Mitral Valve Repair Techniques Research Articles

Loop neochord versus leaflet resection techniques for minimally invasive mitral valve repair: long-term results

Non-leaflet resection techniques including loop chordal replacement are being used with increasing frequency, but the long-term results of these techniques are still unknown. The aim of this study was to compare the long-term results of loop neochord replacement with leaflet resection techniques in patients undergoing minimally invasive mitral valve (MV) repair for MV prolapse. Between 1999 and 2014, 2134 consecutive MV prolapse patients underwent minimally invasive MV repair with isolated loop (n = 1751; 82.1%) or resection techniques (n = 383, 17.9%) at our institution. Follow-up data were available for 86% of patients with a mean follow-up time of 6.1 ± 4.3 years. The 30-day mortality was 0.8% for all patients (loop: 0.7%, resection: 1.6%; P = 0.09). Leaflet resection was associated with more moderate or more mitral regurgitation on predischarge echocardiography (P = 0.003). The 1-, 5- and 10-year survival rates were 98 ± 1%, 95 ± 1% and 86 ± 2% for the loop technique versus 97 ± 1%, 92 ± 1% and 81 ± 2% for resection patients, respectively (P = 0.003). Significant predictors for late mortality were MV repair technique (P = 0.004), left ventricular ejection fraction (P < 0.001), age (P < 0.001) and myocardial infarction (P < 0.001). Freedom from MV reoperation at 1, 5 and 10 years was 98 ± 1%, 97 ± 1%, 97 ± 1% and 97 ± 1%, 97 ± 1%, 96 ± 1% for patients operated on with the loop technique and leaflet resection (P = 0.4). In our patient cohort, MV repair with loop chordal replacement is associated with less early recurrent mitral regurgitation and very good long-term results when compared to classical leaflet resection techniques for MV prolapse and is therefore an excellent option for such patients.

Outcomes with percutaneous mitral repair vs. optimal medical treatment for functional mitral regurgitation: systematic review.

Functional mitral regurgitation (MR) could be defined as a ventricular disease where mitral valve is structurally normal, left chambers are enlarged and mitral annulus is dilated with lack of coaptation of leaflets. Transcatheter mitral valve repair technique has broadened the therapeutic range in the treatment of severe MR. The aim of this study was to review outcomes of MitraClip vs. medical treatment for functional MR. We also planned to review the concept of functional MR, assessment of the degree, prognosis and therapy options. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The Medline through PubMed database was used to search. The present review included manuscripts published between January 2009 and September 2019. Two authors independently screened titles and abstracts of all publications, and performed the selection of studies and data extraction. In the case of disagreements, consensus meetings reached the final decision. Inclusion criteria were: (I) randomized controlled trials and (II) works must compare MitraClip versus optimal medical treatment. Transcatheter mitral valve repair along optimal medical treatment has been compared with optimal medical therapy in two different randomized trials. In the COAPT trial, the MitraClip group showed a significant reduction in mortality and heart failure (HF) hospitalizations. In the MITRA-FR trial, no significant differences were observed between both groups. We reviewed important aspects of functional MR and performed a comprehensive review of both trials comparing them and focusing on their differences.

Standardized loop technique for mitral valve repair offers good midterm results.

We reviewed the midterm results of our approach for mitral valve repair with the use of standardized loops. In a retrospective single-center study, mitral repairs performed between November 2015 and December 2019 with the standardized loop technique were included. Predefined loops of 15 and 25 mm (Gore-Tex) were implanted for posterior or anterior mitral prolapses, respectively. Isolated or concomitant mitral repairs were performed by either a sternotomy or minithoracotomy. Mean follow-up was 25.3 ± 14.7 months. Among 92 patients operated on for mitral repair during this period, 65 had repair with the standardized loop technique. They were mostly men (73.8%) and the mean age was 65.1 ± 9.7 years. Valve prolapse was mainly posterior (87.7%), and cordal rupture was seen in 81.5% of cases. The procedures were carried out by a minithoracotomy in 49.2% of patients. Isolated mitral repairs represented 63.1% of cases. Crossclamp and bypass times were 102 ± 22.8 min and 144.7 ± 34.9 min, respectively. The mean number of loops implanted was 2.7 ± 0.9. No patient left the operating room with moderate or severe mitral regurgitation. Postoperative morbidity was 18.4% (12 patients) and 30-day mortality was 3.1% (2 patients). Overall 4-year survival and freedom from reoperation for mitral repair failure were 84.4% and 91.7%, respectively. The standardized loop technique for mitral repair showed good midterm results. This technique can be valuable in the armamentarium of mitral repairs. Further evaluation is needed for long-term follow-up.

Early myocardial changes in patients undergoing rheumatic mitral valve repair versus replacement.

Rheumatic mitral valve repair and replacement techniques are frequently used with excellent outcomes in experienced centers. This study aims to evaluate the impact of procedural types on left ventricular function in quinquagenarians. Between January 2018 and September 2019, patients with severe rheumatic mitral stenosis were prospectively recruited. Propensity score matching was performed to reduce the selection bias. We compared the strain, twist and synchrony parameters of left ventricle in 70 quinquagenarian patients who underwent rheumatic mitral valve repair and replacement 12 hours before surgery, at 7 days and 6 months postoperatively. The overall group displayed significant improvement of left ventricular deformation after rheumatic mitral valve surgery. Compared with patients undergoing posterior chordal-sparing mitral valve replacement, patients undergoing rheumatic mitral valve repair showed more significant amelioration in global longitudinal strain (-18.6% versus -16.2%, P<0.001), twist (18.2° versus 15.9°, P<0.001), torsion (1.8°/cm versus 1.3°/cm, P<0.001), apical rotation (10.5° versus 8.8°, P<0.001), basal rotation (-7.7° versus -7.1°, P=0.049), systolic dyssynchrony index (4.7% versus 5.1%, P=0.021), standard deviation of time to peak longitudinal (46.9 ms versus 49.3 ms, P=0.024) and radial strain (15.8 ms versus 17.1 ms, P=0.037) at 6-month follow-up. Rheumatic mitral valve repair might provide patients with better postoperative left ventricular performance than posterior chordal-sparing mitral valve replacement. Longer follow-up is required to compare long-term outcomes.

Computer simulations of transapical mitral valve repair with neochordae implantation: Clinical implications.

ObjectivesTransapical beating heart neochordae implantation is an innovative mitral valve repair technique that has demonstrated promising clinical results in patients with primary mitral regurgitation. However, as clinical experience continues to increase, neochordae implantation criteria have not been fully standardized. The aim of this study was to investigate the biomechanical effects of selecting an antero-lateral apical access site compared with a postero-lateral site, and suboptimal neochordae length compared with optimal suture length, on restoring physiologic left heart dynamics.MethodsTransapical neochordae implantation using 3 and 4 sutures was computer simulated under 3 posterior mitral leaflet prolapse conditions: isolated P2, multiscallop P2/P3 and multiscallop P2/P1. Physiologic, pre- and postrepair left heart dynamics were evaluated using a fluid-structure interaction modeling framework.ResultsDespite the absence of residual mitral regurgitation in all postrepair models with optimal neochordae length, selecting an antero-lateral apical entry site for the treatment of P2/P3 prolapse generated a significant increase (>80%) in neochordae tension and P2 peak stress, with respect to a postero-lateral entry site. During isolated P2 prolapse repair, although neochordae overtension by 5% led to minimal hemodynamic changes in the regurgitant volume compared with using an optimal suture length, a significant increase in systolic and diastolic neochordae tension (>300%) and posterior leaflet average stress (70%-460%) was quantified. On the other hand, neochordae undertension by 5% led to worsening of regurgitation severity.ConclusionsThis parametric computer study represents a further step toward an improved understanding of the biomechanical outcomes of transapical neochordae technologies.

Early failure of mitral valve repair with anterior leaflet pericardial patch augmentation in rheumatic and radiation-induced valvulitis.

Rheumatic mitral valve disease remains an important cause of mitral regurgitation (MR), accounting for 7% to 15% of organic MR cases in large epidemiologic studies (1,2). Similarly, a history of radiation to the mediastinum, as is common in the treatment of several malignancies, is associated with future valve dysfunction in up to one-third of patients. Mitral valve repair (MVr) is favored over replacement for severe primary MR; this is due to a significant 30-day and mid to long-term mortality benefit, as well as a reduction in peri-operative complications (3,4). However, due to ongoing inflammation and leaflet infiltration, MVr in rheumatic or radiation-induced valvulitis may be associated with decreased durability and an increased risk of reoperation (5). In order to improve outcomes of MVr in these populations, adjunctive reparative procedures have been introduced. One such technique involves the use of autologous or bovine pericardium to reconstruct or enlarge the anterior mitral leaflet (AML) and normalize its coaptation with the posterior leaflet, with further reinforcement from a supporting annuloplasty ring (Figure 1) (6). While small studies suggest excellent mid-term survival with this approach, moderate or greater recurrent MR and reoperation occurs in 11.2% and 4.6% of patients, respectively, with rheumatic MR. Poor outcome data exists in the literature regarding MVr techniques for radiation-induced valvulitis (6,7). Herein, we provide an in-depth clinical and imaging appraisal of two such cases, with a focused review on pathophysiology and management. Open in a separate window Figure 1 MVr utilizing an annuloplasty ring and AML pericardial patch augmentation. (A) Schematic of AML pericardial patch augmentation MVr. There is a reconstructed and enlarged AML, normalized anterior and posterior leaflet coaptation, and reinforcement from a supporting annuloplasty ring; (B,C) systolic and diastolic transesophageal echocardiography mid-esophageal four-chamber views. Displayed is the augmented anterior mitral leaflet and pericardial patch (red arrow). MVr, mitral valve repair; AML, anterior mitral leaflet; PML, posterior mitral leaflet.

Butterfly technique in mitral valve repair.

Degenerative mitral regurgitation due to posterior leaflet prolapse is often associated with tissue redundancy in the leaflet height and free margin of the prolapsing segment. The butterfly technique has been introduced for focal resection to precisely control the leaflet height without annular plication. This technique is indicated for a high prolapsing leaflet, greater than 20 mm. With intraoperative measurement of leaflet heights and ink dot marking as a depth indicator, the butterfly technique can be safely performed in most high posterior leaflet prolapse cases, without increasing the risk of systolic anterior motion.

Long-term clinical and echocardiographic follow-up of the edge-to-edge technique for surgical mitral valve repair

To evaluate the long-term clinical and echocardiographic performance of mitral valve repair with the edge-to-edge technique. In-hospital results, actuarial freedom from all-cause mortality, cumulative incidence of cardiovascular mortality, recurrent mitral regurgitation ≥3+ and reoperation on the mitral valve were assessed in 180 consecutive patients undergoing mitral repair with the edge-to-edge technique for degenerative or functional regurgitation. Exercise echocardiography was performed in 24 patients to assess valve hemodynamics in the long-term follow-up. The edge-to-edge repair was applied as a first strategy in 157 patients (87.2%) or as a bail-out procedure in 23 patients (12.8%). At discharge, mitral regurgitation grade was absent in 152 patients (84.4%) and trivial in 28 patients (15.6%). Mean gradient was 2.8 ± 0.6 mmHg and effective orifice area was 2.9 ± 0.4 cm2. After a median follow-up of 6.5 (interquartile range 3.5-10.2) years, 93.6% patients were in NYHA functional class I-II. Actuarial survival at 15 years was 89.2 ± 2.7%, whereas the cumulative incidence of cardiovascular mortality was 7.0%, of recurrent mitral regurgitation ≥3+ 12.6% and of reoperation on the mitral valve 3.2%. Exercise stress echocardiography revealed a significant increase of functional area (3.1 ± 0.3 vs 4.0 ± 0.6 cm2, p<0.001) and mean gradients (2.7 ± 0.4 vs 4.6 ± 1.2 mmHg, p<0.001). The edge-to-edge technique effectively corrects degenerative and functional mitral regurgitation and represents a valid bail-out procedure in case other approaches failed to achieve adequate intraoperative valve competence. Long-term results are sustained up to 15 years, with significant improvement in functional status. Despite an altered geometry, the occurrence of iatrogenic mitral stenosis is avoided even at high workload conditions.

P1523 Impact of different techniques for mitral valve repair on left ventricular function: a 2D/3D echocardiographic analysis

Abstract Funding Acknowledgements None Aim Different surgical techniques are available for mitral valve (MV) repair in patients with degenerative severe mitral regurgitation (MR). Leaflet resection (LR) and neochordoplasty (NP), both including ring annuloplasty (RA), are the most frequently performed techniques for posterior mitral leaflet prolapse/flail repair. Despite NP technique is supposed to preserve LV physiology more than LR, it is unclear which technique provides the best haemodynamic pattern. In the present study, the results of the two different surgical techniques in terms of left ventricular (LV) dimension and function are investigated. Methods 23 consecutive patients who underwent MV surgical repair were enrolled. All patients underwent, before surgery and after 8 ± 2 months, 2D and 3D echocardiography with automatic (Heart Model, Philips) assessment of LV volumes and ejection fraction (EF), left atrial (LA) volume, right ventricular (RV) dimension and function, pulmonary artery systolic pressure (PASP), MR, tricuspid regurgitation (TR) and MVPG quantification. MR was corrected using 1) NP with polytetrafluoroethylene sutures and 2) triangular LR, both with RA. Patients were divided in 2 groups according to the surgical technique. Results: techniques were able to successfully correct MR. There were no significant differences in baseline echocardiogram and demographic characteristics between the two groups. There were no significant differences in terms of post-surgical MVPG between the two groups. In all patients a trend in reduction in LV dimension at follow-up was observed, but it was statistically significant only in NP patients (pre-surgical EDV 150 ± 41 VS post-surgical EDV 100 ± 27 ml, p = 0.03). Conclusions Both MV repair techniques showed a successful MV repair and an improvement in LV volumes at follow-up, especially in NP group. Further perspective studies are necessary to demonstrate the hypothesis of more physiological haemodynamic pattern associated with NP techniques. Echo parameters pre VS post MV Repair Parameter pre post p value LVEDV RN (ml) 150 ± 41 100 ± 27 0.03 LVESV RN (ml) 58 ± 20 46 ± 14 NS LVEF RN (%) 58 ± 8 55 ± 7 NS LVEDV RR (ml) 160 ± 58 118 ± 31 NS LVESV RR (ml) 62 ±11 51 ±13 NS LVEF RR (%) 59 ± 8 57 ± 4 NS EDV: end-diastolic volume, ESV: end-systolic volume, EF: ejection fraction, RN = Ring + Neochordae; RR= Ring + Resect.

Aortic valve repair: An evolving space in cardiac surgery

The surgical management of pure aortic regurgitation (AR) continues to evolve and the choice of operation depends on several factors including, the patho-anatomy of the aortic valve and root, patient characteristics and surgical expertise. The absence of an ideal biological or mechanical prosthesis historically stimulated the development of innovative valve-conserving techniques. Early pioneers invented the now established valve sparing aortic root replacement using the remodelling and re-implantation techniques [1,2] which focus on the geometrical correction of the aortic root and restoration of the normal alignment of the aortic valve apparatus to eliminate secondary AR. In the last 10 years or so however, some surgeons have pushed the envelope even further by introducing novel approaches to address primary AR using cusp repair techniques and associated annuloplasty [3-5]. This concept is analogous to more established mitral valve repair techniques which are now refined, reproducible and associated with excellent clinical outcomes. Indeed, it could be said that the current status of aortic valve repair surgery stands where mitral valve repair was some 35 years ago i.e. the preserve of only a hand-full of surgeons working in high-volume centres with a strong innovative ethos.

Recurrent mitral regurgitation after mitral valve repair for bileaflet lesions in the modern era

BackgroundGood mid-term durability of mitral valve repair of bileaflet lesions has been reported; however, patients may develop failure during follow-up. This study assessed late outcomes and mechanisms of failure associated with mitral valve repair of bileaflet lesions.MethodsFifty-six patients (mean age 67 ± 12 years) underwent mitral valve repair of bileaflet lesions due to degenerative disease in 2011–2018. Mitral annuloplasty was added to all procedures except for 1 patient with annular calcification. Mitral valve lesions were identified by surgical inspection. Mean clinical and echocardiography follow-up occurred at 2.7 ± 2.1 and 2.5 ± 1.9 years, respectively.ResultsAdditional mitral valve repair techniques involved triangular resection (n = 15 patients), quadrangular resection with sliding plasty (n = 12), neochordoplasty (n = 52), and commissural plication (n = 26). Prolapse of ≥2 anterior and posterior leaflet scallops occurred in 22 (39%) and 30 (54%) patients, respectively. During follow-up, 10 (17.8%) patients developed moderate or severe mitral regurgitation. Whereas prolapse or tethering was observed early after neochordoplasty or quadrangular resection, recurrent regurgitation occurred late after commissural repair. Five-year freedom from recurrent moderate or severe mitral regurgitation rates was 71.1 ± 11.0%.ConclusionsSeventeen percent of patients developed recurrent mitral regurgitation during follow-up. Repair failure in the early phase occurred owing to aggressive resection of the posterior mitral leaflet or maladjustment of the artificial neochordae. Recurrent mitral regurgitation might occur in the late phase even after acceptable commissural repair. A sequential approach may be useful to improve the quality of mitral valve repair in bileaflet lesions.

Minimally Invasive Mitral Valve Surgery for Rheumatic Valve Disease.

The development of minimally invasive mitral valve surgery has created the motivation for using this approach in young patients with chronic rheumatic valve disease. We report our recent experience with patients undergoing minimally mitral valve surgery in this group of patients. Between July 2014 and June 2018, 142 patients with rheumatic mitral valve dysfunction underwent minimally invasive surgery through a right thoracotomy approach at the University Medical Center of Ho Chi Minh City in Vietnam. Diagnosis was confirmed with transthoracic and transesophageal echocardiography (TTE and TEE). We analyzed the in-hospital and midterm follow-up outcomes of this group. The mean age was 42.6 ± 9.6 years. Sixty patients (42.3%) were male. Sixty-three patients were diagnosed with functional severe tricuspid regurgitation, 29 patients were identified with moderate tricuspid regurgitation, and tricuspid annulus was more than 21 mm/m²). Mitral valve repair was performed in 16 patients (11.3%), and 126 patients underwent mitral valve replacement. Mitral valve repair techniques included annuloplasty, leaflet peeling, and commissurotomy. Thirty-day mortality was 0.7%. Two patients had to be converted to conventional sternotomy, due to left atrial appendage laceration and mitral annular rupture. The overall survival rate was 98.6%. Freedom from reoperation was 97.1%. In patients with rheumatic valve disease, minimally invasive mitral surgery safely and effectively can be performed with few perioperative complications and good midterm results.

Transcatheter mitral valve repair: review of current techniques

Mitral regurgitation is common and is associated with excess morbidity and mortality. Despite these poor outcomes, only a minority of affected patients undergo mitral surgery, for several reasons, which underlines the substantial unmet need for treatment for this disorder. Transcatheter mitral valve repair interventions have been developed to treat mitral regurgitation in an undertreated patient population. The aim of this status quo review is to provide an overview of currently available transcatheter mitral valve repair techniques, the different approaches and the clinical outcomes reported so far.

Minimally Invasive Nonresectional Mitral Valve Repair Can Be Performed With Excellent Outcomes

To review the efficacy of a minimally invasive surgical technique for mitral valve (MV) repair, we analyzed a nonresectional technique for degenerative mitral regurgitation. A retrospective analysis was performed on 101 consecutive patients who underwent a minimally invasive MV repair for severe degenerative mitral regurgitation between 2014 and 2017. All patients underwent a right lateral minithoracotomy and femoral cannulation and were repaired by a nonresectional technique using neochord loop implantation and ring annuloplasty. Patients were followed with longitudinal echocardiograms. The median age was 58 years (interquartile range [IQR], 49-64), and 31% were women. The procedure was successfully performed using a right minithoracotomy in all patients except for 1 who required an extended thoracotomy. A median of 4 neochords were placed. The median length was 16 mm (IQR, 14-18), andring size was 34 mm (IQR, 32-36). Concomitant procedures included left atrial appendage exclusion in 10 patients (10%) and patent foramen ovale closure in 13 (13%). Median cardiopulmonary bypass time was 152 minutes (IQR, 142-164), and aortic cross-clamp time was 90 minutes (IQR, 81-98). Operative mortality was 0% and 1-year survival 100%. At 3 years freedom from recurrent at least moderate mitral regurgitation was 100%, and no patient required a valve-related reoperation. At 1 year the median left atrial diameter decreased by 15% (44 vs 37 mm, P < .001), the left ventricular end-diastolic diameter decreased by 14% (53 vs 46 mm, P < .001), and MV gradients remained low (3.1 vs 2.9 mmHg, P= .54). Minimally invasive MV repair using a nonresectional technique can be performed for severe degenerative mitral regurgitation with a low complication rate, excellent durability, and promising left ventricular reverse remodeling.

Interscallop indentation closure as an adjunctive technique in mitral valve repair for degenerative mitral valve disease.

Interscallop indentation closure is a useful adjunctive technique which presents several different effects in repairing degenerative mitral regurgitation. However, there are some concerns that it might reduce mitral valve area by restricting the posterior leaflet mobility. We aim to assess postoperative echocardiographic findings after mitral valve repair using this technique. Between January 2009 and December 2015, 897 patients underwent mitral valve repair for degenerative mitral regurgitation at our institutions. We reviewed 98 patients in which we used indentation closure technique, and we analyzed operative and echocardiographic data. Ring annuloplasty and concomitant repair techniques such as leaflet resection and neochordal placement were used in all patients. Specific purposes of indentation closure included gap closure (n = 57), prolapse repair (n = 11), leaflet redundancy repair (n = 16), and leaflet deficiency repair (n = 12). Eleven patients had double indentation closure. Postoperative pre-discharge echocardiography showed no moderate or greater residual mitral regurgitation, mean transmitral pressure gradient of 3.4 ± 1.4mmHg, and mitral valve area of 2.7 ± 0.7cm2. Follow-up echocardiography performed at 43.7 ± 23.9months after surgery showed six cases (6.4%) with recurrent moderate or greater mitral regurgitation, mean transmitral pressure gradient of 3.3 ± 1.3mmHg, and mitral valve area of 2.5 ± 0.6cm2. Interscallop indentation closure is a simple and effective adjunctive technique which can be used for several different purposes. It achieves excellent control of mitral regurgitation with preserved mitral valve area when it is used in addition to standard mitral valve repair techniques in selected cases.

Commissuroplasty as a Main Operative Technique in Rheumatic Mitral Valve Repair: Surgical Experiences and Mid-Term Results

We aimed to evaluate the therapeutic effectiveness of commissuroplasty in mitral valve repair for rheumatic mitral valve disease. For this purpose, we summarise our experience with this technique and analyse the mid-term postoperative outcomes. We retrospectively evaluated the records of patients with rheumatic valve disease who underwent mitral valve repair between January 2011 and January 2018 at our centre. Detailed follow-up data were collected. A Kaplan-Meier survival curve for survival free from reoperation and valve failure was constructed. Multivariate Cox regression analyses were performed to identify predictors of relevant end points (death, reoperation, and valve failure). A total of 362 patients underwent rheumatic mitral valve repair during the study period. Mitral valve stenosis was the primary pathological feature. Almost all surgeries were accomplished via commissuroplasty. The mean duration of follow-up was 25.57 ± 19.91 months. Twenty-two (22) endpoint events were noted during follow-up. The 2- and 7-year rates of survival free from reoperation and valve failure were 93.9%±1.4% and 91.5%±2.0%, respectively. Multivariate Cox regression analysis revealed that left atrial anteroposterior diameter >60 mm (hazard ratio, 5.2; p < 0.001) was an independent predictor of all endpoints. Most Chinese patients with rheumatic valve disease were treated effectively via commissuroplasty combined with other surgical procedures, and the mid-term postoperative outcomes were satisfactory.

Choosing the “Best” surgical techniques for mitral valve repair: Lessons from the literature

Mitral valve (MV) repair is the procedure of choice to correct mitral regurgitation caused by degenerative MV disease, due to its well-documented superiority over MV replacement. Repair of the MV is feasible in more than 95% of such patients and restores valve function and preserve ventricular function. Surgeons choose from a wide variety of mitral repair techniques, with the ultimate procedure based upon the pathology and the particular surgeon's personal preference. As a result, there is considerable controversy concerning choice of repair techniques and prostheses (ie, annuloplasty device). This targeted review of available data concerning repair of the degenerative valve will inform surgeon decision-making in MV repair.

Adjusting the neochords height for better leaflets coaptation following mitral valve repair.

Often times, in mitral valve repair techniques, the height of the newly placed Gore-Tex sutures needs correction to achieve better mitral valve leaflet coaptation or to correct systolic anterior motion (SAM). Herein, a less challenging "Hornet" technique to accurately adjust artificial chordal length is described. This technique describes a way to adjust/shorten the Gore-Tex chords, should they need revision. Ideally, this should not be needed, however due to the circumstances for mitral valve repair, this is sometimes necessary. With the annuloplasty band already in place, it is somewhat harder to reinsert new chords and hence, this technique may be beneficial.

Contemporary techniques for mitral valve repair—the Mayo Clinic experience

Mitral valve repair for patients with degenerative or functional mitral valve regurgitation improves symptoms and prognosis, and several techniques have been described. Important principles in operation are simplicity, reproducibility, and durability of repair. At Mayo Clinic, we have operated on more than 6000 patients with degenerative mitral valve disease and valve prolapse, and this review details our approach to mitral valve repair, including robotic and minimally invasive techniques. Most patients with isolated leaflet prolapse can be managed with leaflet plication or triangular resection, and chordal replacement is reserved for repair of anterior leaflet prolapse. Posterior annuloplasty with a standard-sized flexible band is used to reduce annular circumference and improve leaflet coaptation. With these methods, early risk of mortality for mitral valve repair is low in the current era (< 1%), and rate of recurrent valve leakage is 1.5 per 100 patient-years during the first year post-repair and 0.9 per 100 patient-years thereafter. This paper also briefly summarizes important considerations for patients with mitral valve regurgitation and severe calcification, perforations due to endocarditis, and rheumatic heart disease.

Concurrent Mitral Valve Repair during Placement of Continuous-Flow Left Ventricular Assist Device

Purpose Pre-existing mitral valve pathology is common in patients undergoing continuous-flow left ventricular assist device (LVAD) implantation. Best management of pre-existingmitral valve disease remains controversial. Methods Between March 2004 and December 2017, a total of 594 patients received a continuous-flow left ventricular assist device. Of these, a total of 93 patients (16%) underwent a concurrent mitral valve repair, either with an Alfieri stitch via the left ventricular (LV) apex coring site (n =30, 32%) or with an annuloplasty ring via a left atriotomy (n = 63, 68%). Outcomes were compared between patients who received an Alfieri stitch and those who received an annuloplasty ring repair. Results All patients had moderate or greater mitral regurgitation at the time of LVAD implantation. Median age was 54 years (interquartile range [IQR], 43-74) in the annuloplasty cohort, and 56 years (interquartile range [IQR], 44-79) in the Alfieri stitch group. A proportionately greater number of women underwent Alfieri stitch repair (n = 6, 20%) compared to ring annuloplasty (n = 5, 8%; p = 0.01). Additionally, a greater number of patients in the Alfieri group underwent a concomitant valve intervention such as a Park stitch or tricuspid repair (n = 15, or 50%) compared to those patients undergoing a ring annuloplasty (n = 28, 44%; p = 0.04). Cardiopulmonary bypass times were shorter on average in the Alfieri patients, independent of concomitant valve procedure (111 minutes versus 134 minutes, p = .02). Thirty-day survival in the Alfieri group (n = 27, 90%) was similar to that of the ring annuloplasty group (n = 57, 91%); p > 0.05. However, in the 84 patients for whom data was available, 1-year survival was higher in the Alfieri group compared to the ring annuloplasty group (26.3% versus 18.6%, p = 0.032). Conclusion Concomitant mitral valve intervention is fairly common in patients undergoing continuous-flow LVAD placement. Our findings suggest that short-term outcomes are not impacted by type of mitral valve repair technique, but mitral valve repair via the LV apex coring site may be a favorable approach.