in patients with concomitant TVS or CA. All-cause readmission and cardiac readmission for isolated MVr was 37.0% and 14.1%, with the highest rates for those with concomitant TVS or CA. Acute kidney injury and stroke/transient ischemic attack were the most common adverse events over 3 years for all patients. The 3-year mortality and reintervention rates in Medicare patients undergoing degenerative MVr are low. Those undergoing concomitant TVS or CA had directionally higher mortality and cardiac readmission rates. These results help refine outcome benchmarks as new transcatheter MVr procedures continue to emerge.

Risk of Pacemaker Implantation After Degenerative Mitral and Concomitant Tricuspid Valve Surgery

BackgroundA recent multicenter trial showed a reduction in tricuspid regurgitation (TR) progression when tricuspid annuloplasty was performed at the time of surgery for degenerative mitral regurgitation (MR), but with a 14% permanent pacemaker (PPM) rate. We present real-world outcomes at a high-volume center for degenerative MR surgery with/without tricuspid annuloplasty. MethodsPatients undergoing first-time degenerative mitral surgery between 2011 and 2021 were identified (n = 1738). After excluding patients undergoing aortic, aortic valve, or tricuspid replacement procedures, patients were stratified into mitral surgery alone (n = 1068) vs mitral surgery plus tricuspid annuloplasty (n = 417). Outcomes, including operative mortality, new PPM implantation, postoperative length of stay, and risk-adjusted overall mortality, were compared. ResultsAmong 1485 patients in this study, 98% underwent mitral repair. Compared with concomitant tricuspid annuloplasty patients, those undergoing mitral surgery alone were 6 years younger and had lower median The Society of Thoracic Surgeons predicted risk of mortality. Among concomitant tricuspid repair patients, 85% (355 of 417) had moderate or less preoperative TR, whereas 15% (61 of 417) had severe TR. Operative mortality was 1.4%. The incidence of new PPM implantation was 0.7% (7 of 1068) in the mitral only group and 5.5% (23 of 417) in the concomitant tricuspid group (P < .001). Although unadjusted cumulative survival was lower in the concomitant tricuspid group, after risk adjustment, concomitant tricuspid surgery was not associated with worse overall mortality (hazard ratio, 0.80; 95% CI, 0.53-1.19; P = .27). ConclusionsConcomitant tricuspid annuloplasty is safe, with no difference in mortality and a <6% PPM rate at a high-volume mitral center. These data provide real-world context for concomitant tricuspid annuloplasty.