Recurrent Severe Mitral Regurgitation Research Articles

A RARE COMPLICATION OF MITRAL TEER PROCEDURE: CLIP LATE DETACHMENT AND EMBOLIZATION

Abstract Intraprocedural and late complications of MitraClip implantation have already been described. This report highlights the importance of conventional surgical options in the event of percutaneous treatment failure. An 85–year–old woman with a history of chronic anemia, and thalassemia Minor was referred to our clinic for severe mitral regurgitation (MR) due to a P2 flail with significant calcification of the posterior mitral annulus. During the Heart Team discussion, age and comorbidities led to consider the patient eligible for TEER with the MitraClip system (EuroSCORE II 9,34%; STS score 7,47%). TEER procedure was uneventful: one XTW was deployed at the level of the flail (A2–P2), a second XTW was then placed more lateral to treat a separate residual jet, and one NTW was finally placed between them. MR reduction was considered acceptable (moderate MR, mean grad 6 mmHg). After two months, symptoms worsened, and TTE showed severe MR (no device detachment) with increased sPAP and associated moderate TR. A couple of weeks later, the patient was hospitalized. Chest X–ray revealed clip embolization confirmed by coronary angiography that showed an XTW Clip embolized to the Right coronary sinus with partial occlusion of the ostium. Percutaneous clip retrieval is described in the literature, but the embolized device position and the presence of recurrent severe MR led us to prefer an urgent surgical intervention. Under CPB, the embolized XTW was easily retrieved through a small aortotomy; the intervention was completed by mitral valve replacement and tricuspid valve repair. The postoperative course was uneventful. Predischarge TTE showed normal mitral bioprosthesis function, mild AR, mild TR, and preserved LV function. DISCUSSION Clip embolization is a rare but potentially critical complication of TEER and can happen periprocedurally or on early follow–up. Single leaflet detachment is more common, but complete detachment and embolization can occur. Therapeutic options are represented by surgical or transcatheter approaches according to embolization sites and patient comorbidities. In our case, the risk of potential coronary obstruction or thrombosis and the concomitant need for MR treatment have led us to consider surgery as the first option. CONCLUSION TEER can be graved by acute or late complications. The best approach has to be tailored to each patient, and surgery can be an effective and safe option even for initially discarded high–risk patients.

Repeat Mitral Valve Interventions After Transcatheter Edge-to-Edge Repair: The COAPT Trial

The frequency and effectiveness of repeat mitral valve interventions (RMVI) after transcatheter edge-to-edge repair (TEER) for secondary mitral regurgitation (MR) are unknown. We aimed to examine the rate of and outcomes following RMVI after TEER in the COAPT trial.The COAPT tria randomized heart failure (HF) patients with severe secondary MR to TEER with the MitraClipTM device plus guideline-directed medical therapy (GDMT) versus GDMT alone. We evaluated the characteristics and outcomes of patients who had a RMVI during 4-year follow-up. A MitraClip implant was attempted in 293 patients randomized to TEER+GDMT, 10 of whom (underwent a RMVI procedure (9 repeat TEER and 1 surgical mitral valve replacement) after 4-years of follow-up (cumulative incidence 3.90%,95% CI 2.08-7.08; median 182 days after the initial procedure). Patients with RMVI had larger mitral annular diameters, fewer clips implanted and were more likely to have ≥3+ MR at discharge compared with those without RMVI. Reasons for RMVI included failed index procedure due to difficult transseptal puncture (n=2) or tamponade (n=1); residual or recurrent severe MR after an initially successful procedure (n=5); partial clip detachment (n=1); and site-assessed mitral stenosis (n=1). RMVI was successful in 8/10 (80%) patients. Patients who underwent RMVI had higher 4-year rates of HFH but similar mortality compared with those without RMVI. The annualized incidence rates of all HFH in patients who underwent RMVI were 234 events per 100 person years (95% CI 139-395) pre-RMVI and 46 per 100 person years (95% CI 25-86) post-RMVI as compared with 32 events per 100 patient years (95% CI 28-36) among patients not undergoing RMVI. The rate ratio of HFH was reduced after RMVI in patients undergoing RMVI (0.20, 95% CI 0.09-0.45).

Repair of Mitral Prolapse: Comparison of Thoracoscopic Minimally-invasive and Conventional Approaches.

Surgical repair remains the best treatment for severe primary mitral regurgitation. Minimally invasive mitral valve surgery is being increasingly performed, but there is a lack of solid evidence comparing thoracoscopic with conventional surgery. Our objective was to compare outcomes of both approaches for repair of leaflet prolapse. All consecutive patients undergoing surgery for severe mitral regurgitation due to mitral prolapse from 2012 to 2020 were evaluated according to the approach used. Freedom from mortality, reoperation and recurrent severe mitral regurgitation were evaluated by Kaplan-Meier method. Differences in baseline characteristics were adjusted with propensity score matched analysis (1:1, nearest neighbor). 300 patients met inclusion criteria and were divided into thoracoscopic (N = 188) and conventional (sternotomy; N = 112) groups. Unmatched patients in the thoracoscopic group were younger and had lower body mass index, New York Heart Association class and EuroSCORE-II preoperatively. After matching, thoracoscopic group presented significantly shorter mechanical ventilation (9 vs.15h), shorter intensive care unit stay (41 vs 65 h) and higher postoperative hemoglobin levels (11 vs.10.2 mg/dL) despite longer bypass and cross-clamp times (+30 and +17min). There were no differences in mortality or mitral regurgitation grade at discharge between groups nor differences in survival, repair failures and reinterventions during follow-up. Minimally invasive mitral repair can be performed in the majority of patients with mitral prolapse, without compromising outcomes, repair rate or durability, while providing shorter mechanical ventilation and intensive care unit stay and less blood loss.

Abstract 11703: A Rare Case of Redo MitraClip Failure Requiring Salvage Mitral Valve Replacement

Presentation: A 74-year-old lady with history of hypertension, COPD, severe pulmonary hypertension, HFpEF, redo MitraClip placement for severe mitral regurgitation (MR) secondary to mitral valve (MV) prolapse presented with four months of progressive dyspnea and bilateral lower extremity swelling. Vitals were significant for hypotension and tachycardia. Examination revealed a holosystolic murmur at the apex, crackles in bibasilar lung fields, and 3+ bilateral pitting pedal edema. Work-up: TTE revealed EF of 65%, enlarged right ventricle, flattened interventricular septum, multiple mitral clips attached to the MV leaflets, and an eccentric MR jet. TEE revealed severe left atrial dilation, severe MR with eccentric and posteriorly directed regurgitant jet and mal-coaptation of MV leaflets with three MitraClips attached (Figure 1-3). Management: For recurrent severe mitral regurgitation resulting in decompensated heart failure, options included another redo MitraClip procedure versus surgical MV replacement. After extensive discussion with the multidisciplinary team and the patient, a decision was made to proceed with surgical MV replacement accepting a high operative risk with STS risk score of >8%. Intraoperative findings revealed one inverted MitraClip with posterior leaflet detachment and two other clips that had densely scarred into the posterior leaflet leaving an unrecognizable MV (Figure 4). A 29 mm Epic Plus bioprosthetic MV was placed successfully. After a prolonged postoperative course, her clinical status improved. Conclusion: In patients who have failed the MitraClip procedure, significant destruction and fibrosis of the leaflets leaves surgical MV replacement being the only reasonable option. Surgical risk must be determined in conjunction with a multidisciplinary team as MV repair is performed at advanced centers in high-risk patients with good results. This can reduce the number of redo MitraClip and salvage MV surgery.

Robotic mitral valve repair-the Bruxelles experience.

Although the use of the surgical robot facilitates less invasive mitral valve surgery, both real and perceived limitations have slowed the application of this technology. Aim of the present investigation was to report the early and long-term results of robotic mitral valve repair in a single institution over a 10-year period. Between March 2012 and May 2022, a total of 278 consecutive patients underwent robotically assisted mitral valve repair at the Cliniques Universitaires Saint-Luc (Brussels, Belgium). Indications have evolved over time allowing the treatment of complex mitral valve lesions. Clinical and echocardiographic follow-up were 97.8% and 86.1% complete, respectively. Mean age of the study population was 57.8±11.9 years and 221/278 (79.5%) patients were male. Despite being asymptomatic or mildly symptomatic [New York Heart Association (NYHA) class I-II], most of the patients presented with severe mitral regurgitation (MR). Degenerative mitral valve disease was the most common cause of MR. All patients underwent successful mitral valve repair using different techniques, and 25/278 (9.0%) had one or more concomitant procedures associated. The mean cardio-pulmonary bypass and aortic cross clamp times were 153±37 and 106±25 minutes, respectively. There was no operative or in-hospital mortality. Overall survival rate was 97.8%±3.2%, 95.8%±3.2% and 93.7%±3.0% at 3, 7 and 10 years. One early (0.4%) reoperation with re-repair was recorded for ring disruption, while late mitral valve re-repair was necessary in 4/279 (1.4%) patients for recurrent severe MR in three of them and mitral endocarditis in one. The overall freedom from mitral valve reoperation was 98.1%±1.0% at 3, 7 and 10 years. Overall freedom from MR (grade 2+ or more) was 91.7%±3.2%, 77.8%±4.8% and 67.1%±9.2% at 3, 7 and 10 years, respectively. Robotic mitral valve repair is safe and is associated with excellent clinical and echocardiographic results. The use of robotic technologies allows, after an appropriate learning curve, to reproduce all conventional techniques to treat MR, regardless of the complexity of the valve lesion.

Mitral Valve Surgery for Persistent or Recurrent Mitral Regurgitation After Transcatheter Edge-to-Edge Repair Is Associated With Improved Survival.

Background The management of severe mitral regurgitation (MR) after transcatheter edge-to-edge repair (TEER) remains a clinical conundrum. Considering the growing volume of TEER, more outcomes data for mitral surgery in this cohort are needed. Methods and Results Symptomatic patients with persistent or recurrent severe MR after TEER evaluated between May 2014 and June 2021 were included. The primary outcome was all-cause mortality in patients who were treated with surgery versus medical therapy. The Kaplan-Meier and Cox regression methods were used to report risk-adjusted survival analyses. Among the 142 included patients, 44 (31.0%) underwent mitral surgery. Patients who underwent surgery were younger than those treated medically (74.1±8.9 versus 78.6±10.5 years, P=0.01). Major comorbidities were similar except obesity, sleep apnea, left ventricular dimensions, and ejection fraction. Society of Thoracic Surgeons Predicted Risk of Operative Mortality was 9.0±4.7 versus 7.9±4.9 in the surgical versus medical therapy groups, respectively, P=0.22. Time from TEER to detection of severe MR was similar in both groups (median [interquartile range] 97.5 [39.5-384] versus 93.5 [40-389] days in the surgical versus medical groups, respectively [P>0.05]). In the surgical group, valve replacement was performed in all patients. Operative mortality was 4.5% (observed/expected ratio 0.55), and major complications were uncommon. After risk-adjustment, surgery was associated with significantly lower all-cause mortality (adjusted hazard ratio, 0.33 [95% CI, 0.12-0.92], P=0.001) compared with medial therapy. Conclusions Compared with medical therapy, mitral surgery in patients with severe persistent or recurrent MR after TEER is associated with lower mortality despite the high-risk profile of these patients. Patients with severe MR after TEER should be considered for surgery at a referral mitral surgical center.

Early Clinical Outcomes of Thoracoscopic Mitral Valvuloplasty: The First 90 Cases.

We reported 90 cases of thoracoscopic mitral valvuloplasty in its early stages and sought to analyze early clinical outcomes. Ninety consecutive patients, who underwent thoracoscopic mitral valvuloplasty at our institute between April 2020 and December 2021, were assessed for outcomes. Clinical data, including baseline characteristics, operative data, postoperative data, and early follow-up results, were collected. The early clinical outcomes were used to assess the reliability and efficiency of this technique. No in-hospital death occurred. One patient underwent a median sternotomy for bleeding. Intraoperative transesophageal echocardiography revealed no mitral regurgitation in 82 patients and mitral regurgitation of 0-2 cm2 in six. The remaining two patients with mitral regurgitation >2 cm2 experienced serious systolic anterior motion but underwent successful re-valvuloplasty during a second pump-up. the mean cardiopulmonary bypass time was 177.1±54.8 min and aortic clamping time, 114.0±44.9 min. Each patient received a prosthetic ring (CG Future™), and 64 patients received artificial chordae with an average of 2.7±1.5 (ranging from 1 to 6) pairs. The mean follow up was 8.8±7.0 (range, 1-22 months), while two patients were lost to follow up. Recurrent severe mitral regurgitation was observed in one patient three months after the operation, and mitral valve replacement was performed via median sternotomy. During follow up, one patient died of upper respiratory tract infection, and one suffered from low cardiac output. Thoracoscopic mitral valvuloplasty is safe and effective and, once surgeons overcome the learning curve, can achieve excellent early clinical outcomes.

“The Road Not Taken": Successful Use of CardioMEMS to Optimize a Patient in Stage D Heart Failure

Introduction Pulmonary artery (PA) pressure monitoring via the CardioMEMS HF System is currently indicated for those with New York Heart Association (NYHA) Class III heart failure. However, the use of CardioMEMS in those with NYHA Class IV heart failure is less understood. Case Report 44-year old African American male with history of NYHA Class IIIb-IV, Stage D heart failure with reduced ejection fraction secondary to left ventricular noncompaction with recurrent severe mitral regurgitation (MR) despite successful transcatheter mitral-leaflet approximation with the MitraClip device, persistent atrial fibrillation status-post atrioventricular node ablation and cardiac resynchronization therapy (CRT) upgrade presented with frequent hospitalizations for acute decompensated heart failure (HF). He continued to have severe biventricular failure with left ventricular systolic function of 20% and left ventricular internal diameter in diastole of 8.1 cm. Despite medical optimization, MitraClip placement and CRT device implantation, the patient continued to have recurrent HF exacerbations with a total of six hospital admissions, two of which required prolonged intensive care unit stay for cardiogenic shock. He was not considered a candidate for left ventricular assist device due to chronic right sided heart failure. With history of active marijuana use, evaluation for cardiac transplantation was not an immediate option at our center and was deferred. The decision was made to place a CardioMEMS device to aid with assessment of volume status and to help prevent further hospitalizations. After placement of his CardioMEMs device, the patient had pulmonary artery diastolic pressure (PADP) readings ranging from 23-31 mmHg. Six months post implant, with frequent adjustments to his medical regimen, the patient has had no further emergency room visits or hospitalizations. His PADP improved to the range of 18-20 mmHg and he is currently undergoing evaluation for heart transplantation. Summary There is adequate data available that suggest CardioMEMS device reduces hospitalizations in those with NYHA Class III heart failure. Our case suggests that CardioMEMS may be safe and appropriate to aid in management of patients with more severe NYHA Class IIIb/IV heart failure. Future studies are necessary to determine the safety and utility of using CardioMEMS in this population.

Impact of sex on outcomes after percutaneous repair of functional mitral valve regurgitation.

The role of percutaneous repair of functional mitral regurgitation (MR) is evolving. Left ventricle remodeling is known to be different between men and women; however, outcomes following percutaneous repair of functional MR have not considered the impact of sex. Between 2012 and 2018, 175 patients underwent percutaneous repair of functional MR with the Mitra Clip NT/NTR (Abbott) at our institution. Patients were assessed in a dedicated clinic with a follow-up that averaged 0.7 ± 1.2 years and extended to 5.7 years. Men had a larger body surface area than women (p < .001), and were more likely than women to have diabetes preoperatively (p = .02). There were no deaths or instances of single leaflet detachment. Immediate postprocedure MR was ≤2+ in 158 (90%) with a mean trans-mitral valve repair gradient of 3.4 ± 1.0 and 3.5 ± 2.1 mmHg, respectively for women and men (p = .8). One- and 2-year freedom from MR ≥3+ was 86.0 ± 3.5% and 77.6 ± 5.1%, respectively. After adjusting for differences between male and female patients, women were more likely to have recurrent MR ≥3+ (hazard ratio, 4.7; 95% confidence interval, 1.2-18.4; p = .03). Upon adjusted analysis, there was also no association between gender and survival (p = .2). One- and 2-year survival was 69.8 ± 4.3% and 54.3 ± 5.5%, respectively. Women are more likely to have recurrent severe MR after percutaneous repair of functional MR. The mechanism for this remains undetermined.

Quadrangular resection versus chordal replacement for degenerative posterior mitral leaflet prolapse.

BackgroundThe aims of the present study was to compare midterm results of quadrangular leaflet resection versus chordal replacement for the repair of degenerative posterior mitral leaflet (PML) prolapse, and to explore the risk factors for recurrent severe mitral regurgitation (MR).MethodsFrom January 2012 to December 2018, 1,423 consecutive patients underwent mitral valve (MV) repair. A total of 317 had degenerative PML prolapse and constituted the study population. Of these, 74 (23.3%) underwent quadrangular leaflet resection, and 243 (76.7%) underwent chordal replacement. Outcomes were compared by using unadjusted data and propensity score-matched analyses.ResultsPatients with multiple leaflet prolapse were more likely to undergo chordal replacement (18.4% vs. 41.9%, P<0.001), and performed as a minimally invasive approach (47.3% vs. 61.7%, P=0.027). Of the entire cohort, 1 death (0.3%) occurred due to intraoperative aortic dissection, and 1 patient who had undergone chordal replacement required reoperation before discharge for posterior leaflet tearing. There was no significant difference in the probability of freedom from recurrent severe MR at 82 months between the resection and neochordae groups in both the pre-matched (95.6% vs. 88.8%, P=0.105) and matched (95.2% vs. 88.5%, P=0.170) cohorts, which was consistent across all of the examined subgroups (P>0.05). Multivariate Cox regression indicated that dilated left ventricular end-systolic diameter (LVESD) was an independent risk factor for recurrent severe MR [<40 vs. >40 mm, hazards ratio (HR): 3.17, 95% confidence interval (CI): 1.20–8.39, P=0.020]; however, surgical technique was not (resection vs. neochordae, HR: 0.31, 95% CI: 0.07–1.37, P=0.122).ConclusionsChordal replacement for the repair of degenerative posterior MV prolapse yields similar satisfactory outcomes when compared with quadrangular resection, and is promising in minimally invasive cardiac surgery for various lesions. However, it is also associated with more recurrent severe MR, albeit non-significant, for which patients with dilated LVESD are at high risk.

A Case in Which Mitral Valve Replacement Was Performed for Recurrent Severe Mitral Regurgitation by Single Leaflet Device Attachment (SLDA) after MitraClip

A Case in Which Mitral Valve Replacement Was Performed for Recurrent Severe Mitral Regurgitation by Single Leaflet Device Attachment (SLDA) after MitraClip

Very long-term outcomes of twisted auto-pericardial mitral annuloplasty.

During mitral annuloplasty, we twisted the harvested auto-pericardium to enable adequate ring sizing and implanted it to prevent ring-related complications. Indication for twisted auto-pericardial band (APB) was limited to patients with less than severe annular dilation to ensure high reproducibility and durability. The aim of this study was to investigate the long-term outcomes of twisted APB annuloplasty. From 1999 to 2009, 107 patients (62 ± 12years, degenerative 92 and infective endocarditis 15) with isolated posterior mitral leaflet (PML) prolapse with inter-commissural distance of 32mm or smaller underwent twisted APB annuloplasty. Of these, 104 patients without early leaflet repair failure were studied. Leaflet repairs were predominantly performed by quadrangular resection. Median APB size was 28mm. Follow-up rate was 98.1% and duration was 10.9 ± 4.8years. There were two early and 34 late deaths. Survival and freedom from cardiac-related death at 15years were 61.7% ± 5.6% and 83.8% ± 4.7%, respectively. Age and male sex were independent predictors of mortality. There were four late reoperations for recurrent severe mitral regurgitation (MR), three of which were due to new chordal rupture. Freedom from reoperation and freedom from moderate or severe MR at 15years were 93.1% ± 3.5% and 81.3% ± 6.2%, respectively. No patients developed hemolysis, ring dehiscence, or infective endocarditis. The long-term outcomes of twisted APB for isolated PML prolapse without severe annular dilation are satisfactory. Twisted APB annuloplasty may be a preferable option to reduce ring-related complications with sufficient durability.

Durability of mitral valve repair: A single center experience.

This study aims to present clinical outcomes of mitral valve repair in patients with different etiologies. Between June 2006 and August 2017, a total of 421 consecutive patients (266 males, 155 females; mean age 53.1±15.6 years; range, 5 to 89 years) who underwent mitral valve repair with or without concomitant cardiac procedures were retrospectively analyzed. All pre-, intra-, and postoperative data were collected. Echocardiographic examinations were performed at discharge and during follow-up. Kaplan-Meier analysis was used to estimate overall survival and from residual severe mitral regurgitation, endocarditis and reoperation-free survival rates. The mean follow-up was 58.9±35.1 months. Of the patients, 12 (2.8%) had previous cardiac operations. The most predominant pathology was degenerative disease in 265 patients (62.9%). Repair techniques included ring annuloplasty (n=366, 86.9%), artificial chordae implantation (n=185, 44%), and commissurotomy (n=38, 9%). Overall in-hospital mortality rate was 1.2% (n=5). Echocardiography before discharge showed no/trivial mitral regurgitation in 64.9% (n=270) and mild mitral regurgitation in 34.85% (n=145) of the patients. At the late postoperative period, transthoracic echocardiography revealed moderate mitral regurgitation in 23 patients (5.7%) and severe in 11 patients (2.7%). The mean late survival and freedom from endocarditis, reoperation, and recurrent severe mitral regurgitation rates were 92±0.03%, 98.5±0.07%, 98.1±0.01%, and 94.7±0.02%, respectively. Our study results suggest that mitral valve repair is a safe and effective procedure associated with favorable longterm outcomes in experienced centers.

Long-term Performance of Fresh Autologous Pericardium for Mitral Valve Leaflet Repair

Glutaraldehyde-fixed autologous or bovine pericardial patches used for mitral valve leaflet reconstruction have been associated with late calcification. Fresh autologous pericardium (FAP) may be a durable alternative. Transthoracic echocardiography was used to assess valve function (regurgitation, mean pressure gradient, patch pliability, and calcification) in patients undergoing FAP mitral leaflet repairs. Pliability was scored between 1 (similar to native leaflets) and 4 (rigid). Calcification was scored between 1 (echobrightness similar to native leaflets) and 4 (very bright). Between 2002 and 2018, 62 consecutive patients (50% male, 51 ± 2 years, 69% infective endocarditis) underwent mitral valve repair with FAP, and Patch placement was on the anterior (31 of 62), posterior (27 of 62), or both (1 of 62) leaflets. Late echocardiographic follow-up was available for 43 of 62 patients (median follow-up, 3.6 years; range, 0.5-6 years). Average pliability scores were unchanged between discharge (1.2 ± 0.1) and follow-up (1.2 ± 0.2, P= .79). Average brightness scores increased modestly (predischarge, 1.6 ± 0.1; follow-up, 1.8 ± 0.1; P= .01). Three patients had recurrent severe mitral regurgitation, and 2 underwent reoperation, 1 at 1 year postoperatively for recurrent endocarditis and 1 at 6 years postoperatively for degenerative disease progression. At reoperation, patches were pliable, free from calcification, and comparable in thickness to adjacent native leaflet. One patient developed suture line leak, which was repaired. No other evidence of patch dehiscence, retraction, or aneurysm was observed. The 10-year freedom from reoperation of 82% and survival rate of 84% are comparable to repair with glutaraldehyde-fixed or bovine pericardial patches. FAP is an excellent substrate for complex mitral valve leaflet patch repairs and can be used with the expectation of durable, long-term valve function, without evidence of late patch calcification, stiffness, or aneurysmal degeneration.

Durability at 19 Years of Quadrangular Resection With Annular Plication for Mitral Regurgitation

We report the long-term (19 years) clinical and echocardiographic results of the quadrangular resection with annular plication and annuloplasty. Included were 145 consecutive patients (mean age, 58 ± 11.1 years; left ventricular ejection fraction, 0.59 ± 0.095) with severe degenerative mitral regurgitation due to posterior leaflet prolapse/flail who underwent quadrangular resection of the posterior leaflet combined with ring (127 patients [87.5%]) or pericardium (18 patients [12.5%]) annuloplasty. No hospital deaths occurred. At hospital discharge, all patients but 1 had none or trivial mitral regurgitation. Follow-up was 97% complete (median, 19 years; interquartile range, 18 to 20 years). At 20 years, the overall survival was 74% ± 3.7%. At 19 years, cumulative incidence function of cardiac death with noncardiac death as a competing risk was 9.9% ± 2.5% (95% confidence interval [CI], 5.7% to 15.5%). Age was the only significant predictor of cardiac death (hazard ratio, 1.1; 95% CI, 1.0 to 1.1; p= 0.01) at multivariate analysis. Only 6 patients (4%) were reoperated on for recurrent severe mitral regurgitation. At 19 years, cumulative incidence function of reoperation and recurrence of mitral regurgitation 3+or higher with death as a competing risk was 4.3% ± 1.7% (95% CI, 1.7% to 8.8%) and 8.8% ± 2.8% (95% CI, 4.3% to 15.5%), respectively. Indeed, only 11 patients (8%) had recurrent mitral insufficiency 3+ or higher. No predictor of reoperation and recurrence of mitral regurgitation 3+ or higher was identified. At the last follow-up, moderate mitral regurgitation (2+/4+) was detected in 14patients (10%). Quadrangular resection with annular plication for posterior leaflet prolapse, combined with annuloplasty, is associated with a very low probability of reoperation and recurrent mitral regurgitation for up to 2decades after the operation. These results provide reference values to which all of the other more recently introduced surgical and transcatheter options need to becompared.

Transapical off-pump mitral valve repair with Neochord implantation: Early clinical results

BackgroundThis prospective study aims to assess early clinical outcomes in patients undergoing Transapical Off-Pump Mitral Valve Intervention with Neochord Implantation (TOP-MINI). Methods and resultsForty-nine patients with severe symptomatic degenerative mitral regurgitation (MR) were treated. Median age was 72years (IQR 58-78) and median Euroscore-I was 3.26% (IQR 0.88–8.15). Forty-four patients (89.8%) presented with posterior leaflet prolapse (LP), 4 (8.2%) with anterior LP and 1 (2%) with combined disease. Acute procedure success (defined as successful placement of at least 3 neochords with reduction of residual MR to less than 2+) was achieved in all patients. In-hospital mortality was 2%. At 30days major adverse events included one AMI (2%) successfully treated percutaneously and one sepsis (2%), no stroke or bleeding events occurred. At 3months overall survival was 98%. MR was absent in 16 patients (33.4%), was grade 1+ in 15 (31.2%), and was grade 2+ in 12 (25%). Five patients (10.4%) developed recurrent severe MR due to anterior native chordae rupture. Four of them were successfully re-operated. At 3months follow-up freedom from reoperation was 91.7±4%. ConclusionsEarly results with Neochord procedure indicate that TOP-MINI is feasible and safe. Efficacy is maintained up to 3months follow-up with significant clinical benefit for the patients.

Impact of real-time three-dimensional transesophageal echocardiography on procedural success for mitral valve repair.

For mitral valve repair, minimally invasive cardiac surgery as well as transcatheter valvular intervention have been developed. Under these conditions, three-dimensional transesophageal echocardiography (3D-TEE) plays a key role for planning the surgical treatment strategy. However, few data exist regarding the role of 3D-TEE in mitral valve repair. Therefore, we examined the impact of 3D-TEE on procedural success of mitral valve repair. We examined 86 consecutive patients who underwent mitral valve repair for degenerative mitral valve prolapse. Among them, 39 patients were examined by only two-dimensional transesophageal echocardiography (2D-TEE) and 47 patients underwent 3D-TEE in addition to 2D-TEE. The cardiac surgeons and physicians discussed the repair procedure preoperatively with the echocardiographic images. As a result, 18 patients of the 2D-TEE group and 37 patients of the 3D-TEE group underwent mitral valve repair by small thoracotomy including robotic approach. Simple repair was done in 21 with 2D-TEE and 21 with 3D-TEE and complex repair was done in 18 with 2D-TEE and 26 with 3D-TEE. Importantly, three patients with 2D-TEE before surgery had to undergo reoperation due to recurrent severe mitral regurgitation with dehiscence of the annuloplasty rings, although none with 3D-TEE did. These results demonstrate that 3D-TEE is helpful in assessing the morphology of mitral apparatus and complexity of mitral valve repair, particularly in minimally invasive cardiac surgery including robotic ones. We would suggest that sonographers, cardiologists, and cardiac surgeons should be familiar with 3D-TEE and work together throughout the perioperative period for better outcomes.

Late Outcomes of Mitral Valve Repair for Mitral Regurgitation Due to Degenerative Disease

The pathological spectrum of degenerative diseases of the mitral valve (MV) that causes mitral regurgitation (MR) is broad, and there is limited information on late outcomes of MV repair in various subgroups of patients and pathologies. This study examines this issue. All 840 patients who had MV repair for MR due to degenerative diseases from 1985 to 2004 were prospectively followed with clinical and echocardiographic evaluations at biennial intervals up to 26 years, median of 10.4 years. Clinical, hemodynamic, and pathological variables were evaluated for their association with outcomes. Age, left ventricular ejection fraction, and functional class were predictors of late cardiac- and valve-related deaths by multivariable analysis. MV repair failed to restore life span to normal in patients with functional class IV. Thirty-eight patients had repeat MV surgery, and the probability of reoperation at 20 years was 5.9%. During the follow-up, recurrent severe MR developed in 37 patients, and moderate MR developed in 61. Age, isolated prolapse of the anterior leaflet, the degree of myxomatous changes in the MV, lack of mitral annuloplasty, and duration of cardiopulmonary bypass were associated with increased risk of recurrent MR. At 20 years, the freedom from recurrent severe MR was 90.7%, and the freedom from moderate or severe MR was 69.2%. MV repair for degenerative MR restored life span to normal except in patients with symptoms at rest and impaired left ventricular function. Advanced age and complex mitral valve pathologies increased the risk of late recurrent MR.

Chordal replacement with polytetrafluoroethylene sutures for mitral valve repair: A 25-year experience

The study objective was to examine the late results of mitral valve repair with chordal replacement with polytetrafluoroethylene sutures. From 1986 to 2004, 606 consecutive patients with degenerative mitral regurgitation had mitral valve repair with chordal replacement with polytetrafluoroethylene sutures. Patients' mean age was 57 years, and 73.6% were men. Isolated prolapse of the anterior leaflet was present in 17.6% of patients, isolated posterior leaflet prolapse was present in 29.5% of patients, and bileaflet prolapse was present in 52.9% of patients. Prolapse was corrected by creating 2 to 38 neochords of polytetrafluoroethylene sutures (mean, 13 ± 9 per patient). The mean follow-up was 10.1 years, and 96% of the patients had multiple echocardiographic studies over the years. There were 5 early and 106 late deaths. Age, diabetes, hypertension, chronic obstructive lung disease, New York Heart Association functional classes III and IV, and ejection fraction less than 40% were independent predictors of mortality. At 18 years, freedom from reoperation on the mitral valve was 90.2% ± 2.4%, freedom from recurrent severe mitral regurgitation was 91.0% ± 2.7%, and freedom from moderate or severe mitral regurgitation was 67.5% ± 4.2%. Cox regression analysis revealed that isolated prolapse of the anterior leaflet was predictive of reoperation, and that older age, hypertension, and left ventricular ejection fraction less than 40% were predictive of recurrent moderate or severe mitral regurgitation. Chordal replacement with polytetrafluoroethylene sutures expands the indication of repair to patients with prolapse of multiple segments. Valve function remains stable in most patients during the first 2 decades of follow-up.

Impact of MitraClip™ therapy on secondary mitral valve surgery in patients at high surgical risk

Conventional or minimally invasive surgical mitral valve repair (MVR) is the gold-standard treatment for severe mitral regurgitation (MR) of any etiology. Given its good safety profile, trans-catheter MVR with the MitraClip™ device is used increasingly for high-risk or inoperable patients. We report our experience with failed MitraClip™ therapy and its impact on subsequent surgical strategies, such as the feasibility of MVR in high-risk patients. During a follow-up of 344 ± 227 days from the first 215 consecutive patients treated with the MitraClip™ device, six patients required surgical re-intervention due to failed repair (n = 3) or recurrent severe MR (n = 3) at 35.8 ± 47.7 (range 0-117) days after trans-catheter MVR. Feasibility of secondary surgical MVR was assessed with regard to prior clip therapy. In three patients, secondary surgical MVR was successfully performed following the surgical strategy deemed optimal before trans-catheter treatment. Injury of the mitral leaflets caused by prior clip treatment was present in three other patients and influenced the surgical strategy toward more complex surgical techniques in one case and MV replacement in two others. One patient died 6 days after MV replacement. All other patients are alive with adequate valve function at the latest follow-up of 12.4 ± 7.4 months (range 4-22). Secondary surgical MVR was feasible in some patients after prior clip treatment, but led to valve replacement in others. At present, patient selection criteria for trans-catheter MVR should not be expanded toward more healthy patients, as primary trans-catheter MVR may complicate secondary surgery in certain cases and may even preclude reconstructive valve surgery.