Valve Re-repair Research Articles

Rerepair for Mitral Insufficiency

BackgroundMitral valve repair provides superior outcomes to replacement for primary mitral regurgitation. Whether this is true after previous repair is unknown. This study presents the results of a strategy of rerepair for failed mitral valve repair. The study examined patients who were brought to the operating room for an intended mitral valve rerepair. MethodsStudy investigators reviewed the last decade of institutional mitral valve databases at The University of Pennsylvania (Philadelphia, PA) and Baylor Scott & White The Heart Hospital - Plano (Plano, TX) and identified patients who underwent repeat mitral valve repair, in whom the index operation was mitral valve repair. The study analyzed their operative details and the clinical and echocardiographic outcomes. ResultsBetween 2008 and 2021, 71 patients (aged 61.5 ±10.7 years; 20% female) underwent mitral valve reoperation at an mean of 6.24 ± 7.62 years after an index mitral repair. A total of 20% of patients presented with New York Heart Association functional class III or IV symptoms. At the index operation, 34 patients (47.9%) had repair through a right minithoracotomy. Fifteen patients (21.1%) required the reoperation within 1 year. There were 0 early and 8 late deaths. One patient who underwent mitral replacement instead of repair required reoperation for paravalvular leak during the follow-up period. Three patients required mitral valve replacement at an average of 2.28 ± 2.03 years after initial mitral valve rerepair. ConclusionsMitral rerepair can be performed with acceptable results at a valve reference center. Durability and functional advantages of this approach remain to be proven.

Mitral valve re-repair after failed repair with artificial chordae

Mitral valve re-repair after failed repair with artificial chordae

Cone repair after tricuspid valve replacement in Ebstein anomaly.

Cone repair after tricuspid valve replacement in Ebstein anomaly.

Mitral Valve Re-Repair Due to Chordal Pseudo-Elongation Through Repeated Right Anterior Minithoracotomy.

We aim to show the step-by-step surgical technique of mitral valve re-repair by means of a repeated right anterior minithoracotomy in a case of a procedure-related early mitral valve repair failure due to left ventricular positive remodeling and chordal pseudo-elongation. The patient was readdressed to our institution for an early severe mitral valve regurgitation, less than a year after performing a right minithoracotomy mitral valve repair (42-mm annular ring implantation, P2 triangular resection, and P2 neochord positioning). The mechanism was attributed to a positive left ventricle remodeling and neochordal pseudo-elongation. Therefore, we decided to perform a mitral valve re-repair in a redo minimally invasive cardiac surgery. We describe in a video-guided step-by-step fashion the surgical procedure, from the reopening of the right anterior minithoracotomy to the surgical strategy chosen to address the re-repair, guided by the mechanism of the previous repair failure. We replaced the previously implanted ring with a smaller one and positioned a new polytetrafluoroethylene 4-0 neochord at the P2 level. The patient was discharged home on the fifth postoperative day after an uneventful hospital stay. Predischarge echocardiogram demonstrated undetectable residual mitral valve regurgitation. At 3-month follow-up, echocardiographic and clinical data were encouraging. At 9-month follow-up, the patient endorsed no recurrence of cardiologic symptoms. Redo minimally invasive cardiac surgery is a viable option even in case of a mitral valve re-repair due to previous repair failure, especially when procedure related in degenerative mitral disease. Combining the benefits of mitral valve re-repair with those of a minimally invasive surgery may optimize short-term and long-term outcomes.

Robotic mitral valve repair-the Bruxelles experience.

Although the use of the surgical robot facilitates less invasive mitral valve surgery, both real and perceived limitations have slowed the application of this technology. Aim of the present investigation was to report the early and long-term results of robotic mitral valve repair in a single institution over a 10-year period. Between March 2012 and May 2022, a total of 278 consecutive patients underwent robotically assisted mitral valve repair at the Cliniques Universitaires Saint-Luc (Brussels, Belgium). Indications have evolved over time allowing the treatment of complex mitral valve lesions. Clinical and echocardiographic follow-up were 97.8% and 86.1% complete, respectively. Mean age of the study population was 57.8±11.9 years and 221/278 (79.5%) patients were male. Despite being asymptomatic or mildly symptomatic [New York Heart Association (NYHA) class I-II], most of the patients presented with severe mitral regurgitation (MR). Degenerative mitral valve disease was the most common cause of MR. All patients underwent successful mitral valve repair using different techniques, and 25/278 (9.0%) had one or more concomitant procedures associated. The mean cardio-pulmonary bypass and aortic cross clamp times were 153±37 and 106±25 minutes, respectively. There was no operative or in-hospital mortality. Overall survival rate was 97.8%±3.2%, 95.8%±3.2% and 93.7%±3.0% at 3, 7 and 10 years. One early (0.4%) reoperation with re-repair was recorded for ring disruption, while late mitral valve re-repair was necessary in 4/279 (1.4%) patients for recurrent severe MR in three of them and mitral endocarditis in one. The overall freedom from mitral valve reoperation was 98.1%±1.0% at 3, 7 and 10 years. Overall freedom from MR (grade 2+ or more) was 91.7%±3.2%, 77.8%±4.8% and 67.1%±9.2% at 3, 7 and 10 years, respectively. Robotic mitral valve repair is safe and is associated with excellent clinical and echocardiographic results. The use of robotic technologies allows, after an appropriate learning curve, to reproduce all conventional techniques to treat MR, regardless of the complexity of the valve lesion.

Reoperation after early and late failure of mitral valve repair for degenerative disease

ObjectivesTo determine mechanisms of early and late failure after mitral valve repair for degenerative disease, identify factors associated with re-repair, and evaluate durability of re-repair. MethodsFrom January 2008 to July 2020, 330 reoperations were performed for recurrent mitral valve dysfunction after initial valve repair for degenerative disease. Mechanisms of repair failure were determined by review of preoperative imaging and operative reports. Multivariable analysis was performed to identify factors associated with likelihood of re-repair or replacement. Durability of re-repair was assessed using longitudinal analysis of postoperative echo data. ResultsEighty-five of 330 (26%) reoperations were performed for early repair failure within 1 year and 245/330 (74%) for late failure thereafter. Suture/annuloplasty dehiscence, systolic anterior motion, hemolysis, and ventricular remodeling were more common mechanisms of early failure and disease progression and fibrosis late failure. Forty percent (34/85) of early failures were re-repaired versus 24% (59/245) of late failures. Re-repair was more common than replacement in recent years and was associated with earlier reoperation (median 1.5 vs 3.9 years; P = .0001). No in-hospital deaths occurred after re-repair; 2 patients (0.8%) died after valve replacement. Freedom from severe mitral regurgitation after re-repair was 93% at 7 years. ConclusionsMitral valve re-repair can be performed with low rates of mortality and morbidity for early and late valve dysfunction. Mechanisms of early repair failure differ from those of late failure and are generally more amenable to re-repair. In selected patients who present after failed repair, we prefer mitral re-repair to valve replacement whenever technically feasible.

Concomitant Mitral Valve Re-Repair for Mixed Congenital and Degenerative Mitral Disease, Tricuspid Repair, and Cox-Maze Procedure in a College Athlete.

A significant proportion of patients undergoing repair of congenital mitral valve disease will require a subsequent reoperation. During somatic growth, mitral valve repair is preferable to replacement as it allows for annular growth, preservation of ventricular function, and avoidance of lifelong anticoagulation. Techniques to facilitate successful re-repairs for congenital and non-rheumatic mixed degenerative mitral valve disease are not well-described in the literature. Description of the encountered pathology and surgical maneuvers utilized in this case provides real-world tools to help surgeons deal with limited orifice availability, fibrosis, and multilevel lesions. We describe a mitral valve re-repair in a young athlete for a rare cleft posterior mitral leaflet, with a simultaneous tricuspid valve repair and Cox-Maze procedure. We focus on technical pearls that address specific anatomic challenges within our surgical approach.

Lessons from reoperations for mitral stenosis after mitral valve repair

BackgroundThe durability of mitral valve repair (MVr) is usually defined by the absence of recurrent significant mitral regurgitation. Postrepair mitral stenosis (MS) is a less frequent and less studied mode of failure of MVr. We analyzed our experience in patients who underwent reoperation for postrepair MS to characterize mechanisms resulting in MS and to summarize reoperative surgical strategies and mid-term outcomes. MethodsUsing a prospective database, we retrospectively analyzed data on 35 consecutive patients who underwent reoperation for symptomatic moderate to severe MS between January 1, 2011, and February 1, 2020. ResultsThe mean patient age was 61.4 ± 11.4 years, and 69% were female. The median annuloplasty ring size used at the initial repair was 28 mm (interquartile range, 26-30 mm). Additional repair techniques at the initial operation included leaflet resection in 12 patients (34%) and commissuroplasty or edge-to-edge repair in 6 patients (18%). At reoperation, the most common mechanism of MS was pannus ingrowth in 20 patients (57%), leaflet calcification in 12 (34%), commissural fusion in 5 (14%), and tunnel effect (functional MS) in 3 (9%). Twenty-two patients (63%) underwent valve replacement, and 13 (37%) underwent valve re-repair. In patients who underwent re-repair, annuloplasty revision was performed in all patients, with 6 patients (46%) converted from complete ring to band, 4 (11%) converted from ring to pericardial annuloplasty, 2 (6%) converted to no annuloplasty, and 1 (8%) with annuloplasty ring upsizing. There were no in-hospital or 1-year mortalities. Survival at the 5-year follow-up was 93.9%. ConclusionsMS causing late failure of MVr is frequently associated with smaller ring sizes and inflammatory or calcific changes in the valve. Highly selected patients may be good candidates for mitral valve re-repair.

Techniques for Mitral Valve Re-repair

The emergence of mitral valve repair as the preferred treatment for severe mitral regurgitation (MR) caused by degenerative disease has been accompanied by an increasing number of valve repair failures seen by surgeons. Consequently, the feasibility of valve re-repair vs valve replacement at the time of reoperation has become a valid clinical consideration. In this report we explore the mechanisms of mitral valve repair failure as well as factors that meaningfully influence the likelihood of a successful re-repair. We provide illustrations of techniques for re-repair that we have used with reliable success, informed by the mechanism of repair failure. Lastly, we share our outcomes for mitral valve re-repair over the last 5 years and discuss our experience using the techniques illustrated in this report.

Redo mitral valve surgery following prior mitral valve repair.

The optimal treatment strategy following a failed mitral valve repair remains unclear. This study evaluated early and long-term outcomes of redo mitral valve repair (MVr) and replacement (MVR) after prior mitral valve repair. Patients undergoing redo mitral valve surgery after prior mitral valve repair at a single institution between 2002 and 2014 were reviewed. Primary outcomes included operative mortality (30-day or in-hospital mortality) and long-term freedom from mitral valve reoperation and death. Secondary outcomes included postoperative complications. 305 patients underwent redo MVr (n = 48) or MVR (n = 257) after prior mitral valve repair. Concomitant procedures included tricuspid valve repair or replacement (23%), aortic valve replacement (6%), and coronary artery bypass grafting (4%), with no differences between cohorts. 18% were performed via right mini-thoracotomy (24% MVr vs 18% MVR, P = 0.31). Unadjusted and risk-adjusted operative mortality were lower with MVr (0% vs 8%, P = 0.04). Rates of postoperative complications were similar except for blood product transfusion (35% MVr vs 59% MVR, P = 0.003) and prolonged mechanical ventilation (8% MVr vs 29% MVR, P = 0.003). Long-term freedom from mortality was comparable: 96% MVr versus 86% MVR at 1 year and 78% MVr versus 68% MVR at 5 years (P = 0.29). When technically feasible, mitral valve re-repair can be safely performed with outcomes comparable to MVR.

Management of Incomplete Initial Repair in the Treatment of Degenerative Mitral Insufficiency.

We sought to present our institutional protocol to manage incomplete initial repair of degenerative mitral regurgitation and to evaluate its mid-term outcomes. Eight hundred and fifteen patients with degenerative mitral insufficiency undergoing mitral valve repair were investigated in this study. The initial repair attempt was incomplete in 48 patients, leaving a degree of residual regurgitation > mild, and an elevated transmitral gradient or systolic anterior motion (SAM). These patients were further treated with medication or mitral valve re-repair or replacement under reinstituted cardiopulmonary bypass. Transesophageal echocardiographic reports and operational records were reviewed to identify morphological causes and establish management of incomplete initial repair. Mid-term outcomes of patients with re-repair and complete initial repair were evaluated and compared. Residual mitral regurgitation > mild was detected in 25 patients, an elevated transmitral gradient was detected in seven patients, and SAM was detected in 16 patients. The condition of eight patients with SAM was resolved with medication only. Mitral valve re-repair was performed in 23 patients and replacement was performed in 17, with comparable early mortality and morbidity. At 60.3 ± 25.5 months after surgery, late mitral stenosis and reoperation rate were significantly higher in re-repair patients than in patients with complete initial repair, despite comparable survival, left chamber reverse remodeling, and degree of residual regurgitation. Based on our institutional protocol, acceptable outcomes can be achieved for patients with incomplete initial mitral valve repair. Management should be tailored based on the characteristics of the mitral valve complex, expected repair durability, and operative risk.

3-Dimensional–Printed Model for Planning Transcatheter Mitral Valve Replacement

A 69-year-old man with a previous history of mitral valve repair plus aortic valve replacement subsequently developed prosthetic valve endocarditis and underwent aortomitral curtain reconstruction and mitral valve re-repair with a 38-mm Memo 3D (LivaNova, London, United Kingdom) ring and a Bentall

Causes of repair failure for degenerative mitral valve disease and reoperation outcomes.

This study aimed to evaluate the causes of initial mitral valve (MV) repair failure, the details of reoperation and the long-term outcomes of mitral valve re-repair (Re-MVP). We retrospectively reviewed 86 patients who underwent reoperation after MV repair for MR due to degenerative disease from October 1991 to December 2015. First, we analysed the initial MV repair data, causes of MV repair failure, reoperation data and long-term outcomes including survival. Second, the patients were classified into 2 groups based on valve related failure or procedure related failure , and the differences between the groups were analysed. Leaflet prolapse at the initial operation affected the bilateral leaflets in 37 (43%) patients, the anterior leaflet in 30 (35%) patients and the posterior leaftlet in 19 (22%) patients. Median duration from first operation to reoperation was 47.5 (interquartile range 4.8-85.8) months. Reoperation indication included recurrent mitral regurgitation alone in 59 patients, haemolysis combined with recurrent mitral regurgitation in 15 patients, infectious endocarditis combined with recurrent mitral regurgitation in 8 patients, mitral stenosis in 2 patients and left ventricular pseudoaneurysm in 2 patients. The cause of MV repair failure was valve-related in 61 (71%) patients, procedure-related in 20 (23%) patients and both in 5 (6%) patients. Re-MVP was successful in 23 (27%) patients. Re-MVP was more common in patients with procedure-related failure, which occurred earlier than valve-related failure. Freedom from all-cause death was significantly better after Re-MVP. The 5-year freedom from reoperation after Re-MVP was 95.7%. Re-MVP was more common in patients with procedure-related failure, which occurred earlier than valve-related failure. Durability of re-repaired MVs and survival of re-repaired patients were acceptable.

Neonatal Mitral Valve Repair in Biventricular Repair, Single Ventricle Palliation, and Secondary Left Ventricular Recruitment: Indications, Techniques, and Mid-Term Outcomes.

Although mitral valve repair is rarely required in neonates, this population is considered to be at high risk for adverse outcomes. The aim of this study was to review the indications for surgery, mechanisms, repair techniques, and mid-term outcomes of neonatal mitral valve repair. The demographic, procedural, and outcome data were obtained for all neonates who underwent mitral valve repair from 2005 to 2012. The primary endpoints included mortality, transplantation, and mitral valve reoperation. Twenty patients were included during the study period. Median age at operation was 11 days (range: 3-25). Eleven patients (55%) presented with mitral stenosis, three had regurgitation (15%), and six had mixed mitral disease (30%). Nineteen of 20 patients had mild or less regurgitation on immediate postoperative imaging. During a median follow-up of 5 months (1 month-4.8 years), six patients died at a median of 33 months (7-41 months) from repair and one patient required orthotopic heart transplantation. Six patients required mitral valve reoperation, five for mitral valve re-repair, and one for mitral valve replacement. Freedom from death, transplantation, or mitral valve replacement was 84.2 ± 8.4% at 1 month, 71.3 ± 11% at 6 months, 64.1 ± 12% at 1 year, and 51.3 ± 15% at 2 years and was worse for patients presenting with mitral regurgitation compared to stenosis or mixed mitral valve disease. Although mitral valve repair can be performed with acceptable immediate postoperative result, this procedure carries a high burden of late death and mitral valve reoperations.

Simplici-T Annuloplasty Band for Mitral Valve Repair for Degenerative Disease

Sizing of annuloplasty rings and bands is variably based on intertrigonal or intercommissural distances or estimation of the anterior leaflet area. This studyexamines the results of mitral valve repair with Simplici-T annuloplasty band without predetermining its length in patients with mitral regurgitation (MR) as a result of degenerative disease. Three hundred thirty-seven consecutive patients (median age, 58 years; 69% men) underwent mitral valve repair for MR as a result of degenerative disease (52% bileaflet prolapse and 36% anterior leaflet prolapse). Prolapse of the leaflet was corrected by chordal replacement with Gore-Tex sutures and occasionally a triangular resection. A posterior mitral annuloplasty with a Simplici-T band (median length, 70 mm; range, 52 to 80mm) was performed by securing it from the lateral to the medial fibrous trigones. Annular reduction was performed selectively on the commissures, false commissures, and areas of posterior leaflet resection. Mitral valve function, gradients, and areas were assessed perioperatively and annually during a median follow-up of 4.1years (interquartile range, 2.7 to 5.4 years) and was 98% complete. There were 2 operative and 7 late deaths; survival at 5 years was 97.2%. Three patients were discharged from the hospital with mild to moderate MR, and during follow-up a total of 14 patients had MR greater than mild and 1 patient had MR greater than moderate. Mitral valve re-repair was performed in 1 patient who exhibited mitral stenosis. Freedom from MR greater than mild at 5 years was 93.3%. Selective reduction of the mitral annulus with a posterior band without predetermining its length during mitral valve repair for degenerative MR provides excellent functional results.

Results of minimally invasive, video-assisted mitral valve repair in advanced Barlow's disease with bileaflet prolapse.

Minimally invasive mitral valve (MV) surgery has recently gained popularity as the standard approach for MV repair, albeit there could be potential concerns about the feasibility of complex repair in the presence of extreme Barlow's disease via a minimally invasive route. Fifty consecutive patients with advanced Barlow's disease and bileaflet prolapse underwent minimally invasive, video-assisted MV repair via a 5 cm right antero-lateral thoracotomy with peripheral cannulation and external aortic clamping. Mean age, left ventricular ejection fraction and New York Heart Association class were 53±11 years, 62±7% and 3.1±0.8, respectively. Logistic EuroSCORE (mean) was 3.1. Either Custodiol (36 patients; 72%) or crystalloid (14 patients; 28%) cardioplegia were utilized. Complete rings (CE Classic or Physio) were implanted. Chordal reimplantation was carried out by means of polytetrafluoroethylene (PTFE) chordae. All procedures were successfully performed with null/mild residual mitral regurgitation (MR) intraoperatively. A repair strategy of posterior leaflet resection and PTFE chordae implant (for anterior leaflet) or no-resect approach (only PTFE chordae on both leaflets) was performed in 62% (31 patients) and 38% (19 patients) of cases, respectively. Mean aortic cross-clamp and cardiopulmonary bypass times were 98±23 and 131±41 min, respectively. Hospital mortality was 0%. At a median follow-up of 761 days, 2 patients (4%) required reoperation (infective endocarditis: 1 patient; partial ring detachment: 1 patient) and valve rerepair was achieved in both. All patients are alive with a freedom from ≥2+ degree of MR of 100% at the latest echocardiographic evaluation. Minimally invasive approach for complex MV repair is feasible and safe and provided excellent early and mid-term results.

Three hundred robotic-assisted mitral valve repairs: The Cedars-Sinai experience

The study objective was to review our first 300 consecutive robotic-assisted mitral repairs performed from June 2005 to October 2012 and to compare the surgical outcomes of our previously reported initial 120 cases with the subsequent 180 procedures. Our initial 120 robotic-assisted mitral repairs were previously reported, and we now compare our early experience with the recent 180 consecutive procedures for a total of 300 robotic-assisted mitral repairs. There was no patient selection. Every patient in need of isolated mitral valve repair underwent this procedure. All patients received an annuloplasty band and 1 or more of the following: leaflet resection, secondary chordal transposition, or polytetrafluoroethylene neochordal replacement and edge-to-edge repair. All 300 patients had preoperative echocardiographic findings of severe mitral regurgitation. There were no differences (P=not significant) between the initial and the recent cohorts for preoperative characteristics, including age (58.4 ± 10.5 years vs 59.9 years), female gender (35.8% vs 36.1%), ejection fraction (61.9% vs 60.6%), congestive heart failure (35.0% vs 36.7%), creatinine (0.94 mg/dL vs 0.98 mg/dL), and New York Heart Association class. The incidence of anterior and posterior leaflet prolapse was similar in both groups, whereas Barlow syndrome was higher in group 2 (5.8% vs 27.8%). There was 1 (0.33%) hospital mortality and no deaths in the last 180 cases. Overall, 8 patients (2.7%) required subsequent mitral valve replacement via a median sternotomy, 6 (5.0%) in the first group and 2 (1.1%) in the second group (P=.06). One patient in each group had mitral valve re-repair through a right mini-thoracotomy, and 1 patient in the first group required a mitral valve replacement via a mini-thoracotomy during the original procedure. Two of the 180 patients had documented cerebrovascular accident, but both fully recovered clinically. There was no cerebrovascular accident in the last 120 patients. Crossclamp times decreased from 116 minutes to 91 minutes in the second group despite starting a training program with a junior associate performing part of the procedure at the console in the last 100 cases. Post-pump echocardiograms showed no/trace mitral regurgitation in 86.1% of the last 180 patients and mild mitral regurgitation in 11.1%. Follow-up echocardiography for the last 180 patients from 1 month to more than 1 year showed no/trace mitral regurgitation in 64.6% of patients and mild mitral regurgitation in 23.1% of patients. Seven patients (10.8%) had moderate mitral regurgitation, and 1 patient (1.5%) had severe mitral regurgitation. The majority of complications and reoperations occurred early in our experience, especially using the first-generation da Vinci robot (Intuitive Surgical Inc, Sunnyvale, Calif). The newer da Vinci Si HD system with the addition of an adjustable left atrial roof retractor together with increased experience has made robotic-assisted mitral repair of all types of degenerative mitral valve pathology reproducible. The training of young surgeons in a stepwise fashion in high-volume centers will help to avoid the complications encountered during the introduction of this technology.

Incidental Gossypiboma Discovered during Tricuspid Valve Re-Repair 11 Years after Ebstein Anomaly Repair

A retained surgical sponge, an extremely rare occurrence after cardiac surgery, can trigger a granulomatous reaction and form a sizeable mass or gossypiboma. We report the incidental operative finding of a gossypiboma 11 years after repair of Ebstein anomaly. A 24-year-old man, who had previously undergone tricuspid annuloplasty for Ebstein anomaly 11 years earlier at another institution, was referred for recurrent severe tricuspid regurgitation. During the dissection along the superior vena cava and the right atrium, we entered 2 cystic cavities that exuded a pus-like material, which was sent for culture. Mesh from a retained surgical sponge (gossypiboma) was identified. After complete debridement and administration of vancomycin, the tricuspid valve was repaired. Antibiotics were continued until culture results were confirmed to be negative. The patient's postoperative course was uneventful, and he presented no signs of infection. We report a rare case of incidentally found gossypiboma after cardiac surgery.

Re-repair of the mitral valve as a primary strategy for early and late failures of mitral valve repair

With the expanding uptake of mitral valve repair as the primary therapy for mitral valve regurgitation, an increasing cohort of patients are presenting with failures following valve repair. These patients have traditionally been treated by mitral valve replacement. We have adopted an aggressive strategy of valve re-repair for failures of mitral valve repair and present our mid-term results. Fifty-three consecutive adults underwent reoperation by a single surgical team for failed non-rheumatic mitral valve repair. Primary valve repair had been done for degenerative (n=38), congenital (n=6), infective (n=3), functional (n=1) or unknown (n=5) mitral disease. The reoperative mitral procedure occurred at a median interval of 3 (interquartile range 0.9-6.5) years from the primary mitral valve repair. Valve re-repair was attempted if the anterior leaflet was sufficiently pliable, and lesions causing recurrence were identifiable and deemed treatable. Standard repair techniques were employed in re-repair procedures. Valve analysis showed that the mode of failure was progression of original disease in 19 (36%), technical failure in 20 (38%) and new disease in 14 (26%) patients. Valve re-repair was successfully accomplished in 45 (85%) patients. Re-repair was most frequent when the prior aetiology was degenerative (34 of 38, 90%) as opposed to non-degenerative (11 of 15, 73%). There were no hospital deaths. Four-year patient survival was 97%. Freedoms from moderate mitral regurgitation were 100, 95, 88 and 80% at discharge and at 1, 3, and 4 years, respectively. There were no reoperations in the follow-up period. Re-repair of the mitral valve is feasible in most of the cases of failed mitral valve repair of non-rheumatic aetiology and has acceptable mid-term outcomes. The relatively high prevalence of technical failures as the mechanism of failure of the primary mitral valve repair suggests the need for ongoing surgical education and continuing development and refinement of repair techniques.

Strategies for Tricuspid Re-Repair in Ebstein Malformation Using the Cone Technique

Successful tricuspid repair for Ebstein malformation (EM) is challenging. Cone repair has recently emerged as the most anatomic repair technique. There are no data on tricuspid re-repair in EM. We reviewed our experience with tricuspid valve (TV) re-repair using a cone technique. Between June 2007 and October 2012, 134 patients underwent cone repair. Prior TV repair was performed in 20 patients (10 female, 50%). Median age was 15 years (range, 4 to 68 years). Four patients (20%) had prior bidirectional cavopulmonary anastomosis (BDCPA). Preoperative heart failure was present in 8 patients (40%). Recurrent tricuspid regurgitation (TR) was due to incomplete leaflet coaptation with tethered anterior leaflet in all patients; and 10 patients (50%) had diminutive septal leaflet. Prior repair techniques consisted of annuloplasty maneuvers in all patients with no or incomplete surgical delamination in all patients. The TV re-repair using cone technique was possible in all patients. Plication of atrialized right ventricle was done in 6 patients (30%). Modifications included annuloplasty band in 16 patients (80%) and TV leaflet augmentation in 8 (40%). The BDCPA was performed in 3 patients (15%) and modified Cox-maze procedure was done in 10 (50%). There were no mortalities or reoperations. Mean follow-up was 7.7 ± 10.7 months; during follow-up, 18 patients had no or mild TR and 2 had moderate TR. TV re-repair in EM using the cone technique is feasible, particularly when there has been no surgical leaflet delamination at initial operation. Leaflet augmentation facilitates and annuloplasty band stabilizes a competent TV re-repair. Longer follow-up is required to assess durability.