Preoperative Mitral Valve Regurgitation Research Articles

Health-Related Quality of Life Analysis Supports the Recommendation for HeartMate3 Implantation without Concomitant Mitral Valve Surgery

<h3>Purpose</h3> Functional mitral valve regurgitation (MR) is common in patients with end-stage heart failure awaiting left ventricular assist device (LVAD) implantation. The resolution of functional MR in LVAD patients has been detected for different LVAD types and across all grades of MR severity. However, it should be proven if the health-related quality of life (HRQoL) after LVAD implantation is comparable in patients with different preoperative MR grades. <h3>Methods</h3> We performed a single-center HRQoL analysis including 34 patients with HeartMate 3 (HM3) implantation using the SF12 Health Survey and the Hospital Anxiety and Depression Score (HADS) at least 1 year after LVAD implantation. The study groups were classified according to echocardiographically defined grade of MR. The group without severe MR (none, mild or moderate MR) comprised 24 patients; the group with severe MR comprised 10 patients. Clinical characteristics including the six-minute walk test (6MWT) were documented. <h3>Results</h3> Age, gender, history of prior heart valve surgery as well as the rate of heart transplantation, ECMO and RVAD implantation, right heart failure, ventricular arrhythmias, stroke, suction events, LVAD thrombosis, and bleeding events were comparable between LVAD patients with severe and not severe MR (p < 0.05). The 6MWT was comparable in the postoperative period (p = 0.13) and one year after LVAD implantation (p = 0.57). No significant differences were apparent in the SF-12-determined physical health (severe MR: 36.6 ± 8.4; not severe MR: 40.1 ± 9.3; p = 0.32) and mental health (severe MR: 49.5 ± 9.7; not severe MR: 54.3 ± 10.5; p = 0.22) as well as in the HADS-determined anxiety (severe MR: 5.6 ± 3.6; not severe MR: 4.9 ± 3.3; p = 0.58) and depression grade (severe MR: 6.3 ± 3.7; not severe MR: 4.6 ± 4.1; p = 0.28). <h3>Conclusion</h3> Physical and mental health as well as anxiety and the depression grade that were measured with standardized questionnaires are comparable in LVAD patients with preoperative severe and not severe MR. The results of this HRQoL pilot study support the recommendation of the International Society for Heart and Lung Transplantation for a HM3 implantation without concomitant MV repair and replacement.

Validation of mitral regurgitation reversibility in patients with HeartMate 3 LVAD implantation.

The resolution of functional mitral valve regurgitation (MR) in patients awaiting left ventricular assist device (LVAD) implantation is discussed controversially. The present study analyzed MR and echocardiographic parameters of the third-generation LVAD HeartMate 3 (HM3) over 3years. Of 135 LVAD patients (with severe MR, n=33; with none, mild, or moderate MR, n=102), data of transthoracic echocardiography were included preoperatively to LVAD implantation, up to 1month postoperatively, and at 1, 2, and 3years after LVAD implantation. Demographic data and clinical characteristics were collected. Severe MR was reduced immediately after LVAD implantation in all patients. The echocardiographic parameters left ventricular end-diastolic diameter (P<.001), right ventricular end-diastolic diameter (P<.001), tricuspid annular plane systolic excursion (P<.001), and estimated pulmonary artery pressure (P<.001) decreased after HM3 implantation independently from the grade of MR prior to implantation and remained low during the 2years follow-up period. Following LVAD implantation, right heart failure, ventricular arrhythmias, ischemic stroke as well as pump thrombosis and bleeding events were comparable between the groups. The incidences of death and cardiac death did not differ between the patient groups. Furthermore, the Kaplan-Meier analysis showed that survival was comparable between the groups (P=.073). HM3 implantation decreases preoperative severe MR immediately after LVAD implantation. This effect is long-lasting in most patients and reinforces the LVAD implantation without MR surgery. The complication rates and survival were comparable between patients with and without severe MR.

Factors associated with mortality or transplantation versus Fontan completion after cavopulmonary shunt for patients with tricuspid atresia

ObjectiveTricuspid atresia with normally related great vessels (TA) is considered the optimal substrate for the Fontan pathway. The factors associated with death or transplantation after cavopulmonary shunt (CPS) are underappreciated. We aimed to determine factors associated with CPS–Fontan interstage death/transplantation versus transition to Fontan in TA. MethodsA total of 417 infants younger than 3 months of age with TA were enrolled (January 1999 to February 2020) from 40 institutions into the Congenital Heart Surgeons' Society TA cohort. Parametric competing risk methodology was used to determine factors associated with the competing end points of death/transplantation without Fontan completion, and transition to Fontan. ResultsCPS was performed in 382 patients with TA; of those, 5% died or underwent transplantation without transition to Fontan and 91% transitioned to Fontan by 5 years after CPS. Prenatal diagnosis (hazard ratio [HR], 0.74; P < .001) and pulmonary artery band (PAB) at CPS (HR, 0.50; P < .001) were negatively associated with Fontan completion. Preoperative moderate or greater mitral valve regurgitation (HR, 3.0; P < .001), concomitant mitral valve repair (HR, 11.0; P < .001), PAB at CPS (HR, 3.0; P < .001), postoperative superior vena cava interventions (HR, 9.0; P < .001), and CPS takedown (HR, 40.0; P < .001) were associated with death/transplantation. ConclusionsThe mortality rate after CPS in patients with TA is notable. Those with preoperative mitral valve regurgitation remain a high-risk group. PAB at the time of CPS being associated with both increased risk of death and decreased Fontan completion may represent a deleterious effect of antegrade pulmonary blood flow in the CPS circulation.

Left ventricular remodeling after mini-mitral repair-does the complexity of mitral disease matter?

Degenerative mitral valve (MV) regurgitation (MR) is associated with left ventricular (LV) dilatation. Surgical treatment of MR has been shown to favorably affect LV remodeling. We prospectively compared the long-term echocardiographic outcomes of LV remodeling following mini-mitral repair for simple versus complex MV disease. We prospectively followed up 203 consecutive patients who underwent mini-MV repair for severe degenerative MR over a 9-year period. Simple disease (n = 122 patients: posterior leaflet prolapse) was compared to complex disease (n = 81 patients: anterior, bilateral or commissural prolapse). Baseline demographics were similar between simple and complex groups (age: 63 ± 13 years vs 60 ± 15 years; p = .2; sex: 71% male vs 72% male, p = 1; preoperative MR grade ≥ 3+: 100%; n = 122; vs 100%; n = 81; p = 1), respectively. Preoperative left ventricular ejection fraction (LVEF) was significantly lower in the complex group as compared to the simple group (57.2% simple vs 56.0% complex; p = .04). Preoperative LV end-systolic diameter (LVESD: 35 mm simple vs 36 mm complex, p < .05) and LV end-diastolic diameter (LVEDD: 50 mm simple vs 51 mm complex; p < .05), as well as LV mass index (99.5 g/m2 vs 102.4 g/m2 ; p = .06) were larger in the complex group. Despite different baseline characteristics of LV function and geometry, both groups had similar remodeling of LV after MV repair. Patients with complex MV disease are referred late for surgical repair, causing LV function and dimensions to never fully recover. This suggests that earlier referral (before LV changes and potentially before symptoms) may be the preferred approach in those with complex disease.

Reversibility of severe mitral valve regurgitation after left ventricular assist device implantation: single-centre observations from a real-life population of patients.

This study evaluates the impact of untreated preoperative severe mitral valve regurgitation (MR) on outcomes after left ventricular assist device (LVAD) implantation. Of the 234 patients who received LVAD therapy in our centre during a 6-year period, we selected those who had echocardiographic images of good quality and excluded those who underwent mitral valve replacement prior to or mitral valve repair during LVAD placement. The 128 patients selected were divided into 2 groups: Group A with severe MR (n = 65) and Group B with none to moderate MR (n = 63, 28 with moderate MR). We evaluated transthoracic echocardiography preoperatively [15 (7-28) days before LVAD implantation; median (interquartile range)] and postoperatively up to the last available follow-up [501 (283-848) days after LVAD]. We collected mortality, complications and clinical status indicators of the patient cohort. We observed a significant decrease in the severity of MR after LVAD implantation (severe MR 51% pre- vs 6% post-LVAD implantation, P < 0.001). There was no difference between groups in terms of right heart failure, rate of urgent heart transplantation, pump thrombosis or ventricular arrhythmias. There was no difference in 1-year survival and 3-year survival (87.7% vs 88.4% and 71.8% vs 66.6% for Groups A and B, respectively, P = 0.97). Preoperative severe MR resolves in the majority of patients early on after LVAD implantation and is not associated with worse clinical outcomes or intermediate-term survival.

Invited Commentary

As our collective experience with mechanical circulatory support as a treatment for advanced heart failure grows, we have an improved understanding of the physiologic impact of continuous-flow left ventricular assist device (LVAD) therapy. Dr Goodwin and colleagues [1Goodwin M. Nemeh H.W. Borgi J. Paone G. Morgan J.A. Resolution of mitral regurgitation with left ventricular assist device support.Ann Thorac Surg. 2017; 104: 811-819Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar] report on their evaluation of the impact of preoperative mitral regurgitation on postoperative outcomes after LVAD implantation. Unsurprisingly, they find that preoperative mitral regurgitation, regardless of severity, does not affect postoperative patient outcomes. Furthermore, LVAD implantation results in reverse remodeling of the left ventricle and durable improvement in mitral regurgitation. These findings confirm those of Dr Stulak and colleagues [2Stulak J.M. Tchantchaleishvili V. Haglund N.A. et al.Uncorrected pre-operative mitral valve regurgitation is not associated with adverse outcomes after continuous-flow left ventricular assist device implantation.J Heart Lung Transplant. 2015; 34: 718-723Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar], who previously reported that uncorrected mitral regurgitation had no impact on post-LVAD outcomes. Whereas the majority of patients undergoing LVAD implantation have secondary mitral regurgitation, the cause of mitral valve dysfunction becomes irrelevant once ventricular function has deteriorated to the point of requiring mechanical circulatory support. LVAD therapy directly unloads the left ventricle and actively reduces left-ventricular end diastolic pressure (LVEDP) [3Soucy K.G. Bartoli C.R. Phillips D. et al.Continuous-flow left ventricular assist device support improves myocardial supply:demand in chronic heart failure.Ann Biomed Eng. 2017; 45: 1475-1486Crossref PubMed Scopus (9) Google Scholar]. The improvement in heart failure symptoms, respiratory symptoms in particular, is in large part due to this reduction in LVEDP and improvement in mitral regurgitation. This physiologic finding should not be construed as an indication for mitral valve procedures in the context of durable LVAD implantation. The care of patients with advanced heart failure requiring LVAD therapy is complex and fraught with risks. Advocating additional procedures for marginal gain in hemodynamic parameters may not yield significant improvements in patient outcomes. We may be best served to remember Antoine de Saint-Exupery’s maxim: “Perfection is achieved, not when there is nothing more to add, but when there is nothing more to take away.” Resolution of Mitral Regurgitation With Left Ventricular Assist Device SupportThe Annals of Thoracic SurgeryVol. 104Issue 3PreviewCardiac valve disease is common in patients with end-stage heart failure undergoing left ventricular assist device implantation (LVAD). The aim of this study was to determine if preoperative mitral regurgitation (MR) affects outcomes and hemodynamics in patients after LVAD implantation. Full-Text PDF

Successful fast track protocol implementation for patients undergoing transapical transcatheter aortic valve implantation.

BackgroundThe aim of the current study is to report our experience with fast-track treatment of patients undergoing transapical transcatheter aortic valve implantation (TA-TAVI) and to determine perioperative predictors for fast-track protocol failure.MethodsBeing one of the pioneering centers to start performing TA-TAVI back in 2005, we routinely included patients undergoing this procedure into our fast-track management program since 2008. Between January 2008 and June 2013, 207 consecutive high-risk patients (mean age 79 ± 7 years, mean Log. EuroSCORE 24 ± 10) who underwent TA-TAVI accordingly to our institutional fast-track approach were prospectively collected and analyzed. Uni- and multivariate analysis were performed to identify independent pre- and perioperative predictors of fast-track protocol failure, defined as inability to discharge the patient from the intensive care unit (ICU) on the day of surgery or as readmission to the ICU 48 h after the initial discharge.ResultsFast-track management was successful in 83 % of the patients. 30-day mortality was 8 %. Fast-track protocol failure (17 %) was associated with an outcome worsening compared to the remaining patients (mortality: 40 % vs. 2 % and mean hospital stay: 19 ± 12 vs. 10 ± 9 days; P = .002). Independent predictors of fast-track protocol failure were age ≥85 years (OR 3.1; CI 95 % 1.89–6.21), ejection fraction (EF) ≤30 % (OR 2.6; CI 95 % 1.99–7.52), moderate to severe preoperative mitral valve regurgitation (OR 2.7; CI 95 % 1.27–6.43) and fluoroscopy time ≥12 min (OR 2.9; CI 95 % 1.28–7.46).ConclusionsFast-track patient management following TA-TAVI is safe and reproducible in the majority of patients. Besides patient-related preoperative risk factors (age ≥85 years, EF ≤30 % and moderate to severe preoperative mitral valve regurgitation) a technically challenging intraoperative course as evidenced in a prolonged fluoroscopy time are independent predictors of fast-track protocol failure which is associated with high loss of patient outcome.

Uncorrected pre-operative mitral valve regurgitation is not associated with adverse outcomes after continuous-flow left ventricular assist device implantation

Mitral valve regurgitation (MR) is prevalent in patients with heart failure. Because very few data exist examining the influence of significant pre-operative MR on outcomes after left ventricular assist device (LVAD) implantation, we evaluate our experience. Between October 1996 and August 2013, 756 patients underwent primary LVAD implantation at our institutions. Of these, 508 patients received a continuous-flow LVAD and represent the contemporary cohort for this analysis. Devices implanted included the HeartMate II in 410 patients (81%) and HeartWare HVAD in 98 patients (19%). Based on availability of pre-operative echocardiography, 491 patients were divided into 2 study groups according to degree of pre-operative MR; 189 patients (39%) had moderate to severe or greater MR (MR group), and 302 (61%) had less than moderate to severe MR (less MR group). Median age at operation (60 years in MR group vs 58 years in less MR group, p = 0.19), male sex (78% in MR group vs 81% in less MR group, p = 0.42), and ischemic etiology (46% in MR group vs 51% in less MR group, p = 0.35) were similar between groups. There were 40 early deaths (7.9%), and follow-up was available in all 468 early survivors for 641 patient-years of support. Patients in the MR group had higher late survival (2 years, 75%; 4 years, 65%) compared with patients in the less MR group (2 years, 66%; 4 years, 48%; p < 0.04). Cox proportional hazards model confirmed the independent interaction between MR and late survival (hazard ratio 0.62, p = 0.04). There was improved survival in patients with severe pre-operative MR after continuous-flow LVAD implantation in our cohort. These findings may lend insight into the possible lack of value of addressing significant MR at the time of LVAD implantation.

Long-Term Durability of Bicuspid Aortic Valve Repair

Bicuspid aortic valve (BAV) is the most common congenital cardiac malformation, occurring in 1% to 2% of the population. Eventually, 20% develop clinically important valvar regurgitation requiring surgical intervention. Aortic valve repair avoids anticoagulation and prosthetic valve-related complications. This study evaluated long-term durability of BAV repair. From 1985 to 2011, 728 patients, mean age 42±12 years, underwent BAV repair at Cleveland Clinic. Mean follow-up was 9.0±6.2 years (median, 8.3). Factors associated with repair durability (expressed as aortic valve reoperations and echocardiographically estimated gradients and regurgitation) and survival were identified. Hospital mortality was 0.41% (n=3), and stroke occurred in 0.27% (n=2). Freedom from aortic valve reoperation at 10 years was 78%. Risk of reoperation was highest immediately after operation and fell rapidly to approximately 2.6%/year up to 15 years. Primary reasons for reoperation were cusp prolapse (38%), aortic stenosis or regurgitation (17%), and aortic regurgitation from root aneurysm (15%). Aortic valve gradients showed an early initial peak, rapidly declined, then rose steadily, accompanied by an increase in left ventricular mass. Survival was 94% at 10 years. A risk factor for early death was greater preoperative mitral valve regurgitation, and for late death, older age at operation, more severe symptoms, and poorer left ventricular function. BAV repair is safe and durable with low mortality, low prevalence of reoperation, and good long-term survival. Cusp prolapse from technical errors and natural progression of disease are the most common causes for reoperation, but progressive natural increase in valve gradient accounts for a substantial proportion as well.

Impact of preoperative mitral valve regurgitation on outcomes after transcatheter aortic valve implantation

The aim of this single-centre prospective study was to assess the impact of preoperative mitral valve regurgitation (MR) on outcomes of patients undergoing transcatheter aortic valve implantation (TAVI). From June 2007 to January 2011, 176 consecutive patients underwent TAVI at our institution. Patients were divided into two groups according to the degree of MR: <2+, the NoMR group (133 patients); ≥2+, the MR group (43 patients). Clinical and echocardiographic examination were performed before the procedure, at discharge, 1, 3, 6, 12 months after TAVI and yearly thereafter. The mean follow-up was 10.4 ± 7.7 months (range 1-36). MR patients had higher EuroSCORE (27 ± 16 vs. 20 ± 11%, P < 0.001), lower ejection fraction (49 ± 13 vs. 57 ± 12%, P = 0.001), higher systolic pulmonary pressure (50 ± 17 vs. 39 ± 10 mmHg, P < 0.001) and larger left ventricular volumes (end-diastolic volume index: 78 ± 29 vs. 66 ± 20 ml/m(2), P = 0.002) than NoMR. Hospital mortality was 9.3% (four patients) and 3% (four patients) in MR and NoMR groups, respectively (P = 0.10). The Kaplan-Meier survival at 20 months was 78 ± 8 and 75 ± 6% in MR and NoMR groups, respectively (P: n.s.). At follow-up, the degree of MR in the MR group decreased to trivial-mild in 28% of patients. Patients of both groups experienced a significant reduction in the New York Hear Association class, being in class I-II in 91% of cases. Patients undergoing TAVI with preoperative MR ≥ 2+ have a higher surgical risk profile and a trend towards higher hospital mortality. MR was not identified as a risk factor for mortality. At follow-up, a reduction in MR and an improvement of echocardiographic parameters were observed in the MR group.

Left Thoracotomy for Multiple-Time Redo Mitral Valve Surgery Using On-Pump Beating Heart Technique

There are limited reports describing multiple-time redo mitral valve surgery using a left thoracotomy approach and on-pump beating heart technique. A retrospective review of medical records for 16 patients from March 2002 to June 2007 was performed. Mean age was 54 +/- 17 (mean +/- SD) years (8 males). Preoperative mitral valve regurgitation was 3.6 +/- 0.6 in 14, and 2 had severe mitral valve stenosis. New York Heart Association symptom class was 2.9 +/- 1.0 and ejection fraction was 0.4 +/- 0.15 (range, 0.2 to 0.6). Previous cardiac operations were performed twice in 14 and three times in 2 patients with an interval of 4.8 +/- 5.5 years since the last. The procedures included repair (5), replacement (8), and re-replacement (3). All were performed through a fifth intercostal space, left posterolateral thoracotomy with the heart beating on cardiopulmonary bypass (32 to 37 degrees C). Left femoral artery or descending thoracic aorta inflow and left femoral vein or left main pulmonary artery venous drainage with vacuum assist were used. Operation time was 221 +/- 51 minutes and cardiopulmonary bypass time was 71 +/- 27 minutes. Postoperative ventilation time was 10.0 +/- 7.7 hours, intensive care unit stay was 2.9 +/- 1.9 days, and hospital stay was 6.2 +/- 2.4 days. There were two 30-day mortalities and two died late with a follow-up of 30 +/- 22 months. Left thoracotomy using the on-pump beating heart technique is safe, effective, and should be considered for multiple-time redo mitral valve surgery.

Does functional mitral regurgitation improve with isolated aortic valve replacement?

The surgical treatment of mitral valve regurgitation (MR) at the time of aortic valve replacement (AVR) remains controversial. The purpose of this study was to evaluate the change in severity of MR following isolated AVR, and to determine survival benefit. Between 1991 and 2001, 250 patients underwent isolated AVR; 196 patients had concomitant functional MR. Follow-up transthoracic echocardiography (TTE) was available on 107 patients, with a median of 818 +/- 752 days. Aortic valve was stenotic in 77 and regurgitant in 30 patients. Mean age was 67 +/- 15 years and 57 (53%) were male. Preoperative MR was trivial (1+) in 27 (25%), mild (2+) in 44 (41%), moderate (3+) in 29 (27%), and severe (4+) in 7 (7%). At follow-up TTE, MR improved by 1 or 2 grades in 48 patients (45%). Of patients with preoperative 2+ MR, 19 (43%) improved, 16 (36%) remained unchanged, and 9 (21%) worsened. Although some patients with preoperative 3+ MR exhibited improvement, 11 (38%) remained with moderate-to-severe MR. Of those with a preoperative MR of 4+, 3 (71%) improved, and 4 remained with 3-4+ MR. For patients with preoperative 1 to 2+ MR, survival at 3 years was 98% compared to 78% for those with 3 to 4+ MR (p = 0.038). Functional MR does not always improve after isolated AVR. Survival is lower for patients with preoperative 3 to 4+ MR. Moderate-to-severe MR should be repaired at the time of aortic valve surgery.