Surgery For Mitral Valve Disease Research Articles

Effects of Atrial Fibrillation Radiofrequency Ablation in Patients Aged > 75 Years Undergoing Mitral Valve Surgery

Few data exist about the efficacy of radiofrequency (RF) maze procedures in elderly patients with atrial fibrillation (AF) undergoing surgery for mitral valve disease. The aim of the present investigation was to evaluate the effects of AF ablation associated with mitral valve surgery on the recovery and long-term maintenance of sinus rhythm in elderly patients aged > 75 years. Moreover, we evaluated the effects on survival. This study included 96 consecutive patients with AF (42 men and 56 women) aged > 75 years (mean age 78 ± 3) who underwent RF ablation associated with mitral valve surgery (group I). This group was compared to 209 younger patients (mean age 65 ± 8 years) treated in the same period (group II). Baseline clinical and echocardiographic characteristics were similar in the two groups. Four patients died during hospitalization, one aged > 75 years. In surviving patients at the end of the follow-up period, sinus rhythm was present respectively in 64% of the elderly and 74% of younger patients (p = 0.778). The rate of persistence of sinus rhythm without AF recurrences (38% vs. 41%, p = 0.705) was similar in the two groups. After surgery, sinus rhythm was frequently never regained in aged patients (27% vs. 20%, p = 0.231). Elderly patients more frequently needed permanent pacing and had more hospitalizations and a higher number of non-AF atrial tachyarrhythmias. At eight-year follow-up, survival was lower in older patients (48% aged > 75 vs. 79% aged < 75 years). Elderly patients had a similar long-term rate of stable sinus rhythm maintenance in comparison to younger patients after AF radiofrequency ablation associated with mitral valve surgery. However, they needed more frequent permanent pacing and had higher rates of hospitalizations and post-procedural atrial tachyarrhythmias. The effects of survival are difficult to evaluate due to the different life expectancies of the two groups.

Prediction of Surgical Approach in Mitral Valve Disease by XGBoost Algorithm Based on Echocardiographic Features.

In this study, we aimed to develop a prediction model to assist surgeons in choosing an appropriate surgical approach for mitral valve disease patients. We retrospectively analyzed a total of 143 patients who underwent surgery for mitral valve disease. The XGBoost algorithm was used to establish a predictive model to decide a surgical approach (mitral valve repair or replacement) based on the echocardiographic features of the mitral valve apparatus, such as leaflets, the annulus, and sub-valvular structures. The results showed that the accuracy of the predictive model was 81.09% in predicting the appropriate surgical approach based on the patient's preoperative echocardiography. The result of the predictive model was superior to the traditional complexity score (81.09% vs. 75%). Additionally, the predictive model showed that the three main factors affecting the choice of surgical approach were leaflet restriction, calcification of the leaflet, and perforation or cleft of the leaflet. We developed a novel predictive model using the XGBoost algorithm based on echocardiographic features to assist surgeons in choosing an appropriate surgical approach for patients with mitral valve disease.

Surgical ablation in rheumatic heart disease-Uncharted territory.

Atrial fibrillation is a common arrhythmia with a large impact on society and on patients. Rheumatic valve disease is still prevalent in low- and medium-income countries. Performing surgical ablation during surgery for mitral valve disease has been shown to restore sinus rhythm in most patients. In this issue of the Journal of Cardiac Surgery, Ma et al., publish a meta-analysis of surgical ablation in patients with rheumatic heart disease (RHD). They found no difference in short-term outcomes with a higher incidence of restoration to sinus rhythm. In mid- to long-term follow-up, there was no difference in mortality with a signal towards more permanent pacemaker implantation. Despite some inherent limitations and some methodological flows, this meta-analysis has important insights and is valuable for surgeons taking care of patients with RHD.

A study to assess the impact of left atrial size reduction in outcome of the patients undergoing mitral valve surgery for mitral valve disease with left atrial enlargement in a tertiary care hospital

Background: Rheumatic mitral valve disease (mitral stenosis or regurgitation) remains the common heart disease in developing countries. Mitral valve is involved in 99% of cases. The prognostic implication of LA (left atrium) size has also been shown in high-risk subgroups, such as patients with acute myocardial infarction, atrial arrhythmia, LV dysfunction, or dilated cardiomyopathy, and patients undergoing valve replacement for aortic stenosis and mitral regurgitations. Objective of the study was to study the impact of left atrial size reduction in patients undergoing mitral valve surgery for mitral valve disease with left atrial enlargement on clinical outcome and echocardiographic parameters.Methods: A prospective study was done at department of cardiovascular and thoracic surgery, Sri Venkateshwara institute of medical sciences, Tirupati from June 2012 and June 2013.The study population consisted of patients with rheumatic mitral valve disease with or without tricuspid valve disease with left atrial size enlargement who underwent mitral valve surgery alone and mitral valve surgery with left atrial reduction. Twenty consecutive subjects were taken in each group during the study period. Results: The age range is 21 to 61 years. There means age is 39.7±10.3 years. in the study group. Following MVR significant improvement in the NYHA (New York Heart Association) functional class was noted in all the patients. The decrease in RVSP, LA size, and TR was noted in all the patients.Conclusions: It seems reasonable to suggest that patients who undergo LA reduction along with MVR have significant improvement in clinical outcome and NYHA functional class with less thromboembolic complications during long term follow up.

RF72 RIGHT VENTRICLE EVALUATION BY CARDIAC MAGNETIC RESONANCE BEFORE AND AFTER MITRAL VALVE SURGERY

Introduction: There has been growing attention for the development of functional tricuspid regurgitation (TR) and right ventricular dysfunction after left-sided valve surgery. The fate of right ventricle function after mitral valve surgery is still not well defined. Our study aims to describe the evolutions of RV volumes and function evaluated by cardiac magnetic resonance (CMR) after mitral valve surgery in patients with less then severe tricuspid regurgitation. Methods: Sixty patients undergoing mitral valve surgery (58 for degenerative and 2 for functional disease) were analysed by CMR preoperative and at 6 months. Two patient with severe tricuspid regurgitation and 6 who received a tricuspid annuloplasty were exclude, with 52 patients remained for the analysis. Indexed end-diastolic and systolic volumes (RVEDVi and RVESVi) ejection fraction (RVEF) and stroke volume (RVSV) were the primary outcomes of the study. Multivariate linear regression was used to identify risk factors related to the right ventricle volumes and function improvement. Results: Mean age was 57+/-21 years and 40 patients were male. In the global population RVEDVi(83.5 ml/m2 vs 80.1 ml/m2, p &lt; 0.01), RVESVi(43.4 ml/m2 vs 38.6 ml/m2, p &lt; 0.01) and RV ejection fraction(48.3% vs 52.4%, p &lt; 0.01) improved significantly while the stroke volume(78.1 ml vs 79.7 ml, p = 0.6) did not. Preoperative RVESVi(p &lt; 0.01) and RVEDVi were the most significant predictors of improvement in volumes after surgery(p &lt; 0.01). Conclusion: Mitral valve surgery seems to have a positive effect on right ventricle volumes and function improve after surgery for mitral valve disease in patients with less than severe tricuspid regurgitation without other prophylactic procedure.

Surgical ablation in patients undergoing mitral valve surgery: impact of lesion set and surgical techniques on long-term success.

To assess the results and impact of lesion set and surgical technique on long-term success of surgical ablation during mitral surgery. The patient population consisted of 685 subjects with persistent and long-standing persistent atrial fibrillation (AF) undergoing cardiac surgery for mitral valve disease as the primary indication and concomitant ablation between January 2003 and January 2012 at three institutions. One hundred and sixty-six underwent unipolar (24.2%), 371 (54.2%) bipolar, and 148 (21.6%) had combined ablation. Median follow-up was 58.4 months (interquartile range 43.3-67.9). To appropriately account for death, a competing risk model was employed to identify predictors of cumulative incidence of recurrent AF among lesion set and surgical techniques. Eight-year freedom from recurrent arrhythmia without antiarrhythmic drugs was 0.60 ± 0.02. Success rate was higher using bipolar radiofrequency (RF) (P < 0.001), after performing mitral isthmus line (P = 0.003) and following the biatrial technique (P < 0.001). Competing risk regression revealed that use of unipolar RF [sub-hazard ratio (SHR) 2.41 (1.52-3.43), P < 0.001], combined unipolar/bipolar ablation [SHR 1.93 (0.89-2.57), P = 0.003] and the absence of right atrial ablation [SHR 2.79 (1.27-3.48), P < 0.001] were predictors of cumulative incidence of long-term recurrence. Our experience suggests that the use of bipolar clamp improves long-term results in surgical treatment of AF and that right-sided ablation should be routinely added. Randomized studies are necessary to confirm our findings.

Value of robotically assisted surgery for mitral valve disease.

The value of robotically assisted surgery for mitral valve disease is questioned because the high cost of care associated with robotic technology may outweigh its clinical benefits. To investigate conditions under which benefits of robotically assisted surgery mitigate high technology costs. Clinical cohort study at a large multispecialty academic medical center comparing costs of robotically assisted surgery with 3 contemporaneous conventional surgical approaches for degenerative mitral valve disease. From January 1, 2006, through December 31, 2010, a total of 1290 patients with a mean (SD) age of 57 (11) years underwent mitral valve repair for regurgitation from posterior leaflet prolapse. Robotically assisted surgery was performed in 473 patients, complete sternotomy in 227, partial sternotomy in 349, and anterolateral thoracotomy in 241. Comparisons were based on intent to treat, with 3 propensity-matched groups formed based on demographics, symptoms, cardiac and noncardiac comorbidities, valve pathophysiologic disorders, and echocardiographic measurements: robotic vs sternotomy (198 pairs) vs partial sternotomy (293 pairs) vs thoracotomy (224 pairs). Mitral valve repair. Cost of care (expressed as robotic capital investment, maintenance of equipment, and direct technical hospital costs) and benefit of care (based on differences in recovery time). Cost of care (median [15th and 85th percentiles]) for robotically assisted surgery exceeded that of alternative approaches by 26.8% (-5.3% and 67.9%), 32.1% (-6.1% and 69.6%), and 20.7% (-2.4% and 48.4%) for complete sternotomy, partial sternotomy, and anterolateral thoracotomy, respectively. Higher operative costs were partially offset by lower postoperative costs and earlier return to work: a median (15th and 85th percentiles) of 35 (19 and 63) days for robotically assisted surgery, 49 (21 and 109) days for complete sternotomy, 56 (30 and 119) days for partial sternotomy, and 42 (18 and 90) days for anterolateral thoracotomy. Resulting net differences (median [15th and 85th percentiles]) in the cost of robotic surgery vs the 3 alternatives were 15.6% (-14.7% and 55.1%), 15.7% (-19.4% and 51.2%), and 14.8% (-7.4% and 43.6%), respectively. Beyond a volume threshold of 55 to 100 robotically assisted operations per year, distribution of the cost of this technology broadly overlapped those of conventional approaches. In exchange for higher procedural costs, robotically assisted surgery for mitral valve repair offers the clinical benefit of least-invasive surgery, lowest postoperative cost, and fastest return to work. The value of robotically assisted surgery that is similar to that of conventional approaches can be realized only in high-volume centers.

Almanac 2012 adult cardiac surgery

This review covers the important publications in adult cardiac surgery in the last few years, including the current evidence base for surgical revascularisation and the use of off-pump surgery, bilateral internal mammary arteries and endoscopic vein harvesting. The changes in conventional aortic valve surgery are described alongside the outcomes of clinical trials and registries for transcatheter aortic valve implantation, and the introduction of less invasive and novel approaches of conventional aortic valve replacement surgery. Surgery for mitral valve disease is also considered, with particular reference to surgery for asymptomatic degenerative mitral regurgitation.

To the issue of normalizing the heart rhythm in patients with mitral valve disease complicated by atrial fibrillation

Aim. To examine an opportunity of sinus rhythm recovery in patients with mitral valve disease and atrial fibrillation (AF) by the means of surgery and concomitant procedures. Methods. 180 patients with AF who underwent mitral valve surgery using cardiopulmonary bypass in 2007-2011 were examined. Patients’ mean age was 52.5±0.5 years, 71 (39.4%) were male, 109 (60.6%) - female. Patients were divided into 3 groups: 22 patients with paroxysmal AF were included in Group I. 109 patients with persistent AF who underwent mitral valve surgery only were allocated to the Group II. 49 patients with persistent AF who underwent additional pulmonary vein isolation (radiofrequency ablation) were included in the Group III. Results. 83 (46.1%) of patients had single mitral valve disease, 62 (34.4%) of patients had multiple valve disease with involvement of tricuspid valve, 21 (11.7%) of patients had multiple valve disease with involvement of aortic valve, 21 (11.7%) of patients had all abovementioned valves involved. Mean arrhythmia duration was 36.3±3.8 months. Sinus rhythm was restored during the surgery in 16 (72.7%) patients of the Group I, in 60 (55.0%) patients of the Group II, in 41 (83.7%) patients of the Group III. Sinus rhythm was still registered at the discharge in 14 (63.6%), 19 (17.4%) and 13 (26.5%) respectively. Conclusion. It is possible to recover and hold regular rhythm in early postoperative period in more than 60% of cases in patients who underwent surgery for mitral valve disease and concomitant paroxysmal AF. Simultaneous radiofrequency ablation performed in patients with persistent AF increases sinus rhythm recovery rate in first day after surgery.

Almanac 2012: adult cardiac surgery. The national society journals present selected research that has driven recent advances in clinical cardiology

This review covers the important publications in adult cardiac surgery in the last few years, including the current evidence base for surgical revascularisation and the use of off-pump surgery, bilateral internal mammary arteries and endoscopic vein harvesting. The changes in conventional aortic valve surgery are described alongside the outcomes of clinical trials and registries for transcatheter aortic valve implantation, and the introduction of less invasive and novel approaches of conventional aortic valve replacement surgery. Surgery for mitral valve disease is also considered, with particular reference to surgery for asymptomatic degenerative mitral regurgitation.

Almanac 2012: Adult cardiac surgery: The national society journals present selected research that has driven recent advances in clinical cardiology

This review covers the important publications in adult cardiac surgery in the last few years, including the current evidence base for surgical revascularisation and the use of off-pump surgery, bilateral internal mammary arteries and endoscopic vein harvesting. The changes in conventional aortic valve surgery are described alongside the outcomes of clinical trials and registries for transcatheter aortic valve implantation, and the introduction of less invasive and novel approaches of conventional aortic valve replacement surgery. Surgery for mitral valve disease is also considered, with particular reference to surgery for asymptomatic degenerative mitral regurgitation.

Almanac 2012: Adult cardiac surgery: The national society journals present selected research that has driven recent advances in clinical cardiology

This review covers the important publications in adult cardiac surgery in the last few years, including the current evidence base for surgical revascularisation and the use of off-pump surgery, bilateral internal mammary arteries and endoscopic vein harvesting. The changes in conventional aortic valve surgery are described alongside the outcomes of clinical trials and registries for transcatheter aortic valve implantation, and the introduction of less invasive and novel approaches of conventional aortic valve replacement surgery. Surgery for mitral valve disease is also considered, with particular reference to surgery for asymptomatic degenerative mitral regurgitation.

Almanac 2012 adult cardiac surgery: The national society journals present selected research that has driven recent advances in clinical cardiology

Abstract This review covers the important publications in adult cardiac surgery in the last few years, including the current evidence base for surgical revascularisation and the use of off-pump surgery, bilateral internal mammary arteries and endoscopic vein harvesting. The changes in conventional aortic valve surgery are described alongside the outcomes of clinical trials and registries for transcatheter aortic valve implantation, and the introduction of less invasive and novel approaches of conventional aortic valve replacement surgery. Surgery for mitral valve disease is also considered, with particular reference to surgery for asymptomatic degenerative mitral regurgitation.

Almanac 2012: Adult cardiac surgery: The national society journals present selected research that has driven recent advances in clinical cardiology

This review covers the important publications in adult cardiac surgery in the last few years, including the current evidence base for surgical revascularisation and the use of off-pump surgery, bilateral internal mammary arteries and endoscopic vein harvesting. The changes in conventional aortic valve surgery are described alongside the outcomes of clinical trials and registries for transcatheter aortic valve implantation, and the introduction of less invasive and novel approaches of conventional aortic valve replacement surgery. Surgery for mitral valve disease is also considered, with particular reference to surgery for asymptomatic degenerative mitral regurgitation.

Erratum for a missing eComment 'Left ventricular rupture after mitral valve replacement: the most dreaded complication'

Erratum for a missing eComment to ‘Preservation versus non-preservation of mitral valve apparatus during mitral valve replacement: a meta-analysis of 3835 patients’ [Interact CardioVasc Thorac Surg 2012;15:1033–1039]† The publisher regrets having failed to include the following eComment related to the article by Sa et al. [1]. We express our sincere apologies to the author of this eComment. eComment. Left ventricular rupture after mitral valve replacement: the most dreaded complication Author: Ovidio A. Garcia-Villarreal Department of Cardiac Surgery, Hospital of Cardiovascular Disease No. 34, IMSS, Monterrey, Mexico. E-mail: moc.liamtoh@vgoidivo. doi:10.1093/icvts/ivs467 © The Author 2012. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. I have read with great interest the article by Sa et al [1]. This meta-analysis addresses a very important topic in surgery for mitral valve disease, that is, the preservation of subvalvular structures during mitral valve replacement (MVR) and its inherent consequences. As the authors note, after the analysis of 3835 patients (1918 for MVR with subvalvular preservation and 1917 for MVR with non-preservation) the odds ratio for early mortality (0.418, p <0.001), postoperative low cardiac output syndrome (0.299, p <0.001) and 5-year mortality (0.380, p <0.001) were in favour of MVR with subvalvular preservation. Unfortunately, this meta-analysis is not specific for anterior, posterior or bileaflet preservation. Many cardiac surgeons are reluctant to preserve the anterior mitral subvalvular complex due to the risk of left ventricular (LV) outflow tract obstruction. At the same time, there are no papers that conclusively prove the role of anterior subvalvular mitral structures in the concern discussed here. With regard to posterior subvalvular preservation, this is a common and easy procedure to perform in the real world. Particular care should be taken in rheumatic cases because of leaflet calcification and chordae thickening. But perhaps we have overlooked the relationship between the section of the posterior subvalvular apparatus and the LV rupture after MVR. This is a rare but dreaded and potentially lethal complication of mitral valve surgery, with an incidence of up to 1% and an associated mortality of up to 85% [2]. Treasure et al. [3] described type I and type II left ventricular ruptures as those located in the posterior atrioventricular groove, and the area overlying the papillary muscles, respectively. Type III cited by Miller et al. [4] is in an intermediate zone between the base of the papillary and the left atrioventricular sulcus, which is directly related to untethered loop hypothesis proposed by Cobbs et al. [5]. The supporting structures of the posterior LV wall form a loop. The outer portion is composed of longitudinal muscle fibres in the LV wall, and the inner portion consists of the papillary muscles with the chordae attached to the annulus of the posterior leaflet. Thus, the surgical division of the posterior leaflet chordae can seriously weaken the posterior LV wall. In rheumatic cases with advanced alteration of the valvular structures, such as chordae thickening and shortening, and leaflet thickening and calcification, preservation of the second and third order chordae tendinae of the posterior mitral leaflet may be enough to avoid this catastrophe. Conflict of interest: none declared

Surgical ablation for atrial fibrillation

This paper reviews the history of surgical procedures developed for eradication of atrial fibrillation (AF) during cardiac surgery for structural heart disease, and in patients with AF without other indication for cardiac surgery. Current evidence indicates that, despite their proven efficacy, the Cox-Maze procedure and its modifications require cardiopulmonary bypass and cannot be easily justified in the case of AF without other indication for cardiac surgery. In patients undergoing cardiac surgery for mitral valve disease, concomitant ablation techniques using modifications of the Maze and alternative energy sources appear to be safe and effective in treating AF, especially in non-rheumatic disease. Minimally invasive epicardial ablation has been recently developed and can be performed on a beating heart through small access incision ports. Various techniques combining pulmonary vein isolation, ganglionated plexi ablation, and left atrial lines have been tried. Initial results are promising but further clinical experience is required to establish ideal lesion sets, appropriate energy sources, and the benefit-risk ratio of such an approach in patients without other indication for cardiac surgery. The role of surgical ablation in the current management of AF is under investigation.

Functional Tricuspid Regurgitation in Mitral Valve Disease: Epidemiology and Prognostic Implications

In this review we summarize the data on epidemiology and natural history of functional tricuspid valve regurgitation as it applies to surgery for mitral valve disease. Tricuspid regurgitation in the context of mitral valve disease is frequent and is associated with substantial reduction in survival and quality of life. In many patients, the correction of left-sided cardiac lesions does not lead to resolution of tricuspid regurgitation. Significant tricuspid regurgitation after mitral valve surgery portends a poor prognosis, a course that is often not altered by subsequent surgical therapy. Although a liberal approach to tricuspid annuloplasty is widely practiced, the evidence that this approach alters the natural history of functional tricuspid regurgitation is not yet available, so it is not certain how much of the negative impact of tricuspid regurgitation is causative, rather than confounding, and to what degree we will improve long-term outcomes of mitral valve surgery by liberal tricuspid annuloplasty.

Institutional and national trends in isolated mitral valve surgery over the past decade

To review trends in practice for mitral valve surgery in the US over the past decade. Advances in the understanding of mitral valve pathophysiology and the technology involved with mitral valve surgery have led to significant changes of the current practice for mitral valve surgery, with mitral valve repair being the technique of choice. Mitral valve repair is currently applied to close to 60% of patients having surgery for mitral valve disease in the US. This trend in the change of practice also contributed to a sharp decrease in the use of mechanical mitral valve prosthesis even in the younger population. Current practice for mitral valve surgery in the US reflects a steady increase in performed procedures over the last decade. The increased use of mitral valve repair techniques to address mitral valve disease can be related to increased surgical experience and greater understanding of the pathophysiology of mitral valve disease as well as the improved outcome related to mitral valve repair.

Minimally Invasive Cardiac Surgery Using a Flexible Aortic Clamp

Minimally invasive surgery for mitral valve disease has been performed using a variety of technologies, some of which are complex, have a steep learning curve, and are expensive. We have adopted a simple cost-effective approach over the last 7 years to perform a variety of minimally invasive procedures with excellent outcomes. There have been no strokes, no mortalities, and no episodes of limb ischemia in our series. No patient has required reoperation.

Superior Transseptal Approach to Mitral Valve Is Associated With a Higher Need for Pacemaker Implantation Than the Left Atrial Approach

Several studies suggest that the superior transseptal approach to mitral valve surgery leads to sinus node dysfunction. The clinical consequences are not known. Consecutive patients undergoing surgery for mitral valve disease from November 16, 1994 through January 26, 2004 were retrospectively evaluated. The surgeons used either the superior transseptal (group A) or left atrial approach (group B). The risk of pacemaker implantation associated with the superior transseptal approach as compared with the left atrial approach was estimated using the multivariate Cox regression analysis to adjust for possible confounders. We included 577 patients, 150 in group A and 427 in group B. Forty-four patients had a pacemaker implanted after the surgery; 17 in group A and 27 in group B (p = 0.010). The superior transseptal approach was an independent risk factor of pacemaker implantation in multivariate analysis (hazard ratio 2.2 [1.2 to 4.1], p = 0.014). Nineteen patients had a pacemaker implanted because of sinus node dysfunction; 9 in group A and 10 in group B (p = 0.017). Group A was an independent predictor of pacemaker implantation because of sinus node dysfunction in bivariate analyses. The risk of pacemaker implantation because of atrioventricular conduction disturbances was not different between the groups (p = 0.178). The superior transseptal approach has a higher risk of clinically significant sinus node dysfunction than the left atrial approach.