Valve Repair Research Articles

TCT-617 Hospital Dispersion and Patient Outcomes of Transcatheter Mitral Valve Repair

TCT-617 Hospital Dispersion and Patient Outcomes of Transcatheter Mitral Valve Repair

Institutional Variation in PatientRadiationDoses During Transcatheter Valve Interventions: A Statewide Experience.

Little is known about institutional radiation doses during transcatheter valve interventions. The authors sought to evaluate institutional variability in radiation doses during transcatheter valve interventions. Using a large statewide registry, transcatheter edge-to-edge mitral valve repair, transcatheter mitral valve replacement, and transcatheter aortic valve replacement procedures between January 1, 2020, and December 31, 2022, with an air kerma (AK) recorded were analyzed. Patient and procedural characteristics were compared between cases with AK≥2 and<2 Gy. Associations of variables with AK≥2Gy were investigated using Bayesian random effects modeling and median ORs for the performing hospital. Among 9,446 procedures across 30 hospitals, median (Q1-Q3) procedural AK was 0.592Gy (0.348-0.989 Gy) with AK≥2Gy in 533 cases (5.6%). Wide variation in procedural AK was observed, with an institutional frequency of AK≥2Gy ranging from 0.0% to 29.5%. Bayesian modeling identified the performing hospital as more strongly associated with the odds of a procedural AK≥2Gy than any patient or procedural factors (hospital median OR: 3.54 [95% credible interval: 2.52-16.66]). In a large, multicenter state-wide registry, there is wide institutional variability in patient-level radiation doses during transcatheter valve interventions, with the performing hospital having a higher odds of an AK≥2Gy than any patient or procedural factors. Future interventions are warranted to reduce procedural-related variation in radiation exposure.

Effects of Mitral Calcification in Severe Aortic Stenosis with Severe Mitral Regurgitation on Left Heart Remodeling, Surgical Strategy, and Outcomes

To localize and quantify mitral calcification associated with severe aortic stenosis and severe mitral regurgitation and determine its association with cardiac remodeling, operative management, and long-term survival. From July 1998 to July 2010, 158 patients with severe aortic stenosis, severe mitral regurgitation, and mitral calcification underwent surgical aortic valve replacement (SAVR, n=49) or SAVR plus mitral valve repair (SAVR+MVr, n=67) or replacement (SAVR+MVR, n=42). Mitral calcium was localized and quantified on preoperative computed tomography. Random forest methodology was used to correlate calcium volume with cardiac morphology and function. Median follow-up for survival was 4.1 years; 25% were followed ≥14 years. Larger calcium volume was associated with degenerative mitral disease, higher ejection fraction, smaller left ventricular end-systolic volume, and SAVR+MVR (median calcium volume 3.4 cm3) versus SAVR (median calcium volume 1.0 cm3) or SAVR+MVr (median calcium volume 0.41 cm3). Ten-year mortality was higher in patients with more mitral calcification (terciles: 7.1% vs 16% vs 25%), subvalvular involvement (8.1% vs 18%), and SAVR+MVR (5.4% vs SAVR=13% vs SAVR+MVr=26%). Multivariable analysis demonstrated early postoperative mortality was strongly associated with subvalvular mitral calcification, but late mortality was not associated with calcium volume or location. Larger mitral calcium volume is a marker of late-stage cardiac remodeling associated with more extensive mitral valve intervention, but it is not associated with long-term mortality. Quantitative analysis of mitral calcification with computed tomography can aid in patient selection and surgical management decisions in this complex patient population.

TCT-339 Transcatheter Treatment of Dual Aortic-Mitral Pathology Using Transcatheter Aortic Valve Replacement and Transcatheter Mitral Valve Repair

TCT-339 Transcatheter Treatment of Dual Aortic-Mitral Pathology Using Transcatheter Aortic Valve Replacement and Transcatheter Mitral Valve Repair

Assessment of the Right Ventricle Function in Patients With Significant Tricuspid Regurgitation: A Review.

Tricuspid regurgitation (TR) is an increasingly prevalent condition, especially in older populations, and presents significant challenges due to its association with right heart failure, hospital admissions, and high mortality rates. The management of TR has evolved, with new percutaneous valve repair and replacement techniques emerging alongside traditional surgical approaches. However, accurately assessing right ventricular (RV) function-a key prognostic factor in TR-remains difficult due to the RV's unique anatomy and sensitivity to loading conditions. Current echocardiographic methods, such as Tricuspid Annular Plane Systolic Excursion (TAPSE), S' wave analysis, and RV fractional area change (FAC), offer valuable insights but have limitations, particularly regarding load dependence and incomplete assessment of RV function. Advances in 3D echocardiography and myocardial strain imaging provide more comprehensive evaluations, yet challenges persist in integrating these measures in routine clinical practice. The review highlights the importance of a multimodal approach to RV assessment in TR patients, considering both the right atrium and pulmonary artery interactions, and explores potential future tools such as myocardial work and dynamic testing to improve prognostic accuracy and patient outcomes.

Impact of Hospital Transfers on Cardiac Surgery Outcomes: A Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis

Transfers for cardiac surgery are not well studied. We sought to understand the risk profile of transferred patients, determine if transfer rates vary by cardiac surgery, and if transferred patients' outcomes vary with type of referral hospital/surgery. Patients undergoing cardiac surgery with operative risk models were identified from the Society of Thoracic Surgeons database between 7/1/2014-12/31/2022. Patients were stratified as: no transfer, transferred from hospital with cardiac surgery, and transferred from hospital without cardiac surgery. Risk associated with transfer compared to no transfer was derived via multivariable logistic regression for operative mortality and select perioperative outcomes. 1,828,787 patients at 1,145 hospitals were included, with 1,452,491 no transfer patients (79.4%), 28,862 transfers from hospitals with cardiac surgery (1.6%), and 347,434 transfers from hospitals without cardiac surgery (19.0%). Most transferred patients underwent CABG (24.8%), however, transfers from hospitals with cardiac surgery was most common for mitral valve replacement (17.9%). Transferred patients had increased comorbid diseases and urgent/emergent procedures. In multivariable analysis, transfers from hospitals with/without cardiac surgery were not associated with differential risk of adverse outcomes by procedure type. Patients transferred from hospitals with cardiac surgery undergoing mitral and aortic valve replacement and CABG had significantly lower adjusted mortality risk compared to non-transferred patients, while composite morbidity/mortality was higher in mitral valve repair. Patients transferred for cardiac surgery are generally higher-risk, yet outcomes at transfer-to hospitals are as expected or better. However, further research is necessary to examine patients who are transferred, but do not undergo surgery.

TCT-976 Impact of Transcatheter Tricuspid Valve Repair on Preprocedural and Postprocedural Hospitalization Rates

TCT-976 Impact of Transcatheter Tricuspid Valve Repair on Preprocedural and Postprocedural Hospitalization Rates

TCT-340 Outcomes of Sequential Transcatheter Aortic Valve Replacement and Edge-to-Edge Mitral Valve Repair: An STS/ACC TVT Registry Analysis

TCT-340 Outcomes of Sequential Transcatheter Aortic Valve Replacement and Edge-to-Edge Mitral Valve Repair: An STS/ACC TVT Registry Analysis

Additional left atrial plication improves postoperative cardiovascular events in atrial functional mitral regurgitation.

Left atrial (LA) plication is a procedure used to correct an LA that expands posteriorly due to remodeling. This study aimed to determine the efficacy of additional LA plication in reducing postoperative cardiovascular events (CVEs) after mitral valve (MV) repair in atrial functional mitral regurgitation (MR) patients. Between October 2008 and August 2023, MV repair with or without LA plication in 74 patients was studied. This study examined the efficacy of concomitant LA plication during MV repair. All patients underwent mitral annuloplasty. Of these, 26 underwent additional LA plication. In the mid-term periods, protruding posterior LA length in patients with LA plication was shorter than those without LA plication (2.8±0.49 vs. 3.3±0.72 cm, P=0.01). The percentage change in aortomitral angle from preoperative to mid-term periods in patients with LA plication was bigger than those without LA plication (1.04°±0.102° vs. 0.98°±0.084°, P=0.01). Posterior leaflet coaptation angle in patients with LA plication was smaller than those without LA plication (42°±15° vs. 76°±30°, P<0.001). A postoperative posterior leaflet coaptation angle of 101° had the maximum sum of sensitivity and specificity in predicting postoperative CVEs (96.9% and 76.9%, respectively). Patients with a postoperative posterior leaflet coaptation angle of 101° or higher had a poorer prognosis than those with an angle less than 101°, with an event-free rate of 18% vs. 80% at 7 years after surgery (P<0.0001). Additional LA plication might be useful in reducing postoperative CVEs in atrial functional MR patients.

Isolated “on-pump” tricuspid valve repair through right-sided anterolateral thoracotomy by modified femoral-monocaval cannulation in patients with repeated heart intervention – a safe and effective surgical alternative

Isolated “on-pump” tricuspid valve repair through right-sided anterolateral thoracotomy by modified femoral-monocaval cannulation in patients with repeated heart intervention – a safe and effective surgical alternative

Prediction of Cardiovascular Events and Structural and Functional Remodeling of the Heart in Patients With Severe Mitral Regurgitation of Various Genesis Underwent Transcatheter Mitral Valve Repair "Edge-To-Edge".

To search for predictors of adverse cardiovascular events after edge-to-edge transcatheter mitral valve repair (TMVR) in patients with severe mitral regurgitation (MR) of various origins with an assessment of structural and functional remodeling of the heart and left ventricular (LV) contractile function. The study included 73 patients (median age 71 [63; 80] years, 60.3% men) at a high surgical risk with severe MR of primary and secondary genesis, who underwent TMVR. The second-generation (58.9%) and fourth-generation (41.1%) clips were implanted. In addition to standard echocardiographic (EchoCG) indices, the parameters of left heart chamber longitudinal strain and LV myocardial function were assessed at baseline, on days 4-5, and at 6 and 12 months after the intervention. Also, the N-terminal fragment of the pro-brain natriuretic peptide (NT-proBNP) was assessed at baseline and on days 4-5 after TMVR. A significant decrease in MR was achieved during 12 months of follow-up. In the group with primary mitral regurgitation (PMR), MR decreased from 4.0 [3.4; 4.0] to 2.0 [1.5; 2.5] at one year of follow-up (p&lt;0.001). In the group with secondary mitral regurgitation (SMR), MR decreased from 3.5 [3.0; 3.9] to 2.0 [2.0; 2.5] at 12 months of follow-up (p&lt;0.001). This effect was associated with volumetric unloading of the left heart chambers evident as a significant decrease in the volumetric indices of the left chambers and an increase in the cardiac index. In the early postoperative period, the LV function was impaired as shown by decreases in the ejection fraction (EF), global longitudinal strain (GLS), LV myocardial function parameters, and an associated increase in NT-proBNP. By 12 months of follow-up, statistically significant improvements in global constructive work (GCW) and global work index (GWI) relative to baseline values were noted in both groups without significant changes in EF and LV GLS. A strong correlation was found between LV EF and GCW (r=0.812, p&lt;0.001) and GWI (r=0.749, p&lt;0.001). The overall survival was 89%, not differing between groups (p=0.72); the absence of hospitalization for decompensated heart failure (HF) was 79.5%, also without significant differences between the groups (p=0.78). According to multivariate regression analysis, the baseline GCW value was the strongest predictor of rehospitalization for decompensated HF (relative risk (RR) 0.997; 95% confidence interval (CI) 0.995-1.000; p=0.021) and the composite endpoint (CEP) (hospitalization for decompensated HF + all-cause mortality) (RR 0.998; 95% CI 0.996-1.000; p=0.033) in the cohort with PMR. In the group with SMR, the initial degree of MR was related with rehospitalization and the CEP (OR 12.252; 95% CI 2.125-70.651; p=0.005 and OR 16.098; 95% CI 2.944-88.044; p=0.001, respectively). The most significant predictor of overall mortality in the study population was the preoperative value of LV stroke volume (OR 0.824; 95% CI 0.750-0.906; p&lt;0.001). Edge-to-edge TMVR exerts a positive effect on the prognosis and structural and functional remodeling of the heart in patients with PMR and SMR. Myocardial function indices may be useful in assessing the LV contractile function in patients with severe MR of various origins. Identification of predictors for adverse cardiovascular events, including with new EchoCG technologies, may contribute to better patient stratification.

Early Detection For Better Results In The Treatment Of Asymptomatic Cases Of Valvular Heart Disease

Valvular heart disease (VHD) often progresses asymptomatically, leading to delayed diagnosis and treatment, which worsens patient outcomes. Early detection of VHD in asymptomatic cases is crucial to improve treatment effectiveness and long-term prognosis. This study aims to investigate the impact of early detection on treatment outcomes in asymptomatic VHD patients. A cross-sectional study was conducted involving 200 patients diagnosed with VHD, categorized into two groups: those diagnosed early through screening and those diagnosed later after the onset of symptoms. Data were collected through medical records, echocardiograms, and patient interviews. Statistical analysis revealed that early detection significantly improved patient outcomes, with lower rates of complications, better valve repair success, and reduced mortality compared to those diagnosed later. Discussion centers on the importance of routine screenings in at-risk populations and the need for better diagnostic protocols to catch asymptomatic cases early. The conclusion highlights that early detection of asymptomatic VHD leads to better treatment outcomes, underlining the necessity of proactive screening measures to manage VHD effectively.

Impact of Diabetic Condition on the Remodeling of In Situ Tissue-Engineered Heart Valves.

Most in situ tissue-engineered heart valve (TEHV) evaluation studies are conducted in a healthy physical environment, which cannot accurately reflect the specific characteristics of patients. In this study, we established a diabetic rabbit model and implanted decellularized extracellular matrix (dECM) into the abdominal aorta of rabbits through interventional surgery with a follow-up period of 8 weeks. The results indicated that dECM implants in diabetic rabbits exhibited poorer endothelialization and more severe fibrosis compared to those in healthy animals. Furthermore, mechanistic studies revealed that high glucose induced endothelial cell (EC) apoptosis and impeded their proliferation and migration, accompanied by an increase in reactive oxygen species (ROS) concentration and a decrease in the nitric oxide (NO) level. High glucose also led to elevated ROS levels and an increased expression of inflammatory factors and transforming growth factor β1 (TGF-β1) in macrophages, contributing to fibrosis. These findings suggest that oxidative-stress-mediated mechanisms are likely the primary pathways affecting heart valve repair and regeneration under diabetic conditions. Therefore, future design and evaluation of TEHVs may concern more patient-specific circumstances.

Natural biomaterials in the management of the aortic valve pathology. Biomedical and clinical aspects: A review.

Heart valve diseases are a prevalent cardiovascular pathology worldwide, affecting nearly 2.5% of the population. Degenerative aortic stenosis is the most common form of heart valve disease. The treatment options include surgical or transcatheter procedures. There are two main categories of valve prostheses available: mechanical heart valves constructed from synthetic materials and bioprosthetic heart valves made from natural biomaterials. The choice of valve type depends on various factors, including the underlying medical condition, suitability for anticoagulation, valve durability, and the patient's age and preferences. Mechanical heart valves have the advantage of long-term durability. However, patients receiving mechanical implants are subjected to lifelong anticoagulation therapy with an increased risk of thromboembolism and bleeding. Natural biomaterials do not require long-term anticoagulation. However, they experience degenerative changes leading to structural valve deterioration that may require reoperation. The purpose of this article is to review the role of natural biological materials used for aortic valve replacement or repair, assess their biomedical and clinical advantages and limitations, and analyze the direction and perspectives of future development.

Impact of beta-blocker uptitration on patients after transcatheter edge-to-edge mitral valve repair for secondary mitral regurgitation: The OCEAN-mitral registry

BackgroundOptimal medical therapy for patients with secondary mitral regurgitation (SMR) undergoing transcatheter edge-to-edge mitral valve repair (M-TEER) remains unclear. This study aimed to investigate the association between beta-blocker uptitration and clinical outcomes after M-TEER. MethodsUsing data from the Japanese multicenter registry, we examined 1474 patients who underwent M-TEER for SMR between April 2018 and June 2021. Beta-blocker uptitration was defined as an increased dose of beta-blockers 1 month after M-TEER compared with that before M-TEER. The 2-year clinical outcomes were compared between patients with and without beta-blocker uptitration, utilizing multivariable Cox regression analyses and propensity score matching (PSM). ResultsOf the 1474 patients who underwent M-TEER, 272 (18.4 %) were receiving increasing doses of beta-blockers at the 1-month follow-up. These patients had lower left ventricular ejection fraction (LVEF) and higher B-type natriuretic peptide levels. Most patients in the beta-blocker uptitration group received less than the target dose of beta-blockers. Multivariable Cox regression analyses showed that beta-blocker uptitration was significantly associated with a lower risk of all-cause (adjusted hazard ratio [HR]: 0.55; 95 % confidence interval [CI]: 0.36–0.84; P = 0.006) and cardiovascular mortalities (adjusted HR: 0.45, 95 % CI: 0.26–0.79, P = 0.006). PSM analyses revealed consistent findings. Subgroup analyses revealed a significant interaction between beta-blocker uptitration and LVEF≤40 % (interaction P = 0.018). ConclusionsIn patients with SMR, beta-blocker uptitration after M-TEER was associated with better clinical outcomes, especially in the group with an LVEF≤40 %. Efforts to uptitrate guideline-directed medical therapy after M-TEER for SMR may be necessary, even if reaching the target dose proves challenging.

Incidence and predictors of acute coronary syndrome after transcatheter mitral valve repair

ABSTRACT Background Acute coronary syndrome (ACS) post-transcatheter mitral valve repair (TMVR) carries high mortality. We aim to study the incidence and predictors of ACS in patients who underwent TMVR. Research design and methods We queried the U.S. National Readmission Database to identify all cases of TMVR from 2016 to 2019. We further evaluated the incidence of ACS and used multivariable logistic regression to determine independent predictors of ACS in this population. Results Among 3,742 patients who underwent TMVR, 264 (7.05%) developed ACS. Among ACS patients, 204 (77%) had non-ST-segment elevation ACS and 66 (25%) had ST-segment elevation ACS. Independent predictors of ACS were acute limb ischemia, cardiogenic shock, history of coronary artery disease (CAD), smoking, cardiac arrest, respiratory failure requiring mechanical ventilation, and acute kidney injury. In-hospital mortality among ACS was three times higher in ACS patients than without ACS (16.76% vs. 5.45%, p-value < 0.01). Conclusions ACS is not an uncommon complication after TMVR. The occurrence of ACS after TMVR is associated with high in-hospital mortality, longer length of stay, and higher hospital charges. The strongest predictors of ACS in these patients are the development of acute limb ischemia, cardiogenic shock, and a history of CAD.

Dynamics of Thrombogenicity and Platelet Function and Correlation with Bleeding Risk in Patients Undergoing M-TEER Using the PASCAL System.

Transcatheter mitral valve repair is performed in a patient population at risk for thrombotic and bleeding events. The effects on platelet function and reactivity and their association with bleeding events after mitral transcatheter edge-to-edge therapy (M-TEER) have not been systematically examined. We sought to investigate the association of different parameters of platelet function and thrombogenicity with bleeding events post M-TEER. In this single-center study, 100 consecutive patients with mitral regurgitation receiving TEER were analyzed. Blood was taken directly from the guide-catheter in the left atrium before and after placing the device. Blood samples were analyzed using impedance aggregometry (Multiplate) and TEG6s. The results were compared pre- and postprocedural. The primary outcome was any bleeding complication according to the Bleeding Academic Research Consortium classification within 6 months. A total of 41 patients experienced bleeding events. TEG analysis showed a significant decrease in ADP aggregation and increase in ADP inhibition. In ROC-analysis, TEG ADP aggregation and inhibition and Multiplate ADP aggregation showed moderate predictive values for bleeding events. The delta-ADP-Test (Multiplate) showed the strongest prediction of bleeding (area under the curve: 0.69). Adding platelet function and TEG markers to a model of clinical bleeding risk factors improved the prediction for bleeding events. This study indicates that thrombogenicity might be affected immediately after M-TEER probably due to changes in flow conditions. In particular, platelet aggregation involving the ADP receptor pathway significantly correlated with postprocedural bleeding events. Whether these results could guide peri-interventional antithrombotic therapy and improve peri- and postprocedural outcome requires further investigation.

Hyperbilirubinemia and hepatic dysfunction in patients undergoing cardiac surgery: Predictors and outcome- A single center prospective study

Background: We aim to assess the incidence and perioperative risk factors for hyperbilirubinemia and hepatic dysfunction after cardiac surgery and determine its influence on early operative outcome. Methods: This prospective observational study was conducted on 485 patients who underwent cardiac surgical procedures from June 2022 to October 2023. Postoperative hyperbilirubinemia was defined as serum total bilirubin &gt;2.0 mg/dl. Results: The overall incidence of post operative hyperbilirubinemia was 24.5% (119 patients). Total and indirect bilirubin, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase was measured preoperatively and at day 1, day 2 and day 5. Patients undergoing valve repair or replacement had the highest incidence of hyperbilirubinemia (37.1%), followed by coronary artery bypass grafting with concomitant valve surgery (35.3%), congenital heart surgery (24.5%), and coronary artery bypass alone (12.4%). Post operative hyperbilirubinemia was associated with increased duration of inotropic support (p=0.0001), mechanical ventilation (p=0.0001), intensive care unit stay (p=0.001), hospital stay (p=0.006), and mortality (p=0.014). The perioperative factors associated with postoperative hyperbilirubinemia were increased preoperative bilirubin level (p&lt;0.0001), preoperative prothrombin time (p&lt;0.0001), cardiopulmonary bypass time (p=0.026), aortic cross clamp time (p=0.004), and blood transfusion units (p=0.0001). A significant increase of total bilirubin, aspartate aminotransferase, and alkaline phosphatase were noted in the second postoperative day. Significant relation was seen between hypotension and alkaline phosphatase, and aspartate aminotransferase change but hypothermia had not affected alanine aminotransferase, total bilirubin and indirect bilirubin change. Conclusions: Post operative hyperbilirubinemia is seen in patients undergoing cardiopulmonary bypass and is associated with high hospital mortality. The factors associated with its occurrence are increased preoperative bilirubin level, preoperative prothrombin time, cardiopulmonary bypass time, aortic cross clamp time, and blood transfusion units. Persistent hyperbilirubinemia is associated with a worse outcome than early transient hyperbilirubinemia.

Efficacy of Double Valve Replacement/Repair in Patients with Reduced Left Ventricular Ejection Fractions

Introduction: A reduced left ventricular ejection fraction (LVEF) is a known risk factor for double valve replacement or aortic valve replacement in combination with concomitant mitral valve repair (DVR) and is associated with high morbidity and mortality rates. In this study, we sought to analyze the 30-day mortality and long-term survival rates of patients with reduced LVEFs. Methods: A multicenter, retrospective, observational cohort study of patients who underwent DVR was performed at four centers from January 2016 to December 2021. LVEFs were categorized as 41%–50% (n = 120) or ≤40% (n = 58). For the effects of risk factors on 30-day mortality, binary logistic regression was performed. Survival rates were assessed with the Kaplan–Meier method. Results: A total of 178 patients who underwent DVR were included in this study, of whom 67.42% (n = 120) had LVEFs ranging from 41–50% and 32.58% (n = 58) had LVEFs ≤40%. More mechanical valves and tricuspid valve-forming rings were applied in the LVEF ≤40% group (68.97% versus 53.33%, p = 0.047; 31.03% versus 10.83%, p = 0.001). The 30-day mortality rates of DVR patients with LVEFs ranging from 41–50% and ≤40% were 8.33% and 17.24%, respectively (p = 0.078). During the follow-up period, there were no significant differences in long-term survival (log rank p = 0.75). On multivariable logistic regression analysis, age &gt;65 years [odds ratio (OR): 5.559, 95% confidence interval (CI): 1.668–18.524, p = 0.005] and cardiopulmonary bypass (CPB) duration &gt;200 min (OR: 5.031, 95% CI: 1.773–14.277, p = 0.002) were significantly associated with the likelihood of 30-day mortality. Conclusions: Although the differences in 30-day mortality and long-term survival rates between DVR patients with LVEFs ranging from 41–50% and ≤40% were not statistically significant in our cohort, an age &gt;65 years and a CPB duration &gt;200 min were predictors of 30-day mortality.

Adjuncts to annuloplasty in atrial functional mitral regurgitation.

Atrial fibrillation is the most common cardiac arrhythmia, leading to progressive dilation of cardiac chambers, abnormal contraction patterns of the atria and ventricles and, potentially, atrioventricular valvular insufficiency. Moreover, heart failure with preserved ejection fraction is often present and closely intertwined with disease initiation and progression. Surgical valve repair with a true-sized ring annuloplasty is a well-established treatment option in atrial functional mitral regurgitation. While early results are good, recent studies have brought the durability of this repair approach into question, highlighting the need for further refinement of the surgical strategy. In particular, repair strategies that simultaneously target the mitral valve as well as the left ventricle could provide improved repair durability.