Mitral Valve Reconstruction Research Articles

INVESTIGATING ETIOPATHOGENETIC FACTORS OF LEFT VENTRICULAR REMODELING AS THE UNDERLYING MECHANISM OF ISCHEMIC MITRAL REGURGITATION

The purpose of this study is to determine the etiopathogenetic features of the development of ischemic mitral regurgitation in patients with coronary heart disease by investigating the mechanisms of left ventricular remodeling. Materials and Methods. The study included 140 patients (99 male, 41 female) with ischemic mitral regurgitation who underwent myocardial revascularization and mitral valve reconstruction (either repair or replacement). The average age of participants was 65.9 ± 4.0 years, and all had a history of coronary heart disease and ischemic mitral regurgitation. All patients in the sample underwent operations for myocardial revascularization and mitral valve reconstruction (replacement). The data analyzed were obtained from primary medical documentation, including medical histories, patient medical charts, findings of physical and clinical examinations, laboratory and instrumental evaluations, as well as echocardiography findings. The data obtain were processed statistically. Results. This article presents an analysis of the etiopathogenetic features associated with the development of ischemic mitral regurgitation under the clinical course of coronary heart disease. The study examined several etiopathogenetic factors, including the presence of arterial hypertension, left ventricular hypertrophy, and the type of left ventricle remodeling. It was found that 39.1% of patients in the experimental group and 40.8% in the control group had hypertension (p ≥ 0.05). The most prevalent condition was grade II arterial hypertension, which occurred in 52.3% of the experimental group and 60.6% of the control group (p ≥ 0.05). When analyzing the occurrence rate of left ventricular hypertrophy, mild hypertrophy was significantly more common in the experimental group (44.9%) compared to the control group (26.8%) (p = 0.03, χ² = 4.27). Moderate left ventricular hypertrophy was found to be significantly higher in the control group (45.1%) compared to the experimental group (27.5%) (p = 0.04, χ² = 3.92). Eccentric hypertrophy of the left ventricle was prevalent in both groups, with values of 79.7% in the experimental group and 80.3% in the control group. In contrast, the frequency of concentric hypertrophy was higher in the control group (8.4%) compared to the experimental group (2.9%) (p ≥ 0.05). Conclusions: The study has established that the incidence of ischemic heart disease and ischemic mitral regurgitation is significantly associated with sex, with men being affected more frequently than women. Analysis of arterial hypertension revealed that 39.1% of patients in the experimental group and 40.8% in the control group were affected, with grade II arterial hypertension being the most common. Moderate and severe left ventricular hypertrophy, as well as concentric remodeling of the left ventricle, were characteristic of patients who underwent mitral valve replacement. These findings underscore the importance of left ventricular remodeling in determining the appropriate surgical treatment for mitral valve conditions.

Mechanical and Geometric Characterization of a Novel 2-Ply Vacuum-Pressed Biological Scaffold Patch Design for Posterior Mitral Valve Reconstruction.

To assess the mechanical properties of small intestinal submucosal extracellular matrix (SIS-ECM) iterations and choose the optimal version for evaluating functional geometrics after posterior mitral valve reconstruction. Four SIS-ECM versions (2- and 4-ply vacuum-pressed and lyophilized) underwent uniaxial tensile testing. A posterior mitral valve reconstruction patch was developed based on MRI scans (n = 5). Posterior mitral valve reconstruction using 2-ply vacuum-pressed SIS-ECM was performed (n = 7), and geometrics were evaluated using a modified left heart simulator. The vacuum-pressed iterations displayed superior maximum stress values compared to lyophilized (2-ply: median [IQR], 15.8 [15.2-19.0] vs 7.9 [7.3-8.3] MPa, p < 0.001; 4-ply: median (IQR), 15.8 -[14.6-22.0] vs 7.9 [7.6-8.4] MPa). All reconstructed valves were competent with preserved total leaflet area, but individual leaflet segment areas were redistributed. Posterior mitral valve reconstruction with our 2-ply vacuum-pressed SIS-ECM patch design was feasible in vitro. Further in vivo evaluation is warranted.

Analysis of Echocardiography Indicators Depending on the Type of Surgical Correction of the Mitral Valve in Patients with Ischemic Heart Disease

The aim. To study the influence of echocardiography indicators on the choice of surgical intervention on the mitral valve in patients with mitral insufficiency and coronary heart disease. Materials and methods. The study included patients with mitral insufficiency who underwent myocardial revascularization and mitral valve reconstruction (plasty or replacement). The mean age of the study participants was 65.9 ± 4.0 years. The material for analysis was data from the primary medical records: medical history, clinical and instrumental examination data and protocols of operations. The division into study groups was performed retrospectively, according to the mitral valve operation performed: plasty (experimental group) or replacement (control group). Results. We identified the features of the main echocardiographic data that guide the cardiologist when choosing the tactics of surgical correction of the mitral valve. It was established that in patients of the research group, the following was reliably significant: moderate degree of mitral insufficiency (p = 0.02; χ2 = 9.38), decrease in the systolic function of the left ventricle (p = 0.001; χ2 = 10.75); it was found that calcium deposits on the fibrous ring of the mitral valve were insignificant. When analyzing the morphological changes in patients of the experimental group, we found a significantly lower frequency of anterior leaflet prolapse (p = 0.04; χ2 = 4.21) and in general the frequency of all prolapses of any type, while in the control group the frequency of all prolapses was significantly higher (p = 0.04; χ2 = 4.0). In patients of the control group, a significantly higher frequency of akinesis (p = 0.04; χ2 = 4.21) and hypokinesis zones of the posterior-inferior-lateral wall (p = 0.001; χ2 = 19.76) was established, which is an additional sign of involvement of the chordal-muscular apparatus of the mitral valve in pathological process. Conclusions. As a result of the study, echocardiographic differences in the structure of the mitral valve were established, which influenced the selection of the intervention volume. It was found that in patients of the experimental group, the early postoperative mortality and the duration of inpatient treatment were significantly higher than in patients of the control group, which indicates the imperfection of the criteria used by cardiac surgeons when choosing the tactics of surgical correction of the mitral valve in an attempt to perform organ-preserving surgery.

Prevention of SAM phenomenon after reconstructive mitral valve surgery

Systolic anterior motion (SAM) of the mitral valve (MV) can be a life-threatening condition. The SAM can result in severe left ventricular outflow tract obstruction and/or mitral regurgitation and is associated with up to 20% risk of sudden death (which is substantially lower in hypertrophic cardiomyopathy (HCM)).The mechanisms of SAM are complex and depend on the functional status of the ventricle. The SAM can occur in all cases, but is typically observed in patients with HCM or following MV repair.Echocardiography (2D, 3D and stress) has a central diagnostic role as the application of echocardiographic SAM predictors allows the incorporation of prevention techniques during surgery and post-operative SAM assessment.MRI (magnetic resonance imaging) has a special role in understanding the dynamic nature of SAM, especially in anatomically atypical hearts (including HCM).This article describes what the clinician needs to know about SAM ranging from pathophysiological mechanisms and imaging modalities to conservative (medical) and surgical approaches and their respective outcomes.A stepwise approach consisting of medical therapy, followed by aggressive volume loading and beta-adrenoreceptor blockers. Surgery is the final option. The correct choice of surgical technique requires an understanding of the anatomical substrate of SAM.

Intraoperative transesophageal echocardiography in cardiac surgery with a focus on mitral valve reconstruction

Intraoperative transesophageal echocardiography in cardiac surgery with a focus on mitral valve reconstruction

Navigating the challenges of minimally invasive mitral valve surgery: a risk analysis and learning curve evaluation

BackgroundThis study aimed to report the risk and learning curve analysis of a minimally invasive mitral valve surgery program performed through a right mini-thoracotomy at a single institution.MethodsFrom January 2013 through December 2019, 266 consecutive patients underwent minimally invasive mitral valve surgery in our department and were included in the current study. Multiple logistic regression analysis was used for the adverse event outcome. Distribution over time of perioperative complications, defined as clinical endpoints in the Valve Academic Research Consortium-2 (VARC-2) consensus document, as well as CUSUM charts for assessment of cardiopulmonary bypass and aortic cross-clamping duration over time, has been performed for learning curve assessment.ResultsOverall incidences of postoperative stroke (1.1%), myocardial infarction (1.1%), and thirty-day mortality (1.5%) were low. The mitral valve reconstruction rate in our series was 95%. Multivariable analysis revealed that concomitant tricuspid valve surgery (OR 4.44; 95%CI 1.61–11.80; p = 0.003) was significantly associated with adverse event outcomes. Despite a trend towards adverse event outcomes in patients with preexisting active mitral valve endocarditis (OR 2.69; 95%CI 0.81–7.87; p = 0.082), mitral valve pathology did not significantly impact postoperative morbidity and mortality. Distribution over time of perioperative complications, defined as clinical endpoints in the VARC-2 consensus document, showed a trend towards an improved complication rate after the initial 65–100 procedures.ConclusionsMitral valve surgery via right-sided mini-thoracotomy can be implemented safely with low perioperative morbidity and mortality rates. Careful patient selection regarding isolated mitral valve surgery in the presence of degenerative mitral valve disease may represent a significant safety issue during the learning curve.Trial Registration: The cantonal ethics commission of Zurich approved the study (registration ID 2020-00752, date of approval 24 April 2020).

Patient-Reported Postoperative Neuropsychological Deterioration After Heart Valve Replacement and Coronary Artery Bypass Grafting

BackgroundPostoperative cognitive decline (POCD) after cardiosurgical interventions are well described through objective psychometric tests. However, a patient’s subjective perception is essential to clinical assessment and quality of life. This study systematically evaluated patient-reported POCD between subjects undergoing coronary artery bypass grafting and heart valve replacement. MethodsThis study was a multicentre, prospective questionnaire survey conducted at the cardiac surgery departments at the Kerckhoff Clinic in Bad Nauheim and the University Hospital in Giessen, Germany. We included patients undergoing elective coronary artery bypass grafting (CABG), aortic valve replacement (AVR), mitral valve replacement or reconstruction (MVR), and combined surgery (CABG + valve replacement [VR]) with extracorporeal circulation. The Hospital Anxiety and Depression Scale, the Cognitive Failures Questionnaire (CFQ) for Self-assessment (CFQ-S), and the external assessment (CFQ-foreign [F]) were completed preoperatively, as well as at 3 and 12 months postoperatively. ResultsA total of 491 patients were available for analyses (CABG = 182, AVR = 134, MVR = 93, CABG + VR = 82). POCD and postoperative depression increase (PODI) were observed for each surgical procedure. (At the 3-month follow-up: CFQ-S [CABG = 7.1%, AVR = 3.7%, MVR = 9.7%, CABG + VR = 9.8%]; CFQ-F [CABG = 9.9%, AVR = 9.7%, MVR = 9.7%, CABG + VR = 15.9%]; PODI [CABG = 7.7%, AVR = 9.7%, MVR = 6.5%, CABG + VR = 8.5%]. At the 12-month follow-up: CFQ-S [CABG = 6.6%, AVR = 7.5%, MVR = 15.1%, CABG + VR = 7.3%]; CFQ-F [CABG = 7.1%, AVR = 14.9%, MVR = 10.8%, CABG + VR = 9.8%]; PODI [CABG = 10.4%, AVR = 11.2%, MVR = 6.5%, CABG + VR = 4.9%]). No significant between-group effects were observed for the CFQ-S, CFQ-F, or the Hospital Anxiety and Depression Scale. ConclusionsFor clinicians, paying attention to patients' self-reported experiences of reduced cognitive function and symptoms of depression following cardiac surgery is important. Such reporting is an indication that interventions such as cognitive training or psychotherapy should be considered.

Impact of anaemia and iron deficiency on long-term outcomes following transcatheter edge-to-edge repair in degenerative vs. secondary mitral regurgitation: results from a large single-center study

Abstract Background Transcatheter mitral valve edge-to-edge repair (TEER) is an established therapeutic option for significant mitral regurgitation (MR), as an alternative for patients at high risk for open heart surgery. While mitral valve reconstruction is the guideline-recommended treatment modality for degenerative mitral regurgitation (DMR), secondary mitral regurgitation (SMR) is more complex and requires a multifaceted approach. Anaemia and iron deficiency (ID) are both associated with unfavourable outcomes in patients with cardiovascular diseases, particularly in those with heart failure. In patients undergoing TEER, the prevalence of ID and anaemia is exceptionally high. However, data regarding the impact of anaemia and ID on outcomes are limited to short- and mid-term follow-up periods. Purpose This retrospective single center study, aimed to investigate effects of anaemia and ID on long-term outcomes following TEER for relevant MR, as well as to relate it to the underlying MR aetiology. Methods A total of 833 patients (mean age 76.1 ± 8.4 years, 40.7% female, 63.3% secondary MR) were treated by TEER between September 2008 and July 2019. Patients were stratified based on their anaemia status (anaemia was defined as hemoglobin &amp;lt;12 g/dL in females and &amp;lt;13 g/dL in males) or ID (defined according to current HF guidelines as a serum ferritin concentration of &amp;lt;100 ng/mL or 100–299 ng/mL and a transferrin saturation &amp;lt;20%). Clinical follow-up was conducted primarily through in-person visits or by structured telephone interviews at 6 and 12 months after intervention and annually thereafter. The median follow-up time was 5.5 years, with a maximum follow-up of 12.3 years. Results Anaemia and ID were prevalent among patients with 61.6% and 68.1%, respectively. Among all anaemic patients, 73.5% also had ID. Anaemic patients had a lower functional status at baseline and were less likely to show improvement after TEER. Additionally, anaemia was significantly associated with all-cause mortality (hazard ratio [HR]=1.68, 95%-confidence interval [CI]: 1.36-2.07, p&amp;lt;0.001) and the composite endpoint of death or heart failure rehospitalization (HR=1.30, 95%-CI: 1.10-1.54, p=0.002). Moreover, anaemia was found to be an independent predictor for all-cause mortality in patients with secondary MR, with a 5-year mortality rate of 69.9% in anaemic patients compared to 47.8% in non-anaemic patients (p&amp;lt;0.001). However, ID was not associated with an increased risk of all-cause mortality or the composite endpoint of death or heart failure rehospitalization for either degenerative or secondary MR. Conclusion The high prevalence of anaemia and ID in patients undergoing TEER is noteworthy. Anaemia was associated with poorer functional baseline status and less post-interventional improvement. Furthermore, and in contrast to ID, anaemia was linked to higher mortality rates and more heart failure rehospitalizations, particularly in patients with secondary MR.Kaplan Meier survival analysisPredictors for all-cause mortality

Antiplatelet effect of acetylsalicylic acid in patients early after cardiac valve surgery: comparative investigation of the impairment of platelet inhibition by dipyrone versus acetaminophen

Abstract Background Low-dose acetylsalicylic acid (ASA) is recommended in current guidelines for a period of 3 months after surgical implantation of a bioprosthesis in aortic position or after surgical repair of the mitral valve. Dipyrone (D; metamizole) and acetaminophen (A; paracetamol) are frequently used non-opioid analgesics after surgery. The active metabolite of dipyrone (4-methylaminoantipyrine) is a reversible inhibitor of cyclooxygenase-1 and an interaction with the antiplatelet effect of ASA in more than 50 % of patients has been reported. Material and methods We enrolled 162 patients scheduled for cardiac surgery in this prospective investigator-initiated clinical study. Patients were randomized at day 1 after surgery to either 4 x 1g dipyrone iv/day or 4 x 1g acetaminophen iv/day. All patients were on ASA 100 mg daily (200 mg at day 1). The primary endpoint was the proportion of patients with adequate antiplatelet response to ASA assessed via determination of thromboxane B2 in platelet rich plasma after stimulation with arachidonic acid (AA) at day 4/5 after surgery (cutpoint ≤209.8 ng/ml thromboxane B2). Key secondary endpoints comprised platelet reactivity assessed by light transmission aggregometry [LTA] and by multiple electrode impedance aggregometry [MEIA]. Results 15 patients dropped out of the study. Thus, data from 71 patients randomized to dipyrone and 76 patients randomized to acetaminophen were available for data analysis. Patients had a mean age of 66.5±7.6 years and 97 were male and 50 female. Aortic valve was replaced in 92 patients, 54 underwent mitral valve reconstruction and combined surgery was performed in a single patient. The primary endpoint analyzed at day 4/5 after surgery is shown in the Figure. The proportion of non-responders was 12.5% (D) and 3.0% (A), respectively. Platelet reactivity at day 4/5 after surgery was assessed after stimulation with arachidonic acid by LTA or MEIA. No statistically significant difference between the treatment strata was determined in both assays: Maximum aggregation in LTA was 5.0% (median; 95% confidence interval [95% CI]: 4.0 - 8.0%) in D+ASA and 6.0% (95% CI: 5.0 - 11.0%) in A+ASA (p=0.528) and MEIA AUC was 345.5 AU*min (95% CI: 268.0 - 419.0) in D+ASA and 276.5 AU*min (95% CI: 241.0 - 330.0) in A+ASA (p=0.098). Plasma concentrations of MAA in patients treated with dipyrone were higher in patients identified as responders to ASA (86.6 µM; 95% CI: 67.9 - 102.4 µM) compared to non-responders (31.0 µM; 95% CI: 2.9 – 146.7 µM; p=0.0147). Summary and conclusion The proportion of non-responders to ASA is higher in patients treated with dipyrone compared to acetaminophen. The proportion of non-responders in the dipyrone-treated group in our study is substantially lower than reported in previous studies. High plasma concentrations of MAA in responders may contribute to enhanced inhibition of COX-1 in patients treated with dipyrone.

Comparison between Track Technique and Conventional Approach for Measuring Artificial Chordae in the Treatment of Anterior Leaflet Prolapse and Flail during Mitral Valve Repair.

Measuring the chordae tendineae for mitral valve reconstruction is feasible with various techniques. However, the effect of different strategies on the durability of plastics at follow-up is unknown. The study aims to compare a conventional surgical technique for measuring artificial chordae length with our new approach, defined "track technique". We compared the results of patients with anterior leaflet prolapse/flail who underwent mitral valve reconstruction by implanting artificial chordae from January 2020 to January 2022; 22 patients were operated on with a conventional technique, and 25 with our new alternative, "track technique". Clinical and transesophageal echocardiography data were collected postoperatively and at 2 years of follow-up. The primary outcome was freedom from mitral regurgitation. Secondary outcomes were presentation with New York Heart Association (NYHA) class 2 and leaflet coaptation length 10 mm. The patients of the 2 groups had comparable preoperative risk factors regarding the LogEuroSCORE (p = 0.33). Moreover, no difference was observed in terms of the mechanism of mitral valve insufficiency. No hospital or follow-up deaths were recorded for either group. At discharge, no echocardiographic differences were observed in the regarding degree of residual mitral regurgitation, but the measurement of coaptation length was in favor of the alternative group (8.6 1.8 vs. 11 1.4; p = 0.04). At 2 years of follow-up (25 9; range 13-37), the NYHA class was not different; however, the number of patients with 1-2+ recurrent mitral regurgitation was significantly higher in the conventional group (8 vs. 4 patients; p = 0.02), and the coaptation length was in favor of the alternative group (8.8 1.7 vs. 11 1.7; p = 0.04). We devised both techniques to prove effective in achieving good valvular continence, but a significantly greater coaptation length was obtained with our track technique at the 2 years follow-up.

Mitral Valve Prolapse, Not Always an Easy Diagnosis

Abstract We present the case of a 61-year-old male patient, with no medical history, who was presenting for an anterior chest pain, which appeared suddenly during an effort, accompanied by palpitations, fatigue and dyspnea Physical examination revealed the presence of a 4/6 systolic murmur with maximal auscultation at the apex and radiation in the left axilla. Echocardiographic evaluation revealed diagnostically suggestive elements for severe posterior mitral valve prolapse without any rupture, color Doppler showing severe mitral regurgitation, a tricuspid valve prolapse, tricuspid regurgitation grade III and pulmonary hypertension. Coronary angiography revealed coronary arteries without hemodynamically significant lesions, and Holter ECG/24-hour monitoring detected atrial fibrillation in 44% of the monitoring time. In this context, the possible causes of the anterior chest pain were: microvascular angina, traction on the chordae or pulmonary hypertension. The patient had a surgical indication for mitral valve replacement or reconstruction. The department of cardiac surgery undergoes mitral valve replacement with a mechanical prosthesis with a favorable outcome.

Image-based ring size prediction for mitral valve repair.

Annuloplasty rings are routinely used in mitral valve repair (MVr). However, accurate annuloplasty ring size selection is essential to obtain a favourable outcome. Moreover, ring sizing can be challenging in some patients and is highly influenced by surgeons' experience. This study investigated the utility of three-dimensional mitral valve (3D-MV) reconstruction models to predict annuloplasty ring size for MVr. A total of 150 patients undergoing minimally invasive MVr with annuloplasty ring due to Carpentier type II pathology and who were discharged with none/trace residual mitral regurgitation were included. 3D-MV reconstruction models were created with a semi-automated software package (4D MV Analysis) to quantitate mitral valve geometry. To predict the ring size, univariable and multivariable linear regression analyses were performed. Between 3D-MV reconstruction values and implanted ring sizes, the highest correlation coefficients were provided by commissural width (CW) (0.839; P < 0.001), intertrigonal distance (ITD) (0.796; P < 0.001), annulus area (0.782; P < 0.001), anterior mitral leaflet area (0.767; P < 0.001), anterior-posterior diameter (0.679; P < 0.001) and anterior mitral leaflet length (0.515; P < 0.001). In multivariable regression analysis, only CW and ITD were found to be independent predictors of annuloplasty ring size (R2 = 0.743; P < 0.001). The highest level of agreement was achieved with CW and ITD, and 76.6% of patients received a ring with no >1 ring size difference from the predicted ring sizes. 3D-MV reconstruction models can support surgeons in the decision-making process for annuloplasty ring sizing. The present study may be a first step towards accurate annuloplasty ring size prediction using multimodal machine learning decision support.

Simple and Safe: Inverse Plication of the Posterior Mitral Leaflet in Everyday Mitral Valve Reconstruction with and without Concomitant Procedures.

Objective: Cardiosurgical mitral valve repair (MVR) cannot be easily replaced by other interventional procedures due to the complexity of mitral valve regurgitation as well as physiologic and anatomic repair techniques. A wide variety of techniques have been adopted for proper reconstruction of posterior leaflet prolapse. We investigated the long-term results of quadrangular resections and compared them with a simplified reconstruction maneuver, the inverse plication. Methods: We retrospectively collected data from 1977 patients after mitral valve repair between 2004 and 2022. After considering inclusion and exclusion criteria, we analyzed data from 180 patients after MVR with and without concomitant procedures such as CABG and/or aortic valve replacement (AVR). All MVRs were performed with a semi-rigid annuloplasty ring. A total of 180 patients received quadrangular resection (QuadRes, N = 120)) or inverse plication (InvPlic, N = 60) of the posterior leaflet, among other measures. Demographic data, risk factors, procedure times, hospitalization time, early and long-term mortality as well as Kaplan-Meier survival were analyzed. Results: Age (65.3 vs. 63.1 years) and sex (28.8% female vs. 337.5% female) did not differ significantly, and the EuroSCORE was significantly higher in the InvPlic group (6.46 ± 2.75) than in the QuadRes group (5.68 ± 3.1). Procedural times did not differ for cardiopulmonary bypass, and were as follows: InvPlic 136 ± 44 min; QuadRes 140 ± 48 min; X-Clamp: InvPlic 91 ± 31 min; QuadRes 90 ± 32 min. Hospitalization time was slightly but insignificantly lower in the InvPlic group (15.5 days) than in the QuadRes group (16.1 days). Early mortality (5.08% vs. 8.33%) and re-do procedures (1.69% InvPlic; 6.67% QuadRes) did not differ significantly. However, long-term mortality was significantly lower in the InvPlic group (15.25% vs. 32.32%, p = 0.029). Conclusions: Among the surgical measures for the posterior leaflet, inverse plication appears to be non-inferior to quadrangular resection in unselected all-comer patients. Long-term results and absence of re-do procedures indicate very good stability. Thus, inverse plication not only allows correction of PML, but is also completely safe in the long term and can replace quadrangular resection, especially in patients where a reduction in technical challenges and procedure duration is desired.

Echocardiographic right ventricular evaluation in cardiac surgery patients undergoing mitral valve reconstruction: a single center prospective observational study.

Mitral valve (MV) regurgitation (MR) is the second most frequent indication for valvular surgery in Europe. Right ventricular (RV) dysfunction is a common finding after cardiac surgery and might persist for years. The RV-function after MV surgery has been controversially discussed. We therefore aimed to evaluate early RV-performance in patients undergoing MV surgery. Between 09/2020 and 06/2022, ninety-two patients presenting with MR undergoing MV surgery were consented and prospectively included for evaluation. Echocardiographic evaluation was performed one day before surgery, one week after surgery and three months later. Primary endpoints reported RV-function changes including tricuspid annular plane systolic excursion (TAPSE), RV systolic prime (S') and fractional area change (FAC). Secondary endpoints included stability of MV repair, changes in left ventricular functions and early mortality. Mean patients' age was 59.1±11.4 years. Fifty-five (59.7%) patients were male. Most of patients presented with severe (n=88; 95.7%) MR. Mean systolic pulmonary artery pressure was 35.6±15.7 mmHg. Moderate or severe pulmonary arterial hypertension (PAH) was present in 60 (65.2%) patients. Patients underwent either isolated MV surgery (n=67; 72.8%) or combined with tricuspid valve surgery (n=25; 27.2%). Minimal invasive surgery was performed in 26.1% (n=24) of the patients. Postoperative short-term follow-up at 3 months reported RV-dysfunction in 44.5% (n=41) of the patients as indicated by reductions in TAPSE & RV S' from 21.2±4.7 to 14±3.3 mm (P<0.001) and from 14.7±4.3 to 9.7±2.8 cm/s (P<0.001) respectively. The FAC reduction from 42.9%±9.6% to 42.2%±9.9% was non-significant (P=0.593) and no need for redo mitral or tricuspid valve surgery was reported. Finally, the presence and severity of preoperative PAH played significant roles for the incidence of RV dysfunction, P=0.021 and P=0.047, respectively. Minimal invasive surgical procedure significantly reduced the incidence of postoperative RV-dysfunction (P=0.013). Study early results report a significant reduction of RV-function after MV surgery as measured by TAPSE, & RV S', even when the FAC remains unchanged. Even though, this finding has limited prognostic implications during an uneventful surgical course.

Results of mitral valve reconstruction using substitute extracellular matrix.

During the ongoing search for an ideal patch material for reconstructive heart surgery, several versions of extracellular matrix (ECM) have been used. However, long-term performance in different cardiac positions is unknown. We performed a retrospective review of outcomes after mitral valve surgery using ECM in 29 patients from 2011 to 2014. Clinical and echocardiographic follow-up was reviewed (mean time, 6.3±2.8years). ECM was used to reconstruct the posterior mitral annulus in 69% and to repair the mitral leaflet in 65% of the patients. The most prevalent etiology was dystrophic calcification of the annulus (80%) versus endocarditis for leaflet repair (60%). Fifty-five percent of the patients who required annular reconstruction received a mitral valve replacement (MVR). There were 2 perioperative deaths (7%). Long-term data were analyzed according to surgical technique; namely, isolated leaflet repair compared with annular reconstruction with or without MVR. There were 3 late deaths (1 per group). Overall survival was 83% at 7years. Ninety percent of cases with mitral valve repair with or without annular reconstruction were free from more than mild mitral regurgitation, compared with 45% in the MVR and annular reconstruction group. The mechanism of failure was patch degeneration creating a severe paravalvular leak due to prosthesis dehiscence. ECM used to repair the mitral valve leaflets with or without annular reconstruction offers acceptable results. However, caution should be taken with the use of ECM adjacent to prosthetic valve material because of a high rate of failure associated with patch degeneration.

Every day mitral valve reconstruction: What has changed over the last 15 years?

Mitral valve reconstruction (MVR) is one of the cardiosurgical procedures which cannot be substituted by any intervention owing to the quality of the quasi-anatomical, physiological repair. However, technique and strategies have changed over the years. We looked at procedural characteristics and outcome in an all-comer, non-selected cohort of patients. 738 out of 1.977 patients were retrospectively analyzed receiving MVR with and without concomitant procedures. The cohort was divided into three periods. P1: 2004-2009 (134 pts.); P2: 2010-2014 (294 pts.), and P3: 2015-2019 (310 pts.). Early mortality increased from P1 to P2 and decreased from P2 to P3 (9% P1, 13% P2, 10% P3). All patients received an annuloplasty-ring. In P1 resection measures dominated. In P3 artificial chordae were dominant. Age, BMI, and risk scores correlated with early mortality. Survival rates were 66% (5-years), 55% (10-years), 44% (15-years) in P1, 63% (5-years), 50% (10-years) in P2, and 80% (5-years) in P3. Odds ratio for reduced long-term survival were concomitant venous only bypass surgery (10-years 2,701, p = 0.026). 10-year survival was positively influenced by isolated MVR (0.246, p = 0.001), concomitant isolated arterial bypass (IMA) (0.153, p = 0.051), posterior leaflet measure (0.178, p<0.001), and use of artificial chordae (5-years 0.235, p<0.001). Indication for ring implantation remained mandatory while preference changed alongside improved designs. Procedural characteristics changed from mainly resection maneuvers to predominant use of artificial chordae. Long-term results were negatively influenced by co-morbidities and positively influenced by posterior leaflet repair and artificial chordae. MVR underwent a qualitative evolution and remains a valuable cardiosurgical procedure.

Echocardiographic predictors of operative outcome for transapical off-pump mitral valve repair with neochord implantation

Abstract Introduction Transapical off-pump mitral valve repair with artificial neochord implantation (TOP-MINI) is safe and effective for the treatment of primary mitral regurgitation12, however, the current literature regarding echocardiographic criteria prior to the procedure is scarce. Objective To identify preoperative echocardiographic predictors of technical success after TOP-MINI for severe primary mitral regurgitation. Methods All consecutive patients who underwent TOP-MINI for severe primary mitral regurgitation from 2017 to 2022 were included. Preoperative echocardiographic evaluation included transthoracic and transesophageal echocardiography. Transesophageal evaluation included 2D measurements of mitral valve annulus, mitral leaflets, flail gap, and 3D mitral valve reconstruction among others, the leaflet-to-annulus index was estimated in all patients. Mitral valve morphology was classified as: Type A (Central posterior leaflet prolapse/flail) or non-Type A (Type B: posterior multisegment involvement; type C: anterior leaflet prolapse; type D: paracommissural or calcified leaflet). Technical success was defined according to the Mitral Valve Academic Research Consortium criteria. Independent echocardiographic predictors for the primary outcome were identified using a multivariate logistic regression model. Results Fifty-five patients were included. Mean age was 66.7 years (SD 12.9). Technical success with MR &amp;lt;2+ was achieved in 48 (87.27%) patients. Significant predictors for technical success were the leaflet-to-annulus index (OR 1.09; p=0.012; 95% CI: 1.02–1.15), with an optimal cutoff value of 1.26 (sensitivity 73.3%, specificity 85.7%); and a non-type A valve morphology (OR 0.04; p=0.024; 95% CI: 0.01–0.65). The model showed good discrimination (AUC = 0.92) and calibration (Hosmer-Lemeshov p=0.21). Conclusion A thorough preoperative echocardiographic evaluation is key to improve outcomes in TOP-MINI. In this study, a leaflet-to-annulus index &amp;gt;1.26 was associated with technical success, whether a non-type A valve morphology was associated with technical failure. These parameters could help to identify proper candidates for this technique. Funding Acknowledgement Type of funding sources: None.

Decellularized homograft for aortic valve replacement two years after lung transplantation

Cardiac valvular surgery in patients after lung transplantation is a challenging procedure, reports are scarce. We report a 29-year-old patient who underwent concomitant mitral valve reconstruction and implantation of a decellularized aortic homograft two years after bilateral lung transplantation.

Acute and long-term success of left atrial anterior line and mitral isthmus line ablation in patients after mitral valve surgery.

Perimitral flutter and atrial fibrillation may occur in patients with prior surgical mitral valve (MV) repair or replacement and can be challenging for percutaneous catheter ablation. This study sought to determine the feasibility, acute success and durability of catheter ablation of atrial fibrillation or atrial tachycardia by way of a mitral isthmus line (MIL) or an anterior line (AL). A total of 81 patients (49 males, mean age 62±11 years) with prior MV replacement (n=30) or reconstruction (n=51) underwent creation of a MIL (34) and/or an AL (72). Acute bidirectional block of the MIL was successfully achieved in 24/34 cases and of the AL in 64/72 patients. Patients of the control group without prior MV surgery were matched 1:1 with the valve group. In the AL control subgroup, acute bidirectional block was achieved in 65/72 patients. Acute blockage in the MIL control subgroup could be achieved in 31/34 patients. The MIL valve subgroup showed the worst results in terms of durability, whereas a similar trend emerged in the control group and the AL valve subgroup (probability of failure in MIL valve subgroup 2.224vs. MIL control subgroup 0.605 [Hazard Ratio (HR)=0.27, 95% confidence interval (CI), 0.11-0.65), P=.004]; probability of failure in AL valve subgroup 0.844vs. AL control subgroup 1.03 [HR=1.22 (95% CI, 0.66-2.26), P=.523]). Percutaneous creation of MIL and AL is feasible and safe in patients with prior MV replacement/repair and associated with moderate acute and long-term success rates to achieve bidirectional block.

Late Infective Endocarditis After Transcatheter Mitral Valve Reconstruction (MitraClip): A Case Report and a Review of the Literature.

Percutaneous transcatheter mitral valve reconstruction in edge to edge fashion is a well-established option in inoperable or high peri-operative risk patients with severe, symptomatic mitral valve regurgitation. MitraClip in combination with medical treatment improves survival and reduces hospitalization rates compared with optimal medical therapy alone in well selected patients. Clip-associated endocarditis is a rare complication with only few reported cases in the literature. We present a case of late infective endocarditis post Mitral Clip implantation and also review the literature regarding this new rare condition.