Redo Mitral Surgery Research Articles

Robotic-assisted mitral valve surgery without aortic cross-clamping: a safe and feasible technique.

The primary objective of this study was to evaluate the safety and feasibility of robotic-assisted mitral valve surgery without aortic cross-clamping. From January 2010 to September 2022, 28 patients underwent robotic-assisted mitral valve surgery without aortic cross-clamping in our center using DaVinci Robotic Systems. Clinical data during the perioperative period and early outcomes of the patients were recorded. Most patients were in New York Heart Association (NYHA) class II and III. Mean age and EuroScore II of the patients were 71.5 ± 13.5 and 8.4 ± 3.7 respectively. The patients underwent either mitral valve replacement (n = 16, 57.1%) or mitral valve repair (n = 12, 42.9%). Concomitant procedures were performed including tricuspid valve repair, tricuspid valve replacement, PFO closure, left atrial appendage ligation, left atrial appendage thrombectomy and cryoablation for atrial fibrillation. Mean CPB times were 140.9 ± 44.6 and mean fibrillatory arrest duration was 76.6 ± 18.4. Mean duration of ICU stay was 32.5 ± 28.8 h and mean duration of hospital stay 9.8 ± 8.3 days. One patient (3.6%) underwent revision due to bleeding. New onset renal failure was observed in one (3.6%) patient and postoperative stroke in one (3.6%) patient. Postoperative early mortality was observed in two (7.1%) patients. Robotic-assisted mitral valve surgery without cross-clamping is a safe and feasible technique in high-risk patients undergoing redo mitral surgery with severe adhesions as well as in primary mitral valve cases that are complicated with ascending aortic calcification.

Redo mitral surgery after coronary artery bypass grafts under hyperkalemic hypothermia using thoracotomy and axillary artery cannulation in a patient with functioning bilateral internal thoracic arteries and atheromatous aorta

BackgroundRedo mitral valve surgery using resternotomy after coronary artery bypass grafting (CABG) is challenging as previous CABG with patent internal thoracic artery (ITA) poses a risk of injury due to dense adhesion. It is paramount to have alternative method to minimize this risk.Case presentation: We report a case of redo mitral and tricuspid valve repair via right thoracotomy under hypothermia and systemic potassium administration with axillary artery cannulation in a patient after CABG with patent bilateral ITA grafts crossing over the sternum. Herein, critical dissection around the aorta and functioning ITA grafts was avoided by performing the procedure under systemic hypothermia via thoracotomy. Furthermore, considering the presence of atheroma in the aorta, the axillary artery was used as a perfusion route to prevent stroke events. Postoperative course was uneventful and echocardiography demonstrated preserved cardiac function.ConclusionPerforming axillary artery cannulation and right thoracotomy under hypothermic cardiac arrest with systemic hyperkalemia without clamping the patent bilateral ITAs and aorta allowed us to perform redo mitral valve surgery after CABG without major postoperative cardiac or cerebral complications.

Beating Heart Mitral Valve Replacement in Secondary Mitral Regurgitation with Poor Left Ventricular Function Literature Review

The poor early and mid-term prognosis of secondary mitral regurgitation (MR) with impaired left ventricular function after restrictive annuloplasty with cardioplegic arrest has opened the way for transcatheter repair. The indication for surgery is only incontestable when concomitant coronary revascularization is required. Beating heart mitral valve surgery without aortic clamping has been promoted as an alternative to the technique of cardioplegic arrest. Its potential advantage is the elimination of ischemic reperfusion injury and its impact on myocardial function. On the other hand a randomized study confirmed that for ischemic MR, mitral valve replacement (MVR) reduces the rate of MR recurrence and re-hospitalization compared to restrictive annuloplasty. We performed a review of the literature to assess the strength of the evidence supporting the efficacy of beating heart MVR without aortic clamping compared to the conventional technique for secondary MR with poor left ventricular function. In a randomized study of patients with chronic severe mitral regurgitation and left ventricular dysfunction, beating heart MVR was associated with better LV function, reduction of cardiac enzymes early postoperatively, reduced duration of mechanical ventilation, and ICU than MVR using warm blood cardioplegic arrest. This together with the absence of related perioperative mortality and the major complications suggests that this technique is safe and beneficial to LV function. This finding has been verified by a multitude of other observational studies which have shown that the benefit of this technique is more palpable in cases of redo mitral surgery or in cases of MR with poor left ventricular function.

Modifiable and nonmodifiable risk factors in redo mitral surgery

Highlights. In the present study, we conducted a retrospective analysis redo mitral valve replacement due to prosthesis failure. Predictors of adverse events and death have been analyzed. The quality of obtained predictors was verified using ROC analysis.Aim. To analyze predictors of adverse events and death in redo mitral procedure for treating mitral bioprostheses failure.Methods. The retrospective registry study of catamnesis of patients undergoing treatment for mitral valve prosthesis dysfunction was carried out. The age and gender of patients, medical history, underlying and comorbid diseases, features of primary replacement and reoperation, durability of the primary prosthesis, adverse events and death after redo mitral valve replacement and others (more than 30 factors) were taken into account. Stepwise logistic regression was used for statistical processing. The quality of obtained predictors was verified using ROC analysis.Results. The results of the study have revealed that there are modifiable risk factors such as cardiopulmonary bypass time, ischemia time, and nonmodifiable risk factors like reoperation, baseline severity of the patient's condition, complications of median resternotomy, concomitant interventions on aortic valve during reoperation. Moreover, treating atrial fibrillation during primary replacement proved to have an overall protective effect.Conclusion. Тhe only modifiable factors that can be influenced during redo mitral valve replacement due to biological prosthesis failure are cardiopulmonary bypass duration and aortic cross-clamping time.

Access options for transcatheter mitral valve implantation in patients with prior surgical bioprosthesis.

Transcatheter mitral valve-in-valve (TMVIV) procedure, either transapical (TA) or trans-septal (TS) has become a valuable alternative to conventional redo surgery in case of failing mitral bioprosthesis with good clinical outcomes. Here we present our fourteen-year institutional experience. All consecutive patients treated with TMVIV with either TA or TS access at our centre between July 2007 and July 2020 were included. Periprocedural and 30-day follow-up (FU) results are reported and TA and TS data are compared. Eighty-two patients were included, of those 60 (73.2%) were TA while 22 (26.8%) were TS. Men represented 51.2% of the population with a mean age of 77.3±9.0 years. STS score and EuroSCORE II were 11.4%±6.2% and 11.5%±6.5% respectively. Baseline characteristics of TA and TS groups were comparable. TMVIV was performed at a median time of 9.3 years [interquartile range (IQR), 7.9-12.0 days] from the initial mitral valve surgery. Balloon expandable transcatheter heart valve (THV) prostheses (Edwards LifeSciences Corp., Irvine, CA, USA) were used exclusively. Technical success was 97.6% (96.7% and 100.0% for TA and TS respectively) with two (2.4%) periprocedural death, both in the TA group (P=0.533). We observed four (4.9%) left ventricular outflow tract (LVOT) obstructions with one being hemodynamically significant. Six (7.3%) major bleeding occurred in the TA group, not significantly different from TS group (P=0.279). The median length of stay was 6 days (IQR, 4-12 days, 1.5 vs. 7.0 days for TS and TA groups respectively, P=0.001). The overall 30-day mortality rate was 3.7%. We also observed three (3.7%) structural valve deteriorations and in one (1.2%) case the patient required redo mitral surgery at two months. Eighty-seven-point-eight percent of patients were I-II New York Heart Association (NYHA) class. At 30-day FU mean transmitral valve gradient was 7.3±2.7 mmHg and one patient (1.2%) had mitral regurgitation greater than mild. TA and TS groups were comparable. Our 14-year single-center experience with TMVIV confirms procedural safety and is an effective alternative to redo surgery with comparable results with both TA and TS. With device, technical improvements and increasing operators' experience, TS is the preferred option for TMVIV. However, in some highly selected patient, TA may still play an important role.

Reoperative mitral valve surgery via sternotomy or right thoracotomy: A propensity-matched analysis.

There is, as yet, no broad consensus regarding the optimal surgical approach for patients requiring reoperative mitral valve surgery. Consequently, we sought to evaluate the perioperative outcomes for patients undergoing redo mitral surgery via right mini thoracotomy as compared with traditional resternotomy. A comprehensive retrospective review of our prospectively collected database was undertaken from January 2011 to December 2017. We propensity matched 90 patients who underwent reoperative mitral valve surgery via right mini thoracotomy with a concurrent cohort of patients who had redo median sternotomy. Intraoperative data and short-term clinical outcomes were analyzed. The 30-day mortality was 3.3% (six deaths) in the entire cohort, not significantly different between redo sternotomy and mini thoracotomy groups. Patients who had their procedure via right mini thoracotomy had reduced intensive care unit (P = .029) and overall hospital (P < .0001) lengths of stay, a diminished requirement for perioperative transfusion (P = .023), and a trend towards faster postoperative extubation. Right thoracotomy patients experienced shorter cardiopulmonary bypass (P = .012) and cardiac arrest (P < .0001) times than did the sternotomy cases. Peripheral cannulation was utilized more frequently in the mini thoracotomy group, as were fibrillatory arrest techniques. Reoperative mitral valve surgery via right mini thoracotomy is safe, and is associated with shorter extracorporeal circulation times, reduced transfusion, and faster postoperative recovery.

RF67 REDO MITRAL SURGERY AND HOSPITAL OUTCOME: A MULTICENTRE EXPERIENCE REGARDING SURGICAL FACTORS AND COMPLICATIONS

Background and Aim: Redo mitral surgery is an high risk procedure. Several preoperative conditions identify patients at unusual surgical risk. Few studies clarify technical issues and perioperative complications affecting early survival. The aim of this multicentre study is to determine predictors of adverse outcome among intraoperative factors and postoperative events. Methods: Operative mortality and major morbidity events from 832 redo mitral procedures, from January 2005 to December 2014 at eight European centres, were analysed. Statistical analysis was performed by the SPSS 13.0 program for Windows (SPSS, Inc., Chicago, IL, USA). Normally distributed continuous variables were compared using the unpaired t-test, not-normally distributed variables using the Mann–Whitney U-test and categorical variables using the χ2test. Only variables with a P &lt; 0.10 at univariable analysis were included into the regression models. Results: Injury of a previous patent left internal mammary artery graft (LIMA) [odds ratio (OR) 4.2, 95% confidence interval (CI): 1.6–11.5; P = 0.005], major cardiovascular iatrogenic lesions at re-entry (OR 19.2, 95% CI: 9.2–39.9; P &lt; 0.001), extracellular crystalloid cardioplegia (OR 7.3, 95% CI: 1.4–37.8; P = 0.018) and incremental cardiopulmonary bypass time (OR 1.1, 95% CI: 1.0–1.2; P = 0.001) independently predicted operative mortality. Conclusion: Operative mortality in redo mitral surgery is still significant. Injury of a previous LIMA graft identifies patients at higher. Prolonged cross-clamp times, extracellular crystalloid cardioplegia, massive transfusions, perioperative myocardial infarction, prolonged intubation also predict adverse early outcome. Combined antegrade + retrograde cardioplegia seems to be the only protective factor these high-risk patients.

OC62 REDO MITRAL SURGERY AND HOSPITAL OUTCOME: IMPACT OF FAILED MITRAL VALVE REPAIR

Background and Aim: Mitral valve repair is the gold standard for mitral valve regurgitation, even if failed mitral repairs (FMR) have been reported. The aim of this study was to evaluate the impact of FMR on early outcome after redo mitral surgery. Methods: Operative mortality and major morbidity events from 920 redo mitral procedures at nine European centres were analysed. Statistical analysis was performed by the SPSS 13.0 program for Windows (SPSS, Inc., Chicago, IL, USA). To identify indipendent predictors of operative deaths, variables with a P &lt; 0.10 at univariable analysis were included in the regression models. All the outcome parameters were then adjusted by propensity matching, to compare similar cohorts of patients with FMR or diseased native mitral valves and similar cohorts of patients with FMR and malfunctioning prostheses. Results: FMR did not impact mortality at multivariable analysis (P = 0.64). Propensity-matched cohorts of FMR and native mitral valves showed no differences in mortality (P = 0.69). A preoperative Global Initiative for Chronic Obstructive Lung Disease score &gt;2 chronic lung disease (COPD) (OR 15.2, P &lt; 0.01), left ventricular ejection fraction &lt;30% (odds ratio (OR) 21.5, P = 0.005), major injury to cardiovascular structures at re-entry (OR 27.2, P &lt; 0.01) or to patent left internal mammary artery-coronary artery bypass graft (OR 7.6, P = 0.03) predicted mortality in the FMR population. Conclusions: A failed mitral repair does not impact hospital outcome of redo surgery. Severe left ventricular dysfunction, COPD and injury at re-entry predict adverse early outcome.

Hospital Outcome and Risk Indices of Mortality after redo-mitral valve surgery in Potential Candidates for Transcatheter Procedures: Results From a European Registry

Transcatheter mitral valve-in-valve/valve-in-ring procedures (TM-VIVoR) are increasing. The authors aimed to identify independent predictors for hospital mortality in redo mitral valve surgery as possible future selection criteria for TM-VIVoR. Retrospective multicenter registry. Tertiary university and community hospitals. Two-hundred and sixty patients (out of 920 enrolled) who are potentially candidates for TM-VIVoR undergoing redo-surgery. Redo mitral surgery. Regression analyzes and receiver operating characteristic (ROC) curves identified independent predictors of death. Patients potentially candidates for TM-VIVoR reported significant hospital mortality (9.2%; EuroSCORE II: 13.2 ± 13.1, Society of Thoracic Surgeons [STS] score: 6.2 ± 3.1) and major morbidity (3.8% acute myocardial infarction, 5% stroke, 16.9% perioperative respiratory failure, 16.5% acute renal insufficiency, 25% massive transfusions). EuroSCORE II (odds ration [OR] 1.06; confidence interval [CI] 1.01-1.10; p = 0.005), STS score (OR 1.58; CI 1.27-1.97; p = 0.001), age at surgery (OR 1.05; CI 1.00-1.15; p = 0.05), preoperative dialysis (OR 2.5; CI 1.8-12.6; p = 0.042), left ventricular ejection fraction (LVEF) <30% (OR 4.8; CI 1.12-37.1; p = 0.021), severe pulmonary hypertension (OR 7.5; CI 1.9-29.4; p = 0.003), and previous coronary artery bypass grafting (CABG) (OR 11.8; CI 1.7-36.9; p = 0.002) were independent predictors of hospital mortality. ROC analyses reported good prediction for EuroSCORE II (AUC: 0.76; cut-off value: >13.1; 70.8% sensitivity and 68.2% specificity) and better prediction for STS score (AUC: 0.81; cut-off value: 7.4; 75.0% sensitivity and 66.2% specificity). Quintiles stratification identified EuroSCORE II ≥18.7 (5th quintile, observed mortality: 19.3%) and STS score >9.1 as strong predictors of death within each risk-categorization (OR 5.9 and 12.1, respectively). High EuroSCORE II and STS scores, advanced age at surgery, LVEF <30%, previous CABG, severe pulmonary hypertension or preoperative dialysis might represent in the future preferred indications for TM-VIVoR in the redo-mitral surgery scenario.

Long-Term Outcomes Comparison of Mitral Valve Replacement Versus Repair in Elderly Patients

Objective: To compare survival and postoperative valve durability following mitral valve replacement and repair (MVR/r) in patients > 70 years-old in order to better inform optimal operative decision-making. Methods: All patients undergoing MVR/r at our institution since 1960 have been prospectively followed for survival and explant on an annual basis. Expected survival was calculated for each patient from age-gender-operative year-matched US life tables. Observed and Expected survival curves were plotted and compared using Standardised Mortality Ratio (SMR = total observed deaths/total expected deaths). The cumulative incidence function (CIF) was used to determine valve explant rates at 12 years. Results: There were 771 patients > 70 years of age at time of isolated MVR/r (1971-2015) with 5,126 patient-years of follow-up. The survival and explant outcomes of all mitral repairs (MVr, 375) and MVR with mechanical (170), porcine (118) and pericardial (103) implants were compared. There were no significant differences in age, gender or incidence of CABG. Observed survival for porcine and mechanical MVR was very much worse than expected (SMR = 2.0 and 1.7 respectively, p < 0.001 for both); slightly worse than expected for MVr (SMR = 1.16; 95%CI = 1.02-1.37); whereas survival following pericardial MVR was equal to expected (SMR = 1.2; 95%CI = 0.89-1.75). However, the cumulative incidence of redo mitral surgery or prosthetic valve explant at 14 years was 0% for pericardial MVR, which is equal to (significantly LESS THAN) mechanical MVR (2%), but significantly lower than that for mitral repair (8%) and porcine MVR (7.5%). Conclusions: In patients > 70 years old, mitral repair, mechanical MVR and porcine MVR do not restore expected survival, whereas pericardial MVR restores expected survival. However the incidence of redo mitral surgery following MVr is significantly higher than that following pericardial MVR. These data suggest that the long-term outcomes of pericardial MVR may be superior to native MVr for patients > 70 years old, as pericardial MVR both preserves survival and minimises reoperation.

Mitral regurgitation after previous aortic valve surgery for bicuspid aortic valve insufficiency.

Regurgitant bicuspid aortic valves (BAV) are reported to be associated with myxomatous degeneration of the anterior mitral leaflet. We examined the risk of late new-onset mitral regurgitation (MR) in patients who underwent aortic valve/aortic root surgery for BAV regurgitation and concomitant root dilatation. A total of 97 consecutive patients (47±11 years, 94% men) were identified from our institutional BAV database (N.=640) based on the following criteria: 1) BAV regurgitation; 2) aortic root diameter >40 mm; 3) no relevant mitral valve disease (i.e., MR<2+) and no simultaneous mitral intervention at the time of BAV surgery. All patients underwent isolated aortic valve replacement (AVR subgroup, N.=59) or aortic root replacement with a composite graft (i.e., for root aneurysm >50 mm) (ARR subgroup, N.=38) from 1995 through 2008. Echocardiographic follow-up (1009 patient-years) was obtained for all 96 (100%) hospital survivors. The primary endpoint was freedom from new-onset MR>2+ and redo mitral valve surgery. Nine patients (9.4%) showed new-onset MR>2+ after mean echocardiographic follow-up of 10.4±4.0 years postoperatively. Myxomatous degeneration and prolapse of the anterior mitral leaflet was found in all 9 patients, and the posterior leaflet was involved in 3 of them. Two patients (2%) in AVR subgroup underwent re-do mitral surgery. No MR>2+ occurred in ARR subgroup. Freedom from MR>2+ or mitral surgery at 15 years was significantly lower in AVR subgroup vs. ARR subgroup (i.e., 38% vs. 100%, P=0.01). The risk of new-onset MR is significantly increased in patients with BAV regurgitation and aortic root dilatation who undergo isolated AVR rather than root replacement. The mechanism by which aortic root replacement may prevent the occurrence of late MR in BAV root phenotype patients is to be determined.

Surgical factors and complications affecting hospital outcome in redo mitral surgery: insights from a multicentre experience.

Several single-centre experiences have reported significant operative mortality and morbidity after mitral valve surgery in redo scenarios (ReMVS). Several preoperative risk factors outlining 'high-risk' categories have been reported, but scanty data on the impact of different operative techniques for these major challenging procedures have been analysed to date. The aim of the study is to investigate those intraoperative factors and postoperative events affecting early survival after redo mitral procedures. Operative mortality and major morbidity events from a large multicentre registry enrolling 832 consecutive redo mitral procedures were analysed. Intraoperative technical issues and postoperative complications impacting operative mortality were identified. ReMVS was associated with significant operative mortality (12.5%), acute myocardial infarction (AMI; 5.9%), stroke (4.9%), acute respiratory insufficiency (14.8%), pneumonia (7.0%), acute renal insufficiency (16.1%) and failure (12.6%), reintervention for bleeding (7.6%), massive transfusion (28.0%), need for permanent pacemaker (10.1%). Injury of a previous patent left internal mammary artery (LIMA) graft [odds ratio (OR) 4.2, 95% confidence interval (CI): 1.6-11.5; P = 0.005], major cardiovascular iatrogenic lesions at re-entry (OR 19.2, 95% CI: 9.2-39.9; P < 0.001), extracellular crystalloid cardioplegia (OR 7.3, 95% CI: 1.4-37.8; P = 0.018), and incremental cardiopulmonary bypass time (OR 1.1, 95% CI: 1.0-1.2; P = 0.001) independently predicted operative mortality, whereas combined antegrade + retrograde cardioplegia (OR 0.2, 95% CI: 0.09-0.4; P = 0.001) was the only protective factor against mortality. Among complications, AMI (OR 4.1, 95% CI: 1.8-9.6; P = 0.001), need for intra-aortic balloon pumping (IABP; OR 3.1, 95% CI: 1.5-6.1; P = 0.001), prolonged intubation >48 h (OR 5.3, 95% CI: 2.9-9.4; P = 0.001) and massive (>6 units) transfusions (OR 4.4, 95% CI: 2.4-8.0; P = 0.001) also predicted operative mortality. ReMVS still carries the risk of significant early mortality and major morbidity. Major lesion to cardiovascular structures is the most dreadful iatrogenic complication, and injury of a previous LIMA graft identifies patients at higher risk of operative mortality. Prolonged cross-clamp times, extracellular crystalloid cardioplegia and massive transfusions have profound impact on early outcome, as well as the development of perioperative AMI, eventually requiring IABP and prolonged intubation. The combination of antegrade and retrograde cardioplegia seems to offer a better myocardial protection in these high-risk patients.

Risk Factors and Complications Affecting Hospital Outcome after Redo Mitral Surgery

Risk Factors and Complications Affecting Hospital Outcome after Redo Mitral Surgery

Transaortic Repair as Bailout Procedure for Left Atrial Tear in Redo Mitral Valve Surgery via Superior Transseptal Approach

We encountered a tear of the left atrium with severe calcification during redo mitral surgery, and report a technique for its repair. An 82-year-old woman underwent redo mitral valve replacement. The mitral valve was performed via a superior transseptal approach. The atriotomy was closed directly. The roof of the left atrium was found to be torn after aortic de-clamping. There was no remaining intact left atrial tissue on the aortic side. Patch closure was performed using transaortic stitches passing through the subaortic curtain to fix the patch. The left atrial roof and atrial septum were closed with the same patch.

Minimally invasive approach for redo mitral valve surgery.

Redo cardiac surgery represents a clinical challenge due to a higher rate of peri-operative morbidity and mortality. Mitral valve re-operations can be particularly demanding in patients with patent coronary artery bypass grafts, previous aortic valve replacement, calcified aorta or complications following a previous operation (abscesses, perivalvular leaks, or thrombosis). Risk of graft injuries, hemorrhage, the presence of dense adhesions and complex valve exposure can make redo valve operations challenging through a median sternotomy. In this review article we provide an overview of minimally invasive approaches for redo mitral valve surgery discussing indications, techniques, outcomes, concerns and controversies. Scientific literature about minimally invasive approach for redo mitral surgery was reviewed with a MEDLINE search strategy combining "mitral valve" with the following terms: 'minimally invasive', 'reoperation', and 'alternative approach'. The search was limited to the last ten years. A total of 168 papers were found using the reported search. From these, ten papers were identified to provide the best evidence on the subject. Mitral valve reoperations can be safely and effectively performed through a smaller right thoracotomy in the fourth intercostal space termed "mini" thoracotomy or "port access". The greatest potential benefit of a right mini-thoracotomy is the avoidance of sternal re-entry and limited dissection of adhesions, avoiding the risk of injury to cardiac structures or patent grafts. Good percentages of valve repair can be achieved. Mortality is low as well as major complications. Minimally invasive procedures with an unclamped aorta have the potential to combine the benefits of minimally invasive access and continuous myocardial perfusion. Less invasive trans-catheter techniques could be considered as the natural future evolution for management of structural heart disease and mitral reoperations. The safety and efficacy of these procedures has never been compared to open reoperations in a randomized trial, although published case series and comparisons to historical cohorts suggest that they are an effective and feasible alternative. Ongoing follow-up on current series will further define these procedures and provide valuable clinical outcome data.

Redo cases for mitral valve replacement on fibrillating heart – is the outcome better?

Methods Between 2011 and 2013 a total number of 55 patients, 29 female and 26 male, with average age 62 years (from 42 to 75), underwent redo mitral surgery in our institution. Those were divided in two groups. Group 1 – patients operated on fibrillation heart without aortic crossclamping (15 patients, average age 61 years, 4 female and 11 males) and Group 2 – patients operated with aortic cross-clamping and cardioplegic arrest (40 patients, average age 62 years, 25 female and 15 male). In all patients mitral valve replacement was performed. In 32 patients at least one more major cardiac procedure was also performed during the same surgery.

Transcatheter transapical mitral valve-in-valve implantations for a failed bioprosthesis: A case series

Mitral valve replacement with bioprosthetic valves is becoming more common. The incidence of structural valve deterioration and the need for reoperative mitral surgery are expected to increase. The operative mortality and morbidity associated with redo mitral surgery remains high. Transapical transcatheter mitral valve-in-valve implantation might offer an alternate and safer approach for high-risk patients. From July 2007 to April 2010, 11 patients with symptomatic mitral prosthetic valve dysfunction underwent transapical transapical transcatheter mitral valve-in-valve implantation in our institution. Data were collected and entered into a database prospectively. The mean age was 81 ± 5 years, with 64% being female. The mean Society of Thoracic Surgeons risk score was 16.1% ± 5.8%. All patients had successful transapical transcatheter mitral valve-in-valve implantation with no 30-day mortality. One patient died 45 days after surgical intervention from respiratory failure, and 1 patient died on day 135. All other patients were alive and in New York Heart Association class I/II at a median follow-up of 357 days. The median postprocedural transvalvular gradient was 7 mm Hg, and minimal transvalvular or paravalvular regurgitation was seen. Transcatheter transapical valve-in-valve implantations into a failed mitral bioprosthesis is technically feasible with acceptable results. It might be a viable approach for selected high-risk patients.

Less Invasive Mitral Valve Surgery via Right Minithoracotomy

Current trends in cardiac surgical intervention are moving toward less invasiveness, with smaller wound or sternum-sparing, less pump time or off-pump, and beating rather than arrested heart. Data on the efficacy and safety of these newer less invasive techniques, as well as their cosmetic results, are limited. This study analyzed the results of a sternum-sparing mitral valve operation. Thirty patients with mitral valve diseases, including 20 who underwent mitral valve repair and 10 mitral valve replacement, were enrolled. Cardiopulmonary bypass was established via femoral cannulation, and blood cardioplegic arrest was induced by using a percutaneous, transthoracic cross-clamp. The main surgical wound was made over the lateral border of the right breast. Two additional small wounds were required for the transthoracic aortic clamp and the mitral retractor. There was no operative mortality, and all patients had an uneventful recovery. Two patients underwent redo mitral surgery. Nine associated procedures were performed including tricuspid valve annuloplasty in six patients, tricuspid valve replacement in two patients and atrial septal defect repair in one patient. The length of the main wound was between 5.8 and 7.8 cm (mean, 7.1 cm). The mean cardiopulmonary bypass time and cross-clamp time were 91.1 and 43.7 minutes, respectively. Although the length of stay was not significantly reduced compared with traditional median sternotomy, all patients had satisfactory results with good cosmesis. Sternum-sparing mitral valve surgery appears to be a safe and effective alternative to conventional mitral valve surgery; it is less invasive and provides superior cosmetic results for patients.

Long-term results of reoperative mitral valve surgery in patients with rheumatic disease

Background Reoperative (redo) mitral valve surgery is still a continuing challenge to surgeons. The aim of this study was to detect the factors that affect late mortality or morbidity after redo mitral valve surgery in patients with rheumatic disease. Methods Between May 1983 and February 2003, 92 patients who underwent redo mitral valve surgery for rheumatic disease were enrolled. Risk factors influencing survival or cardiac events were investigated with univariate analysis and a Cox model. Results Operative mortality rate was 4.2%. Kaplan-Meier actuarial analysis demonstrated an 84.7% 5-year, a 69.5% 10-year, and a 65.9% 15-year survival. Multivariate analysis demonstrated that age at surgery and preoperative New York Heart Association (NYHA) class were found to be independent predictors of late deaths, and that higher age, advanced NYHA class, and previous mitral valve replacement were independent predictors of cardiac events. Conclusions Redo mitral valve surgery can be achieved with low early mortality. However, long-term results of redo mitral surgery are not necessarily satisfactory in patients with preoperative advanced NYHA class or with a previous mechanical heart valve, and especially in 60 years or older age.