Mitral Valve Repair Or Replacement Research Articles

Incidence and risk factors for permanent pacemaker implantation in patients undergoing tricuspid valve surgery

Abstract Background Bradyarrhythmias requiring permanent pacemaker (PPM) implantation are commonly described after cardiac surgeries. Numerous studies evaluated the demographic and clinical risk factors for PPM placement following aortic and mitral valve surgeries. However, a paucity of data exists when it comes to tricuspid valve surgery (TVS). Purpose Our study aimed to evaluate the incidence of PPM placement after TVS and investigate the demographic, clinical, and procedural risk factors associated with the need for a PPM. Methods We included 13 294 patients from the Medicare database who underwent isolated TV repair (N=1319 (10%)), isolated TV replacement (N=2123 (16%)), or concomitant TV repair or replacement with different combinations of surgical aortic valve replacement (SAVR), mitral valve repair or replacement (MVR), and coronary artery bypass graft (CABG). Patients who underwent TV surgery for endocarditis were excluded. The primary exposure of interest for the study was new pacemaker placement after TV surgery and before discharge, or within 30 days from discharge date. Each patient from the pacemaker group was matched to up to 3 controls from the no pacemaker group. Results Among the included patients, 2518 (18.9%) required a PPM placement after TVS. In the logistic regression including patients’ variables, subjects who needed PPM implantation were more likely to be women (64.4% vs. 57.6%, P<0.001) and had a higher prevalence of prior sternotomy (P=0.01), chronic kidney disease (P=0.03), heart failure (P=0.04) and tumor (P=0.02). Patients who underwent isolated TV replacement and TV replacement with concomitant surgeries had a significantly higher risk of PPM implantation when compared to isolated TV repair and TV repair with concomitant surgeries (P<0.0001) (Table). Conclusion Post-procedural PPM implantation is a very frequent complication of TVS, especially in TV replacement with or without concomitant left-sided heart surgeries. Numerous demographic and clinical factors are associated with an increased risk of PPM placement. Adequate risk stratification and counseling of patients before surgery decision is essential.Demographic & Surgical Risk Factors

Association between hospital volume, clinical events, resource utilization, and costs of septal myectomy and alcohol septal ablation procedures in US patients with hypertrophic cardiomyopathy

Abstract Background Prior studies have evaluated the relationship between hospital procedural volumes of septal reduction therapies (SRT) for obstructive hypertrophic cardiomyopathy (HCM) and outcomes. Other analyses, including economic outcomes, are needed to support clinical decisions among adult patients diagnosed with HCM. Objective The objective of this study was to reconfirm the relationship between higher SRT procedural volume, including septal myectomy (SM) -with and without mitral valve repair or replacement (MVRR)- and alcohol septal ablation (ASA), and clinical events, healthcare resource utilization, and hospitalization costs using more contemporary hospitalization data. Data & Methods This cross-sectional study utilizes retrospective observational data from the PINC AI™ Healthcare Database (PHD), a US hospital administrative database. The study population consists of adult patients with HCM undergoing ASA or SM procedures between January 1, 2012, and March 31, 2022. Hospital volume was determined by tertiles of total SRT performed for ASA, SM separately during the study period. We compare clinical events (including death, stroke, acute renal failure, and pacemaker implantation), readmission, index length of stay, and hospitalization costs across tertiles. We present p-values between tertiles and within procedure types. Results A total of 3,068 adult HCM patients in 315 US hospitals underwent SRT during the study period, including 1,400 with ASA and 1,668 with SM. Table 1 shows the patient and hospital characteristics by tertiles of hospital volume. The median age of patients was 66 years for ASA and 62 years for SM. Medicare coverage accounted for 59.9% of ASA and 44.9% of SM, followed by commercial coverage (28.5% of ASA and 39% of SM). Most hospitals in the study were teaching hospitals (74% for ASA and 67% for SM). In the highest SRT volume tertile (5% of hospitals performing SRT) the average annual number of procedures was 3.5 ASA and 4.9 SM. Table 2 presents the outcomes by hospital volume (low-, mid-, and high-volume). Recorded in-hospital death rates for ASA were 1.4%, 1.4%, and 1.1%, respectively (not statistically different); for SM, 5.1%, 3.4% and 2.9%, respectively (not statistically different). For ASA and SM, index hospital costs, and 30-day readmission rates had an inverse relationship to hospital volume, with statistically significant differences for both procedures between the low- and high-volume hospitals (p<0.05). Conclusion The annual number of SRT procedures for obstructive HCM remains low, even for higher volume hospitals. This study shows high variability in clinical events, resource utilization, and in-hospital costs by hospital procedure volume and type of SRT. We reconfirmed that higher hospital procedure volume is associated with fewer adverse clinical events and lower costs.

Outcomes following permanent pacemaker implantation in patients undergoing tricuspid valve surgery

Abstract Background PPM implantation are commonly described after cardiac surgeries and notably after tricuspid valve surgery (TVS). Purpose Our study aimed to compare outcomes in patients who underwent PPM placement versus patients who did not following TVS. Methods We included 13 294 patients from the Medicare database who underwent isolated TV repair (N=1319 (10%)), isolated TV replacement (N=2123 (16%)), or concomitant TV repair or replacement with different combinations of surgical aortic valve replacement (SAVR), mitral valve repair or replacement (MVR), and coronary artery bypass graft (CABG). Patients who underwent TV surgery for endocarditis were excluded. The primary exposure of interest for the study was new pacemaker placement after TV surgery and before discharge, or within 30 days from discharge date. Each patient from the pacemaker group was matched to up to 3 controls from the no pacemaker group. The primary study outcome was all-cause mortality in follow-up in patients who underwent pacemaker placement after TV surgery versus patients who did not. The study’s secondary outcomes included 1-year mortality and the risk of hospital readmission with a diagnosis of endocarditis or heart failure (HF) in follow-up. Results Among the included patients, 2518 (18.9%) required a PPM placement after surgery. PPM placement was associated with a longer length of hospital stay (median 12 days (IQR 8-19 days) vs. 10 (7-17 days), P<0.001). It was not associated with a difference in risk of 1-year mortality (18.9% vs. 20.7%, OR 0.90, 95% CI 0.79-1.03, P=0.1). After a median follow-up of 3.1 years (IQR 1-5.5 years), PPM placement was also not associated with a significant increase in the risk of mortality in comparison to patients who did not require PPM (HR 1.02, 95% CI 0.93-1.12, P=0.7) (Figure 1). However, it was associated with a higher risk of HF readmission in follow-up (HR 1.28, 95% CI 1.14-1.43, P<0.001) when compared to no PPM (Figure 2). Finally, PPM was not associated with any difference in risk of endocarditis in follow-up (HR 1.03, 95% CI 0.74-1.45, P=0.8). Conclusion Post-procedural PPM implantation is a frequent complication of TVS. While mortality is not increased, PPM placement leads to higher HF hospitalization rates. Adequate risk stratification and counseling of patients before surgery decision is essential.Survival after TVSHeart Failure after TVS

The impact of concomitant mitral valve intervention on outcomes of aortic root replacement.

To investigate the impact of concomitant mitral valve repair (MVr) or replacement (MVR) at the time of aortic root replacement (ARR). We queried our aortic database for consecutive patients undergoing ARR in combination with MVr or MVR from 1997 to 2021. Patients undergoing valve sparing root replacement (VSRR) were excluded. We compared operative mortality (OM) and a composite of major adverse events (MAE) in those undergoing CVG both with (Group 2) and without a concomitant MV procedure (Group 1). We also analyzed outcomes between patients undergoing MV repair versus MV replacement. Sixty-one patients underwent ARR with concomitant MVr (29/47.5%) or MVR (32/52.5%). Compared to patients in Group 2 (n = 955), those in Group 1 presented with worse NYHA class, lower ejection fraction, higher rate of connective tissue disease, and underwent more frequently urgent/emergent procedures. Group 1 had higher incidence of postoperative MAE (8/61(13%) vs 51/955(5%), p = .03). There was no difference in operative mortality between the two groups (0/61(0%)vs. 3/955(0.3%), p = 1). Compared to the ARR + MVR subgroup, the ARR + MVr subgroup had higher incidence of postoperative MAE (5/29(17.2%) vs. 3/32(9.4%), p = 0.02). Multivariate analysis identified MVr (OR 2.78, 95% confidence interval [CI] [1.03;7.48], p = 0.04) as an independent predictor of MAE. Operative mortality remained low in both groups. The addition of MVR/MVr to composite valve-graft replacement of the aortic root does not increase OM in experienced hands. The incidence of MAEs was higher in those undergoing MVr but may be a reflection of greater preoperative comorbidity rather than issues related to a more complex operation.

Temporal trends and predictors of surgical ablation for atrial fibrillation across a multistate healthcare system.

BackgroundMultiple class I and class IIa recommendations exist related to surgical ablation (SA) of atrial fibrillation (AF) in patients undergoing cardiac surgery.ObjectiveExamine temporal trends and predictors of SA for AF in a large US healthcare system.MethodsWe retrospectively analyzed data from the Society for Thoracic Surgery (STS) Adult Cardiac Surgery Database for 21 hospitals in the Providence St. Joseph Health system. All patients with preoperative AF who underwent isolated coronary artery bypass graft (CABG) surgery, isolated aortic valve replacement (AVR), AVR with CABG surgery (AVR+CABG), isolated mitral valve repair or replacement (MVRr), and MVRr with CABG surgery (MVRr+CABG) from July 1, 2014, to March 31, 2020 were included. Temporal trends in SA were evaluated using the Cochran-Armitage trends test. A multilevel logistic regression model was used to examine patient-, hospital-, and surgeon-level predictors of SA.ResultsAmong 3124 patients with preoperative AF, 910 (29.1%) underwent SA. This was performed most often in those undergoing isolated MVRr (n = 324, 44.8%) or MVRr+CABG (n = 75, 35.2%). Rates of SA increased over time and were highly variable between hospitals. Years since graduation from medical school for the primary operator was one of the few predictors of SA: odds ratio (95% confidence interval) = 0.71 (0.56–0.90) for every 10-year increase. Annual surgical (both hospital and operator) and AF catheter ablation volumes were not predictive of SA.ConclusionWide variability in rates of SA for AF exist, underscoring the need for greater preoperative collaboration between cardiologists, electrophysiologists, and cardiac surgeons.

National Trends and Outcomes of Surgical Aortic Valve Replacement With Concomitant Mitral Valve Surgery

BackgroundIncidence of multivalvular heart disease is increasing, with aortic stenosis and mitral regurgitation being the most common. Data are limited on outcomes of patients undergoing multivalvular surgery. The purpose of this study was to evaluate contemporary trends and in-hospital outcomes for combined surgical aortic valve replacement (SAVR) and mitral valve repair (MVr) or replacement (MVR). MethodsWe identified patient hospitalizations aged ≥18 years who underwent SAVR + MVr or MVR between 2004 and 2018 using the National Inpatient Sample. Data were weighted to estimate national estimates of the entire US hospitalized population. Exclusion criteria included endocarditis, history of heart transplant or left ventricular assist device, and any other concomitant valve surgery. ResultsBetween January 1, 2004, and December 31, 2018, there were 68,882 weighted admissions for SAVR with concomitant mitral valve surgery. Overall, in-hospital mortality was 8.34% with significantly higher inpatient mortality in SAVR + MVR group compared with SAVR + MVr group (9.91% vs 5.57%, p < 0.001). During the study period, adjusted in-hospital mortality decreased in both SAVR + MVr group (p-trend 0.004) and SAVR + MVR group (p-trend <0.001). Age ≥70 years was associated with higher in-hospital mortality compared to those < 70 years (9.95% vs 6.70%, p < 0.001). ConclusionCombined aortic and mitral valve surgery is associated with a high risk of in-hospital mortality, especially in patients ≥ 70 years of age. Further research is needed to assess the role of transcatheter approaches in the treatment of multivalvular heart disease.

Feasibility and Safety of Permanent Left Bundle Branch Pacing in Patients With Conduction Disorders Following Prosthetic Cardiac Valves.

Background: The feasibility and safety of left bundle branch pacing (LBBP) in patients with conduction diseases following prosthetic valves (PVs) have not been well described.Methods: Permanent LBBP was attempted in patients with PVs. Procedural success and intracardiac electrical measurements were recorded at implant. Pacing threshold, complications, and echocardiographic data were assessed at implant and follow-up visit.Results: Twenty-two consecutive patients with atrioventricular (AV) conduction disturbances (10 with AV nodal block and 12 with infranodal block) underwent LBBP. The PVs included aortic valve replacement (AVR) in six patients, mitral valve repair or replacement (MVR) with tricuspid valve ring (TVR) in four patients, AVR with TVR in one patient, AVR with MVR plus TVR in three patients, transcatheter aortic valve replacement (TAVR) in five patients, and MVR alone in three patients. LBBP succeeded in 20 of 22 (90.9%) patients. LBB potential was observed in 15 of 22 (68.2%) patients, including 10 of 15 (66.7%) patients with AVR/TAVR and five of seven (71.4%) patients without AVR/TAVR. AVR and TVR served as good anatomic landmarks for facilitating the LBBP. The final sites of LBBP were 17.9 ± 1.4 mm inferior to the AVR and 23.0 ± 3.2 mm distal and septal to the TVR. The paced QRS duration was 124.5 ± 13.8 ms, while the baseline QRS duration was 120.0 ± 32.5 ms (P = 0.346). Pacing threshold and R-wave amplitude at implant were 0.60 ± 0.16 V at 0.5 ms and 11.9 ± 5.5 mV and remained stable at the mean follow-up of 16.1 ± 10.8 months. No significant exacerbation of tricuspid valve regurgitation was observed compared to baseline.Conclusion: Permanent LBBP could be feasibly and safely obtained in the majority of patients with PVs. The location of the PV might serve as a landmark for guiding the final site of the LBBP. Stable pacing parameters were observed during the follow-up.

The STS Participant-Level, Multiprocedural Composite Measure for Adult Cardiac Surgery

BackgroundComposite performance measures for the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database participants (typically hospital departments or practice groups) are currently available only for individual procedures. To assess overall participant performance, STS has developed a composite metric encompassing the most common adult cardiac procedures. MethodsAnalyses included 1-year (July 1, 2018 to June 30, 2019) and 3-year (July 1, 2016 to June 30, 2019) time windows. Operations included isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), isolated mitral valve repair (MVr) or replacement (MVR), AVR + CABG, MVr or MVR + CABG, AVR + MVr or MVR, and AVR + (MVr or MVR) + CABG. The composite was estimated using Bayesian hierarchical models with risk-adjusted mortality and morbidity end points. Star ratings were based upon whether the 95% credible interval of a participant’s score was entirely lower than (1 star), overlapping (2 star), or higher than (3 star) the STS average composite score. ResultsThe North American procedural mix in the 3-year study cohort was as follows: 448 569 CABG, 72 067 AVR, 35 708 MVr, 29 953 MVR, 45 254 AVR + CABG, 12 247 MVr + CABG, 10 118 MVR + CABG, 3743 AVR + MVr, 6846 AVR + MVR, and 3765 AVR + (MVr or MVR) + CABG. Mortality and morbidity weightings were similar for 1- and 3-year analyses (76% and 24% [3-year]), as were composite score distributions (median, 94.7%; interquartile range, 93.6% to 95.6% [3-year]). The 3-year time frame was selected for operational use because of higher model reliability (0.81 [0.78-0.83]) and better outlier discrimination (26%, 3 star; 16%, 1 star). Risk-adjusted outcomes for 1-, 2-, and 3-star programs were 4.3%, 3.0%, and 1.8% mortality and 18.4%, 13.4%, and 9.7% morbidity, respectively. ConclusionsThe STS participant-level, multiprocedural composite measure provides comprehensive, highly reliable, overall quality assessment of adult cardiac surgery practices.

The Society of Thoracic Surgeons 2021 Adult Cardiac Surgery Risk Models for Multiple Valve Operations

BackgroundThe Society of Thoracic Surgeons (STS) Quality Measurement Task Force has developed risk models and composite performance measures for isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), isolated mitral valve replacement or repair (MVRR), AVR+CABG, and MVRR+CABG. To further enhance its portfolio of risk-adjusted performance metrics, STS has developed new risk models for multiple valve operations ± CABG procedures. MethodsUsing July 2011 to June 2019 STS Adult Cardiac Surgery Database data, risk models for AVR+MVRR (n = 31,968) and AVR+MVRR+CABG (n = 12,650) were developed with the following endpoints: Operative Mortality, major morbidity (any 1 or more of the following: cardiac reoperation, deep sternal wound infection/mediastinitis, stroke, prolonged ventilation, and renal failure), and combined mortality and/or major morbidity. Data were divided into development (July 2011 to June 2017; n = 35,109) and validation (July 2017 to June 2019; n = 9509) samples. Predictors were selected by assessing model performance and clinical face validity of full and progressively more parsimonious models. Performance of the resulting models was evaluated by assessing discrimination and calibration. ResultsC-statistics for the overall population of multiple valve ± CABG procedures were 0.7086, 0.6734, and 0.6840 for mortality, morbidity, and combined mortality and/or morbidity in the development sample, and 0.6953, 0.6561, and 0.6634 for the same outcomes, respectively, in the validation sample. ConclusionsNew STS Adult Cardiac Surgery Database risk models have been developed for multiple valve ± CABG operations, and these models will be used in subsequent STS performance metrics.

Joint preoperative transthoracic and intraoperative transoesophageal echocardiographic assessment of functional mitral regurgitation severity provides better association with long-term mortality.

Functional mitral regurgitation (MR) is observed with ischaemic heart disease or aortic valve disease. Assessing the value of mitral valve repair or replacement (MVR/P) is complicated by frequent discordance between preoperative transthoracic echocardiographic (pTTE) and intraoperative transoesophageal echocardiographic (iTOE) assessment of MR severity. We examined the association of pTTE and iTOE with postoperative mortality in patients with or without MR, at the time of coronary artery bypass grafting (CABG) and/or aortic valve replacement without MVR/P. Medical records of 6629 patients undergoing CABG and/or aortic valve replacement surgery with or without functional MR and who did not undergo MVR/P were reviewed. MR severity assessed by pTTE and iTOE were examined for association with postoperative mortality using proportional hazards regression while accounting for patient and operative characteristics. In 72% of 709 patients with clinically significant (moderate or greater) functional MR detected by pTTE, iTOE performed after induction of anaesthesia demonstrated a reduction in MR severity, while 2% of patients had increased severity of MR by iTOE. iTOE assessment of MR was better associated with long-term postoperative mortality than pTTE in patients with moderate MR [hazard ratio (HR) 1.31 (1.11-1.55) vs 1.02 (0.89-1.17), P-value for comparison of HR 0.025] but was not different for more than moderate MR [1.43 (0.96-2.14) vs 1.27 (0.80-2.02)]. In patients undergoing CABG and/or aortic valve replacement without MVR/P, these findings support intraoperative reassessment of MR severity by iTOE as an adjunct to pTTE in the prediction of mortality. Alone, these findings do not yet provide evidence for an operative strategy.

Abstract 16691: The Effect of Socioeconomic Status: Patients in the Lowest Quartile of Income May be Subject to Worse Outcomes After Major Cardiac Surgery

Introduction: Racial disparities in cardiac surgery (CS) are well documented, but socioeconomic status (SES)’s role, independent of race and other factors, requires further study. Our purpose is to investigate effects of low SES on patient outcomes after CS. Methods: National Inpatient Sample 2010-15, was queried. Adult patients undergoing coronary artery bypass grafting (CABG), surgical aortic valve replacement (SAVR), mitral valve repair (MVRR) or replacement (MVRT) were identified. Patient &amp; hospital characteristics, charges, and outcomes of patients in the lowest quartile of income by zip code (low SESP) and highest (high SESP) were compared, per procedure. Multivariable analysis was used to determine effects of SES on outcomes; primary was in-hospital mortality (death). Results: Number of procedures, low v. high SESP: CABG (30,799).

Volume-Outcome Association of Mitral Valve Surgery in the United States

Early surgery for severe primary degenerative mitral regurgitation is recommended, provided optimal outcomes are achievable. Contemporary national data defining mitral valve surgery volume and outcomes are lacking. To assess national 30-day and 1-year outcomes of mitral valve surgery and define the hospital- and surgeon-level volume-outcome association with mitral valve repair or replacement (MVRR) in patients with primary mitral regurgitation. This multicenter cross-sectional observational study used the Society of Thoracic Surgeons Adult Cardiac Surgery Database to identify patients undergoing isolated MVRR for primary mitral regurgitation in the United States. Operative data were collected from July 1, 2011, to December 31, 2016, and analyzed from March 1 to July 1, 2019, with data linked to the Centers for Medicare and Medicaid Services. The primary outcome was 30-day in-hospital operative mortality after isolated MVRR for primary mitral regurgitation. Secondary outcomes were 30-day composite mortality plus morbidity (any occurrence of bleeding, stroke, prolonged ventilation, renal failure, or deep wound infection), rate of successful mitral valve repair of primary mitral regurgitation (residual mitral regurgitation of mild [1+] or better), and 1-year mortality, reoperation, and rehospitalization for heart failure. A total of 55 311 patients, 1094 hospitals, and 2410 surgeons were identified. Increasing hospital and surgeon volumes were associated with lower risk-adjusted 30-day mortality, lower 30-day composite mortality plus morbidity, and higher rate of successful repair. The lowest vs highest hospital volume quartile had higher 1-year risk-adjusted mortality (hazard ratio [HR], 1.61, 95% CI, 1.31-1.98), but not mitral reoperation (odds ratio [OR], 1.51; 95% CI, 0.81-2.78) or hospitalization for heart failure (HR, 1.25; 95% CI, 0.96-1.64). The surgeon-level 1-year volume-outcome associations were similar for mortality (HR, 1.60; 95% CI, 1.32-1.94) but not significant for mitral reoperation (HR, 1.14; 95% CI, 0.60-2.18) or hospitalization for heart failure (HR, 1.17; 95% CI, 0.91-1.50). National hospital- and surgeon-level inverse volume-outcome associations were observed for 30-day and 1-year mortality after mitral valve surgery for primary mitral regurgitation. These findings may help to define access to experienced centers and surgeons for the management of primary mitral regurgitation.

Outcomes of mitral valve surgery for severe ischemic mitral regurgitation.

This study evaluated outcomes of mitral valve surgery for severe ischemic mitral regurgitation (IMR). Patients undergoing coronary artery bypass grafting (CABG) with concomitant mitral valve repair (MVr) or replacement (MVR) for severe IMR at a single center between 2010 and 2017 were included. The primary outcome was 5-year survival. Secondary outcomes included operative mortality and morbidity, hospital readmission, recurrence of at least moderate mitral regurgitation (MR), and mitral valve reoperation. A total of 358 patients underwent concomitant mitral valve surgery with CABG for severe IMR (275 MVr and 83 MVR). Unadjusted and risk-adjusted operative mortality was higher in MVR (16% vs 8%; P = .04). MVR patients had higher rates of postoperative renal failure, prolonged ventilation, and deep sternal wound infection. The unadjusted 5-year survival was similar (MVR 64% vs MVr 64%; P = .41), a finding that persisted after risk-adjustment. The 5-year freedom from mitral valve reoperation was 96% and 97% (P = .47). Freedom from at least moderate MR at 1-year and 3-years was 100% vs 86% (P = .09) and 100% vs 68% (P = .06) for MVR and MVr, respectively. However, only three MVr patients developed severe MR by 3 years. Cumulative hazards for all-cause readmission and heart failure-specific readmission were higher with MVR. Despite a trend towards higher risk of MR recurrence, patients undergoing MVr have similar rates of survival and mitral valve reoperation, with lower rates of readmission at 5-years. This, combined with lower operative mortality rates, makes MVr a reasonable choice particularly in sicker patients with higher operative risk and more limited life expectancy.

Outcomes of Mitral Valve Repair Versus Replacement in the Elderly

This study evaluated outcomes of mitral valve surgery (MVS) in the elderly. Patients 75 years or older undergoing MVS at a single center between 2010 and 2018 were included. Patients were stratified into mitral valve repair (MVr) or replacement (MVR). The primary outcome was mortality. Secondary outcomes included postoperative complications, readmissions, and freedom from at least moderate mitral regurgitation. Multivariable Cox regression was used for risk adjustment. A subanalysis of isolated, non-reoperative MVS for degenerative disease was also performed. Elderly patients (n= 472) underwent MVS, 301 (64%) with MVr and 171 (36%) with MVR. The majority of cases (68%) were performed for degenerative etiologic process. Survival was similar between MVr and MVR at 1 year (84% versus 86%; P= .40) and 5 years (64% versus 64%; P= .59). Postoperative complications were also comparable. Freedom from readmission was lower in the MVR cohort at 1 year (57% versus 68%; P= .02) and 5 years (33% versus 43%; P= .02). In isolated MVS for degenerative etiologic process, there was no difference in early or late mortality between MVr and MVR, although readmissions were lower with MVr. Overall, freedom from mitral valve reoperation was comparable, and the freedom from at least moderate regurgitation was 86% at 5 years in the MVr group. This study indicates that the outcomes of elderly patients undergoing MVS are acceptable with approximately 64% survival at 5 years. Our data suggest that MVr in the elderly may not confer a survival advantage but can be performed with durable results.

Impact of 3D echocardiography on grading of mitral stenosis and prediction of clinical events

Background: The mitral valve orifice area (MVOA) is difficult to assess accurately by 2D echocardiography because of geometric assumptions; therefore, 3D planimetry may offer advantages. We studied the differences in MVOA measurements between the most frequently used methods, to determine if 3D planimetry would result in the re-grading of severity in any cases, and whether it was a more accurate predictor of clinical outcomes.Methods: This was a head-to-head comparison of the three most commonly used techniques to grade mitral stenosis (MS) by orifice area and to assess their impact on clinical outcomes. 2D measurements (pressure half-time (PHT), planimetry) and 3D planimetry were performed retrospectively on patients with at least mild MS. The clinical primary endpoint was defined as a composite of MV balloon valvotomy, mitral valve repair or replacement (MVR) and/or acute heart failure (HF) admissions.Results: Forty-one consecutive patients were included; the majority were female (35; 85.4%), average age 55 (17) years. Mean and peak MV gradients were 9.4 (4) mmHg and 19 (6) mmHg, respectively. 2D and 3D measures of MVOA differed significantly; mean 2D planimetry MVOA was 1.28 (0.40) cm2, mean 3D planimetry MVOA 1.15 (0.29) cm2 (P = 0.003). Mean PHT MVOA was 1.43 (0.44) cm2 (P = 0.046 and P < 0.001 in comparison to 2D and 3D planimetry methods, respectively). 3D planimetry reclassified 7 (17%) patients from mild-tomoderate MS, and 1 (2.4%) from moderate to severe. Overall, differences between the two methods were significant (X2, P < 0.001). Only cases graded as severe by 3D predicted the primary outcome measure compared with mild or moderate cases (odds ratio 5.7).Conclusion: 3D planimetry in MS returns significantly smaller measurements, which in some cases results in the reclassification of severity. Routine use of 3D may significantly influence the management of MS, with a degree of prediction of clinical outcomes.

EP28 PRIMARY MITRAL VALVE REGURGITATION: A RETROSPECTIVE ANALYSIS OF MITRAL VALVE SURGERY AND LONG TERM FOLLOW-UP

Abstract Background and aim: Surgery of mitral valve is one of the most evolving topic, especially for repair techniques and is often challenging for surgeons. We retrospectively evaluate the results of mitral valve repair (MVRep) or replacement (MVR) in primary MR. Methods: 165 consecutive patients (mean age 65 ± 12.5 years) between January 2014 and December 2018 underwent MVRep (89 pts, 54%) or MVR (76 pts, 46%). Mean EuroSCORE II was 3 ± 2%. 89 pts were severely symptomatic for dyspnea (53.9%). In all cases of MVRep a prosthetic ring was implanted; adjunctive procedure were a triangular (11%) or quadrangular resection (11%) and edge to edge (24%). A mechanical prosthesis were implanted in 60 pts (36%). Mean follow-up (95% complete, 157 patients) was 50.2 ± 17.9 months. Results: Overall in hospital mortality was 4.8%; 1.1% (1pts) and 9.2% (7 pts) for MVRep and MVR respectively. Three of these 8 patients were octogenarian and at high risk surgery with an EuroSCORE II&gt;7%. Follow-up mortality was 6.3% (10 pts), cardiac death was 3.8%. 6 years survival was 90.7 ± 3%. Three patients (MVRep) underwent MVR for MR recurrence with a 6 years freedom from reoperation of 97.9 ± 1.2%. Freedom from symptoms was 89.6 ± 3.2%. No significantly differences was found between MVRep and MVR in terms of survival (logRank test, p = 0.61), reoperation (logRank test, p = 0.138) and symptoms (logRank test, p = 0.264). Conclusioni: MVRep appears to have lower in-hospital mortality than MVR (p = 0.025). Long term results showed excellent survival and comparable outcomes in terms of reintervention and relief of symptoms between MVRep and MVR.

Incidence and outcomes of early percutaneous coronary intervention after isolated valve surgery.

Coronary ischemia requiring early percutaneous coronary intervention (PCI) is a rare but serious complication of isolated valve surgery. We sought of assess the incidence, predictors and outcomes of early PCI after isolated valve surgery using the national inpatient sample. Patients who underwent isolated aortic valve replacement (AVR), isolated mitral valve repair (MVr) or replacement (MVR) between 2003 and 2014 were identified. Patients who had early postoperative PCI were compared with patients who did not require PCI. Primary end point was in-hospital mortality. Secondary endpoints were complications, length-of-stay and cost. Among the 135,611 included patients, 1,074 (0.8%) underwent PCI prior to discharge. Unadjusted in-hospital mortality was higher in patients requiring early PCI following AVR (11.2 vs. 3.1%), MVR (24.1 vs. 5.5%), and MVr (22.4 vs. 2.5%) (P < 0.001) compared with patients not requiring PCI. Postoperative PCI remained independently associated with higher mortality after adjusting for demographics, comorbidities and hospital characteristics (adjusted OR [aOR] = 3.74, 95%CI 2.70-5.17 for AVR, aOR = 6.10, 95%CI 4.53-8.23 for MVR, and aOR = 9.90, 95%CI 7.22-13.58 for MVr). Patients undergoing PCI had higher incidences of stroke, acute kidney injury, infectious complications, higher hospital charges, and longer hospitalizations. Age, robotic-assisted surgery, and chronic renal failure were independent predictors of needing early postoperative PCI. Early PCI after isolated aortic or mitral valve surgery is rare but is associated with substantial in-hospital morbidity, mortality, and cost. Further studies are needed to identify preventable causes, and optimal management strategies of this serious complication.

RESULTS OF SURGICAL MANAGMENT OF PRIMARY MITRAL REGURGITATION IN A SINGLE-CENTER STUDY

Mitral regurgitation (MR) remains the second dominant defect in the structure of valvular cardiac diseases. It affects more than 2 million people in the USA. Basic causes are classified as degenerative (with valve prolapse) and ischemic (due to ischemic heart disease) in advanced countries or rheumatic ones (in developing countries). Alone radical method of MR treatment is surgical correction through mitral valve repair (MVRe) or replacement (MVR) yielding definitely higher survival percentage and improvement of heart failure (HF) class comparing to pharmacotherapy. Evolution of approaches to the management of non-ischemic MR passed through some stages starting from predominantly MVR to organ-preserving approaches like plastic repair. In the prospective single-center study were analyzed the results of treatment of 72 patients with primary MR (PMR) who were subjected to mitral valve replacement (MVR) or plastic mitral valve repair (MVRe) performed in the Department of cardiac surgery affiliated with Lviv regional clinical hospital (Ukraine) since October, 2013 till February, 2016. The conclusions of performed study are next: 1) Key direct cause of MR is the chordal rupture of MV cusps; etiological factor in the majority of advanced countries is degenerative changes in contrast to rheumatic changes in the developing countries. 2) Principal method of MR surgical correction in out center is MVR, though the preferable global trend is MVRe. 3) Complications and lethality percentages in this study were higher among the patients from MVR group. Improvement of HF class according to NYHA was more evident in the MVRe group. This corresponds to results of other studies and guidelines that recommend MVRe as optional method for MR correction.

PRIMARY MITRAL REGURGITATION AND RESULTS OF SURGICAL MANAGEMENT IN A PROSPECTIVE STUDY

Mitral regurgitation (MR) remains the second dominant defect in the structure of valvular cardiac diseases [1]. It affects more than 2 million people in the USA. Basic causes are classified as degenerative (with valve prolapse) and ischemic (due to ischemic heart disease) in advanced countries or rheumatic ones (in developing countries) [2, 3]. Alone radical method of MR treatment is surgical correction through mitral valve repair (MVRe) or replacement (MVR) yielding definitely higher survival percentage and improvement of heart failure (HF) class comparing to pharmacotherapy [4]. Evolution of approaches to the management of non-ischemic MR passed through some stages, starting from predominantly MVR to organ-preserving approaches like plastic repair [5]. In the prospective single-center study the results of treatment of 72 patients with primary MR (PMR) who were subjected to mitral valve replacement (MVR) or plastic mitral valve repair (MVRe) performed in the Department of cardiac surgery affiliated with Lviv regional clinical hospital (Ukraine) since October, 2013 till February, 2016 were analyzed. The conclusions of performed study are the following: 1) Key direct cause of MR is the chordal rupture of MV cusps, etiological factor in the majority of advanced countries is degenerative changes in contrast to rheumatic changes in the developing countries. 2) Principal method of MR surgical correction in out center is MVR, though the preferable global trend is MVRe. 3) Complications and lethality percentages in this study were higher among the patients from MVR group. Improvement of HF class according to NYHA was more evident in the MVRe group. This corresponds to results of other studies and guidelines that recommend MVRe as optional method for MR correction

Surgical Ablation of Atrial Fibrillation in the United States: Trends and Propensity Matched Outcomes

Surgical ablation (SA) for atrial fibrillation (AF) effectively restores sinus rhythm. Incompletely defined risk has previously limited concomitant performance of SA during cardiac operations. The study goals were to define performance trends and risk-adjusted outcomes for contemporary SA. From July 2011 to June 2014, 86,941 patients with AF, but without endocarditis, underwent primary nonemergent cardiac operations in The Society of Thoracic Surgeons (STS) database. Cochran-Armitage tests examined performance trends of SA for six operative categories: mitral valve repair or replacement (MVRR) with or without coronary artery bypass graft surgery (CABG), aortic valve replacement (AVR) with or without CABG, CABG, AVR with MVRR, stand-alone SA, and other concomitant operations. The risk of concomitant SA was analyzed by propensity matching 28,739 patient-pairs with and without SA by AF type, primary operation, and STS comorbid risk variables using greedy 1:1 matching algorithms. Among all patients with AF, 48.3% (42,066 of 86,941) underwent SA. Mitral operations had the highest rate of SA (MVRR ± CABG 68.4% [14,693 of 21,496]; MVRR+ AVR 59.1% [1,626 of 2,750]). The AVR ± CABG and isolated CABG rates were 39.3% (6,816 of 17,349) and 32.8% (9,156 of 27,924), respectively. Nearly half of other concomitant operations underwent SA, 47.6% (6,939 of 14,586). Performance frequency increased throughout the study period. After propensity matching, SA was associated with a reduction in relative risk (RR) of 30-day mortality (RR 0.92, 95% confidence interval [CI]: 0.85 to 0.99) and stroke (RR 0.84, 95% CI: 0.74 to 0.94), but an increase in renal failure (RR 1.12, 95% CI: 1.03 to 1.22) and pacemaker implantation (RR 1.33, 95% CI: 1.24 to 1.43). Contemporary utilization of SA is increasing across all operative categories. Performance of SA is accompanied by a 30-day reduction in mortality and stroke. These findings further refine our understanding of the role of SA in the treatment of AF.