Mitral Valve Repair Surgery Research Articles

Clinical value of preoperative cardiac magnetic resonance imaging and echocardiography to identify post-operative left ventricular dysfunction in primary mitral regurgitation

Abstract Background Post-operative left ventricular (LV) dysfunction remains a common adverse consequence in patients with primary mitral regurgitation (MR) undergoing mitral valve (MV) surgery. Currently, cardiac magnetic resonance imaging (CMR) is a very useful imaging modality that complements echocardiography (Echo) in providing accurate grading of MR severity in these patients. Yet it remains unclear whether the consideration of CMR-assessed LV volumes and function would offer advantages over conventional echocardiographic LV measurements in identifying patients at risk of LV systolic dysfunction after MV surgery. Purpose We sought to compare the relationship between CMR- or Echo-assessed preoperative LV volumetric and function measurements and the occurrence of post-operative LV systolic dysfunction in patients with chronic significant primary MR undergoing MV surgery. Methods The study population consisted of 214 patients (median age: 59 years, 20% women) with chronic significant primary MR due to MV prolapse or flail who underwent echocardiography and CMR in 2 tertiary centers, between 2005 and 2022, before MV repair surgery. The endpoint was the occurrence of post-operative LV systolic dysfunction (defined as LV ejection fraction [EF] < 50%) at echocardiographic follow-up when available. ROC curves were used to evaluate relations between preoperative Echo or CMR characteristics and post-operative LV dysfunction. Side-by-side comparisons of AUCs were done using DeLong’s tests. Results At echocardiographic follow-up, 40 patients (19%) had post-operative LV dysfunction, with a median follow-up time of 8.6 months (interquartile range: 6.7 – 12.5 months) after MV surgery. Compared with those with normal LV function, patients with post-operative LV dysfunction exhibited higher absolute and indexed (ind) LV end-systolic diameters (ESD) and volumes (ESV) (all p<0.043, Figure 1). These patients also showed lower preoperative CMR-assessed LVEF (p=0.004), while Echo-LVEF did not show a significant relationship (p=0.071). Additionally, no relationship was found between MR quantitative parameters (regurgitant orifice area, volume, or fraction) and post-operative LV function (all p>0.247). The AUCs of the imaging preoperative characteristics tested (LVESD, indLVESD, Echo-indLVESV, CMR-indLVESV, Echo-LVEF, CMR-LVEF) numerically ranged from 0.59 (0.50-0.69), p=0.034 (Echo-LVEF) to 0.69 (0.60-0.77), p<0.001 (Echo-indLVESD, Figure 2). No significant differences were found in the side-by-side comparisons of the AUCs (all p>0.118). Conclusion In this series of patients with chronic significant primary MR who underwent MV surgery, conventional preoperative Echo and CMR LV measurements had similar diagnostic value in detecting post-operative LV systolic dysfunction. Our results indicate that both echocardiography and CMR are valuable imaging tools for identifying primary MR patients at risk of post-operative LV dysfunction. Figure 1 Figure 2

Aorto-mitral angle: an emerging indicator for successful alcohol septal ablation in hypertrophic obstructive cardiomyopathy - a pilot study

Abstract Background Approximately 10-20% of patients with hypertrophic obstructive cardiomyopathy (HOCM) undergoing alcohol septal ablation (ASA) exhibit a suboptimal response, despite accurate targeting of the septal artery. This suboptimal response may be due to structural and functional factors related to the mitral valve and left ventricular (LV) dimensions. Currently, there is a lack of specific parameters or cutoffs to predict ASA success. The aorto-mitral angle is crucial for predicting systolic anterior motion (SAM) in mitral valve repair surgery, but its relationship with ASA outcomes remains underexplored. Purpose This study aims to investigate the relationship between aorto-mitral angle values and the success of alcohol septal ablation, and to assess the impact of this parameter on ASA outcomes. Methods The study retrospectively included 23 HOCM patients who underwent ASA in our clinic, with data collected from thorough evaluations conducted before and at least six months after the procedure. The left ventricular outflow tract pressure gradient (LVOT PG) and other standard parameters were measured using transthoracic echocardiography. The aorto-mitral angle was assessed through three-dimensional data acquisition during transoesophageal echocardiography, analyzed offline using specific software (zoom 3D of the mitral valve, MVQ). Results Nineteen patients experienced successful ASA, defined as a >50% reduction in LVOT PG compared to baseline, while four patients had suboptimal results. There were no significant differences in baseline LV dimensions, LVOT PG, age, or comorbidities between the groups. The aorto-mitral angle was significantly higher in patients with successful ASA (138.21 ± 7.6 versus 115 ± 9.2 degrees, p<0.001). This angle correlated with the percentage decrease in LVOT PG (R = 0.59, p = 0.02), though the correlation with the absolute decrease was not statistically significant (R = 0.38, p = 0.06). After further validation, the aorto-mitral angle may be useful for predicting ASA success (logistic regression odds ratio 1.37, 95% confidence interval (1.01, 1.86), p = 0.04). Additionally, significant differences were found between redundant anterior mitral leaflet (AML) length, anterior displacement of the coaptation point, and ASA success in this cohort (p = 0.04 for both). Conclusion The aorto-mitral angle appears to play a role in the obstruction mechanism of HOCM and could serve as a valuable predictor for ASA success. These findings may prompt further investigation and potential inclusion of this parameter in a prediction model alongside other mitral valve and LV size parameters.

A Novel Transcatheter Posterior Ventricular Anchoring Neochordoplasty Mitral Valve Repair Device.

Advancements in minimally invasive technologies to decrease postoperative morbidity and recovery times represent a large opportunity for mitral valve repair operations. However, current technologies are unable to replicate gold standard surgical neochord implantation. We developed a novel neochordal repair device, Minimally Invasive Ventricular Anchoring Neochordoplasty (MIVAN), which operates via transcatheter, trans-septal anchoring to the posterior ventricular wall. We evaluated MIVAN in an ex vivo heart simulator and compared it with surgical neochordal repair and MitraClip using a prolapse model. Upon MIVAN repair of the model (n = 5), regurgitant fraction was reduced from 19.46 ± 1.77% to 7.30 ± 0.99% (p = 0.01). Surgical neochordal repair reduced regurgitant fraction to 5.65 ± 0.66%, but there was no significant difference between MIVAN and surgical repair (p = 0.22). Unpaired MitraClip repair had significantly higher regurgitant fraction of 11.9 ± 1.40%, compared with those of neochord (p < 0.01) and MIVAN (p = 0.03) repairs. MIVAN represents a high-value opportunity for minimally invasive mitral valve repair. The benefits of the percutaneous, trans-septal approach for implantation on the posterior ventricular wall necessitate the expanded exploration of this device as a treatment alternative.

Learning curve of robotic mitral repair: prospective two-centre study of proficiency and clinical outcomes.

Robotic-assisted mitral valve repair surgery has a steep learning curve, and it is not clear whether previous experience in minimally invasive mitral valve surgery (MIMVS) facilitates this process. We aimed to investigate the initial experience of 2 cardiac centres starting their robotic programmes, evaluating the impact of previous MIMVS experience. Retrospective analysis was performed for the 1st consecutive cases operated due to severe degenerative mitral valve regurgitation using the robotic surgical platform in 2 European centres, 1 transitioning from conventional surgery (centre 1) and the other from mini thoracotomy MIMVS (centre 2). Cumulative sum analysis was used to evaluate the learning process using both surgical times and a combined primary outcome including relevant intra- and postoperative results. First 62 patients in each centre were included. All median surgical times were shorter in centre 2: cardiopulmonary bypass: 238 vs 115 min, P < 0.001; cross-clamp: 143 vs 82 min, P < 0.001; and total intervention: 313 vs 228 min, P < 0.001. The combined primary outcome showed no significant differences (9.7% vs 8%; P = 1). However, the turning point making the end of the learning phase was detected at the 60th case in centre 1 and at the 50th in centre 2. Regarding surgical time, the learning curve was steeper in centre 1 with both cardiopulmonary bypass and cross-clamp overcoming the learning phase after 32 cases, as compared to 16 cases in centre 2. A successful robotic-assisted mitral repair programme can be safely started coming from either conventional open approach or mini thoracotomy MIMVS. However, previous mini thoracotomy MIMVS experience had positive impact on the initial learning curve.

Establishment and validation of a prediction model for the outcome of rheumatic mitral valve repair surgery based on transthoracic echocardiography

Abstract Background The outcome of mitral valve repair over replacement in degenerative diseases has been recognized, but the patient selection of mitral valve repair in rheumatic diseases are still controversial. At present, there is a lack of comprehensive evaluation methods for rheumatic mitral valve disease, which cannot guide the selection of patients before surgery. Purpose The aim of this study was to establish a comprehensive evaluation method and innovative indicators for rheumatic mitral valve disease using transthoracic echocardiography, and to establish a model for predicting the outcome of rheumatic mitral valve repair. Methods This prospective, multicenter, observational cohort study included 167 patients who underwent rheumatic mitral valve surgery in 4 centers from 2022 to 2023. Each enrolled patient underwent a comprehensive transthoracic echocardiography evaluation and measured 94 ultrasound indicators, mainly covering leaflets, annulus, subvalvular apparatus, and atrial and ventricular function. The main endpoint event was the failure of mitral valve repair (including switching to replacement after repair, and moderate to severe stenosis or regurgitation during follow-up after repair). Patients were randomly assigned to the modeling and validation groups at a ratio of 7:3. In the modeling group, LASSO regression was used for variable selection, and logistic regression was used for modeling. A nomogram was drawn and a webpage rating calculator was created. In the validation group, model comparisons were conducted using the C-statistic and Net Reclassification Index (NRI). Results 112 patients (67.1%) underwent mitral valve repair with satisfactory results, 47 patients (28.1%) ultimately underwent mitral valve replacement, and 8 patients (4.8%) found moderate to severe mitral stenosis or regurgitation during follow-up after repair. Three indicators, including mitral valve orifice area, leaflet calcification score, and anterior leaflet-annulus angle, were selected through LASSO regression. No collinearity was found between the three indicators, and they were ultimately included in the logistic regression model. The C statistics in the modeling group and validation group were 0.846 and 0.958, respectively, indicating that the constructed model has satisfactory predictive ability. Compared to the Wilkins score, the proportion of correctly classified items increased by 19.8%, significantly better than the Wilkins score. Finally, a nomogram was drawn based on the model, and a web rating calculator was created to guide clinical decision-making. Conclusion This study explored a comprehensive evaluation method and innovative indicators for rheumatic mitral valve disease by transthoracic echocardiography, established and validated a model for predicting the outcome of repair surgery, and had certain guiding significance for doctors to choose suitable patients for rheumatic mitral valve repair.Validation of the predictive modelNomogram

Surgical outcomes of complete atrioventricular septal defect repair in children at the Cardiovascular Center, E Hospital

Objective: To evaluate the outcomes of complete atrioventricular septal defect repair in children at the Cardiovascular Center, E Hospital Methods: An observation study was conducted on 45 patients ≤15 years old diagnosed and surgically treated for complete atrioventricular septal defect at E Hospital from January 2017 to May 2024. Results: Among a total of 45 participants, the mortality and rate of terminal discharge was 6,7% (3 patients), with one patient (2,2%) requiring a second surgery to repair the mitral valve. The most common complications were infections (62.2%) and low cardiac output syndrome (22.2%), with pacemaker implantation in 1 patient (2,2%). Postoperative echocardiography showed residual ventricular septal defect in 45.2% of patients. After 3-6 months of follow-up, 36 patients were evaluated. Among them, 2 patients required a second surgery for mitral valve repair and 4 patients died or were terminal discharged due to severe respiratory failure or pneumonia. The residual ventricular septal defect rate decreased to 8.3%. Analysis showed that patients who died or terminal discharged had significantly longer mechanical ventilation post-surgery time, intensive care time, higher VIS in the first 24 hours, presence of low cardiac output syndrome, acute kidney failure and use of peritoneal dialysis during post-operative care compared to the control group (p &lt; 0.05). The estimated survival rates at 6, 12, and 36 months were 88.9%, 86.7%, and 84.4% respectively, with a mortality rate of 0.51/100 patient-years, showing no significant difference in outcomes between patients aged ≤6 months and those older than 6 months (p=0.09). Conclusion: Complete atrioventricular septal defect repair at E Hospital shows promising results with low mortality rate. However, the rates of complications and residual lesions remain high, requiring active post-operative monitoring and management.

Differential hypoxemia during peripheral cardiopulmonary bypass.

Minimally invasive cardiac surgery (MICS) for mitral valve repair often uses cardiopulmonary bypass (CPB) through peripheral femoro-femoral cannulation. A rare complication of differential hypoxemia can cause upper body hypoxia. A 38-year-old man with Barlow Syndrome underwent MICS mitral valve repair with peripheral CPB. During the procedure, his right upper limb SpO2 dropped to 65% due to dislodgement of the venous cannula from the superior vena cava (SVC), causing inadequate right heart venous drainage, leading to differential hypoxemia. Repositioning the venous cannula to the SVC restored SpO2 to 100%, allowing the surgery to proceed without complications. Differential hypoxemia happens when deoxygenated blood from the left ventricle mixes with oxygenated CPB blood. A literature review found only one previous case of this complication on peripheral CPB for MICS. Unlike our case, Kanda et al. monitored cerebral hypoxia, underscoring the importance of cerebral oxygenation monitoring in future MICS procedures due to higher stroke risk compared to conventional sternotomy. We recommend cerebral oxygenation monitoring in future MICS to prevent neurological complications, and highlight the need for effective team communication in the cardiac operating theatre.

Characterization of atrial arrhythmias following mitral valve repair: Incidence and risk factors.

This study aims to investigate the occurrence, type and correlation of early and late atrial arrhythmias following mitral valve repair in patients with no preoperative history of atrial arrhythmias. Patients undergoing mitral valve (MV) repair for degenerative disease were included. Early and late postoperative electrocardiograms were evaluated for the incidence and type of atrial arrhythmia (atrial fibrillation [AF] or atrial tachycardia [AT]). The 192 patients were included. Early atrial arrhythmias occurred in 100/192 (52.1%) patients; AF in 61 (31.8%) patients, early AT in 15 (7.8%) and both in 24 (12.5%). In total 89% of patients were discharged in sinus rhythm. During a follow-up time of 7.3 years, 14 patients (7.3%) died and 49 (25.5%) patients developed late atrial arrhythmias. At 10 years, the cumulative incidence of any late atrial arrhythmia, with death as competing risk, was 64% (95% confidence interval [CI] = 55%-72%). On Fine-Gray model analysis, only early postoperative AF lasting >24 h was related to the development of late AF (hazard ratio 5.99, 95% CI = 1.78%-20.10%, p = .004). Early postoperative ATs were related to the development of late tachycardias, independent of their duration (<24 h hazard ratio 4.25, 95% CI = 1.89-9.57, p = .001 and >24 h hazard ratio 3.51, 95% CI = 1.65-7.46, p = .001). Early and late atrial arrhythmias were common after MV repair surgery. Only early postoperative AF lasting >24 h was a risk factor for the occurrence of late AF. Conversely, any postoperative AT was correlated to the development of late ATs.

Clinical implications of different methods to assess left atrial remodeling: A comparative study between echocardiography and cardiac magnetic resonance imaging for left atrial volume index quantification

BackgroundLeft atrial volume index (LAVI) serves as a crucial marker for assessing left atrial (LA) remodeling, particularly in patients with mitral valve regurgitation (MR). Recent guidelines recommend a LAVI exceeding 60 mL/m2 as Class IIa recommendation for mitral valve repair surgery in asymptomatic MR patients with preserved left ventricular function. Traditionally, echocardiography is the standard for assessing LAVI in MR patients. However, cardiac magnetic resonance imaging (CMR) is increasingly recognized for its more precise measurements of cardiac dimensions and volumes. But still, literature remains scarce on comparing the efficacy of both modalities in assessing LAVI measurements. MethodsThis retrospective study included 168 MR patients undergoing both echocardiography and CMR assessments within a six-month period. LAVI measurements were compared using Pearson correlation and Bland-Altman plots. Patients were stratified based on MR grades, and clinical implications were assessed. ResultsMean LAVI differed significantly between echocardiography and CMR (47.1 ± 20.8 mL/m2 versus 70 ± 20.3 mL/m2, p < 0.001, respectively). CMR consistently yielded higher LAVI measurements compared to echocardiography, with a mean difference of approximately 20 mL/m2. CMR measurements resulted in an increased incidence of patients meeting the class IIa LAVI criterion (LAVI >60 mL/m2) by 37%. Variations in LAVI did not differ across MR grades. ConclusionEchocardiography systematically underestimates LAVI compared to CMR in MR patients. While current guidelines rely on echocardiography, CMR's precision suggests the need for CMR-specific LAVI cutoff values to guide clinical management effectively. Establishing such values could refine patient stratification and timing of surgery, potentially improving clinical outcomes for MR patients.

Biomarkers of inflammation and coagulation after minimally invasive mitral valve surgery: a prospective comparison to conventional surgery

STRUCTURED ABSTRACT Objectives Minimally invasive cardiac surgery techniques are increasingly used but have longer cardiopulmonary bypass time, which may increase inflammatory response and negatively affect coagulation. Our aim was to compare biomarkers of inflammation and coagulation as well as transfusion rates after minimally invasive mitral valve repair and mitral valve surgery using conventional sternotomy. Design A prospective non-randomized study was performed enrolling 71 patients undergoing mitral valve surgery (35 right mini-thoracotomy and 36 conventional sternotomy procedures). Blood samples were collected pre- and postoperatively to assess inflammatory response. Thromboelastometry (ROTEM) was performed to assess coagulation, and transfusion rates were monitored. Results The minimally invasive group had longer cardiopulmonary bypass times compared to the sternotomy group: 127 min ([115–146] vs 79 min [65–112], p < 0.001) and were cooled to a lower temperature during cardiopulmonary bypass, 34 °C vs 36 °C (p = 0.04). IL-6 was lower in the minimally invasive group compared to the conventional sternotomy group when measured at the end of the surgical procedure, (38 [23–69] vs 61[41–139], p = 0.008), but no differences were found at postoperative day 1 or postoperative day 3. The transfusion rate was lower in the minimally invasive group (14%) compared to full sternotomy (35%, p = 0.04) and the chest tube output was reduced, (395 ml [190-705] vs 570 ml [400–1040], p = 0.04). Conclusions Our data showed that despite the longer use of extra corporal circulation during surgery, minimally invasive mitral valve repair is associated with reduced inflammatory response, lower rates of transfusion, and reduced chest tube output.

Mechanical Analysis of the Connection Structure of a Double-Layered Valve Stent within an Annuloplasty Ring

Background: In this study, to address the failure of mitral valve repair surgery, a novel valve-in-ring model for an artificial mitral valve annuloplasty ring and a new double-layer mitral valve were established. A suitable number and length of ventricular fixation struts within the annuloplasty ring, as well as the implantation depth, result in variations in stress and strain for the inner and outer stent layers. Methods: The compression and self-expansion model of the stent was established via finite element analysis. The changes in stress and strain were analyzed by setting the length and number of the ventricular fixed struts and implantation depth. Results: When only affected by factors such as blood pressure, the maximum stresses of stent structures with three and six ventricular fixed struts are 476 and 222 MPa, respectively, in the right posterior annular region. At implantation depths of 0, 0.5, 1, and 2 mm, the maximum stresses are located in the left posterior annular region of the outer stent and are 740, 697, 709, and 742 MPa, respectively, and the maximum displacements of the inner stent are all in the right posterior ventricular fixed strut region of the posterior annulus and are 3.71, 3.10, 2.48, and 1.87 mm, respectively. In the three and six ventricular fixed strut stents, when the ventricular fixed strut length is 3, 4, and 5 mm, the maximum stresses are 570, 557, and 621 MPa and 674, 666, 644 MPa, respectively. Conclusions: Appropriately increasing the number of ventricular fixed struts can effectively reduce damage to the stent inside the body, and the damage to the stent is relatively consistent across different implantation depths; however, the right side of the stent's posterior annulus is particularly susceptible to damage. However, if the implantation depth is lower, the impact on the inner stent will be more significant. As the number of ventricular fixed struts increases, the strut length variation has a relatively stable impact on stent damage.

An unusual presentation of subacute Haemophilus parainfluenzae endocarditis in a low-risk woman treated by minimally invasive mitral valve repair: a case report

BackgroundHACEK endocarditis is usually insidious and can often be difficult to diagnose due to the slow-growing nature of the organisms. This report presents our experience in treating a patient with Haemophilus parainfluenzae endocarditis.Case presentationWe describe the case of a previously fit and well 23 year-old woman who presented to her local emergency department with a four-week history of persistent febrile illness. She had associated nausea, vomiting, and lethargy. This was preceded by an episode of mucopurulent rhinorrhoea. She was treated empirically with oral amoxicillin for a putative diagnosis of rhinosinusitis. Initially, her symptoms abated, however, she was readmitted with high fevers and a new pansystolic murmur. Transthoracic echocardiography revealed a large, mobile, echogenic mass, tethered to the posterior mitral valve leaflet (PMVL) and mild mitral regurgitation (MR). On examination, she had multiple non-tender, erythematous macules on the plantar surface of her feet, consistent with Janeway lesions. Two separate blood cultures grew H. parainfluenzae. Infectious diseases recommended a four-week course of intravenous ceftriaxone. Transesophageal echocardiography demonstrated a perforation within the P3 segment of the PMVL. Subsequently, the patient underwent mitral valve repair surgery with an uneventful recovery.ConclusionsOur case highlights the importance of promptly diagnosing HACEK endocarditis. A prolonged course of antibiotic therapy can be lifesaving, and surgery is often necessary to address complications such as perforation within the mitral valve leaflets. In our patient, we were able to perform a sliding P2 leaflet plasty for good quality repair of the mitral valve, through a minimally invasive right anterior thoracotomy.

Large Animal Translational Validation of 3 Mitral Valve Repair Operations for Mitral Regurgitation Using a Mitral Valve Prolapse Model: A Comprehensive In Vivo Biomechanical Engineering Analysis.

Various mitral repair techniques have been described. Though these repair techniques can be highly effective when performed correctly in suitable patients, limited quantitative biomechanical data are available. Validation and thorough biomechanical evaluation of these repair techniques from translational large animal in vivo studies in a standardized, translatable fashion are lacking. We sought to evaluate and validate biomechanical differences among different mitral repair techniques and further optimize repair operations using a large animal mitral valve prolapse model. Male Dorset sheep (n=20) had P2 chordae severed to create the mitral valve prolapse model. Fiber Bragg grating force sensors were implanted to measure chordal forces. Ten sheep underwent 3 randomized, paired mitral valve repair operations: neochord repair, nonresectional leaflet remodeling, and triangular resection. The other 10 sheep underwent neochord repair with 2, 4, and 6 neochordae. Data were collected at baseline, mitral valve prolapse, and after each repair. All mitral repair techniques successfully eliminated regurgitation. Compared with mitral valve prolapse (0.54±0.18 N), repair using neochord (0.37±0.20 N; P=0.02) and remodeling techniques (0.30±0.15 N; P=0.001) reduced secondary chordae peak force. Neochord repair further decreased primary chordae peak force (0.21±0.14 N) to baseline levels (0.20±0.17 N; P=0.83), and was associated with lower primary chordae peak force compared with the remodeling (0.34±0.18 N; P=0.02) and triangular resectional techniques (0.36±0.27 N; P=0.03). Specifically, repair using 2 neochordae resulted in higher peak primary chordal forces (0.28±0.21 N) compared with those using 4 (0.22±0.16 N; P=0.02) or 6 neochordae (0.19±0.16 N; P=0.002). No difference in peak primary chordal forces was observed between 4 and 6 neochordae (P=0.05). Peak forces on the neochordae were the lowest using 6 neochordae (0.09±0.11 N) compared with those of 4 neochordae (0.15±0.14 N; P=0.01) and 2 neochordae (0.29±0.18 N; P=0.001). Significant biomechanical differences were observed underlying different mitral repair techniques in a translational large animal model. Neochord repair was associated with the lowest primary chordae peak force compared to the remodeling and triangular resectional techniques. Additionally, neochord repair using at least 4 neochordae was associated with lower chordal forces on the primary chordae and the neochordae. This study provided key insights about mitral valve repair optimization and may further improve repair durability.

Relationship between fragmented QRS complex and early left ventricular dysfunction after mitral valve repair

BackgroundPreoperative left ventricular (LV) ejection fraction (PreLVEF) and preoperative LV end-systolic diameter (PreESD) are known predictors for postoperative LV dysfunction after mitral valve repair (MVR). Fragmented QRS (fQRS) evaluated in 12-derivation electrocardiography has widely been accepted as a sign of myocardial fibrosis.In the present study, we aimed to evaluate the relationship between fQRS in preoperative 12‑lead electrocardiography (ECG) and postoperative LV dysfunction that develop after MVR in patients with severe primary mitral regurgitation (MR) due to mitral valve prolapse (MVP). MethodsFrom 2019 to 2022, 49 patients who had undergone successful MVR surgery for severeMR caused by MVP were enrolled in the study. The preoperative and postoperative echocardiographic data were collected retrospectively. We analyzed the demographic, echocardiographic, operative and postoperative parameters to assess the relationship between fQRS and early postoperative LV dysfunction, defined as an LVEF<60%. ResultsPreLVEF of all patients were ≥ %65. A total of 22 patients had fQRS (44.9%) and postoperative LV dysfunction was found to be 36.7%. A significantly higher rate of fQRS was observed in the group with postoperative LV dysfunction compared to the group without (12 (66.7%) vs 10 (32.3%), p: 0.036). In multivariate analysis for fQRS, PreESD, preoperative pulmonary artery systolic pressure (PrePASP), preoperative atrial fibrillation (PreAF), and male gender, only fQRS was found to be a significant predictor of postoperative LV dysfunction (p: 0.003, OR: 4.28, 95% CI (1.15–15.96). ConclusionfQRS was found to be a predictor of postoperative LV dysfunction in the early period after MVR. fQRS may be a readily available and cost-effective test that can be used in clinical practice to predict postoperative LV dysfunction in patients undergoing MVR.

Clinical Outcome of Rheumatic Mitral Valve Repair and Replacement Surgery in Indonesia; A Comparison with Non-Rheumatic Aetiology.

Mitral valve repair (MVr) has been shown to achieve better outcomes than mitral valve replacement (MVR) in degenerative aetiology. However, that cannot be applied in rheumatic mitral valve disease. Therefore, this study aims to evaluate early and late clinical outcomes and mid-term survival in RHD compared to the non-RHD group and whether mitral valve repair is a better surgical approach in RHD patients. Patients who underwent mitral valve surgery with or without coronary artery bypass grafting were included in this study. All patients were divided into the RHD and non-RHD group by the type of mitral surgery performed. Early and late outcomes were evaluated, and mid-term cumulative survival was reported. A total of 1382 patients post MV surgeries were included. The 30-day mortality was significantly higher in the RHD group compared to the non-RHD group (8.7% vs. 4.4%, p = 0.003). There was no difference in 30-day mortality between repair and replacement in each respective group. During follow-up (12-54 months), all-cause mortality between RHD and non-RHD groups (16.7% vs. 16.2%) was not different. In the RHD group, the survival of MVr was 85.6% (95% CI 82.0%-88.5%), and MVR was 78.3% (95% CI 75.8%-80.6%), p-value log rank 0.26 However, in the non-RHD group, patients who underwent MVr had better survival than MVR, with cumulative survival of 81.7% (95% CI 72.3%-88.2%) vs. 71.1% (95% CI 56.3%-81.7%) p-value log rank 0.007. Early mortality rate in rheumatic mitral valve surgery was higher than in non-rheumatic valve surgery. Although in rheumatic MV disease MV repair did not show a significant survival advantage over MV replacement, a trend towards more favourable survival in the repair group was observed.

Personalized risk prediction of mortality and rehospitalization for heart failure in patients undergoing mitral valve repair surgery.

Accurately assessing the postoperative mortality and rehospitalization for heart failure risks in patients undergoing mitral valve repair surgery is of significant importance for individualized medical strategies. We sought to develop and validate a risk assessment system for the prediction of mortality and rehospitalization for heart failure. Personalized risk prediction system of mortality and rehospitalization for heart failure was developed. For developing a prediction system with death as the outcome, there were 965 patients (70%) and 413 patients (30%) were included in the the derivation cohort and the validation cohort. For developing a prediction system with rehospitalization for heart failure as the outcome, there were 927 patients (70%) and 398 patients (30%) were included in the derivation cohort and the validation cohort. There were 42 routine clinical variables used to develop the models. The performance evaluation of the model is based on the area under the curve (AUC). Evaluate the improvement with Euro Score II according to NRI and IDI net reclassification improvement (NRI) and integrated discrimination improvement (IDI). The median follow-up time was 685 days, the incidence of death was 3.85% (n = 53), and the incidence of rehospitalization for heart failure was 10.01% (n = 138). The AUC values of the mortality prediction model in the derivation and validation cohorts were 0.825 (0.764-0.886) and 0.808 (0.699-0.917), respectively. The AUC values of the rehospitalization for heart failure prediction model in the derivation and validation cohorts were 0.794 (0.756-0.832) and 0.812 (0.758-0.866), respectively. NRI and IDI showed that the mortality prediction model exhibited superior performance than the Euro Score II. The mortality and rehospitalization for heart failure risk prediction models effectively stratified patients into different risk subgroups. The developed and validated models exhibit satisfactory performance in prediction of all-cause mortality and rehospitalization for heart failure after mitral valve repair surgery. http://www.clinicaltrials.gov, Unique identifier: (NCT05141292).

Pushing boundaries in cardiac surgery: minimally invasive mitral valve repair combined with tricuspid valve repair and/or other concomitant procedures.

Minimally invasive mitral valve repair/replacement has emerged as a widely accepted surgical approach for managing mitral valve disorders. Continuous technological progress has contributed to the refinement of this procedure, leading to improved safety, decreased surgical trauma, and faster recovery times. Despite these advancements, there remains a scarcity of data concerning minimally invasive complex mitral valve repair surgeries when combined with additional procedures. Between November 2008 and December 2022, 153 patients underwent an operation using a minimally invasive technique. All patients underwent mitral valve surgery for severe mitral valve insufficiency/stenosis in combination with at least one additional procedure for tricuspid valve repair (n = 52, 34%), patent foramen ovale or atrial septal defect closure (n = 34, 22.2%), left atrial appendage occlusion (n = 25, 16.3%), or electrophysiological procedure (n = 101, 66.0%). Two concomitant procedures were conducted in 98 patients (64.1%), three concomitant procedures in 49 patients (32%), and four concomitant procedures in 6 patients (3.9%). Surgical success was achieved in 99.3% of the patients (n = 152), one patient required a revision of the mitral valve repair on the first postoperative day due to systolic anterior motion phenomenon. Mitral valve repair was performed in 136 patients (88.9%), while 15 patients (9.8%) received a mitral valve replacement as per a preoperative decision due to severe mitral valve stenosis, and two patients (1.3%) underwent other mitral valve procedures. Therapeutic success in treating atrial fibrillation was achieved in 86 patients (85.1%) of the 101 who received an additional maze-procedure. The 30-day mortality rate was 0.7%, with one patient succumbing to respiratory failure. Neurological complications occurred in 7 patients (4.6%). Freedom from reoperation was calculated as 98% at 5-year follow-up and 96.5% at 10-year follow-up. Minimally invasive mitral valve surgery, even when performed alongside concomitant procedures, stands out as a reproducible and safe technique with outstanding outcomes. It is imperative to advance towards the next frontier in minimally invasive surgery, encouraging experienced surgeons to undertake more complex procedures using minimally invasive approaches. These results help envision extending the boundaries of minimally invasive surgery by performing complex mitral valve procedures and associated interventions entirely through endoscopic means in suitable patients.

Trends in Isolated Mitral Valve Repair or Replacement Surgery in Australia: A Statewide Cohort Linkage Study

Global trends in mitral valve surgery (MVSx) suggest increasing repair compared with replacement, especially in the United States and European countries. The relative use, and outcomes of, MV repair and replacement in Australia are unknown. New South Wales residents who underwent isolated MVSx between 2001 and 2017 were identified from the Admitted-Patient-Data-Collection database. Mortality outcomes were tracked to 31 Dec 2018 and adjusted based on age, sex, urgency of operation, and comorbidity status. The study cohort comprised 5,693 patients: 2020 (35%) underwent repair (MVr), 1,656 (29%) underwent mechanical replacement (mech.MVR), and 2017 (35%) underwent bioprosthetic replacement (bio.MVR). Respective median ages [interquartile range] were 67 yo [59-75 yo], 64 yo [55-71 yo], and 75 yo [68-80 yo] (p<0.001 across groups). Between 2001 and 2017, total MVSx increased steadily with population growth. Whereas the relative use of MVr remained static (34% to 38%), that for bio.MVR (22% to 50%) and mech.MVR (45% to 13%) changed significantly. MVr had the best outcome with 1.2% in-hospital, 2.5% 1-year, and 21.6% total cumulative mortality during a median follow-up of 6.5 years. Compared to MVr, the adjusted hazard ratio (aHR) for mech.MVR and bio.MVR for long-term mortality were 1.41 (95% confidence interval [CI]=1.24-1.61) and 1.73 (95% CI=1.53-1.95), respectively. Heart failure and sepsis were the main cardiovascular and noncardiovascular causes of death in all groups. In this statewide Australian cohort examined over 17 years, MVr is potentially underutilised despite having superior outcomes to MVR. Access to quality dataset which provides the indication for MVSx and quantitative clinical factors is critical to further improve MVr coverage and outcome MVSx.

Early mitral valve repair surgery versus active surveillance in patients with asymptomatic severe primary mitral regurgitation; insights from the Dutch AMR registry

Abstract Background Management of asymptomatic patients with severe mitral regurgitation (MR) and preserved left ventricular function is still a challenging clinical entity. According to international guidelines, early mitral valve repair (MVR) surgery and active surveillance with facilitated surgery are both possible treatment strategies. Conflicting evidence is available on the number of patients that reach an indication for facilitated surgery during follow-up in the active surveillance strategy group [1, 2]. In the multicenter Dutch AMR registry, asymptomatic MR patients were allocated to either strategy according to the heart team decision [3]. In this registry there was a low threshold to perform additional testing (i.e. cardiac magnetic resonance imaging, holter monitoring and/or cardiopulmonary exercise testing). Purpose To prospectively assess the percentage of MR patients undergoing facilitated surgery during a long-term active surveillance strategy. Methods Since 2013, 99 patients with severe primary MR were included in the Dutch AMR Registry in 5 medical centers. Enrollment for early surgery or active surveillance was based on ESC guidelines and heart team decision. During long term follow-up, we assessed primary endpoints for both groups; occurrence of atrial fibrillation, cerebrovascular accident, heart failure, MVR surgery and cardiovascular/non-cardiovascular death. In particular, we assessed the number and timing of patients that underwent facilitated surgery in the active surveillance group. Results In total, 71 patients were allocated to the active surveillance and 28 to the early surgery group. 39 Patients in the active surveillance group reached a primary endpoint including 3 deaths (2 cardiovascular and 1 non-cardiovascular) (Figure 1). In the early surgery group, 4 patients reached a primary endpoint including 2 cardiovascular deaths. Over a mean follow-up time of 4.4 years, 36 patients (51%) of the active surveillance population underwent facilitated surgery due to either symptomatic or asymptomatic triggers (Table 1). Conclusions In the Dutch AMR registry, 51% of MR patients under active surveillance needed facilitated surgery within 4.4 years. Approximately half of these patients were still asymptomatic when developing an indication for surgery. Cardiovascular mortality rates were similar between the two treatment strategies. This result shows that active surveillance can be safely accomplished in asymptomatic severe MR patients. The Dutch AMR registry will further elucidate 1) whether MR patients can be stratified at baseline to either strategy based on additional testing and 2) whether facilitated surgery is non-inferior to early surgery in terms of surgical outcome, quality of life and long-term survival. For now, the current results support an active surveillance strategy in selected asymptomatic MR patients based on guidelines since half of patients are still free of symptoms without guideline indications for surgery.Figure 1Table 1

Spatial transcriptomic analysis identifies a border zone with localized expression of brain natriuretic peptide in the inferobasal region of the left ventricle in patients with mitral valve prolapse

Abstract Background/Introduction Mitral valve prolapse (MVP) is a common cause of mitral regurgitation (MR), adverse left ventricular (LV) remodeling and arrhythmias. MVP induces mechanical stretch to the inferobasal (IB) myocardium and papillary muscles. The underlying regional and molecular pathology of MVP-induced LV remodeling remains incompletely understood. Purpose The aim was to characterize the molecular effects of mechanical stretch by comparing the regional gene expression of the IB region of LV with the interventricular septum in patients with MVP. Methods Myocardial biopsies were obtained from the IB LV (i.e. between papillary muscles) and the interventricular septum during mitral valve repair surgery for MVP-induced primary MR. The degree of cardiac fibrosis was detected and quantified by histology. We used spatial transcriptomics (ST) that - in contrast to traditional analyses of tissue homogenates - allows regional expressional analysis. Results Automated clustering of ST results correlated with histological staining of fibrosis in the IB and septal regions (R=0.97, P&amp;lt;0.0001), demonstrating good automated identification of fibrotic regions. The extent of fibrosis was similar between the inferobasal region and the septal control in the respective patients with MVP as determined by histological analysis and ST. The localized fibrotic areas of the inferobasal region showed decreased expression of cardiac myocytegenes such as RYR2, TNNI3, TNNC1 or TPM1, and increased expression of fibrous and EndMT markers such as COL3A1, BGN, SM22 or FN1. In the IB region, we identified a transition zone between healthy myocardium and fibrous tissue. This transition zone showed increased expression of the NPPB gene encoding brain natriuretic peptide (BNP), whereas NPPB was not increased in the septal region of the same patients. The upregulation of NPPB (6.4-fold, P=0.004) in the inferobasal region compared to the septal control was confirmed by qPCR in biopsies from patients with MVP. The identified transition zones were characterized by increased expression of genes such as IGFBP2 and LTBP2, which have been described to be associated with adverse LV remodeling in heart failure. Interestingly, the serum NT-proBNP levels (mean 276.8 ± 121.6 pg/ml) of the patients correlated with NPPB levels from the inferobasal region (R=0.76, P=0.01, N=9), whereas no correlation was found with NPPB levels from the septal control regions (R=0.17, P=0.65) of the same patients. Conclusions ST analysis in MVP identifies a transition zone of the inferobasal region of LV which is exposed to high mechanical stretch. This transition zone - but not the inferobasal fibrotic area nor the LV septum - is characterized by a specific increase in NBBP expression that correlates with increased NT-ProBNP serum concentrations. These special sequencing results indicate that mechanical stretch induces highly localized myocardial pathologies with systemic consequences.