Results Of Mitral Valve Repair Research Articles

4D-transesophageal echocardiography and emerging imaging modalities for guiding mitral valve repair.

Two-dimensional transesophageal echocardiography (2D-TEE) had a transformative impact on surgical treatment of mitral valve pathology in the 1980s. 2D-TEE provided unprecedented, high-quality views of the mitral valve that enabled pre-operative repair strategizing and immediate post-operative assessment of repair efficacy. Several decades later, the commercialization of four-dimensional transesophageal echocardiography (4D-TEE) and other emerging imaging modalities such as 4D computed tomography (4DCT) and cardiac magnetic resonance imaging (CMRI) potentiate yet another transformative phase in the practice of mitral valve repair surgery. Bypassing the “mental integration” step required for 2D image interpretation, these higher dimensional modalities provide a more intuitive, complete description of valve morphology and dynamics that can be leveraged as a tool for more effective surgical decision support. Current research shows that these modalities may enhance mitral valve repair outcomes in four ways: (I) by increasing the precision of mitral valve diagnostics in order to tailor the repair plan to an individual’s valve pathology; (II) as a means of risk stratification to determine which patients might benefit from valve repair over valve replacement; (III) by predicting the outcome of a given repair technique using image-derived valve models as input to computational biomechanical analysis; and (IV) by optimizing annuloplasty ring design. Research highlights in each of these areas are given below.

Mitral valve repair for rheumatic mitral regurgitation: Mid-term results.

This retrospective study was undertaken to evaluate the midterm results of mitral valve repair for rheumatic mitral regurgitation, in term of survival rate and late valve failure. From January 2003 to January 2014, 97 patients underwent mitral valve repair in our hospital. Age ranged from 8 to 74 years, mean 24 ± 1.4 years; 74 (76%) patients were female. Mean preoperative functional class was 2.47 ± 0.07. Mean preoperative ejection fraction was 59.9% ± 2%. The lesions were pure mitral regurgitation in 79 (81.4%) patients, predominant mitral regurgitation with stenosis in 9 (9.3%), and predominant mitral stenosis with regurgitation in 9 (9.3%). Seventy-one (73%) patients were in normal sinus rhythm. One patient died in the postoperative period, and 8 were lost during follow-up. Follow-up time ranged from 6 to 137 months, mean 58.8 ± 4.2 months. There were 6 late deaths. Actuarial survival at 5 and 10 years was 95.5% and 89.2%, respectively. Twenty-seven (27.8%) patients had mitral regurgitation during follow-up, and 7 underwent reoperation with no hospital mortality. Freedom from reoperation at 5 and 10 years was 94.5% and 82.7%, respectively. Freedom from reoperation or progression of mitral regurgitation at 5 and 10 years was 70.4% and 61.8%, respectively. Freedom from all late events at 5 and 10 years was 68 % and 56.4%, respectively. Mitral valve repair for rheumatic mitral regurgitation is associated with a significant rate of valve failure and reoperation. However, it has a satisfactory survival rate and is a good alternative to valve replacement, especially for young patients, to avoid the life-long risks of a prosthetic valve.

Invited Commentary

Mitral regurgitation (MR) accompanying ventricular septal defect (VSD) is uncommon and when present is often presumed to be a result of the physiologic mechanisms of VSD, with left ventricular dilatation that is a consequence of intracardiac shunting. The common expectation is for MR to regress as the ventricle remodels after VSD closure. Indeed, several studies have observed that ventricular volume load and associated MR regress with time after VSD closure alone [1Cho H.J. Ma J.S. Cho Y.K. Ahn B.H. Na K.J. Jeong I.S. Timing in resolution of left heart dilation according to the degree of mitral regurgitation in children with ventricular septal defect after surgical closure.J Pediatr (Rio J). 2014; 90: 71-77Crossref PubMed Scopus (7) Google Scholar, 2Mahadin D.R. Srivastava S. Parness I.A. et al.Outcomes of mitral regurgitation associated with large ventricular septal defect and a normal mitral valve apparatus: does intact atrial septum have an impact?.Pediatr Cardiol. 2011; 32: 1128-1131Crossref PubMed Scopus (9) Google Scholar], or even without VSD closure [3Kleinman C.S. Tabibian M. Starc T.J. Hsu D.T. Gersony W.M. Spontaneous regression of left ventricular dilation in children with restrictive ventricular septal defects.J Pediatr. 2007; 150: 583-586Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar]. Indications to intervene for specific types of MR in this setting may lack clear definition. Among 1,898 consecutive VSD closures, Jang and colleagues [4Jang W.S. Kim W.-H. Cho J.Y. et al.Surgical indications and results of mitral valve repair in pediatric patients with ventricular septal defects accompanied by mitral valve regurgitation.Ann Thorac Surg. 2015; 99: 891-898Scopus (6) Google Scholar] found MR in 5.6% of patients, and mitral repairs were judged necessary in half of those with MR. Of the patients who underwent concomitant mitral repair, 35 of 48 patients had prolapse of the anterior mitral valve leaflet, and the remaining patients had annular dilatation alone. At follow-up, all the patients who had VSD closure alone had regression or stability of the degree of MR. Of the patients who underwent repair, MR was also stable or improved, although 2 patients had mild to moderate mitral stenosis. Jang and colleagues demonstrate that, at least in short- to midterm follow-up, annular growth and sustained competence is achievable when posterior annuloplasty and commissuroplasty techniques are used to repair the mitral valve in infancy. Such repair in infancy is not without cost, however, as evidenced by the 2 patients who exhibited mitral stenosis after repair. The history of surgical and catheter-based interventions for cardiac defects is rife with junctures at which we are challenged to separate what we can do from what we should do. It is established that MR from annular dilatation regresses after closure of the VSD and generally does not require valvuloplasty. The fate of MR from structural valve abnormalities in addition to annular enlargement is less clearly defined. Jang and colleagues describe anterior leaflet prolapse as a common structural abnormality among those who underwent valvuloplasty in their series. The prognosis of untreated isolated mitral prolapse in children may be good [5Bisset G.S. Schwartz D.C. Meyer R.A. James F.W. Kaplan S. Clinical spectrum and long-term follow-up of isolated mitral valve prolapse in 119 children.Circulation. 1980; 62: 423-429Crossref PubMed Scopus (88) Google Scholar], but prolapse in the setting of VSD has not undergone specific scrutiny. It would be useful for the authors to leverage their large experience to specifically compare outcomes of treated versus untreated anterior mitral prolapse in the setting of VSD. Surgical Indications and Results of Mitral Valve Repair in Pediatric Patients With Ventricular Septal Defects Accompanied by Mitral Valve RegurgitationThe Annals of Thoracic SurgeryVol. 99Issue 3PreviewVentricular septal defects (VSDs) can be accompanied by mitral regurgitation (MR) owing to chronic volume overload or mitral valve (MV) abnormalities. This study investigates the surgical indications, results, and natural course of pediatric VSD patients with MR. Full-Text PDF

Long-term outcomes of mitral valve repair with the Duran flexible ring.

Mitral annuloplasty is a reliable mitral valve repair technique. There are two types of annuloplasy rings: the rigid ring and the flexible ring. This study sought to examine the long-term results of mitral valve repair using a Duran flexible ring. We retrospectively reviewed 226 patients who underwent primary mitral valve repair using the Duran flexible ring for mitral regurgitation between September 1994 and March 2003. Patients' mean age was 56.7 years, and 39% were female. The mean follow-up was 10.6 years (0.04 ∼ 18.3), and echocardiographic follow-up was 83.3% complete. There were three early and 25 late deaths. Survival was 89.3 ± 2.2 for 10 years, and 83.5 ± 3.2% for 15 years. The 10- and 15-year freedom from reoperation on the mitral valve were 96.4 ± 1.4 and 95.3 ± 1.7%, respectively. The 10- and 15-year freedom from moderate or severe mitral regurgitation were 92.5 ± 2.2 and 73.7 ± 7.1%, respectively. Cox regression analysis revealed that age, male gender, and isolated anterior leaflet prolapse were predictive of recurrent moderate or severe mitral regurgitation. Mitral valve repair for mitral regurgitation using a flexible Duran ring is safe and durable for more than 10 years.

Surgical Indications and Results of Mitral Valve Repair in Pediatric Patients With Ventricular Septal Defects Accompanied by Mitral Valve Regurgitation

Ventricular septal defects (VSDs) can be accompanied by mitral regurgitation (MR) owing to chronic volume overload or mitral valve (MV) abnormalities. This study investigates the surgical indications, results, and natural course of pediatric VSD patients with MR. One hundred seven patients (median age, 4.5 months; median body weight, 6.2 kg; M:F= 46:61) who had VSD with accompanying MR between 2002 and 2012 were retrospectively analyzed and classified into two groups: group I, MV repair group; group II, no MV repair group. Of 107 patients, 48 patients (44.9%) required MV repair. Annular dilatation (n= 46) and anterior MV prolapse (n= 35) were the representative MV diseases in group I and their incidences were higher than in group II (n= 26 and n= 6, respectively; both p < 0.001). Increased preoperative z values of MV annulus, and mean diastolic and systolic left ventricle internal diameters were observed in group I (1.9 ± 1.0, 3.4 ± 1.3, and 3.1 ± 1.3, respectively) in comparison with group II (1.0 ± 0., 2.6 ± 1.7, and 2.3 ± 1.7, respectively; p < 0.001, p= 0.02, and p= 0.024, respectively). Posteromedial commissure annuloplasty in 23 patients and posterior annuloplasty in 19 patients were the most commonly used techniques to repair the MV; no reoperations were performed owing to MR. In group I, all patients showed an MR grade of 2 or less during the follow-up period. In group II, all patients showed the same or lower MR degree. Mitral valve repair in pediatric VSD patients with accompanying MR is a feasible and durable procedure with growth potential.

Standardized Strategy and Long-Term Surgical Outcome of Mitral Valve Repair in Congenital Mitral Stenosis

Objectives: Having collected a large series of congenital mitral stenosis we studied the operative results and long-term outcome of our evolving mitral valve (MV) repair techniques performed to correct this lesion. Methods: Between 1986 and 2012, 137 infants and children (mean age 4.1 ± 5.0 (range 1 month to 16.8 years) underwent surgical correction of congenital mitral stenosis (CMS). In 48 patients, CMS is involved in Shone's anomaly. CMS was defined according to Ruckman and Van Praagh's classification. Type I, typical congenital MS, was seen in 56 patients. Hypoplastic MV (Type II), d was seen in 15 patients. TSupravalvar mitral ring (Type III) was seen in 48 patients. VParachute MV (Type IV) was seen in 10 patients, described as having the usual two leaflets and commissures, but all chordae merged into one major papillary muscle. T Results: MV repair was performed using commissurotomy, division of chordae tendinae, papillary muscle splitting and fenestration, and resection of mitral ring, applied according to the presenting morphology in patients with either previously corrected or concomitant correction of the left-sided obstructive lesions. Postoperative echocardiography showed absence of MV stenosis and immediate improvement of symptoms, except in a 3-month-old infant who died 18 days postoperatively due to myocardial failure. During the 24-year follow-up, 23 patients underwent repeat MV repair and 1 underwent MV replacement after failed attempts at repair. Mean duration of follow-up was 17.5 ± 1.5 years (range 6.4–24.2 years). Freedom from reoperation was 97.6 ± 2.4%, 89.3 ± 5.1%, 77.1 ± 7.2%, 72.0 ± 8.3% and 52.8 ± 11.8%, at 30 days, 1, 5, 10 and 15 years postoperatively, respectively Cumulative survival rate was 97.6 ± 2.4%, 92.3 ± 4.3%, 83.8 ± 6.1%, 75.7 ± 7.8% and 70.3 ± 8.9%, at 30 days, 1, 5, 10 and 15 years postoperatively, respectively Mortality unrelated to valve repair accounted for 9 (20%) deaths. Age at operation, severity of mitral abnormalities and concomitant left ventricular outflow tract lesions proved to be independent risk factors for reoperation and mortality (p < 0.05). Conclusions: Long-term functional outcome of mitral valve repair in children with CMS is satisfactory. Repeat MV repair and/or replacement may be deemed necessary during the course of follow-up.

Mitral Valve Repair for Congenital Mitral Valve Disease: Impact of the Use of a Biodegradable Annuloplasty Ring

This study compares the midterm results of mitral valve repair using the biodegradable ring versus repair with non-ring annuloplasty techniques for congenital mitral valve disease in young children where it was not possible to use standard commercial rings. Between February 2006 and November 2011, 68 patients underwent mitral valve repair for congenital mitral valve disease. Thirty-nine (57%) patients underwent concomitant annuloplasty using the biodegradable ring (group A) and 29 (43%) patients using non-ring annuloplasty techniques (group B). The median age of repair was 2 years (range 1 month to 14 years). There were no hospital deaths or major postoperative morbidity. At a median follow-up of 3.8 years (range, 2 months to 5.1 years), overall survival at 5 years was 97% ± 3% for group A and 88% ± 8% for group B (p= 0.29). Freedom from valve failure was 90% ± 7% in group A and 74% ± 9% in group B (p= 0.026). The freedom from reoperation was 100% in group A and 84% ± 9% in group B (p= 0.04). The mean transmitral gradients were 4.3 ± 1.8 mm Hg in group A and 4.2 ±1.7 mm Hg in group B (p= 0.77). Mitral valve repair using the biodegradable ring for congenital mitral valve disease was superior compared with non-ring annuloplasty repair. Excellent survival benefit, freedom from reoperation, and valve failure without significant elevation of transmitral gradients, suggests its important role in young children with smaller annular sizes where standard commercial rings are not available or recommended.

A 25-year study of chordal replacement with expanded polytetrafluoroethylene in mitral valve repair†.

This study examines the outcome of mitral valve repair with chordal replacement using expanded polytetrafluoroethylene over the past 25 years. From July 1988 to February 2013, 224 consecutive patients (mean age 57 years, 34% women) underwent mitral valve repair with chordal replacement using expanded polytetrafluoroethylene sutures at our institution. Isolated anterior leaflet prolapse was observed in 134 patients (60%), isolated posterior leaflet prolapse was observed in 13 patients (6%) and bileaflet prolapse was observed in 77 patients (34%). The number of replaced artificial chordae ranged from 2 to 12 (mean 3.7) per patient. Transthoracic echocardiography was performed pre- and postoperatively and in the follow-up period. The follow-up period ranged from 0.3 to 25.3 years (mean 7.4, median 6.2). There was 1 early death and 15 late deaths, of which 7 were cardiac related. The actuarial survival rates at 10 and 20 years were 92 and 81%, respectively. Thirty-three patients (15%) developed recurrent moderate or severe mitral regurgitation during the follow-up period and 30 patients (13%) required reoperation on the mitral valve. Rates of freedom from reoperation and freedom from recurrent moderate or severe mitral regurgitation were 84 and 82% at 10 years, and 74 and 59% at 20 years, respectively. Multivariate analysis revealed that the independent predictors of recurrent mitral regurgitation were mitral valve repair without annuloplasty ring and greater than mild postoperative mitral regurgitation; and the independent predictors of mitral reoperation were previous cardiac surgery and greater than mild postoperative mitral regurgitation. Histopathological analysis of the expanded polytetrafluoroethylene sutures removed during reoperation revealed complete endothelialization without calcification or microthrombi. Our 25-year follow-up demonstrated reliable long-term outcomes of chordal replacement with expanded polytetrafluoroethylene sutures.

Long-term outcomes of mitral valve repair versus replacement for degenerative disease: a systematic review.

The short-term advantage of mitral valve repair versus replacement for degenerative disease has been extensively documented. These advantages include lower operative mortality, improved survival, better preservation of left-ventricular function, shorter post-operative hospital stay, lower total costs, and fewer valve-related complications, including thromboembolism, anticoagulation-related bleeding events and late prosthetic dysfunction. More recent written data are available indicating the long-term advantage of repair versus replacement. While at some institutions, the repair rate for degenerative disease may exceed 90%, the national average in 2007 was only 69%. Making direct comparisons between mitral valve repair and replacement using the available studies does present some challenges however, as there are often differences in baseline characteristics between patient groups as well as other dissimilarities between studies. The purpose of this review is to systematically summarize the long-term survival and reoperation data of mitral valve repair versus replacement for degenerative disease. A PubMed search was done and resulted in 12 studies that met our study criteria for comparing mitral valve repair versus replacement for degenerative disease. A systematic review was then conducted abstracting survival and reoperation data.

Surgical outcome of mitral valve repair in Iceland 2001-2012

To review, for the first time, the outcome of mitral valve repair operations in Iceland. A retrospective study of all mitral valve repair patients (average age 64 yrs, 74% males) operated in Iceland 2001-2012. All 125 patients had mitral regurgitation; either due to degenerative disease (56%) or functional regurgitation (44%). Survival was estimated using the Kaplan-Meier method. The median follow-up time was 3.9 years The number repair-procedures increased from 39 during the first half of the study period to 86 during the latter period. The mean EuroSCORE was 12.9% and 2/3 of the patients were in NYHA class III/IV. Half of them had severe mitral regurgitation, 12% had a recent myocardial infarction, and 10% a history of previous cardiac surgery. A ring annuloplasty was performed in 98% of cases, a posterior leaflet resection was done in 51 patients (41%), 28 received artificial chordae (Goretex(®)) and 7 an Alfieri-stitch. Concomitant cardiac surgery was performed in 83% of cases, where coronary artery bypass (53%), Maze-procedure (31%) or aortic valve replacement (19%) were most common. Major complications occurred in 56% of the cases and minor complications were noted in 71% of cases. Two patients later required mitral valve replacement. Eight patients died within 30 days (6%) and 5-year overall survival was 79%; or 84% and 74% for the degenerative and functional groups, respectively. The number of mitral valve repairs in Iceland increased significantly over the study period. Complications are common but operative mortality and long-term survival is similar to that reported in studies from other countries.

Invited Commentary

The report of David and colleagues [1David T.E. David C.M. Manlhiot C. Simplici-T Annuloplasty Band for mitral valve repair for degenerative disease.Ann Thorac Surg. 2014; 98: 1551-1556Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar] using an unmeasured, experience-based approach for mitral annuloplasty is similar to that of Brown and colleagues [2Brown M.L. Schaff H.V. Li Z. Suri R.M. Daly R.C. Orsulak T.A. Results of mitral valve annuloplasty with a standard-sized posterior band: is measuring important?.J Thorac Cardiovasc Surg. 2009; 138: 886-891Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar]. Bothe and colleagues [3Bothe W. Miller C. Doenst T. Sizing for mitral annuloplasty: where does science stop and voodoo begin?.Ann Thorac Surg. 2013; 95: 1475-1483Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar] recently provided an insightful summary of the need for detailed studies of the effects of the various mitral annuloplasty techniques. We also believe that the issues involved are complex and require rigorous investigation using clinical, echo, 2D, 3D, cMRI, cardiac CTA, finite stress analysis, and other engineering data to appreciate fully the effects of different repairs. Our own focus during repair is restoration of the relationships of all the elements whose interrelated structures and dynamic behavior are necessary for normal mitral valve function, starting with normal mitral diastolic locking [4Lawrie G.M. Structure, function, and dynamics of the mitral annulus: importance in mitral valve repair for myxomatous mitral valve disease.Methodist Debakey Cardiovasc J. 2010; 6: 8-14PubMed Google Scholar, 5David D. Michelson E.L. Naito M. Chen C.C. Schaffenburg M. Dreifus L.S. Diastolic locking of the mitral valve: importance of atrial systole and intraventricular volume.Circulation. 1983; 67: 640-645Crossref PubMed Scopus (36) Google Scholar, 6Decloedt A. Verheyen T. Sys S. De Clercq D. Bijnens B. Loon G.V. Influence of atrioventricular interaction on mitral valve closure and left ventricular isovolumic contraction measured by tissue Doppler imaging.Circ Cardiovasc Imaging. 2013; 6: 109-116Crossref PubMed Scopus (12) Google Scholar]. We have reported 100% reparability [7Lawrie G.M. Earle E.A. Earle N.R. Intermediate-term results of a nonresectional dynamic repair technique in 662 patients with mitral valve prolapse and mitral regurgitation.J Thorac Cardiovasc Surg. 2011; 141: 368-376Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar], superior durability of the annulus attachment [7Lawrie G.M. Earle E.A. Earle N.R. Intermediate-term results of a nonresectional dynamic repair technique in 662 patients with mitral valve prolapse and mitral regurgitation.J Thorac Cardiovasc Surg. 2011; 141: 368-376Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 8Spratt J.R. Spratt J.A. Beachley V. Kang Q. Strength comparison of mitral annuloplasty ring and suturing combinations: an in-vitro study.J Heart Valve Disease. 2012; 21: 286-292PubMed Google Scholar], and restoration of near normal annular dynamics [9Little S.H. Ben Zekry S. Lawrie G.M. Zoghbi W.A. Dynamic annular geometry and function in patients with mitral regurgitation: insights from three dimensional annular tracking.J Am Soc Echocardiogr. 2010; 23: 872-879Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 10Ben Zekry S. Lang R. Sugeng L. et al.Mitral annulus dynamics early after valve repair: Preliminary observations of the effect of resectional versus non-resectional approaches.J Am Soc Echocardiogr. 2011; 24: 1233-1242Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar]. Left ventricular outflow tract dimensions and aortic-mitral angle by cMRI are unchanged postoperatively. Strain analysis showed normal strain distribution in all cases [11Ben Zekry S. Lawrie G. Little S. et al.Comparative evaluation of mitral valve strain by deformation tracking in 3-D echocardiography.Cardiovasc Eng Tech. 2012; 3: 402-412Crossref Scopus (13) Google Scholar]. No patient has undergone reoperation for SAM [7Lawrie G.M. Earle E.A. Earle N.R. Intermediate-term results of a nonresectional dynamic repair technique in 662 patients with mitral valve prolapse and mitral regurgitation.J Thorac Cardiovasc Surg. 2011; 141: 368-376Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar]. Preservation of normal annular dynamics eliminates the need for leaflet resection and enables the repair rate to rise to 100%, with 90% durability at 10 years by echo. We believe that optimal annular function is the essential foundation for reproducibly excellent results. Simplici-T Annuloplasty Band for Mitral Valve Repair for Degenerative DiseaseThe Annals of Thoracic SurgeryVol. 98Issue 5PreviewSizing of annuloplasty rings and bands is variably based on intertrigonal or intercommissural distances or estimation of the anterior leaflet area. This study examines the results of mitral valve repair with Simplici-T annuloplasty band without predetermining its length in patients with mitral regurgitation (MR) as a result of degenerative disease. Full-Text PDF

Comparative long-term results of mitral valve repair in adults with chronic rheumatic disease and degenerative disease: Is repair for “burnt-out” rheumatic disease still inferior to repair for degenerative disease in the current era?

Mitral valve repair is perceived to be of limited durability for advanced rheumatic disease in adults. We aim to examine the long-term outcomes of repair for rheumatic disease, identify predictors of durability, and compare with repair for degenerative disease. Rheumatic and degenerative mitral valve repairs in patients aged 40 years or more were prospectively analyzed. The primary outcomes investigated were mortality, freedom from reoperation, and valve failure. Logistic regression analysis was performed to define predictors of poor outcome. Between 1997 and 2011, 253 rheumatic and 148 degenerative mitral valves were repaired. The age of patients in both groups was similar, with a mean of 54.1 ± 8.4 years versus 55.6 ± 7.3 years (P = .49). Freedom from reoperation for rheumatic valves at 5 and 10 years was 98.4%, comparable to 95.3% (P = .12) for degenerative valves. Freedom from valve failure at 5 and 10 years was 91.4% and 81.5% for rheumatic repairs and 82.5% and 75.4% for degenerative repairs, respectively (P = .15). The presence of residual mitral regurgitation greater than 2+ before discharge was the only significant independent predictor of reoperation, whereas residual mitral regurgitation greater than 2+ and leaflet procedures were significant risk factors for valve failure. The durability of rheumatic mitral valve repair in the current era has improved and is comparable to the outstanding durability of repairs for degenerative disease, even in the adult rheumatic population. Modifications of standard repair techniques, adherence to the importance of good leaflet coaptation, and strict quality control with stringent use of intraoperative transesophageal echocardiography have all contributed to the improved long-term results.

Long-Term Outcomes of Mitral Valve Repair for Isolated Commissural Prolapse: Up to 17-Year Experience

Mitral valve repair has been shown to be effective for degenerative mitral regurgitation (MR). However, outcomes of mitral valve repair for commissural prolapse has not been well defined. Commissural prolapse has been often categorized into the groups of posterior leaflet prolapse or bileaflet prolapse, and outcomes and prognosis of isolated commissural prolapse has been rarely reported. We aimed to determine clinical and echocardiographic outcomes of mitral valve repair for isolated commissural lesion. Between 1992 and 2010, 1,112 patients underwent mitral valve repair for degenerative MR at our institution. Among those, we reviewed 122 patients with isolated commissural prolapse. We analyzed operative outcomes, long-term survival rate, freedom from reoperation rate, and freedom from recurrent moderate or severe MR rate. The mean age was 57.0 ± 14.4 years old, 83 patients (68.0%) were men, 16 patients (13.1%) had infective endocarditis, 43 patients (35.2%) had atrial fibrillation, 27 patients (22.1%) had anterolateral commissural prolapse, 91 (74.6%) had posteromedial commissural prolapse, and 4 (3.3%) had bilateral commissural prolapse. We performed leaflet resection in 111 (91.0%) (concomitant sliding plasty in 43), chordal replacement in 94 (77.0%), and ring annuloplasty in 121 patients (99.2%). Residual mild MR was confirmed in 7 patients (5.7%) on predischarge echocardiography. No patients had moderate or severe MR at the time of discharge. Fifteen-year survival and freedom from mitral reoperation were 87.6% and 93.0%, respectively. Freedom from recurrent moderate or severe MR at 15 years was 87.4%. Mitral valve repair for isolated commissural prolapse demonstrated excellent early and late outcomes.

Preoperative risk factors of medium-term mitral valve repair outcome.

This study aimed to evaluate risk factors that affect mitral valve (MV) repair outcomes. From 2002 to 2012, 580 consecutive patients with mitral regurgitation (MR) underwent MV repair. Of the total number of patients, 48.9% were found to be in New York Heart Association (NYHA) Class III or IV. Anterior, posterior and bileaflet prolapse was present in 34.8, 47.6 and 17.6% of patients, respectively. Atrial fibrillation (AF) was found in 29.7% of patients. The mean follow-up was 5.3 ± 2.6 years. There were eight early and 14 late deaths. NYHA Class III/IV, left ventricular ejection fraction ≤50%, systolic pulmonary artery pressure ≥50 mmHg, AF and low cardiac output syndrome with extracorporeal membrane oxygen were independent predictors of early mortality. AF, NYHA Class III/IV, left ventricular end-systolic diameter ≥40 mm and systolic pulmonary artery pressure ≥50 mmHg remained predictors of late mortality. At 5 years, the rate of survival, freedom from reoperation and recurrent moderate to severe MR was 99.0 ± 0.6 97.2 ± 0.8 and 93.3 ± 1.2%, respectively. Anterior leaflet involvement was predictive of reoperation and recurrent moderate to severe MR. In patients with a moderate tricuspid regurgitation (TR) and annulus <40 mm, the degree of TR during follow-up was worse with right ventricular dilatation. MV repair should be performed before the deterioration of ventricular function, development of pulmonary hypertension and AF occurrence. The pathophysiology of MR affects MV repair durability, while concomitant tricuspid annuloplasty should be considered in patients with moderate TR despite annular dilatation.

Simplici-T Annuloplasty Band for Mitral Valve Repair for Degenerative Disease

Sizing of annuloplasty rings and bands is variably based on intertrigonal or intercommissural distances or estimation of the anterior leaflet area. This studyexamines the results of mitral valve repair with Simplici-T annuloplasty band without predetermining its length in patients with mitral regurgitation (MR) as a result of degenerative disease. Three hundred thirty-seven consecutive patients (median age, 58 years; 69% men) underwent mitral valve repair for MR as a result of degenerative disease (52% bileaflet prolapse and 36% anterior leaflet prolapse). Prolapse of the leaflet was corrected by chordal replacement with Gore-Tex sutures and occasionally a triangular resection. A posterior mitral annuloplasty with a Simplici-T band (median length, 70 mm; range, 52 to 80mm) was performed by securing it from the lateral to the medial fibrous trigones. Annular reduction was performed selectively on the commissures, false commissures, and areas of posterior leaflet resection. Mitral valve function, gradients, and areas were assessed perioperatively and annually during a median follow-up of 4.1years (interquartile range, 2.7 to 5.4 years) and was 98% complete. There were 2 operative and 7 late deaths; survival at 5 years was 97.2%. Three patients were discharged from the hospital with mild to moderate MR, and during follow-up a total of 14 patients had MR greater than mild and 1 patient had MR greater than moderate. Mitral valve re-repair was performed in 1 patient who exhibited mitral stenosis. Freedom from MR greater than mild at 5 years was 93.3%. Selective reduction of the mitral annulus with a posterior band without predetermining its length during mitral valve repair for degenerative MR provides excellent functional results.

Twenty years of mitral valve repair. An experience in 322 patients

Mitral valve repair is the preferred procedure for the surgical treatment of mitral valve insufficiency (MI), procedure that we initiated 20 years ago. To assess our experience and long-term results of mitral valve repair. The database of the cardiology department was reviewed for the period between December 1991 and December 2012. A total of 322 patients aged 18 to 89 years (62% males) undergoing mitral valve repair were identified. Long-term survival information was obtained consulting death certificate records of the Chilean Identification Service. The latest echocardiogram available was analyzed. MI was degenerative in 144 patients (45%) and ischemic in 104 (32%). A prosthetic ring was used in all ischemic and in 92% of non-ischemic MI. Operative mortality was 7.5%, 13% in ischemic and 4.4% in non-ischemic MI (p < 0.01). Overall long-term survival was 14.1 years; 9.3 and 16 years for ischemic and non-ischemic MI, respectively (p < 0.001). Survival at 5, 10, 15 and 20 years was 79, 63, 54 and 42%, respectively. For degenerative MI survival at 5 and 10 years was 90 and 76% and for ischemic MI, it was 64 and 44%, respectively (p < 0.001). On a multivariate analysis the main predictors of late mortality were age, associated valvular disease and ischemic etiology. Echocardiographic follow-up was available for 223 patients; MI was absent in 53% and was mild in 29%. In a 20 years follow-up, mitral valve repair for MI had excellent long-term survival and echocardiographic results. The most common etiologies of MI were degenerative and ischemic diseases. The latter had a worst prognosis. The main predictors of long term mortality were age, associated valvular disease and ischemic etiology.

PP-305 Functional and Hemodynamic Outcome of Mitral Valve Repair and Echo Dobutamine Assessment in Barlow’s Disease

PP-305 Functional and Hemodynamic Outcome of Mitral Valve Repair and Echo Dobutamine Assessment in Barlow’s Disease

Mitral valve repair versus replacement in the elderly: Short-term and long-term outcomes

To compare the short-term and long-term outcomes of mitral valve repair (MVP) versus mitral valve replacement (MVR) in elderly patients. All patients, age 70 years or greater, with mitral regurgitation who underwent MVP or MVR with or without coronary artery bypass graft (CABG), tricuspid valve surgery, or a maze procedure between 2002 and 2011 were retrospectively identified. Patients with a rheumatic cause or who underwent concomitant aortic valve or ventricular-assist device procedures were excluded. Overall, 556 patients underwent MVP and 102 patients underwent MVR. The mean age of the patients in the MVR group was 78 years versus 77 years for those in the MVP group (P<.02). The patients in the MVR group had a better mean left ventricular ejection fraction than those in the MVP group (60% vs 55%, P=.04). The incidence of concomitant CABG, tricuspid valve operations, and atrial fibrillation ablation procedures was similar in both groups, but perfusion time was significantly longer for the MVR group (median 177 minutes vs 146 minutes for MVP, P=.001). Postoperatively, patients in the MVR group had a higher incidence of stroke (6% vs 2%, P<.10) and significantly longer intensive care unit stay (median 86 hours vs 55 hours, P=.001) and hospital stay (9 days vs 8 days, P<.01). Operative mortality of patients was significantly higher for the MVR group (8.8% vs 3.6%, P=.03) and remained significant long-term on Kaplan-Meier analysis. Cox regression analysis of all 658 patients and propensity-matched analysis of 96 patients also confirmed these results. Elderly patients with mitral regurgitation who undergo MVP have better postoperative outcomes, lower operative mortality, and improved long-term survival than those undergoing MVR. MVP is a safe and more effective option for the elderly with mitral regurgitation.

Clinical outcomes of mitral valve repair: a single-center experience in 100 patients

Amac: Calismamizda mitral yetersizlik (MY) ve mitral darlik icin uygulanan kapak tamirlerinin klinik sonuclari degerlendirildi. Ca­lis­ma­ pla­ni:­ Bu klinik calismaya, mitral tamir uygulanan ardisik ilk 100 hasta (46 erkek, 54 kadin; ort. yas 52.1±15.5 yil; dagilim 16-77 yil) dahil edildi. Patolojiler romatizmal (n=44), iskemik (n=30), miksomatoz (n=29) ve korda rupturu (n=7) idi. Mitral anuloplasti halkasi rutin olarak kullanildi. Hastalarin %79’una es zamanli islemler uygulandi; koroner arter baypas greftleme (n=35) ve trikuspid halka anuloplasti (n=34). Ameliyat sonrasi komplikasyonlar kaydedildi. Ekokardiyografik incelemeler taburcu sirasinda ve klinik takip surecinde yapildi. Kaplan-Meier analizi genel sagkalim ve reziduel ciddi MY, tromboembolizasyon, endokardit ve tekrar ameliyatsiz sagkalim oranlarinin tahmininde kullanildi. Bul gu lar: Dusuk kardiyak debi ve sepsis nedeniyle bes hastada erken (30 gun) mortalite gelisti. Taburculuk sirasinda ekokardiyografi ile hastalarin %59.5’inde eser/hic MY, %30.8’inde hafif MY ve %5.3’unde orta MY saptandi. Ortalama takip suresi, 94 hasta icin 22.7±5.8 aydi. Takip doneminde transtorasik ekokardiyografide %96.6 hastada hafif MY izlendi. Sadece iki hastada (%2.1) endokardit ve iskemiye bagli ciddi MY saptandi. Ortalama sol ventrikul sistol (p=0.01) ve diyastol sonu (p<0.05) caplarinda ameliyat sonrasinda azalma goruldu. Kaplan-Meier analizi ile sagkalim, reziduel ciddi MY, tromboembolizasyon, endokardit, MY nuksu ve tekrar ameliyatsiz sagkalim oranlari ameliyat sonrasi 30 ay icin sirasiyla; %94.0±2.3, %96.9±2.2, %98.4±1.5, %98.9±1.1, %96.9±2.2 ve %98.9±1.1 idi. So­nuc:­ Mitral kapak tamiri farkli kapak patolojileri ve karmasik lezyonlarin tedavisinde basarili ve etkin bir yontemdir. Anah tar soz cuk ler: Mitral yetersizlik; mitral darlik; mitral kapak tamiri; mitral kapak. Background:­ In this study, we evaluated the clinical outcomes of valve repair for mitral regurgitation (MR) and mitral stenosis. Methods: This clinical study included the first 100 consecutive patients (46 males, 54 females; mean age 52.1±15.5 years; range 16 to 77 years) who underwent mitral repair. Pathologies were rheumatic (n=44), ischemic (n=30), myxomatous (n=29), and chordal rupture (n=7). Mitral annuloplasty ring was used routinely. Concomitant procedures were performed in 79% of patients including coronary artery bypass grafting (n=35) and tricuspid ring annuloplasty (n=34). Postoperative complications were recorded. Echocardiographic examinations were performed at discharge and during follow-up. KaplanMeier analysis was used to estimate overall survival and from residual severe MR, thromboembolization, endocarditis and reoperation-free survival rates. Results:­Early (30 days) mortality developed in five patients due to low cardiac output and sepsis. At discharge, echocardiography revealed none/trivial MR in 59.5%, mild MR in 30.8%, and moderate MR in 5.3% of patients. The mean follow-up was 22.7±5.8 months in 94 patients. During follow-up, transthoracic echocardiography showed mild MR in 96.6% patients. Only two patients (2.1%) presented with severe MR due to endocarditis and ischemic disease. The mean left ventricular end-systolic (p=0.01) and end-diastolic diameters (p<0.05) decreased postoperatively. Kaplan-Meier estimates showed that death, severe MR, thromboembolization, endocarditis, MR recurrence and reoperation-free survival rates were 94.0±2.3%, 96.9±2.2%, 98.4±1.5%, 98.9±1.1%, 96.9±2.2%, and 98.9±1.1% at postoperative 30 months, respectively. Conclusion:­ Mitral repair is a successful and effective procedure in the treatment of distinct mitral valve pathologies and complex lesions.

The early and mid-term results of mitral valve repair for mitral regurgitation in children

To review the surgical techniques and mid-term results of mitral valve repair in children with moderate or severe mitral regurgitation (MR). One hundred and seven children with moderate or severe MR, aged 19.6 ± 8.5 months, were enrolled in this study. The surgical techniques used for mitral valve repair varied according to the mitral valve morphology, and included annuloplasty, annuloplasty ring, cleft closure, reconstruction of the posterior leaflet, etc. The concomitant cardiac anomalies were treated simultaneously. The results of repair were evaluated by transesophageal echocardiography performed during the operation and by serial transthoracic echocardiography performed during the follow-up. One hundred and six cases had no more than mild regurgitation intraoperatively, whereas only one case had moderate regurgitation. This patient underwent redo repair immediately, and the subsequent regurgitation was trivial. The in-hospital mortality rate was 0.9 % (1/107). The average follow-up was 46.5 ± 8.2 months. One patient died of heart failure 10 months postoperatively. The freedom from moderate or severe regurgitation after mitral valve repair was 92.3 ± 3.3 %. Pediatric patients with moderate or severe MR require early surgical treatment. The early and mid-term results of mitral valve repair in pediatric patients were satisfactory.