Rate Of Mitral Valve Repair Research Articles

599 Case-Volumes and Outcomes Following Concomitant Aortic, Mitral and Tricuspid Valves Surgery Statewide Over 17-Years: A Population-Linkage Study

Studies reporting concomitant cardiac tri-valvular surgery remains rare. Prevalence and outcomes of these patients have not been reported in Australia. From the Admitted-Patient-Data-Collection registry, all New South Wales residents who underwent surgery for aortic, mitral and tricuspid valves pathology between 1-July, 2001 and 31-December, 2018 were identified. Cause-specific mortality were tracked from the statewide death registry. Concomitant tri-valvular surgery comprised 1.2% (347/28667 cases) of all cardiac valves surgeries statewide. Case-volumes rose from 8 in year-2002 to a peak of 37 cases in 2012, and between 23 and 30 cases-per-annum since. The study cohort comprised 340 persons (mean[±SD] age: 68.2±15.2yrs; 50% males); 20.3% had concomitant coronary artery bypass surgery (males vs females: 29.4% vs 11.2%, p<0.001). Main surgery on aortic and mitral valve was replacement (95.9% and 70.6% respectively). Mitral valve replacement was more common in females than males (79.4% vs 61.8%, p=0.001). Overall mitral valve repair rate was 10% (males vs females: 13.5% vs 6.5%, p=0.045). For tricuspid valve, annuloplasty was performed in 90.6% of patients. Cardiac-related (28.0%), heart failure (24.0%) and sepsis (24.0%) were the three main in-hospital cause-specific deaths, with no stroke-related death. Post-discharge, the main cardiovascular cause-specific death was heart failure (22.5%), and 6.7% and 4.2% were from embolic and haemorrhaging stroke respectively. Sepsis (20.0%) was the main noncardiovascular cause-specific death post-discharge. Concomitant cardiac tri-valvular surgery remains rare and associated with high short and intermediate-term mortality. Careful patient selection and better postoperative care is required to improve outcomes of these patients.

Mitral valve repair based on intraoperative objective parameters measurement: State of the art and perspective

Currently, mitral valve repair (MVr) success for primary mitral regurgitation relies mainly on surgeon's expertise and major heterogeneities are observe concerning MVr rate, technics, and results. MVr success is estimated by a morphological echocardiographic assessment after aortic unclamping. To date, coaptation forces have been poorly characterized. We developed a device allowing a precise morphologic and qualitative assessment of coaptation. A first prototype allowing three-dimensional mapping of coaptation forces was developed and a provisional patent was filed. A number of features informed the design of the new device, including force sensitivity, flexibility, and biocompatibility. Varying sensing technologies were screened (including piezo-electric, piezo-resistive, and resistive sensors), and a specific device to hold the sensor was designed and prototyped. The first generation of prototype was tested on a porcine ex vivo beating heart model. The device was inserted between the mitral leaflet through a left atrial incision between two running sutures. The sensor was positioned and connected to a custom-made acquisition system. The coaptation signal was recorded in normal valves and after creation of a posterior central prolapse. We were able to obtain precise surface mapping of mitral coaptation forces in this model. The coaptation signal was notably more intense in the normal valve compare to the prolapsed valve in otherwise similar hemodynamic conditions ( Fig. 1 ). A mapping of coaptation forces along the entire mitral valve surface can be achieved with the method and device we have developed. This technology may be useful to assist surgeons during MVr while providing real-time objective measurement in support of the conventional intraoperative morphological assessment. An extensive development roadmap has been developed and is being put in place to move our invention toward clinical trials.

P6489Preoperative determination of artificial chordae length by transesophageal echocardiography

Abstract The use of artificial chordae is one of the main techniques used in mitral valve repair to treat prolapsing leaflets, especially in anterior and bileaflet prolapse. With the use of PTFE sutures to replace elongated or ruptured chords mitral valve repair rates have significantly improved. The main difficulty with this technique is to determine the optimal length of the artificial chordae. Intraoperative transoesophageal echocardiography (TOE) is mandatory in mitral valve repair in order to determine the type of lesion of the mitral valve but also to evaluate the quality of the repair. We examined the accuracy of preoperative prediction of artificial chordae length by the preoperativeTOE. Patients and methods Twenty-one consecutive patients (7 females) underwent mitral valve repair with artificial chordae for significant mitral valve prolapse in our department during the last year. The median age of the patients was 62 y. (range 25 - 87) and the mean EuroSCORE II 3,36% (SD 4,61%). During the prep TOE we determined the predicted length of the required replacement chordae for the repair using mainly the 4 chamber view to calculate the distance between the tip of the papillary muscle and the coaptation point of the two leaflets and we subtracted 5mm which is the minimum of the desired coaptation length (top right part of the Figure). All the patients underwent totally endoscopic mitral repair through a 3 cm right periareolar incision. 14,3% of the patients had anterior leaflet (AML) prolapse, 23,8% bileaflet and 61,9% posterior (PML). The appropriate length of the required chordae was measured intraoperatively. Results We used on average 3 loops of artificial chordae size 23,3 mm (SD 1,15mm) to treat the AML prolapse, 5 loops size 23,2 mm (SD 2,28mm) to treat the bileaflet prolapse and 2,23 loops size 18mm (SD 2mm) to treat the PML prolapse (bottom part of the figure). The predicted size of the artificial chordae had a positive correlation to the length used (Pearson correlation, p&lt;0,001) as demonstrated in the top left part of the Figure. An annuloplasty band was implanted to all the patients. All the patients had no mitral regurgitation in the postoperative TOE. The mean valve area was 3,54cm2 (SD 0,57) and the mean peak gradient 5,6 mmHg (SD 1,82). There was no mortality. Chordae length predicted by echo Conclusion The length of artificial chordae can be predetermined with great accuracy with the use of TOE, making TOE an important tool not only for the determination of the mitral lesion and quality of the repair but also for the planning of the operation.

Mitral Valve Repair Rate at a Veterans Affairs Hospital Utilizing a Multidisciplinary Heart Team

Between 2000 and 2008, the mitral valve (MV) repair rate in patients with severe mitral regurgitation at our low-volume Veterans Affairs hospital was 21%. After instituting a multidisciplinary valve team in 2009, we determined whether this rate increased and characterized the outcomes of patients with degenerative disease. We retrospectively reviewed data from 103 MV operations performed at our hospital between 1/2009 and 8/2016. MV pathology was categorized as degenerative, rheumatic, endocarditis, ischemic, hypertrophic cardiomyopathy, or failed prior MV repair. The surgical techniques used for MV repair were reviewed. For the patients with degenerative disease who underwent MV repair, we assessed leaflet involvement and postoperative valve function. For the full cohort, the MV repair rate was 67% and the 30-day mortality rate was 0.97%. Of the 74 patients with degenerative disease, 64 (86.5%) underwent MV repair (none required reoperation). For these patients, the MV repair rate was significantly higher when the surgical approach was sternotomy rather than minimally invasive right minithoracotomy (92.5% vs 71.4%, P = 0.03). After MV repair, 95.3% of the degenerative disease patients had mild or less mitral regurgitation; median echocardiography follow-up time was 555 days. Anatomic features associated with a reduced MV repair rate in patients with degenerative disease were dystrophic leaflet calcification and severe mitral annular calcification. In an institution with a low volume of MV operations, preoperative surgical planning with a multidisciplinary valve team was associated with improved MV repair rates and excellent repair quality in patients with degenerative valve disease.

Mitral valve repair, how to make volume not matter; techniques, tendencies, and outcomes, a single center experience

BackgroundRecent evidence has showed us that quality of mitral valve repair is strongly related to volume. However, this study shows how low-volume centers can achieve results in mitral valve repair surgery comparable to those reported by referral centers. It compares outcomes of mitral valve repair using resection versus noresection techniques, tendencies, and rates of repair.MethodsBetween 2004 and 2017, 200 patients underwent mitral valve repair for degenerative mitral valve disease at Fundación Cardioinfantil-Institute of Cardiology. Fifty-eight (29%) patients underwent resection and 142 (71%) noresection.ResultsFollow-up was 94% complete, mean follow-up time was 2.3 years. There was no 30-day mortality. Five patients required mitral valve replacement after an average of 5.3 years (Resection = 2; Noresection = 3). Freedom from severe mitral regurgitation was 98% at 6.6 years of follow-up for the noresection group, and 92.5% at 7 years for the resection group (log rank: 0.888). At last follow-up, two patients died of cardiovascular disease related to mitral valve, 181 patients (86%) showed no or grade I mitral regurgitation. Patients with previous myocardial infarction had increased risk of recurrent mitral regurgitation (p = 0,030). Within four years, we inverted the proportion of mitral valve replacement and repair, and in 2016 we achieved a mitral valve repair rate of 96%.ConclusionThis study suggests that resection and noresection techniques are safe and effective. Recurrence of severe mitral regurgitation and need for mitral valve replacement are rare. We show that low-volume centers can achieve results comparable to those reported worldwide by establishing a mitral valve repair team. We encourage hospitals to follow this model of mitral valve repair program to decrease the proportion of mitral valve replacement, while increasing mitral valve repair.

Isolated Mitral Valve Surgery: The Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis

Data from The Society of Thoracic Surgeons Adult Cardiac Surgery Database were analyzed to identify trends in patient characteristics and outcomes of mitral valve operations in North America. All patients with isolated primary mitral valve operations with or without tricuspid valve repair, surgical atrial fibrillation ablation, or atrial septal defect closure performed July 2011 to September 2016 were identified. A subgroup analysis assessed patients with degenerative leaflet prolapse (DLP). Isolated primary mitral valve operations were performed on 87,214 patients at 1,125 centers, increasing by 24% between 2011 (n= 14,442) and 2016 (n= 17,907). The most common etiology was DLP (60.7%); 4.3% had functional mitral regurgitation. Preoperatively, 47.3% of patients had an ejection fraction less than 60% and 34.2% had atrial fibrillation. Overall mitral valve repair rate was 65.6%, declining from 67.1% (2011) to 63.2% (2016; p<0.0001). Repair rates were related to etiology (DLP, 82.5%; rheumatic, 17.5%). Of the 29,970 mitral valve replacements, 16.2% were preceded by an attempted repair. Repair techniques included prosthetic annuloplasty (94.3%), leaflet resection (46.5%), and artificial cord implantation (22.7%). Bioprosthetic valves were implanted with increasing frequency (2011, 65.4%; 2016, 75.8%; p<0.0001). Less-invasive operations were performed in 23.0% and concomitant tricuspid valve repair in 15.7%. Unadjusted operative mortality was 3.7% (replacements) and 1.1% (repairs). Patients undergoing primary isolated mitral valve operations commonly have ventricular dysfunction, atrial fibrillation, and heart failure. Although contemporary outcomes are excellent, earlier guideline-directed referral and increased frequency and quality of repair may further improve results of mitral valve operations.

Triple valve surgery: results from a multicenter experience.

Triple valve surgery (TVS) may still be considered a challenge in cardiac surgery, and is still associated with a not negligible mortality and morbidity. This study analyzed retrospectively patients' data from RERIC (Registro Regionale degli Interventi Cardiochirurgici) registry, to evaluate early and mid-term results of TVS. From April 2002 to December 2013, data from n = 44 211 cardiac surgical procedures were collected from six Cardiac Surgery Departments (RERIC). Two hundred and eighty patients undergoing TVS were identified, including aortic and mitral replacement with tricuspid repair in 211 patients (75.3%), aortic replacement with mitral and tricuspid repair in 64 (22.9%) and triple valve replacement in 5 (1.8%). Univariate and multivariate analyses were performed to identify predictors of overall mortality or adverse outcomes. The mean age of the patients was 67.5 ± 12.2. Overall in-hospital mortality rate was 7.9%: in-hospital mortality was 10.9% in mitral valve repair and 6.6% in mitral valve replacement, respectively. Tricuspid valve replacement was associated with the highest mortality rate (40%). Independent predictors of in-hospital mortality were serum creatinine greater than 2 mg/dl [odds ratio (OR) 4.5; P = 0.03], concomitant coronary artery bypass graft (CABG) (OR 3.8; P = 0.01) and previous cardiac surgery (OR 5.1; P = 0.04). Overall cumulative mortality rate at 1, 3 and 5 years was 14.7, 24.1 and 28.9%, respectively. Mitral valve replacement associated with tricuspid valve repair showed better survival rate (hazard ratio 0.1; P = 0.007). TVS has demonstrated satisfactory results in terms of in-hospital and mid-term mortality rate. Renal failure, reoperations and concomitant CABG resulted as risk factors for mortality; moreover, we could not demonstrate a mid-term better survival rate of mitral valve repair compared with the replacement.

Re-repair of the failed mitral valve: insights into aetiology and surgical management.

Mitral valve (MV) repair is the gold standard for treatment of degenerative mitral regurgitation. A variety of surgical techniques allow surgeons to achieve a high rate of MV repair even with MV diseases of other aetiologies. However, a certain number of repairs fail over time. The aim of this study was to review our single-centre experience of MV re-repair and analyse the mode of repair failure, re-repair safety and efficiency in relation to the initial aetiology. Between 1997 and 2015, 91 patients underwent redo MV re-repair. The first MV repair was performed in our institution in 59% of cases. Follow-up information was available for 93% of our patients. The median follow-up was 56 months. The initial aetiology was degenerative disease in 40 (44%) patients, rheumatic disease in 25 (27.5%), endocarditis in 10 (11%), ischaemic in 6 (7%), severe mitral annulus calcification in 5 (5.5%), congenital disease in 4 (4%) and unknown in 1 (1%). The mean age was 58 ± 15 years. The median delay between the 1st and 2nd repair was 49 months with 6 early re-repairs. Re-repair was urgent or emergent in 19% of cases; indications for surgery were mitral regurgitation in 48%, stenosis in 19%, endocarditis in 19%, mitral disease in 11%, ring thrombosis in 2% and systolic anterior motion in 1%. The main mechanisms of failure included technical error (30%), progression of disease (35%), new disease (29%) and unknown (6%.) Re-repair was performed through a median sternotomy in 96% of cases, and 34% of patients had concomitant procedures. Eight (9%) postoperative deaths (4 of mitral annulus calcification, 2 of endocarditis, 1 of degenerative disease, 1 of ischaemia) and 5 (6%) early failures occurred (3 of rheumatic disease, 1 of degenerative disease, 1 of a congenital condition), requiring MV replacement in 4 and new repair in 1. Overall survival at 5 and 10 years was 76% and 57%, 83% and 49% in patients with degenerative diseases and 95% and 95% in patients with rheumatic disease. Overall freedom from reoperation at 5 and 10 years was 82% and 61%, 94% and 87% with degenerative disease and 60% and 45% with rheumatic disease. MV re-repair is feasible and has good mid-term results in patients with degenerative MV disease. Rheumatic MV disease is associated with a certain risk of failure over time; nevertheless, these patients show excellent survival after re-repair.

Comparison of Endoaortic and Transthoracic Aortic Clamping in Less-Invasive Mitral Valve Surgery

Less-invasive mitral valve surgery has become a widespread procedure in recent years, although mode of perfusion and aortic clamping are still debated questions. The aim of this study was to compare the results between transthoracic aortic clamping (TTC) and endoaortic clamping (EAC) in a multicenter, retrospective study. Data from 3 centers experienced in both TTC and EAC were retrospectively analyzed. Five hundred consecutive patients undergoing less-invasive mitral valve surgery received either TTC (n= 250) or EAC (n= 250). Age, sex, logistic EuroSCORE, ejection fraction, associated procedures, and mitral valve repair rate were similar. A higher incidence of previous cardiac operations was observed in the EAC group (TTC 8.8% versus EAC 16.8%, p= 0.001). Clamping and cardiopulmonary bypass times were comparable between the 2 groups. Reoperation for bleeding (TTC 11.2% versus EAC 3.2%, p < 0.001), conversion to full sternotomy (6 cases in the TTC group), and hospital length of stay (TTC 9 days versus EAC 8 days, p= 0.01) were higher in the TTC group. No differences were found in respiratory failure, renal failure, major vascular complication, stroke, and in-hospital mortality rate. Despite recent concerns arising about EAC, this large multicenter study shows equivalence in terms of safety and effectiveness of this technique compared with TTC. Reduction in postoperative bleeding was observed in the EAC group despite the higher rate of complex redo cases.

Staged percutaneous coronary intervention followed by minimally invasive mitral valve surgery versus combined coronary artery bypass graft and mitral valve surgery for two-vessel coronary artery disease and moderate to severe ischemic mitral regurgitation.

The optimal treatment for concomitant two-vessel coronary artery disease (CAD) and moderate to severe ischemic mitral regurgitation (IMR) remains unclear. We compared the results of a staged percutaneous coronary intervention followed by minimally invasive mitral valve surgery (PCI+MIVS) versus combined coronary artery bypass graft and mitral valve surgery (CABG+MVS) in this population. All consecutive patients with two-vessel CAD and moderate to severe IMR, who underwent PCI+MIVS or CABG+MVS at our institution between February 2009 and April 2014, were retrospectively evaluated. There were nine patients identified who underwent PCI+MIVS, and 15 who underwent CABG+MVS, with a mean age of 71±7, and 70±7 years, respectively (P=0.86). The remaining baseline characteristics were similar between both groups, with the exception of a higher prevalence of pre-operative clopidogrel administration (78% versus 27%, P=0.03) and left anterior descending plus left circumflex CAD (78% versus 27%, P=0.03), in those who underwent PCI+MIVS. The PCI+MIVS approach was associated with decreased mean cardiopulmonary bypass (111±41 versus 167±49 min, P=0.01) and aortic cross-clamp (79±32 versus 129±35 min, P=0.003) times, and less median number of intraoperative packed red blood transfusions {2 [interquartile range (IQR), 0-2] versus 3 units (IQR, 1-4), P=0.05}, when compared with CABG+MVS. The rate of mitral valve repair, postoperative complications, 30-day mortality, and 1-year survival did not differ between the surgical approaches. PCI+MIVS for two-vessel CAD and moderate to severe IMR is feasible, and associated with satisfactory outcomes, as compared with CABG+MVS.

Relation of Mitral Valve Surgery Volume to Repair Rate, Durability, and Survival

BackgroundDegenerative mitral valve repair rates remain highly variable, despite established benefits of repair over replacement. The contribution of surgeon-specific factors is poorly defined. ObjectivesThis study evaluated the influence of surgeon case volume on degenerative mitral valve repair rates and outcomes. MethodsA mandatory New York State database was queried and 5,475 patients were identified with degenerative mitral disease who underwent mitral valve operations between 2002 and 2013. Mitral repair rates, mitral reoperations within 12 months of repair, and survival were analyzed using multivariable Cox modeling and restricted cubic spline function. ResultsMedian annual surgeon volume of any mitral operations was 10 (range 1 to 230), with a mean repair rate of 55% (n = 20,797 of 38,128). In the subgroup of patients with degenerative disease, the mean repair rate was 67% (n = 3,660 of 5,475), with a range of 0% to 100%. Mean repair rates ranged from 48% (n = 179 of 370) for surgeons with total annual volumes of ≤10 mitral operations to 77% (n = 1,710 of 2,216) for surgeons with total annual volumes of >50 mitral operations (p < 0.001). Higher total annual surgeon volume was associated with increased repair rates of degenerative mitral valve disease (adjusted odds ratio [OR]: 1.13 for every additional 10 mitral operations; 95% confidence interval [CI]: 1.10 to 1.17; p < 0.001); a steady decrease in reoperation risk until 25 total mitral operations annually; and improved 1-year survival (adjusted hazard ratio: 0.95 for every additional 10 operations; 95% CI: 0.92 to 0.98; p = 0.001). For surgeons with a total annual volume of ≤25 mitral operations, repair rates were higher (63.8%; n = 180 of 282) if they operated in the same institution as a surgeon with total annual mitral volumes of >50 and degenerative mitral valve repair rates of >70%, compared with surgeons operating in the other institutions (51.3%; n = 580 of 1,130) (adjusted OR: 1.79; 95% CI: 1.24 to 2.60; p < 0.001). ConclusionsThis study suggests that individual surgeon volume is a determinant of not only mitral repair rates, but also freedom from reoperation, and survival. The data from this study support the guideline’s concept of reference referral to experienced mitral surgeons to improve outcomes in patients with degenerative mitral valve disease.

Chordae Tendineae Rupture in the United States: Trends of Outcomes, Costs and Surgical Interventions.

To describe national trends in the incidence and outcomes of patients with chordae tendineae rupture (CTR). Patients who were diagnosed with CTR between 2000 and 2012 were identified in National (Nationwide) Inpatient Sample (NIS) registry. CTR was defined using validated International Classification of Diseases, 9th Edition, Clinical Modification diagnosis (ICD9-CM) codes.Results: A total of 37,287 (14,833 mitral valve repair, 7780 mitral valve replacement) CTR cases were identified. Overall, in-hospital mortality in CTR decreased by 3% from 2000 to 2012 (P < 0.001). From 2000 to 2012, the rate of mitral valve repair increased from 27.2% to 46.4%, (P < 0.001) with a concurrent decrease in the rate of mitral valve replacement (from 27.8 to 17.7%, P < 0.001). After multivariate adjustment, patient age (OR = 1.04, 95% CI 1.03-1.06, P < 0.001), congestive heart failure (CHF) (OR = 2.08, 95% CI 1.19-3.64, P = 0.01), myocardial infarction (MI) (OR = 3.58, 95% CI 2.10-6.11, P < 0.001), Deyo/Charlson comorbidity index (OR = 1.23, 95% CI 1.07-1.41, P < 0.003) and use of the intra aortic balloon pump (IABP) (OR = 4.81 95% CI 2.71-8.55, P < 0.001) were found to be independently associated with greater odds of mortality in these patients. Additionally, mitral valve replacement was significantly associated with higher costs of hospitalization (coefficient 15693, 95% CI 12638-18749, P < 0.001)Conclusion: Mitral valve repair is associated with reduced inpatient mortality and costs compared with mitral valve replacement. A substantial increase in the percentage of cases undergoing mitral valve repair with a concurrent decrease in cases undergoing mitral valve replacement were observed. Increasing age and comorbidity index, history of CHF and MI, and use of IABP were identified as factors that could increase the risk of mortality in patients with CTR.

Degenerative mitral valve disease-contemporary surgical approaches and repair techniques.

Given the increasing age of the US population and the accompanying rise in cardiovascular disease, we expect to see an increasing number of patients affected by degenerative mitral valve disease in a more complex patient population. Therefore, increasing the overall rate of mitral valve repair will become even more important than it is today, and the capability to provide a universally and uniformly accepted quality of repair will have important medical, economic, and societal implications. This article will describe preoperative and intraoperative considerations and the currently practiced mitral valve repair approaches and techniques. The aim of the article is to present our contemporary approach to mitral valve repair in the hope that it can be adopted at other institutions that may have low repair rates. Adoption of simple and reproducible mitral valve repair techniques is of paramount importance if we as a profession are to accomplish overall higher rates of mitral valve repair with optimal outcomes.

Transapical Beating-Heart Mitral Valve Repair With an Expanded Polytetrafluoroethylene Cordal Implantation Device: Initial Clinical Experience.

Degenerative mitral valve (MV) disease is a common cause of severe mitral regurgitation (MR) and accounts for the majority of MV operations. Conventional MV surgery requires cardiopulmonary bypass, aortic cross-clamping, cardioplegia, and a thoracotomy or sternotomy and, therefore, is associated with significant disability, risks, and unpredictable rates of MV repair. Transesophageal echocardiography-guided beating-heart MV repair with expanded polytetrafluoroethylene cordal insertion has the potential to significantly reduce surgical morbidity. We report the first-in-human clinical experience with a novel preformed expanded polytetrafluoroethylene knot implantation device (Harpoon TSD-5) designed to treat degenerative MR. Through a small left thoracotomy, the device was inserted into the heart and guided by transesophageal echocardiography to the ventricular surface of the prolapsed leaflet. Multiple expanded polytetrafluoroethylene cords were anchored in the leaflet and then adjusted to the correct length to restore MV leaflet coaptation and secured at the epicardium. Eleven patients with posterior leaflet prolapse and severe MR, with mean±SD age of 65±13 years and mean ejection fraction of 69±7%, were treated with 100% procedural success. Immediate postprocedural mean MR grade was trace. At 1 month, the mean MR grade was mild with significant decreases in end-diastolic volume (139 to 107 mL; P=0.03) and left atrial volume (118 to 85 mL; P=0.04). A novel device used for beating-heart image-guided MV repair demonstrates a significant reduction in MR with favorable left ventricular and left atrial reverse remodeling. This approach has the potential to decrease invasiveness and surgical morbidity. Further follow-up is necessary to assess long-term efficacy. URL: https://clinicaltrials.gov. Unique identifier: NCT02432196.

“A Prospective Randomized Case-Control Study To Evaluate Mini Right Thoracotomy versus Conventional Sternotomy For Mitral Valve Repair In Rheumatic Heart Disease.”

Purpose: Right mini thoracotomy has been evaluated in many studies for mitral valve repair mainly in degenerative valvular disease but not in rheumatic heart disease. Mitral valve repair is more challenging in rheumatic etiology due to complexity of lesions. This prospective randomized case control study was designed to evaluate repair through mini right thoracotomy and to compare the clinical and echocardiographic outcomes with sternotomy in rheumatic patients. Methods: 25 patients of rheumatic heart disease underwent mitral valve repair through mini right thoracotomy (group I). Various clinical and functional parameters were compared with 25 patients of mitral valve repair through sternotomy (group II). On follow up the results were compared in both groups for clinical and echocardiographic parameters. Results: The various pre-operative demographic parameters were comparable in two groups. Equal rate of mitral valve repair (group I-21/25, 84% and group II-21/25, 84%) was achieved in both groups. The various intra-operative and post-operative clinical parameters were better in group I .There were equivalent functional and valve related outcomes in both groups in term of NYHA class (1.28 ± 0.613 vs 1.08 ± 0.276, P = 0.144), post-operative mitral valve area (2.43 ± 0.891 vs 2.82 ± 0.662, P = 0.090), incidence of more than mild mitral regurgitation (0) and mean pressure gradient across mitral valve (4.98 ± 3.33 vs 4.23 ± 1.5, P = 0.309). Conclusion: Mitral valve repair through mini right thoracotomy approach in rheumatic etiology is feasible and safe with equivalent rate of successful repair as compared to median sternotomy. It is associated with lesser morbidity, cosmetic advantage and lesser resource utilization.

Early and long-term outcomes of minimally invasive mitral valve surgery through right minithoracotomy: a 10-year experience in 1604 patients.

BackgroundTo report early and long-term outcomes of patients undergoing minimally invasive mitral valve surgery (MIMVS) through right mini-thoracotomy (RT) over a 10-year period.MethodsFrom September 2003 to December 2013, a total of 1604 consecutive patients underwent MIMVS through RT.ResultsThe mean age was 63 ± 13 years, 770 (48 %) patients were female and 218 (13.6 %) had previous cardiac operations. The most predominant pathology was degenerative disease (70 %), followed by functional mitral valve regurgitation (12 %), rheumatic disease (9.4 %), endocarditis (5 %) and prosthetic dysfunction (3.2 %). Mitral valve repair was performed in 1137 (71 %) patients and 476 (29 %) had mitral valve replacement. Direct aortic cannulation was achieved in 1325 (83 %) patients. Among patients with degenerative disease candidate for repair (n = 958), rate of mitral valve repair was 95 %. Repair techniques included annuloplasty (95 %), leafleat resection (63 %), neochordae implantation (16 %) and sliding plasty (11 %). Concomitant procedures included tricuspid valve repair (14.6 %), atrial fibrillation ablation (9.5 %) and atrial septal defect closure (3.2 %). Overall in-hospital mortality was 1.1 %. Thirty-four patients (2.1 %) had conversion to sternotomy. Incidence of stroke was 2 %. Overall survival at 10 years was 88 ± 2 %. Freedom from reoperation at 10 years was 94 ± 2 % for repair and 80 ± 6 % for replacement. Freedom from recurrent mitral regurgitation >3+ at 10 years was 90 ± 3 %.ConclusionsMinimally invasive mitral valve surgery is a safe and reproducible approach associated with low mortality and morbidity, high rate of mitral valve repair and excellent late results.

ECHOCARDIOGRAPHY PREDICTORS OF SUCCESSFUL MITRAL VALVE REPAIR IN DEGENERATIVE MITRAL VALVE REGURGITATION

Background and aim of the study: Mitral repair is now as the treatement of choice in patients suffering mitral regurgitation due to mitral valve prolapse or flail. However, mitral valve repair demands the mitral valve morphology being feasible for repair. The study aims at evaluating transthoracic and transesophageal echocardiographic features in consecutive patients with mitral valve prolapse or flail undergoing surgical repair at Hue Central Hospital. The correlation between preoperative and intraoperative echocardiographic features and surgical findings in these patients. These echocardiographic data may predict the surgical outcome. Methods: From December 2010 to January 2013, 73 patients (37 men, 36 women; average age 37.5) were recruited into the study. All patients had degenerative mitral valve disease causing important regurgitation and underwent systematic preoperative transthoracic echocardiography, preoperative and intraoperative transesophageal echocardiography for delineation of six segments (scallops) of anterior and posterior leaflets. Results: Among 73 patients, 64 patients were in fibroelastic deficiency (87.7%) and 9 patients suffered Barlow disease (12.3%). Mitral valve repair was performed in 52 patients (71.2%) and mitral replacement was performed in 21 patients (28.8%). All 52 mitral valve repair (81.3%) and 12 mitral valve replacement (18.7%) was performed in fibroelastic deficiency patients. All 9 Barlow patients must undergo mitral valve replacement (100%). A prolapse or flail of mitral valve in 73 patients was documented by transthoracic and transesophageal echocardiography and confirmed on surgical inspection. Accuracy of transthoracic echocardiography was (89.0%) and accuracy of transesophageal echocardiography was (91.8%) in identifying mitral valve segments prolapse or flail. Success rate of mitral valve repair was (98.0%) in prolapse of 1 or 2 segments, but was low (36.0%) in prolapse &gt; 3 segments. Success rate of mitral valve repair was (96.6%) in prolapse of posterior leaflet, but was (63.6%) in prolapse anterior leaflet or bileaflet. Conclusion: - Mitral valve repair was favorable in fibroelastic deficiency patients, but difficult in Barlow patients. - Accuracy of transthoracic and transesophageal echocardiography was high in identifying mitral valve segments prolapse or flail. - Success rate of mitral valve repair was high in prolapse of 1 or 2 segments. - Success rate of mitral valve repair was high in in prolapse of posterior leaflet. Key words: Mitral repair, echocardiography, degenerative, Barlow, fibroelastic deficiency, prolapse, flail

Minimally invasive mitral valve repair through right minithoracotomy in the setting of degenerative mitral regurgitation: early outcomes and long-term follow-up.

Mitral valve (MV) repair is the gold standard for the treatment of degenerative MV regurgitation. Recently, minimally invasive mitral valve surgery (MIMVS) has shown excellent postoperative outcomes compared with conventional surgery. The aim of our study is to report early and long-term outcomes of patients undergoing MIMVS through right mini-thoracotomy (RT) over an eight year period. From September 2003 to December 2011, a total of 1,604 consecutive patients underwent MIMVS through RT. The mean age was 62±13 years, 295 (42%) patients were female and 16 (2.3%) had previous cardiac operations. MV repair was successfully performed in 670 patients, with a rate of success of 95.3%. Repair techniques included annuloplasty (89%), leaflet resection (n=54.2%), neochordae implantation (12.1%), and sliding plasty (10.5%). Overall in-hospital mortality was 0.1%. Incidence of stroke was 1.3%. At eight-year follow-up, overall survival was 90.1%, freedom from reoperation 93%, and freedom from recurrent mitral regurgitation was 90%. MIMV repair through right minithoracotomy is a safe and reproducible procedure associated with high rate of MV repair, and excellent early postoperative and long-term results.

Invited Commentary

Yazdchi and colleagues [1Yazdchi F. Koch C.G. Mihaljevic T. et al.Increasing disadvantage of “watchful waiting” for repairing degenerative mitral valve disease.Ann Thorac Surg. 2015; 99: 1992-2000Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar] have contributed a 26-year experience describing trends in patient characteristics, surgical approaches, and outcomes in patients with degenerative mitral valve regurgitation. The news is encouraging. The authors document an important shift toward referral for mitral valve operation earlier in the disease process, before the adverse consequences of mitral regurgitation on the heart and pulmonary vasculature compromise long-term outcomes. Patients undergoing mitral valve operations for degenerative disease in this experience have progressively smaller ventricular and atrial dimensions, less manifest heart failure, a lower incidence of atrial fibrillation, and a higher likelihood of presenting without symptoms. The extremely low mortality and high rates of repair are a tribute to the entire perioperative care team, and these outcomes undoubtedly have shifted the equation toward earlier referral. The author’s institution is ahead of the national curve, where fewer than 10% (compared with 44% in this report) of referred patients are asymptomatic (The Society of Thoracic Surgeons Adult Cardiac Surgery Database, accessed October 2013). The repair rate of 93% exceeds the national average of 85% and is a reminder that highly reliable and durable mitral repair is probably best achieved by surgeons with a dedicated subspecialization in mitral valve repair. Key unanswered questions include the worth of “minimally invasive” mitral valve operations, which seem to be driving substantially increased cardiopulmonary and cross-clamp times. The next steps in the therapy of degenerative mitral valve disease include continued earlier referral for operation, truly less invasive (non-cardiopulmonary bypass and catheter-based) interventions, and simplification of repair strategies to increase mitral valve repair rates and enhance durability of repair. We are looking forward to the next era. Increasing Disadvantage of “Watchful Waiting” for Repairing Degenerative Mitral Valve DiseaseThe Annals of Thoracic SurgeryVol. 99Issue 6PreviewSuccessful durable repair of severe degenerative mitral regurgitation with low operative mortality encourages intervention in asymptomatic patients rather than “watchful waiting.” Our objectives were to assess trends in patient characteristics, timing of intervention, and evolving surgical techniques at a high-volume center, and determine effects of these changes on outcomes after mitral valve (MV) repair over a 25-year period. Full-Text PDF

Very High Repair Rate Using Minimally Invasive Surgery for the Treatment of Degenerative Mitral Insufficiency

BackgroundMinimally invasive mitral valve surgery (MIMVS) is an established alternative to median sternotomy for mitral valve repair. However, this technique has yet to gain widespread adoption, partly because of concerns that this approach might yield lower repair rates or repairs that are less durable than those performed through a sternotomy. The purpose of this study was to report our inaugural experience with MIMVS, with a focus on mitral valve repair rate and midterm outcomes. MethodsBetween May 2006 and April 2012, minimally invasive mitral valve repair was attempted in 200 consecutive patients with degenerative mitral disease. The approach used was a 4- to 5-cm right anterolateral minithoracotomy with femorofemoral cannulation for cardiopulmonary bypass. Mean follow-up was 2.9 ± 1.8 years, and follow-up was 99% complete. ResultsThe mitral valve was successfully repaired in all but 2 patients, yielding a repair rate of 99%. Hospital mortality occurred in 2 patients (1%). Intraoperative conversion to sternotomy was necessary in 12 patients (6%), including 1 of the 2 unsuccessful repairs. Mean cardiopulmonary bypass and aortic cross-clamp times were 130.8 ± 41.3 minutes and 104.8 ± 35.6 minutes, respectively. Median hospital stay was 5 days. The 5-year survival and freedom from reoperation were 97.9% ± 1.5% and 98.1% ± 1.3%, respectively. ConclusionsA very high repair rate can be achieved using MIMVS for the treatment of degenerative mitral regurgitation, including during the learning phase. Midterm survival and freedom from valve-related reoperation are excellent. MIMVS is a safe and effective alternative to mitral valve repair through a sternotomy.