Surgical Treatment Of Mitral Regurgitation Research Articles

Application of a Novel Mitral Valvuloplasty Strategy in Children with Mitral Regurgitation.

To retrospectively analyze the clinical efficacy of an innovative mitral valvuloplasty strategy in the treatment of mitral regurgitation in children. From January 2018 to December 2022, 140 patients undergoing surgical treatment for mitral regurgitation in our hospital were enrolled. Ninety patients underwent three-step standardized pediatric mitral valvuloplasty (group A) and 50 patients underwent simple annuloplasty (group B). The incidence of primary and secondary study endpoint was compared between the two groups, and the independent risk factors for the primary study endpoint were determined. Our primary study endpoint was a composite endpoint of postoperative functional mitral failure, postoperative heart failure, transplantation, and/or mortality. Secondary end points were defined as perioperative complications. During the follow-up period, there was no all-cause death. Primary endpoint events occurred in 22 patients, including 12 patients in group A and 10 patients in group B. There was no significant difference in the incidence of primary and secondary endpoint events between the two groups. Multivariate Cox proportional hazards regression analysis showed that younger age and residual mitral regurgitation at discharge were independent risk factors for the primary endpoint events, while type of MV repair was not an independent risk factor. Subgroup analysis based on age showed that primary endpoint events occurred in 4 patients in group A and 7 patients in group B in patients < 1year old. The incidence of primary endpoint events in group A was lower than that in group B (6.06% vs. 20.59%, P = 0.041). In patients ≥ 1year old, the primary endpoint event occurred in 8 cases in group A and 3 cases in group B. There was no significant difference in the incidence of primary endpoint events between groups A and B (33.33% vs. 18.75%, P = 0.312). The degree of mitral regurgitation at discharge was significantly improved compared with that before operation in both groups (P < 0.001), and the degree of mitral regurgitation at the last follow-up was not significantly worse than that at discharge (P = 0.090). The mid-term results of mitral valvuloplasty for mitral regurgitation in children are encouraging. The perioperative recovery and postoperative outcomes of three-step standardized mitral valvuloplasty in children are not inferior to those of annuloplasty alone. Three-step standardized pediatric mitral valvuloplasty has better postoperative outcomes than simple mitral annuloplasty, especially for patients younger than 1year old. Children with residual mitral regurgitation at discharge should be followed up regularly to be alert to the occurrence of poor prognosis.

Renal function improvement correlates with 3D echocardiographic findings: Effect of surgical mitral valve repair.

The association between surgical treatment of mitral regurgitation (MR) and renal function is not sufficiently well-known. We tried to evaluate renal function before and after the procedure of surgical mitral valve repair (SMVR) in degenerative severe MR. Patients with primary severe (4+) MR and normal left ventricular ejection fraction (LVEF) that underwent SMVR, examined by a cutting-edge 3-dimensional (3D) echocardiographic probe were enrolled in this study. We took three CKD-EPI equations to measure estimated glomerular filtration rate (eGFR) before SMVR and shortly before patients discharge. A total of 40 patients with baseline lower mean eGFR were evaluated. Measurements substantiated statistically significant improvements in eGFR (p < 0.001), multivariable linear regression modeling indicating prominent associations between increase in eGFR and decrease of MR (p = 0.003), decline of pulmonary arterial systolic pressure (p = 0.018), as well as increment of forward stroke volume (p = 0.02), in spite of LVEF reduction, left ventricular global longitudinal strain worsening and left atrial ejection fraction impairment. Renal function improves after SMVR in patients with degenerative significant MR and preserved LVEF, regardless of cardiac functional worsening.

Surgical treatment of mitral regurgitation.

Mitral repair is the best treatment for degenerative mitral regurgitation. Many patients are referred too late for optimal outcomes. The US repair vs. replacement rate is only 60-80%, at a time when the inferiority of replacement has been established. Therefore, widely used traditional techniques of repair are being reappraised. Identification of risk factors predictive of poor early and late outcome have improved timing for surgical referral. Composite risk scores have been developed. Novel echocardiographic, cardiac MRI, and molecular level risk factors could improve timing. Analysis of factors contributing to low repair rates is also of critical importance. The role of institutional and surgeon volumes have been identified. More detailed data on the importance of dynamic function of the mitral valve have led to improved repair techniques such as intraoperative simulation of end diastole and early systole, use of expanded polytetrafluoroethylene neochords instead of leaflet resection, and dynamic instead of rigid annuloplasty. Our perception of mitral regurgitation has changed from a seemingly simple condition to one of considerable complexity at multiple levels. National guidelines should be studied and followed.

CRT-600.36 A Balancing Act: The Impact of Reducing Mitral Regurgitation at the Expense of Increased Mitral Gradients Using Percutaneous Mitral Valve Repair

Percutaneous mitral valve repair (PMVR) using the MitraClip system (Evalve Inc., Menlo Park, California) has emerged as a minimally invasive treatment option for patients at prohibitive risk for surgical treatment of mitral regurgitation (MR). However, a reduction of MR severity may be at the cost

Surgical treatment of mitral regurgitation in patients with hypertrophic obstructive cardiomyopathy

<h3>ЦЕЛЬ ИССЛЕДОВАНИЯ</h3> Оценить эффективность изолированной трансаортальной септальной миоэктомии и сочетания данной операции с пластикой митрального клапана у пациентов с гипертрофической обструктивной кардиомиопатией. <h3>МАТЕРИАЛ И МЕТОДЫ</h3> В исследование включены 62 пациента с обструктивной гипертрофической кардиомиопатией и средним градиентом давления в выводном тракте левого желудочка (ЛЖ) 109,1±29,8 мм рт.ст. Средний возраст больных составил 54,3±12,4 года. Пациенты были разделены на две группы: 1-я группа — 44 пациента (19 мужчин, 25 женщин), которым выполнена септальная миоэктомия в сочетании с трансаортальной пластикой митрального клапана по методике edge-to-edge (O. Alfieri, 1996); 2-я группа — 18 пациентов (7 мужчин, 11 женщин), которым была выполнена изолированная септальная миоэктомия по Morrow. В 1-й группе наблюдалась относительная митральная недостаточность III—IV ст., во 2-й группе — II—III ст. Оценка результатов лечения проводилась в раннем послеоперационном периоде, через 6, 12, 24, 36 и 60 мес. <h3>РЕЗУЛЬТАТЫ</h3> Градиент давления в выводном тракте ЛЖ в 1-й группе снизился с 112,8±30,9 мм рт.ст. до 19,3±13,1 мм рт.ст., во 2-й группе — с 101,1±25,4 мм рт.ст. до 20,7±16,0 мм рт.ст. (<i>p</i>&lt;0,05). Толщина межжелудочковой перегородки в 1-й группе уменьшилась с 22,5±2,9 до 16,4±1,1 мм, во 2-й группе — с 20,4±5,4 до 17,3±3,8 мм (<i>p</i>&lt;0,05). Степень митральной регургитации уменьшилась с 2,7±0,4 до 1,4±0,1 в 1-й группе и с 1,9±0,4 до 1,7±0,5 во 2-й группе (<i>p</i>&lt;0,05). В раннем послеоперационном периоде имплантация двухкамерного электрокардиостимулятора потребовалась двум пациентам из 1-й группы в связи с полной атриовентрикулярной блокадой, во 2-й группе — 1 пациенту. Функциональный класс сердечной недостаточности снизился с III—IV до I—II по NYHA. Госпитальная летальность в раннем послеоперационном периоде и отдаленном сроке в изучаемых группах отсутствовала. <h3>ВЫВОД</h3> Изолированная септальная миоэктомия по Morrow является эффективным методом хирургического лечения обструктивной гипертрофической кардиомиопатии с умеренной митральной недостаточностью. При обструктивной гипертрофической кардиомиопатии с выраженной митральной недостаточностью сочетание септальной миоэктомии с трансаортальной пластикой митрального клапана сопровождается более значимым уменьшением степени митральной регургитации в отделенном послеоперационном периоде.

Unilateral pulmonary edema after minimally invasive mitral valve surgery

Introduction Unilateral right-sided pulmonary edema (UPE) is a rare but potentially life-threatening complication after minimally invasive mitral valve surgery (MICS). Methods We will present a case of severe unilateral pulmonary edema with cardiopulmonary instability after mitral valve repair with right minithoracotomy. Results A 45-year-old man (182 cm, 82 kg) was referred to the authors’ hospital for surgical treatment of mitral regurgitation. His medical history included hypertension and chronic obstructive pulmonary disease. Mitral valve repair was performed with plication of prolapsed part of the posterior leaflet and annuloplasty, under general anesthesia. The right lung was decompressed with differential lung ventilation by a double-lumen tracheal tube. Cross-clamp time was 128 min, and CPB time was long (193 min). Three hours after the surgery, oxygen saturation suddenly dropped to approximately 90 %, and frothy pink sputum was blast out from the tracheal tube. Chest radiograph showed unilateral right-sided massive infiltrate. No evidence of residual mitral insufficiency was detected by trans-thoracic echocardiography. Arterial pressure was maintained with high dose norepinephrine. Cardiac output was maintained with epinephrine and dobutamine, which were gradually attenuated within the first postoperative day. Mechanical ventilation was performed with high PEEP and high FiO2 (12 mmHg, 100 %, respiratory rate 16/min, tidal volume 5 ml/kg) by assist/control mode to maintain oxygenation. Pulse steroid therapy was applied for 3 days. Urine output was maintained at least 50 ml/h through the perioperative period. Patient was extubated 21 h after surgery. On the postoperative day 2, chest radiography showed reduced right-sided infiltration. Patient was discharged home on the 8th postoperative day. Discussion The reasons of unilateral right-sided pulmonary edema are multifactorial, including complete lung collapse and ischemic reperfusion injury, systemic inflammatory reaction and extracorporeal circulation, level of mean pulmonary arterial pressure, chronic obstructive pulmonary disease, and increasing CPB time. Perioperative medical team should be aware of the heightened perioperative risk of UPE during MICS.

Variation in the Echocardiographic Surveillance of Primary Mitral Regurgitation.

Clinical outcomes after surgical treatment of mitral regurgitation are worse if intervention occurs after deterioration of left ventricular size and function. Transthoracic echocardiographic (TTE) surveillance of patients with mitral regurgitation is indicated to avoid adverse ventricular remodeling. Overly frequent TTEs can impair patient access and reduce value in care delivery. This balance between timely surveillance and overutilization of TTE in valvular disease provides a model to study variation in the delivery of healthcare services. We investigated patient and provider factors contributing to variation in TTE utilization and hypothesized that variation was attributable to provider practice even after adjustment for patient characteristics. We obtained records of all TTEs from 2001 to 2016 completed at a large echocardiography laboratory. The outcome variable was time interval between TTEs. We constructed a mixed-effects linear regression model with the individual physician as the random effect in the model and used intraclass correlation coefficient to assess the proportion of outcome variation because of provider practice. Our study cohort was 55 773 TTEs corresponding to 37 843 intervals ordered by 635 providers. The mean interval between TTEs was 12.4 months, 17.0 months, 18.3 months, and 17.4 months for severe, moderate, mild, and trace mitral regurgitation, respectively, with 20% of providers deemed overutilizers of TTEs and 25% underutilizers. We conclude that there is substantial variation in follow-up intervals for TTE assessment of mitral regurgitation, despite risk-adjustment for patient variables, likely because of provider factors.

Abstract 047: Variation by Provider in Echocardiographic Surveillance of Mitral Regurgitation

Clinical outcomes after surgical treatment of mitral regurgitation (MR) are worse if intervention occurs after deterioration of left ventricular (LV) size and function. Echocardiographic surveillance of patients with MR is therefore indicated to avoid ventricular remodeling that could worsen patient outcomes. However, overly frequent trans-thoracic echocardiograms (TTEs) can impair access for other patients and reduce value in the delivery of care. Given the balance between timeliness of surveillance and possible over-utilization of TTE in valvular disease, we sought to investigate patient and provider factors contributing to variation in TTE utilization. We hypothesized that there was variation attributable to provider practice even after adjustment for patient characteristics. We obtained records of all TTEs from 2001-2016 ordered at a large echocardiography laboratory. For each TTE, we linked to patient demographic data from hospital administrative records. To control for both clinical and demographic predictors of frequency of echocardiography, we constructed a hierarchical mixed-effects linear regression model with the individual physician as the random effect in the model. The outcome variable was time interval between TTEs. Intra-class correlation coefficient (ICC) was used to assess the proportion of total variation in the outcome variable due to provider practice, and shrinkage estimates were used to measure the contribution of individual providers. After application of exclusion criteria, 79,194 TTEs corresponding to 55,663 TTE intervals remained. The mean interval between TTEs was 11.9 months for severe MR, 15.4 months for moderate MR, and 17.6 and 17.7 months for mild and trace MR respectively. After multivariate adjustment, male gender (Rate Ratio (RR) 0.96; 95% CI 0.94-0.98) was associated with shorter follow up, and Hispanic race (RR 1.11; 95% CI 1.01-1.21) was associated with longer follow-up intervals. Eight hundred and sixty-seven physicians were included in the analysis. After adjustment for patient factors, 31% of the variation in intervals was associated with provider practice and 19% of providers (161 of 867) were over-utilizers of TTEs and 24% (210 of 867) were under-utilizers. We conclude that substantial variation exists in follow up intervals for TTE assessment of MR even after risk-adjustment for clinical and demographic variables, likely due to provider factors including specialty and experience. The association of TTE interval with race and gender warrants further investigation. Improving standardization of follow-up intervals may offer opportunity to reduce both overutilization and underutilization of echocardiography.

Surgical treatment of mitral regurgitation

IntroductionMitral regurgitation (MiR) is a very common valvular disease. Surgical treatment improves patients’ prognosis and quality of the life. Traditional mitral valve replacement was mostly substituted by mitral valve repair which improved early and log-term survival. The aim of our study was to assess results of mitral valve surgery in our department. Patients and methodsRetrospective study of data from cardiac operations registry was performed. From January 2009 to December 2014 seven hundred eighty six patients with mitral valve regurgitation were operated on. There were 471 men and 315 women, 78.9% of them were in NYHA class II or III. Functional etiology of MiR was in 56.4% patients mainly as a consequence of coronary artery disease, structural deterioration of the valve was in 43.6% mainly due to degenerative disease. ResultsMitral valve repair was performed in 78.0% of patients; in rest of the patients the mitral valve was replaced mainly with bioprosthesis. Combined procedure involving particularly coronary artery bypass grafting and/or, tricuspid valve repair and/or MAZE procedure was performed in 59.5% patients. The most frequent postoperative complication was new onset of atrial fibrillation in 34.8% of the patients. Low cardiac out syndrome occurs in 20.7%. Thirty eight patients (4.8%) died within 30 days after operation. ConclusionSurgical approach is a method of choice in treatment of significant MiR. Mitral repair is preferred operation and its results are excellent provided that proper technique is tailored for the specific patient including miniinvasive approach. Since ischemic etiology is quite frequent coronary artery bypass grafting is common concomitant procedure. Tricuspid valve repair or MAZE belong to other common concomitant procedures. If complex combined procedure is necessary more frequent occurrence of cardiac and extra cardiac complications should be taken into account.

New approach in the surgical treatment of mitral regurgitation: beating heart transapical neochord implantation

Severe mitral regurgitation due to prolapse of the valve demands early surgical intervention. Recently artificial chord implantation is the prefered solution, which requires cardioplegia and application of cardiopulmonary bypass using the left atrial approach. Transoesophageal echocardiography guided transapical neochord implantation is an emerging new technique for the treatment of mitral regurgitation. It enables the operation through left minithoracotomy on beating heart using a special instrument introduced into the left ventricle. Acute procedural success rates in different centres vary between 86 and 100%. According to reports, 92% of the patients do not require additional intervention at the 3-month follow-up. Continuous integration of data resulting improved outcomes supports the hope that this novel, less-invasive technique will be applied widely for the treatment of mitral regurgitation.

Transcatheter mitral valve repair: a brief review.

Surgical treatment of mitral regurgitation has evolved from mitral valve replacement to repair, because the latter produces superior long-term outcomes. In addition, mitral valve repair can be achieved through minimally invasive approaches. The desire for less invasive approaches has driven the field of percutaneous mitral valve repair. Various technologies have emerged and are at different stages of investigation. So far, only the MitraClip device has been tested in large numbers of patients, whereas the reproducibility and the real effectiveness of the other devices still remain to be demonstrated.

Leakage test during mitral valve repair.

Mitral valve repair is the preferred surgical treatment for mitral regurgitation. Cardiac surgeons must increasingly pursue high-quality mitral valve repair, which ensures excellent long-term outcomes. Intraoperative assessment of a competency of the repaired mitral valve before closure of the atrium is an important step in accomplishing successful mitral valve repair. Saline test is the most simple and popular method to evaluate the repaired valve. In addition, an "Ink test" can provide confirmation of the surface of coaptation, which is often insufficient in the assessment of saline test. There are sometimes differences between the findings of the leakage test in an arrested heart and the echocardiographic findings after surgery. Assessment of the mitral valve in an arrested heart may not accurately reflect its function in a contractile heart. Assessment of the valve on the beating heart induced by antegrade or retrograde coronary artery perfusion can provide a more physiological assessment of the repaired valve. Perfusion techniques during beating heart surgery mainly include antegrade coronary artery perfusion without aortic cross-clamping, and retrograde coronary artery perfusion via the coronary sinus with aortic cross-clamping. It is the most important point for the former approach to avoid air embolism with such precaution as CO2 insufflation, left ventricular venting, and transesophageal echocardiography, and for the latter approach to maintain high perfusion flow rate of coronary sinus and adequate venting. Leakage test during mitral valve repair increasingly takes an important role in successful mitral valve reconstruction.

Feasibility and Efficacy of Mitral Valve Repair for Degenerative Mitral Regurgitation in the Elderly

The number of elderly patients who require surgical treatment for mitral regurgitation (MR) is increasing. However, the feasibility and efficacy of mitral valve repair in elderly patients are unclear. We retrospectively reviewed 55 patients, aged ≥75 years, who underwent mitral valve repair for degenerative MR between 1991 and 2011. All patients were followed up for 4.7 ± 3.4 years. The patients aged ≥75 years were more symptomatic and had a higher incidence of persistent atrial fibrillation and pulmonary hypertension than those aged &lt;75 years. Thirty-day and in-hospital mortality was 1.8% and 7.3%, respectively, and the 5-year survival rate was 81.6% ± 5.8%. The leading cause of late death was stroke, which primarily occurred in patients with postoperative atrial fibrillation. Except for a single failure of repair due to technical reasons, there was no recurrence of severe MR or reoperation on the mitral valve. In the late follow-up period, the mean left ventricular diastolic diameter significantly decreased and the mean left ventricular ejection fraction was approximately 60%. Most patients had mild symptoms at follow-up. Mitral valve repair can provide satisfactory early as well as long-term outcomes and can preserve left ventricular function even in the elderly.

Immediate effect of the MitraClip(R) procedure on mitral ring geometry in primary and secondary mitral regurgitation

Percutaneous treatment of mitral regurgitation (MR) has been shown to reduce MR severity and improve functional outcomes. Surgical treatment of MR usually includes mitral annulus reduction. The influence of the MitraClip on annulus geometry is not clear. We wanted to investigate whether the procedure itself reduces annulus diameter and if there may be differences between secondary or functional (SMR) and primary (PMR) MR. We retrospectively assessed 3D echocardiography (3D-TEE) data of 55 patients acquired during the procedure shortly before and after clip placement for changes in annulus diameter and area. Measurements were done with QLAB software. Patients were categorized as having either SMR (n = 41) or PMR (n = 14). In SMR, we were able to demonstrate a significant reduction in annulus area (meanΔ 1.30 ± 1.44 cm2; P < 0.001), anterior-posterior (AP)-diameter (meanΔ 0.28 ± 0.32 cm; P < 0.001), tenting area (meanΔ 0.39 ± 0.49 cm2; P < 0.001). No significant change could be found for latero-medial (LM)-diameter. In contrast, we could not demonstrate significant changes in any of the parameters described above in patients with PMR. Percutaneous treatment with the MitraClip device can produce immediate reductions in mitral annulus size in SMR, probably supporting procedural success. It also reduces tenting, which may have prognostic implications. In contrast, these effects on mitral geometry cannot be demonstrated in PMR. Knowledge of this difference between SMR and PMR may be important to improve procedural strategies.

SHA 015. The role of the edge-to-edge repair in the surgical treatment of mitral regurgitation

SHA 015. The role of the edge-to-edge repair in the surgical treatment of mitral regurgitation

The Role of the Edge-to-Edge Repair in the Surgical Treatment of Mitral Regurgitation

The edge-to-edge (E-to-E) technique was introduced in the early 1990s and has provided a useful contribution to the surgical armamentarium of mitral valve repair. The free edges of the mitral leaflets have to be approximated in correspondence of the site of the regurgitant jet in such a way that mitral regurgitation is corrected without producing stenosis. A prosthetic ring is usually implanted to stabilize the repair. Middle- and long-term surgical results are now available. Appropriate indications and awareness of the important technical aspects of the procedure are prerequisites for a good outcome. In this review the present role of the E-to-E repair, the relevant technical aspects of the procedure, and some controversial issues will be outlined and discussed.

Cardiovascular MRI derived mitral valve geometry predicts the surgical treatment of mitral regurgitation

Cardiovascular MRI derived mitral valve geometry predicts the surgical treatment of mitral regurgitation

Simple Suture Mitral Annuloplasty with Left Ventriculotomy

Surgical treatment of mitral regurgitation, especially when compounded by ventricular aneurysm, remains a challenge. Several procedures have been developed to repair the mitral valve and reduce regurgitation. We describe a technique of intraventricular annuloplasty which is much less time-consuming than mitral valve repair through a left atriotomy. This procedure is considered technically easy and useful.

Effect of Strut Chordae Transection on Mitral Valve Leaflet Biomechanics

Strut chordae transection (SCT) has been recommended as a surgical treatment for mitral regurgitation (MR) arising from ischemic heart disease. However, little is known about the contribution of anterior strut chordae to leaflet tissue mechanics. In this study, experimental measurements of mitral valve deformation under quasi-static pressure loading were performed on isolated pig hearts before and after transecting both strut chordae. Biplane video images of markers placed on the anterior leaflet surface were used to reconstruct the 3D position of the markers. The 2D nonhomogeneous deformations in the anterior leaflet were calculated by least squares fit to the 3D marker coordinates in successive pressure loading states. Results show that the anterior leaflet undergoes large, anisotropic and nonhomogeneous deformation, with a significant radial stretch gradient and smaller, uniform circumferential stretch. Following chordal transection, the radial deformation decreases. A gradient in the circumferential stretch is observed as an increase from the annulus toward the coaptation line. Without the support provided by the strut chordae, the center portion of the anterior leaflet experienced a substantial change in shape in response to the systolic pressure, altering the load-bearing mechanism in the valvular structure. The shift of the deformation distribution suggests that additional strain energy is absorbed by the circumferentially oriented collagen fibers following SCT and may result in long-term tissue remodeling. This study provides detailed biomechanical data for interpreting the results of previous investigations of SCT, as well as for exploring a greater understanding of how SCT affects MR through computational modeling.

Valve Repair for Chronic Mitral Regurgitation

Valve repair is the best surgical treatment for mitral regurgitation. In the present article we describe the results of mitral valve repair in patients with chronic mitral regurgitation treated at our center during the last eight years. The degree of correction of valve insufficiency, functional benefit, in-hospital morbidity and mortality, postoperative outcome of ventricular function, and middle-term overall and reoperation-free survival are analyzed.