Mitral Valve Reconstruction Research Articles

Entire mitral valve reconstruction using porcine extracellular matrix: static in vitro evaluation.

To investigate the feasibility of reconstruction of the entire mitral valve using a tube graft made of 2-ply small intestinal submucosa extracellular matrix in vitro. Seven explanted mitral valves with intact subvalvular apparatus from 80 kg pigs were evaluated in a left heart simulator and served as controls. After testing the native valve, the leaflets and chordae tendineae were explanted, and the 2-ply small intestinal submucosa extracellular matrix (CorMatrix®; Cardiovascular Inc., Alpharetta, GA, USA) tube graft was implanted. The characterization was based on geometric data from digital images, papillary muscle force, annular tethering force and leaflet pressure force. The tube grafts were fully functional without any signs of leakage, tearing or rupture during incrementally increased pressures from 0 mmHg to 120 mmHg. The posterior leaflet moved anteriorly and became larger after reconstruction when compared with the native valve. However, the mid coaptation point was preserved. The anterior papillary muscle force decreased significantly (5.2 N vs 4.4 N, P = 0.022 at 120 mmHg), and the posterior papillary muscle force increased significantly (4.8 N vs 5.6 N, P = 0.017 at 120 mmHg) after reconstruction. The entire mitral valvular and subvalvular reconstruction with a 2-ply small intestinal submucosa extracellular matrix tube graft is feasible in an in vitro model. Our method of reconstruction increased the convexity of the anterior leaflet's coaptation line and significantly redistributed the papillary muscle force towards the posterior papillary muscle. These promising results and the prospect of the entire mitral valvular and subvalvular reconstruction warrant further in vivo evaluations.

Five Maneuvers to Facilitate Faster Robotic Mitral Valve Repair

Robotically assisted mitral valve reconstruction has become a cornerstone in the management of degenerative mitral valve regurgitation. High-volume centers report exceptional outcomes with minimal morbidity and mortality in select patient populations. As compared to conventional sternotomy, robotically assisted surgery has yielded comparable efficacy and safety, with potential benefits of improved cosmesis and a faster recovery period. Despite the potential benefits of a robotic approach, there has been a reluctance in widespread adoption due to concerns over increased operative and crossclamp times as compared to conventional sternotomy approaches. In light of this specific concern, we have identified opportunities to improve the efficiency of robotic mitral valve repair by application of 5 innovations and surgical strategies.

New Device for the Treatment of Functional Ischemic Mitral Regurgitation: Proof of Concept in an In Vitro Model.

Optimal surgical treatment of functional ischemic mitral regurgitation (FIMR) is still controversy. Due to the underlying pathophysiology, stand-alone ring annuloplasty is assumed with a high recurrence rate of mitral regurgitation, thus additional subvalvular repair techniques might improve the results. This in vitro study introduces a new device for subvalvular mitral valve repair. We developed a new device for subvalvular mitral valve repair, consisting of two frames for papillary muscle (PM) attachment, which are connected with two holding bars serving for fixation of the device on an annuloplasty ring. In the first experimental run, porcine mitral valves including the chordae tendineae and PMs were fixated on a holding device, consisting of a holding ring simulating mitral annulus dilation and height-adjustable frames for PM attachment simulating leaflet tethering. In vitro regurgitant volume was determined in a pulse duplicator. Afterward, the frames for PM attachment were replaced by our newly developed device and the measurements were repeated. In the model simulating FIMR, the regurgitant volume was 44.3 ± 12.38 mL/stroke. After subvalvular reconstruction with our new device, the regurgitant volume was significantly reduced to 33.1 ± 11.68 mL/stroke (p = 0.009). In this specific in vitro model, our new device for subvalvular mitral valve reconstruction led to a significant reduction of the regurgitant volume, thus representing a promising technique to potentially improve the results of mitral reconstruction in ischemic functional mitral valve regurgitation. Additional studies are required to further investigate and improve our device.

Three-dimensional mitral valve reconstruction based on TEE images

Three-dimensional mitral valve reconstruction based on TEE images

Clinical performance of a three-dimensional saddle-shaped, rigid ring for mitral valve repair†

The Profile 3D annuloplasty ring is a complete, rigid, saddle-shaped ring indicated for reconstruction and/or remodelling of the pathological mitral valve (MV) in patients with mitral insufficiency. This prospective, non-randomized, observational, postmarket release study characterized the patient population for which the study ring was chosen for MV repair, assessed the relief from MV dysfunction and determined the level of mitral regurgitation (MR) at follow-up (6-12 months postimplant). Between February 2013 and July 2015, 151 patients were enrolled at 7 centres; data were excluded for 3 patients. The mean age of the remaining 148 patients was 63.8 ± 12.3 years, and 85 patients (57.4%) were men. Ischaemic cardiomyopathy was present in 15 patients (10.1%) and dilated cardiomyopathy in 12 patients (8.1%). MR was severe in 86 of 145 patients with available data (59.3%). Implantation was successful in 141 of 147 attempted procedures. Two deaths (n = 148, 1.4%) occurred within 30 days, and 1 death (0.7%) occurred >30 days after implant. Analysis of patients with data from both visits (n = 111) demonstrated that MR was none or mild in 94.5% of patients, moderate in 3.6% and moderate to severe in 1.8% at follow-up. Nearly all (104 of 109, 95.4%) patients were in New York Heart Association Class I/II. Among patients with ischaemic cardiomyopathy or dilated cardiomyopathy preoperatively, 16 of 19 patients with available data (84.2%) had no or mild MR at follow-up. MV repair using the Profile 3D annuloplasty ring is a safe and effective treatment for MR. Further investigation is warranted to determine whether patients with ischaemic cardiomyopathy or dilated cardiomyopathy derive unique benefit from this saddle-shaped ring. www.clinicaltrials.gov, NCT01112566.

Initial Experience and Early Results of Mitral Valve Repair With CardioCel Pericardial Patch

The objective of this study was to assess the performance of a tissue engineering process-treated bovine pericardium patch (CardioCel, Admedus Regen Pty Ltd, Perth, Australia) in the setting of reconstructive mitral valve surgical procedures. Between March 2014 and April 2016, 30 patients (57.2 ± 14.3 years of age; 27% female) underwent mitral valve leaflet repair with a CardioCel patch. Perioperative mortality was 7% (2 patients, non-graft related). In the 28 remaining patients, predischarge echocardiography demonstrated good repaired valve function. At a mean follow-up of 1.7 ± 0.9 years, three additional deaths occurred (tworesulting from infective endocarditis and one non-cardiac related). On follow-up echocardiography (follow-up time of 1.7 ± 0.8 years; available for 26 of 28 [93%] hospital survivors), recurrent regurgitation was seen in 2 patients (both with infective endocarditis), and 1 patient underwent reoperation (no infection at the level of patch repair was observed). In the remaining patients, the most recent echocardiogram demonstrated no regurgitation or mild regurgitation and stable gradients. The thickness and echodensity of the implanted patch on follow-up echocardiograms were comparable with postoperative echocardiograms. Initial results with the CardioCel patch in mitral valve repair operations were satisfactory. The resistance to infection and late degeneration will need to be assessed in the future.

Previous Sternotomy as a Risk Factor in Minimally Invasive Mitral Valve Surgery.

Cardiac redo surgery, especially after a full sternotomy, is considered a high-risk procedure. Minimally invasive mitral valve surgery (MIMVS) is a potential therapeutic approach. However, current developments in interventional cardiology necessitate additional discussion regarding the therapy of choice in high-risk patients. In this context, it is necessary to clarify the perioperative and postoperative risks induced by the factor previous sternotomy in the setting of MIMVS. Thus, we present a comparative study analyzing the outcome of MIMVS after previous sternotomy vs. primary operation. We identified 19 patients who received isolated or combined mitral valve (MV) surgery via the MIMVS approach after previous full sternotomy (PS group) and compared the results to those of a group of 357 patients who received primary MIMVS (non-PS group). After a propensity score analysis, groups of n = 15 and n = 131, respectively, were subjected to a comparative evaluation. A 1-year follow-up analysis of functional cardiac parameters and clinical symptoms was performed, accompanied by a Kaplan-Meier analysis. Except for the rate of realized MV reconstructions (PS group: 53.8% vs. non-PS group: 85.5%; p = 0.011), no significant differences were to be noted within the intraoperative and early postoperative course. However, patients in the PS group experienced an increased intensive care unit stay length (PS group: 2 days, 95% CI, 1-8 vs. non-PS group: 1 day, 95% CI, 1-2; p = 0.072). The follow-up examinations revealed excellent functional and clinical outcomes for both groups. The Kaplan-Meier analysis displayed no significant difference regarding the postoperative mortality (p = 0.929) related to the patients at risk. A previous sternotomy remains a risk factor for MIMVS and demands special attention in the early postoperative period. Nevertheless, the early- and late-term results concerning the functional and clinical outcomes suggest that the MIMVS procedure is satisfactory, even after a full sternotomy.

Отдаленные результаты использования методики край в край как дополнительного маневра коррекции остаточной регургитации после реконструкции митрального клапана

<b>Введение.</b> Доля реконструктивных операций на митральном клапане (МК) ежегодно увеличивается. Рост мастерства и опыта хирургов привел к расширению показаний к пластике. Иногда во время выполнения многокомпонентных реконструкций возникает значимая остаточная регургитация. В такой ситуации возникает дилемма: протезировать клапан или продолжать попытки реконструкции? G. Gatti с коллегами предложили использовать маневр край в край для коррекции остаточной регургитации. Мы в своей практике в подобной ситуации также иногда используем методику край в край. Редкое применение методики связано с возможной нестабильностью результатов в отдаленном периоде, что и определило цель настоящего исследования. <br /> <b> <br /> Цель исследования:</b> изучить отдаленные результаты использования методики край в край как дополнительного маневра коррекции остаточной митральной регургитации при реконструкции митрального клапана. <br /> <br /> <b>Материал и методы.</b> В отделении НМИЦССХ им. А.Н. Бакулева с 2001 г. по май 2013 г. было выполнено 202 операции реконструкции МК при изолированной митральной недостаточности, обусловленной различной патологией. Интраоперационно у 19 пациентов была выявлена значимая остаточная митральная регургитация, для коррекции которой использована методика край в край. Результаты применения методики оценены в непосредственном и отдаленном периодах. Средний возраст пациентов составил 47±20 лет, мужчин было 9 (47,6%). Все пациенты относились к III–IV функциональному классу по NYHA. Основной причиной недостаточности являлся дегенеративный процесс. До операции у всех пациентов имелась тяжелая митральная недостаточность III–IV степени. В зависимости от характера патологии митрального клапана пациентам выполнялась вальвулопластика: треугольная резекция, создание неохорд и т. д. Во всех случаях реконструкция была дополнена аннулопластикой. <br /> <br /> <b>Результаты.</b> Летальных исходов и реопераций на госпитальном этапе не было. Значимой регургитации на митральном клапане не отмечалось. Все пациенты выписаны в удовлетворительном состоянии. В отдаленном периоде были обследованы 15 (79%) пациентов. Средний срок наблюдения составил 57±33 (от 15 до 114) мес. Отмечены 2 (10,5%) летальных исхода (тромбоэмболия легочной артерии и ишемическая болезнь сердца), в одном (5,2%) случае выполнена реоперация. Пиковый (8,3±3,4 мм рт. ст.) и средний диастолический (3,1±1,35 мм рт. ст.) градиенты на МК почти не изменились по сравнению с таковыми в раннем послеоперационном периоде и оставались приемлемыми во всех наблюдениях. Отмечался 1 (6,5%) случай возвратной регургитации III степени, пациент был реоперирован, 2 (13%) случая регургитации II степени, однако без клинической симптоматики. Функциональный класс пациентов в отдаленном послеоперационном периоде по NYHA в среднем составил 1,25. <br /> <br /> <b>Заключение.</b> При использовании в качестве дополнительного маневра для коррекции остаточной регургитации методика край в край показывает удовлетворительные клинические результаты в отдаленном послеоперационном периоде: обеспечивает высокую свободу от возврата регургитации, реопераций и хорошую выживаемость. Данная методика не обладает стенозирующим эффектом даже при использовании опорных конструкций для аннулопластики. Однако требуются дальнейшее на- копление материала и анализ результатов при длительных сроках наблюдения.

Случай успешной реконструкции митрального клапана у пациента после левосторонней пульмонэктомии и выраженной дислокации сердца

Перенесенная пульмонэктомия и сердечная патология, требующая оперативного лечения, – крайне редкое сочетание. Отсутствие рекомендаций, стандартизированного подхода и крайне малое количество публикаций подобного рода зачастую останавливают хирурга. Однако постепенное увеличение числа успешных случаев операций у этой категории больных указывает на их операбельность и высокую выживаемость. В мировой литературе за период более 40 лет описано 30 случаев. Из них лишь в 30% выполнены операции на клапанах сердца. Пульмонэктомия ведет к значительному изменению анатомии средостения, может создать технические сложности при выполнении кардиохирургического вмешательства и затруднить восстановление дыхания в послеоперационном периоде. В русскоязычной литературе какого-либо описания подобных операций не отмечено. Нами успешно выполнена реконструктивная операция митрального клапана у пациента 76 лет с ранее перенесенной левосторонней пульмонэктомией.

Pediatric mitral valve reconstruction in acute endocarditis.

Pediatric mitral valve reconstruction in acute endocarditis.

Трехмерная реконструкция митрального клапана в выборе тактики хирургической коррекции порока.

Трехмерная реконструкция митрального клапана в выборе тактики хирургической коррекции порока.

A case of mitral valve reconstruction with idiopathic thrombocytopenic purpura and positive antiphospholipid antibodies

A case of mitral valve reconstruction with idiopathic thrombocytopenic purpura and positive antiphospholipid antibodies

Transvalvular pressure gradients for different methods of mitral valve repair: only neochordoplasty achieves native valve gradients.

Many surgical and interventional methods are available to restore patency for patients with degenerative severe mitral valve regurgitation. Leaflet resection and neochordoplasty, which both include ring annuloplasty, are the most frequently performed techniques for the repair of posterior mitral leaflet flail. It is unclear which technique results in the best haemodynamics. In this study, we investigated the effect of different mitral valve reconstruction techniques on mitral valve haemodynamics and diastolic transvalvular pressure gradient in an ex vivo porcine model. Eight porcine mitral valves were tested under pulsatile flow conditions in an in vitro pulsatile flow loop for haemodynamic quantification. Severe acute posterior mitral leaflet flail was created by resecting the posterior marginal chorda. The acute mitral valve regurgitation was corrected using 4 different repair techniques, in each valve, in a strictly successive order: (i) neochordoplasty with polytetrafluoroethylene sutures alone and (ii) with ring annuloplasty, (iii) edge-to-edge repair and (iv) triangular leaflet resection, both with ring annuloplasty. Valve haemodynamics were measured and quantified for all valve configurations (native, rupture and each surgical reconstruction). The results were analysed using a validated statistical linear mixed model, and the P-values were calculated using a 2-sided Wald test. All surgical reconstruction techniques were able to sufficiently correct the acute mitral valve regurgitation. Neochordoplasty without ring annuloplasty was the only reconstruction technique that resulted in haemodynamic properties similar to the native mitral valve (P-values from 0.071 to 0.901). The diastolic transvalvular gradient remained within the physiological range for all reconstructions but was significantly higher than in the native valve for neochordoplasty with ring annuloplasty (P < 0.000), edge-to-edge repair (P < 0.000) and leaflet resection (P < 0.000). Neochordoplasty without ring annuloplasty resulted in a significantly better pressure gradient than neochordoplasty with a ring annuloplasty (P < 0.000). Additionally, neochordoplasty with a ring annuloplasty resulted in significantly lower transvalvular pressure gradients than edge-to-edge repair (P < 0.000) and leaflet resection (P < 0.000). Neochordoplasty with or without ring annuloplasty was the reconstruction technique that almost achieved native physiological haemodynamics after repair of posterior mitral leaflet flail after acute isolated chordal rupture in our ex vivo porcine model.

Leaflet repair techniques in mitral valve reconstruction

Recently, there has been tremendous development in mitral valve repair, especially in imaging modalities, minimally invasive approaches and surgical techniques. Among various surgical techniques, leaflet techniques have also advanced for treatment of different types of mitral valve diseases. The optimal leaflet technique depends on the involvement of anterior or posterior leaflet, aetiology of the disease and the usage of surgical approach. In degenerative disease for posterior leaflet prolapse, the current trends are from classical quadrangular resection to limited triangular resection. Development of techniques like peeling and pericardial leaflet augmentation has made mitral valve repair feasible in rheumatic heart disease. Similarly, with better understanding of pathophysiology of ischemic mitral regurgitation, the new techniques involving leaflets and subvalvular apparatus have also progressed for more stable and durable repair. In this review, various leaflet repair techniques, which are applicable to various types of functional classification for different aetiology, have been described in detail.

Fifteen years' experience with the use of artificial chords for valve reconstruction in children.

To retrospectively review our experience with artificial chords in mitral and tricuspid reconstructive surgery in children. All consecutive paediatric (<18 years) patients who underwent mitral or tricuspid valve reconstruction with the use of artificial chords in our centre in the past 15 years were retrospectively analysed. Thirty-nine patients (age 3 days to 17 years) underwent reconstruction of the mitral (n = 27) or tricuspid (n = 12) valve using artificial chords. Mean number of chords was 3.5 ± 1.7. In 26 of 27 mitral valve patients, chords were placed on the anterior leaflet, in one on the posterior leaflet. In 10 of the 12 tricupid valve, patients chords were placed on the anterior leaflet and in 2 on the septal leaflet. All mitral patients underwent annuloplasty (10 bilateral Wooler-Kay and 17 rigid ring annuloplasty). Ten of the 12 tricuspid patients underwent annuloplasty (1 rigid ring and 9 commissural plication). Follow-up was after 8.7 ± 5.5 years. There was no early or late mortality. The actuarial freedom from reoperation rates at 1, 5 and 10 years were 95%, 91% and 81%, respectively. No reoperations occurred in the tricuspid group. In the mitral group, there were 2 early failures and 3 late reoperations due to mitral stenosis. Restricted leaflet motion probably caused by the artificial chords was seen in only 1 patient. Our data show that long-term durability of mitral and tricuspid valve reconstruction using artificial chords in children is good. Despite patient growth, restricted leaflet motion by the artificial chords does not seem to form a major problem.

Possibilities of Echocardiography at the Stages of Surgical Treatment of the Patient with the Mitral Valve Posterior Leaflet Prolapse Resulted in Mitral Insufficiency and Atrial Fibrillation (A Case Report)

The mitral valve prolapse is characterized by the degeneration of the valve leaflets, accompanied by their thickening, increasing surface area and flexibility. The mitral valves leaflets bulge (prolapse) beyond the plane of the atrioventricular ring into the left atrium during ventricular systole and lose the ability to close tightly, leading to the mitral regurgitation. Acute chord rupture of the mitral valve posterior leaflet is a rare but important cause of severe mitral regurgitation and the development of acute or progressive chronic heart failure. Acute mitral insufficiency, accompanied by hemodynamic disorders, requires an urgent valve plastic surgery or valve prosthetics. The mitral valve plastic surgery gives a number of undeniable advantages over prosthetics, providing the best hemodynamic parameters, saving the patient from lifelong receiving of anticoagulant drugs. Detailed qualified echocardiographic evaluation of all structures of the mitral valve (fibrous ring, MV leaflets by segments, overlapping structures, structure of the chordal apparatus, papillary muscles) provides the necessary information for the mitral valve reconstructive plastic surgery with the choice of the method that is most optimal for a certain patient at the preoperative stage. We report herein a clinical observation of the patient with a diagnosis: acquired heart disease, the mitral valve posterior leaflet prolapse with mitral insufficiency Grade 3. Chronic heart failure IIA. II FC. Atrial fibrillation. The patient underwent multicomponent mitral valve reconstruction with the creation of a neochord and the fibrous ring plastic on the duplicate of a PTFE strip (soft support ring), pairwise isolation of the pulmonary vein entrance and right cavotricuspid isthmus.

Cardiac surgery 2016 reviewed

For the year 2016, more than 20,000 published references can be found in Pubmed when entering the search term "cardiac surgery". Publications last year have helped to more clearly delineate the fields where classic surgery and modern interventional techniques overlap. The field of coronary bypass surgery (partially compared to percutaneous coronary intervention) was enriched by five large prospective randomized trials. The value of CABG for complex coronary disease was reconfirmed and for less complex main stem lesions, PCI was found potentially equal. For aortic valve treatment, more evidence was presented for the superiority of transcatheter aortic valve implantation for patients with intermediate risk. However, the 2016 evidence argued against the liberal expansion to the low-risk field, where conventional aortic valve replacement still appears superior. For the mitral valve, many publications emphasized the significant impact of mitral valve reconstruction on survival in structural mitral regurgitation. In addition, there were many relevant and other interesting contributions from the purely operative arena in the fields of coronary revascularization, surgical treatment of valve disease, terminal heart failure (i.e., transplantation and ventricular assist devices), and aortic surgery. While this article attempts to summarize the most pertinent publications it does not have the expectation of being complete and cannot be free of individual interpretation. As in recent years, it provides a condensed summary that is intended to give the reader "solid ground" for up-to-date decision-making in cardiac surgery.

İleri yaş hastalarda kardiyak miksomanın cerrahi tedavisi

Objective: Cardiac myxoma usually presents during early adulthood. There is generally a tendency for prompt surgical resection. However, advanced age of patients presenting with this disease may increase the operative risk due to other cardiac and non-cardiac problems. Therefore, we evaluated elderly patients who underwent surgery for myxoma to review the management of treatment. Methods: Between September 1985 and March 2012, a total of 17 consecutive patients over 65 years of age (5 male, 12 female; mean age: 69.3±3.5 years) who had undergone surgical resection for cardiac myxoma were analyzed retrospectively. Echocardiography had been performed in all patients to diagnose the myxoma and evaluate other cardiac pathologies. Coronary angiography had been performed in all patients except in two cases who underwent emergency surgery. Results: Thirteen patients (76.4%) survived the operation. Two patients who underwent emergency operation died early and four patients died during the follow-up time. Concomitant procedures included coronary artery bypass grafting in two, radiofrequency ablation in one, mitral valve reconstruction in one and femoral embolectomy in one patient. Conclusions: In an era of aging population, myxoma tends to be diagnosed more frequently in elderly and high-risk patients. Complete preoperative assessment of these patients is a more appropriate approach in stable patients than the traditional emergency surgery applied to all cases.

Echocardiographic analysis of left and right ventricular function in patients after mitral valve reconstruction

Echocardiographic analysis of left and right ventricular function in patients after mitral valve reconstruction

Comprehensive patient-specific information preprocessing for cardiac surgery simulations.

Patient-specific biomechanical simulations of the behavior of soft tissue gain importance in current surgery assistance systems as they can provide surgeons with valuable ancillary information for diagnosis and therapy. In this work, we aim at supporting minimally invasive mitral valve reconstruction (MVR) surgery by providing scenario setups for FEM-based soft tissue simulations, which simulate the behavior of the patient-individual mitral valve subject to natural forces during the cardiac cycle after an MVR. However, due to the complexity of these simulations and of their underlying mathematical models, it is difficult for non-engineers to sufficiently understand and adequately interpret all relevant modeling and simulation aspects. In particular, it is challenging to set up such simulations in automated preprocessing workflows such that they are both patient-specific and still maximally comprehensive with respect to the model. In this paper, we address this issue and present a fully automated chain of preprocessing operators for setting up comprehensive, patient-specific biomechanical models on the basis of patient-individual medical data. These models are suitable for FEM-based MVR surgery simulation. The preprocessing methods are integrated into the framework of the Medical Simulation Markup Language and allow for automated information processing in a data-driven pipeline. We constructed a workflow for holistic, patient-individual information preprocessing for MVR surgery simulations. In particular, we show how simulation preprocessing can be both fully automated and still patient-specific, when using a series of dedicated MVR data analytics operators. The outcome of our operator chain is visualized in order to help the surgeon understand the model setup. With this work, we expect to improve the usability of simulation-based MVR surgery assistance, through allowing for fully automated, patient-specific simulation setups. Combined visualization of the biomechanical model setup and of the corresponding surgery simulation results fosters the understandability and transparency of our assistance environment.