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Andrási TB, Glück AC, Ben Taieb O, Talipov I, Abudureheman N, Volevski L, Vasiloi I. Outcome of Surgery for Ischemic Mitral Regurgitation Depends on the Type and Timing of the Coronary Revascularization. J Clin Med 2023; 12:3182. [PMID: 37176621 PMCID: PMC10179469 DOI: 10.3390/jcm12093182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/11/2023] [Accepted: 04/15/2023] [Indexed: 05/15/2023] Open
Abstract
OBJECTIVE Long-term outcomes of mitral valve (MV) repair versus MV replacement for ischemic mitral regurgitation (IMR) in patients undergoing either prior (PCR) or concomitant coronary revascularization (CCR) by surgery (CABG) or intervention (PCI) are uncertain. METHODS AND RESULTS Of 446 patients receiving MV surgery for IMR between July 2006 and December 2010, 125 patients-87 CCR (69.1%) and 38 PCR (30.9%)-were eligible for inclusion in the study. Survival was higher in CCR versus PCR at long-term follow-up (78.83% vs. 57.9%, p = 0.016). The incidence of MACCE was lower in the CCR compared to PCR at both hospital discharge (34.11% vs. 63.57%, p = 0.003) and at follow-up (34.11% vs. 65.79%, p = 0.0008). Patients receiving CABG or CABG with PCI in PCR had higher mortality risks after MV surgery than CCR patients (X2 = 6.029, p = 0.014 and X2 = 6.466, p = 0.011, respectively). Whereas in the PCR group, MV repair and MV replacement achieved similar survival probability (X2 = 1.551, p = 0.213), MV repair in the CCR group led to improved survival compared to MV replacement (X2 = 3.921, p = 0.048). In MV replacement, LAD-CABG improved survival compared to LAD-PCI (U = 15,000.00, Z = -2.373 p = 0.018), and a substantial impact of arterial IMA-LAD grafting was revealed in the Cox-regression analysis (HR 0.334, CI: 0.113-0.989, p = 0.048) as opposed to venous-LAD grafting (HR 0.588, CI: 0.166-2.078, p = 0.410). CONCLUSION Early treatment of IMR concomitant to coronary revascularization enhances long-term survival compared to delayed MV surgery after PCR. MV repair is not superior to MV replacement when performed late after coronary revascularization; however, MV repair leads to better survival than MV replacement when performed concomitantly with CABG with arterial LAD revascularization.
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Affiliation(s)
- Terézia B. Andrási
- Department of Cardiac Surgery, Philipps University of Marburg, 35043 Marburg, Germany
| | - Alannah C. Glück
- Department of Cardiac Surgery, Philipps University of Marburg, 35043 Marburg, Germany
- School of Medicine, Philipps University of Marburg, 35032 Marburg, Germany
| | - Olfa Ben Taieb
- Department of Cardiac Surgery, Philipps University of Marburg, 35043 Marburg, Germany
| | - Ildar Talipov
- Department of Cardiac Surgery, Philipps University of Marburg, 35043 Marburg, Germany
| | - Nunijiati Abudureheman
- Department of Cardiac Surgery, Philipps University of Marburg, 35043 Marburg, Germany
- School of Medicine, Philipps University of Marburg, 35032 Marburg, Germany
| | - Lachezar Volevski
- Department of Cardiac Surgery, Philipps University of Marburg, 35043 Marburg, Germany
- School of Medicine, Philipps University of Marburg, 35032 Marburg, Germany
| | - Ion Vasiloi
- School of Medicine, Philipps University of Marburg, 35032 Marburg, Germany
- Department of Cardiac Surgery, University of Basel, 4031 Basel, Switzerland
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Ngardig Ngaba N, Chibuzo UN, Patel M, Gulati A, Ola O, Djindimadje A, Khan IA. Mitral stenosis in a teenager after rheumatic mitral valve regurgitation valve repair: A case report. Front Cardiovasc Med 2022; 9:978874. [PMID: 36588572 PMCID: PMC9797729 DOI: 10.3389/fcvm.2022.978874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 11/16/2022] [Indexed: 12/23/2022] Open
Abstract
Introduction Mitral stenosis (MS) is a widely known complication of mitral valve repair for non-rheumatic mitral regurgitation (MR). Few reports are available on the occurrence of MS after mitral valve repair for rheumatic MR in young populations. Case summary A 14-year-old girl presented with orthopnea, abdominal distension, and bilateral lower-limb edema. She was cachectic, with a high-pitched holosystolic murmur best heard at the cardiac apex, bilateral basal crackles, tender hepatomegaly, pitting pedal edema, and jugular venous distension. Antistreptolysin O (ASO) titer was elevated. Transthoracic echocardiography (TTE) revealed the loss of central coaptation of the mitral valve with leaflet restriction and MR, annular dilatation of the tricuspid valve, and tricuspid regurgitation (TR). She had AHA/ACC stage D mitral and TR s. Tricuspid annuloplasty and mitral valve repair for rheumatic MR were performed using Carpentier Edwards numbers 30 and 34, respectively. Following surgery, the weight and body mass index (BMI) rapidly normalized. The patient also developed progressive MS. Discussion Previous studies in adults have described the etiopathogenesis of MS after non-rheumatic mitral valve repair. There is a paucity of reports describing the development of MS over the span of months after rheumatic MR valve repair in early pubescent children. Conclusion Growth spurts during puberty can potentially affect MR repair, as the mitral valve prosthesis based on the preoperative Body Surface Area (BSA) is outgrown. There is a need for research on planning, prognostication, and development of an optimal, individualized, and adaptable approach to MR intervention in early pubescence.
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Affiliation(s)
| | | | - Meet Patel
- Interfaith Medical Center, Brooklyn, NY, United States
| | - Amit Gulati
- Maimonides Medical Center, Brooklyn, NY, United States
| | - Olatunde Ola
- Division of Hospital Medicine, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic Health System, La Crosse, Wisconsin and Center for Clinical and Translational Science, Rochester, MN, United States
| | | | - Imteyaz A. Khan
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
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Biomechanical engineering comparison of four leaflet repair techniques for mitral regurgitation using a novel 3-dimensional-printed left heart simulator. JTCVS Tech 2022; 10:244-251. [PMID: 34977730 PMCID: PMC8691825 DOI: 10.1016/j.xjtc.2021.09.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 09/24/2021] [Indexed: 01/05/2023] Open
Abstract
Objective Mitral valve repair is the gold standard treatment for degenerative mitral regurgitation; however, a multitude of repair techniques exist with little quantitative data comparing these approaches. Using a novel ex vivo model, we sought to evaluate biomechanical differences between repair techniques. Methods Using porcine mitral valves mounted within a custom 3-dimensional-printed left heart simulator, we induced mitral regurgitation using an isolated P2 prolapse model by cutting primary chordae. Next, we repaired the valves in series using the edge-to-edge technique, neochordoplasty, nonresectional remodeling, and classic leaflet resection. Hemodynamic data and chordae forces were measured and analyzed using an incomplete counterbalanced repeated measures design with the healthy pre-prolapse valve as a control. Results With the exception of the edge-to-edge technique, all repair methods effectively corrected mitral regurgitation, returning regurgitant fraction to baseline levels (baseline 11.9% ± 3.7%, edge-to-edge 22.5% ± 6.9%, nonresectional remodeling 12.3% ± 3.0%, neochordal 13.4% ± 4.8%, resection 14.7% ± 5.5%, P < 0.01). Forces on the primary chordae were minimized using the neochordal and nonresectional techniques whereas the edge-to-edge and resectional techniques resulted in significantly elevated primary forces. Secondary chordae forces also followed this pattern, with edge-to-edge repair generating significantly higher secondary forces and leaflet resection trending higher than the nonresectional and neochord repairs. Conclusions Although multiple methods of degenerative mitral valve repair are used clinically, their biomechanical properties vary significantly. Nonresectional techniques, including leaflet remodeling and neochordal techniques, appear to result in lower chordal forces in this ex vivo technical engineering model.
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Manohar P, Naik L R, Mohan Rao PS. Auto-Pericardial Mitral Valve Implantation: A Pilot Study. Heart Lung Circ 2021; 31:575-581. [PMID: 34656441 DOI: 10.1016/j.hlc.2021.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 09/03/2021] [Accepted: 09/18/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Developing nations continue to grapple with rheumatic heart disease, particularly in the young. There is a need for an alternative to prosthetic mitral valve replacement in irreparable mitral valves, which avoids the need for anticoagulation and risks of thromboembolism. METHODS Twelve (12) patients with irreparable severe mitral valve disease underwent auto-pericardial mitral valve implantation from August 2020 to February 2021. The mitral valve leaflets were excised. Autologous pericardium treated with 0.5% glutaraldehyde for 8 minutes was fashioned into anterior and posterior mitral leaflets as per the dimensions on an indigenously designed template based on the studies by Ranganathan and Lam. The pericardial leaflets were sutured onto an appropriately sized mitral annuloplasty ring. The ring with the leaflets was implanted onto the mitral annulus. The leaflets were supported with neo-chordae prepared with Gore-Tex (W L Gore and Associates, Inc. Newark, DE, USA) and polyester sutures to mimic a repaired mitral valve in its structure and dynamics. RESULTS The mean cross-clamp time was 138±21.7 minutes. None of the patients required re-exploration. On the third postoperative day, a mean mitral valve orifice area of 3±0.47 cm and mean mitral valve gradient of 2±1.04 were observed. None of the patients had any more than 1+ mitral regurgitation. None of them have required a re-intervention for mitral insufficiency to date. DISCUSSION Auto-pericardial mitral valve re-implantation is a safe and effective procedure for severe, irreparable, mitral valve pathologies. However, the mid-term and long-term results need to be compared with conventional mitral valve replacement with a prosthetic valve in a randomised controlled trial.
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Affiliation(s)
- Prabhu Manohar
- Department of Cardiothoracic and Vascular Surgery, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, Karnataka, India.
| | - Rakesh Naik L
- Department of Cardiothoracic and Vascular Surgery, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, Karnataka, India
| | - Prasanna Simha Mohan Rao
- Department of Cardiothoracic and Vascular Surgery, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, Karnataka, India
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De Bonis M, Zancanaro E, Lapenna E, Trumello C, Ascione G, Giambuzzi I, Ruggeri S, Meneghin R, Abboud S, Agricola E, Del Forno B, Buzzatti N, Monaco F, Pappalardo F, Castiglioni A, Alfieri O. Optimal versus suboptimal mitral valve repair: late results in a matched cohort study. Eur J Cardiothorac Surg 2020; 58:328-334. [DOI: 10.1093/ejcts/ezaa103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 01/26/2020] [Accepted: 01/28/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
After mitral repair for degenerative mitral regurgitation (MR), no or mild (≤1+/4+) residual MR should remain. Occasionally patients are left with more than mild residual MR (>1+/4+) for a number of reasons. The aim of this study was to assess the late implications of such a suboptimal repair in a matched cohort study.
METHODS
From 2006 to 2013, a total of 2158 patients underwent mitral repair for degenerative MR in our institution. Fifty patients (2.3%) with residual MR >1+ at hospital discharge (study group) were matched up to 1:2 with 91 patients operated on during the same period who were discharged with MR ≤1+ (control group). The median follow-up was 8 years (interquartile range 6.3–10.1, longest 12.7 years). A comparative analysis of the outcomes in the 2 groups was performed.
RESULTS
Overall survival at 8 years was 87 ± 8% in the study group and 92 ± 3% in the control group (P = 0.23). There were 3 late deaths (6.0%) in the study group and 6 deaths (6.6%) in the control group. Freedom from reoperation was similar (P = 1.0). At 8 years the prevalence of MR ≥3+ was significantly higher in the study group (15.6% vs 2.1%, P < 0.001) as was the use of diuretics, beta-blockers and angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers. Interestingly, even in the control group, a gradual progression of MR was observed because 13.3% of the patients had MR ≥2+ at 8 years with a significant increase over time (P < 0.001).
CONCLUSIONS
Residual MR more than mild at hospital discharge is associated with lower durability of mitral repair and the need for more medical therapy in the long term. However, even an initial optimal result does not completely arrest the progression of the degenerative process.
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Affiliation(s)
- Michele De Bonis
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Edoardo Zancanaro
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elisabetta Lapenna
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cinzia Trumello
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Guido Ascione
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ilaria Giambuzzi
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefania Ruggeri
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Roberta Meneghin
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sabrin Abboud
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Eustachio Agricola
- Division of Cardiology, Echocardiography Laboratory Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Benedetto Del Forno
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicola Buzzatti
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabrizio Monaco
- Anesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federico Pappalardo
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Anesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Castiglioni
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ottavio Alfieri
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Sardari Nia P, Heuts S, Daemen JHT, Olsthoorn JR, Chitwood WR, Maessen JG. The EACTS simulation-based training course for endoscopic mitral valve repair: an air-pilot training concept in action. Interact Cardiovasc Thorac Surg 2020; 30:691-698. [DOI: 10.1093/icvts/ivz323] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 12/16/2019] [Accepted: 12/19/2019] [Indexed: 02/01/2023] Open
Abstract
Abstract
OBJECTIVES
We have developed a high-fidelity minimally invasive mitral valve surgery (MIMVS) simulator that provides a platform to train skills in an objective and reproducible manner, which has been incorporated in the European Association for Cardiothoracic Surgery (EACTS) endoscopic mitral valve repair course. The aim of the study is to provide data on the application of simulation-based training in MIMVS using an air-pilot training concept.
METHODS
The 2-day EACTS endoscopic mitral training course design was based on backwards chaining, pre- and post-assessment, performance feedback, hands-on training on MIMVS, theoretical content and follow-up. One hundred two participants who completed the full programme throughout 2016–2018 in the EACTS endoscopic mitral training courses were enrolled in the current study.
RESULTS
Of the 102 participants, 83 (83.3%) participants were staff/attending surgeons, 12 (11.8%) participants had finished residency and 5 (4.9%) participants were residents. Theoretical pre- and post-assessment showed that participants scored significantly higher on post-assessment (median score 58% vs 67%, P < 0.001). Pre- and post-assessment of skills on MIMVS showed that participants could work with long-shafted instruments more accurately (suture accuracy 43% vs 99%, P < 0.001) and faster (87 vs 42 s, P < 0.001). Follow-up, based on course evaluation and a survey, had a response rate of 55% (57 participants). Of all surveyed participants, 33.3% (n = 19) had started an endoscopic mitral programme successfully, while 66.7% (n = 38) did not yet start.
CONCLUSIONS
The MIMVS is a valuable tool for the development and assessment of endoscopic mitral repair skills. This EACTS course provides surgeons with theoretical knowledge and necessary skills to start an endoscopic mitral valve programme successfully.
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Affiliation(s)
- Peyman Sardari Nia
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Jean H T Daemen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Jules R Olsthoorn
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - W Randolph Chitwood
- Department of Cardiovascular Sciences, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
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7
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Durability of mitral valve repair: A single center experience. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2019; 27:459-468. [PMID: 32082910 DOI: 10.5606/tgkdc.dergisi.2019.18165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 07/14/2019] [Indexed: 11/21/2022]
Abstract
Background This study aims to present clinical outcomes of mitral valve repair in patients with different etiologies. Methods Between June 2006 and August 2017, a total of 421 consecutive patients (266 males, 155 females; mean age 53.1±15.6 years; range, 5 to 89 years) who underwent mitral valve repair with or without concomitant cardiac procedures were retrospectively analyzed. All pre-, intra-, and postoperative data were collected. Echocardiographic examinations were performed at discharge and during follow-up. Kaplan-Meier analysis was used to estimate overall survival and from residual severe mitral regurgitation, endocarditis and reoperation-free survival rates. Results The mean follow-up was 58.9±35.1 months. Of the patients, 12 (2.8%) had previous cardiac operations. The most predominant pathology was degenerative disease in 265 patients (62.9%). Repair techniques included ring annuloplasty (n=366, 86.9%), artificial chordae implantation (n=185, 44%), and commissurotomy (n=38, 9%). Overall in-hospital mortality rate was 1.2% (n=5). Echocardiography before discharge showed no/trivial mitral regurgitation in 64.9% (n=270) and mild mitral regurgitation in 34.85% (n=145) of the patients. At the late postoperative period, transthoracic echocardiography revealed moderate mitral regurgitation in 23 patients (5.7%) and severe in 11 patients (2.7%). The mean late survival and freedom from endocarditis, reoperation, and recurrent severe mitral regurgitation rates were 92±0.03%, 98.5±0.07%, 98.1±0.01%, and 94.7±0.02%, respectively. Conclusion Our study results suggest that mitral valve repair is a safe and effective procedure associated with favorable longterm outcomes in experienced centers.
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Sardari Nia P, Daemen JH, Maessen JG. Development of a high-fidelity minimally invasive mitral valve surgery simulator. J Thorac Cardiovasc Surg 2019; 157:1567-1574. [DOI: 10.1016/j.jtcvs.2018.09.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 08/19/2018] [Accepted: 09/04/2018] [Indexed: 11/25/2022]
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Wang X, Zhang B, Zhang J, Ying Y, Zhu C, Chen B. Repair or replacement for severe ischemic mitral regurgitation: A meta-analysis. Medicine (Baltimore) 2018; 97:e11546. [PMID: 30075522 PMCID: PMC6081181 DOI: 10.1097/md.0000000000011546] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The best surgical option for severe ischemic mitral regurgitation (IMR) is still controversial. The aim of this study was to perform a meta-analysis to compare the clinical outcomes of mitral valve repair (MVP) with replacement (MVR). METHODS A literature search was conducted in PubMed, Embase, and Medline using the terms "ischemic mitral regurgitation" and "repair or annuloplasty or reconstruction" and "replacement" in the title/abstract field. The primary outcomes of interest were perioperative mortality and long-term survival. Secondary outcomes were mitral regurgitation (MR) recurrence and reoperation. RESULTS Of 276 studies, 13 studies met the inclusion and exclusion criteria. A total of 1993 patients were included in these studies, consisting of 1259 (63%) repair cases, and 734 (37%) replacement cases. Perioperative mortality was lower with MVP compared with MVR [OR 0.61; (95% CI, 0.43-0.87; P < .05)]. There was no difference with respect to long-term survival [HR 0.75; (95% CI, 0.52-1.09; P = .14)] and reoperation [OR 0.77; (95% CI, 0.38-1.57; P = .47)]. MVP is associated with a higher recurrence of MR [OR = 4.09; (95% CI, 1.82-9.19; P < .001)]. CONCLUSION MVP is associated with a lower perioperative mortality but a higher recurrence of MR compared with MVR for severe IMR. No differences were found with respect to long-term survival and reoperation.
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Bogachev-Prokophiev A, Afanasyev A, Zheleznev S, Fomenko M, Sharifulin R, Kretov E, Karaskov A. Mitral valve repair or replacement in hypertrophic obstructive cardiomyopathy: a prospective randomized study†. Interact Cardiovasc Thorac Surg 2017; 25:356-362. [DOI: 10.1093/icvts/ivx152] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 03/21/2017] [Indexed: 01/24/2023] Open
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Lazam S, Vanoverschelde JL, Tribouilloy C, Grigioni F, Suri RM, Avierinos JF, de Meester C, Barbieri A, Rusinaru D, Russo A, Pasquet A, Michelena HI, Huebner M, Maalouf J, Clavel MA, Szymanski C, Enriquez-Sarano M, Michelina H, Poulain H, Remadi JP, Touati G, Trojette F, Biagini E, Di Bartolomeo R, Ferlito F, Marinelli G, Pacini D, Pasquale F, Rapezzi C, Savini C, Boulif J, El Khoury G, Gerber B, Noirhomme P, Vancraeynest D, Collard F, Habib G, Metras D, Riberi A, Tafanelli L, Bursi F, Lugli R, Mantovani F, Manicardi C, Grazia M, Bacchi-Reggiani L. Twenty-Year Outcome After Mitral Repair Versus Replacement for Severe Degenerative Mitral Regurgitation. Circulation 2017; 135:410-422. [DOI: 10.1161/circulationaha.116.023340] [Citation(s) in RCA: 168] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 11/15/2016] [Indexed: 11/16/2022]
Abstract
Background:
Mitral valve (MV) repair is preferred over replacement in clinical guidelines and is an important determinant of the indication for surgery in degenerative mitral regurgitation. However, the level of evidence supporting current recommendations is low, and recent data cast doubts on its validity in the current era. Accordingly, the aim of the present study was to analyze very long-term outcome after MV repair and replacement for degenerative mitral regurgitation with a flail leaflet.
Methods:
MIDA (Mitral Regurgitation International Database) is a multicenter registry enrolling patients with degenerative mitral regurgitation with a flail leaflet in 6 tertiary European and US centers. We analyzed the outcome after MV repair (n=1709) and replacement (n=213) overall, by propensity score matching, and by inverse probability-of-treatment weighting.
Results:
At baseline, patients undergoing MV repair were younger, had more comorbidities, and were more likely to present with a posterior leaflet prolapse than those undergoing MV replacement. After propensity score matching and inverse probability-of-treatment weighting, the 2 treatments groups were balanced, and absolute standardized differences were usually <10%, indicating adequate match. Operative mortality (defined as a death occurring within 30 days from surgery or during the same hospitalization) was lower after MV repair than after replacement in both the entire population (1.3% versus 4.7%;
P
<0.001) and the propensity-matched population (0.2% versus 4.4%;
P
<0.001). During a mean follow-up of 9.2 years, 552 deaths were observed, of which 207 were of cardiovascular origin. Twenty-year survival was better after MV repair than after MV replacement in both the entire population (46% versus 23%;
P
<0.001) and the matched population (41% versus 24%;
P
<0.001). Similar superiority of MV repair was obtained in patient subsets on the basis of age, sex, or any stratification criteria (all
P
<0.001). MV repair was also associated with reduced incidence of reoperations and valve-related complications.
Conclusions:
Among patients with degenerative mitral regurgitation with a flail leaflet referred to mitral surgery, MV repair was associated with lower operative mortality, better long-term survival, and fewer valve-related complications compared with MV replacement.
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Affiliation(s)
- Siham Lazam
- From Université Catholique de Louvain, Brussels, Belgium (S.L., J.-L.V., C.d.M., A.P.); Mayo Clinic College of Medicine, Rochester, MN (H.I.M., M.H., J.M., M.-A.C., M.E.-S.); University of Bologna, Italy (F.G., A.R.); Inserm, ERI-12, University Hospital, Amiens, France (C.T., D.R., C.S.); Aix-Marseille Université, Marseille, France (J.-F.A.); University of Modena, Italy (A.B.); and Cleveland Clinic, Department of Thoracic and Cardiac Surgery, OH (R.M.S.)
| | - Jean-Louis Vanoverschelde
- From Université Catholique de Louvain, Brussels, Belgium (S.L., J.-L.V., C.d.M., A.P.); Mayo Clinic College of Medicine, Rochester, MN (H.I.M., M.H., J.M., M.-A.C., M.E.-S.); University of Bologna, Italy (F.G., A.R.); Inserm, ERI-12, University Hospital, Amiens, France (C.T., D.R., C.S.); Aix-Marseille Université, Marseille, France (J.-F.A.); University of Modena, Italy (A.B.); and Cleveland Clinic, Department of Thoracic and Cardiac Surgery, OH (R.M.S.)
| | - Christophe Tribouilloy
- From Université Catholique de Louvain, Brussels, Belgium (S.L., J.-L.V., C.d.M., A.P.); Mayo Clinic College of Medicine, Rochester, MN (H.I.M., M.H., J.M., M.-A.C., M.E.-S.); University of Bologna, Italy (F.G., A.R.); Inserm, ERI-12, University Hospital, Amiens, France (C.T., D.R., C.S.); Aix-Marseille Université, Marseille, France (J.-F.A.); University of Modena, Italy (A.B.); and Cleveland Clinic, Department of Thoracic and Cardiac Surgery, OH (R.M.S.)
| | - Francesco Grigioni
- From Université Catholique de Louvain, Brussels, Belgium (S.L., J.-L.V., C.d.M., A.P.); Mayo Clinic College of Medicine, Rochester, MN (H.I.M., M.H., J.M., M.-A.C., M.E.-S.); University of Bologna, Italy (F.G., A.R.); Inserm, ERI-12, University Hospital, Amiens, France (C.T., D.R., C.S.); Aix-Marseille Université, Marseille, France (J.-F.A.); University of Modena, Italy (A.B.); and Cleveland Clinic, Department of Thoracic and Cardiac Surgery, OH (R.M.S.)
| | - Rakesh M. Suri
- From Université Catholique de Louvain, Brussels, Belgium (S.L., J.-L.V., C.d.M., A.P.); Mayo Clinic College of Medicine, Rochester, MN (H.I.M., M.H., J.M., M.-A.C., M.E.-S.); University of Bologna, Italy (F.G., A.R.); Inserm, ERI-12, University Hospital, Amiens, France (C.T., D.R., C.S.); Aix-Marseille Université, Marseille, France (J.-F.A.); University of Modena, Italy (A.B.); and Cleveland Clinic, Department of Thoracic and Cardiac Surgery, OH (R.M.S.)
| | - Jean-Francois Avierinos
- From Université Catholique de Louvain, Brussels, Belgium (S.L., J.-L.V., C.d.M., A.P.); Mayo Clinic College of Medicine, Rochester, MN (H.I.M., M.H., J.M., M.-A.C., M.E.-S.); University of Bologna, Italy (F.G., A.R.); Inserm, ERI-12, University Hospital, Amiens, France (C.T., D.R., C.S.); Aix-Marseille Université, Marseille, France (J.-F.A.); University of Modena, Italy (A.B.); and Cleveland Clinic, Department of Thoracic and Cardiac Surgery, OH (R.M.S.)
| | - Christophe de Meester
- From Université Catholique de Louvain, Brussels, Belgium (S.L., J.-L.V., C.d.M., A.P.); Mayo Clinic College of Medicine, Rochester, MN (H.I.M., M.H., J.M., M.-A.C., M.E.-S.); University of Bologna, Italy (F.G., A.R.); Inserm, ERI-12, University Hospital, Amiens, France (C.T., D.R., C.S.); Aix-Marseille Université, Marseille, France (J.-F.A.); University of Modena, Italy (A.B.); and Cleveland Clinic, Department of Thoracic and Cardiac Surgery, OH (R.M.S.)
| | - Andrea Barbieri
- From Université Catholique de Louvain, Brussels, Belgium (S.L., J.-L.V., C.d.M., A.P.); Mayo Clinic College of Medicine, Rochester, MN (H.I.M., M.H., J.M., M.-A.C., M.E.-S.); University of Bologna, Italy (F.G., A.R.); Inserm, ERI-12, University Hospital, Amiens, France (C.T., D.R., C.S.); Aix-Marseille Université, Marseille, France (J.-F.A.); University of Modena, Italy (A.B.); and Cleveland Clinic, Department of Thoracic and Cardiac Surgery, OH (R.M.S.)
| | - Dan Rusinaru
- From Université Catholique de Louvain, Brussels, Belgium (S.L., J.-L.V., C.d.M., A.P.); Mayo Clinic College of Medicine, Rochester, MN (H.I.M., M.H., J.M., M.-A.C., M.E.-S.); University of Bologna, Italy (F.G., A.R.); Inserm, ERI-12, University Hospital, Amiens, France (C.T., D.R., C.S.); Aix-Marseille Université, Marseille, France (J.-F.A.); University of Modena, Italy (A.B.); and Cleveland Clinic, Department of Thoracic and Cardiac Surgery, OH (R.M.S.)
| | - Antonio Russo
- From Université Catholique de Louvain, Brussels, Belgium (S.L., J.-L.V., C.d.M., A.P.); Mayo Clinic College of Medicine, Rochester, MN (H.I.M., M.H., J.M., M.-A.C., M.E.-S.); University of Bologna, Italy (F.G., A.R.); Inserm, ERI-12, University Hospital, Amiens, France (C.T., D.R., C.S.); Aix-Marseille Université, Marseille, France (J.-F.A.); University of Modena, Italy (A.B.); and Cleveland Clinic, Department of Thoracic and Cardiac Surgery, OH (R.M.S.)
| | - Agnès Pasquet
- From Université Catholique de Louvain, Brussels, Belgium (S.L., J.-L.V., C.d.M., A.P.); Mayo Clinic College of Medicine, Rochester, MN (H.I.M., M.H., J.M., M.-A.C., M.E.-S.); University of Bologna, Italy (F.G., A.R.); Inserm, ERI-12, University Hospital, Amiens, France (C.T., D.R., C.S.); Aix-Marseille Université, Marseille, France (J.-F.A.); University of Modena, Italy (A.B.); and Cleveland Clinic, Department of Thoracic and Cardiac Surgery, OH (R.M.S.)
| | - Hector I. Michelena
- From Université Catholique de Louvain, Brussels, Belgium (S.L., J.-L.V., C.d.M., A.P.); Mayo Clinic College of Medicine, Rochester, MN (H.I.M., M.H., J.M., M.-A.C., M.E.-S.); University of Bologna, Italy (F.G., A.R.); Inserm, ERI-12, University Hospital, Amiens, France (C.T., D.R., C.S.); Aix-Marseille Université, Marseille, France (J.-F.A.); University of Modena, Italy (A.B.); and Cleveland Clinic, Department of Thoracic and Cardiac Surgery, OH (R.M.S.)
| | - Marianne Huebner
- From Université Catholique de Louvain, Brussels, Belgium (S.L., J.-L.V., C.d.M., A.P.); Mayo Clinic College of Medicine, Rochester, MN (H.I.M., M.H., J.M., M.-A.C., M.E.-S.); University of Bologna, Italy (F.G., A.R.); Inserm, ERI-12, University Hospital, Amiens, France (C.T., D.R., C.S.); Aix-Marseille Université, Marseille, France (J.-F.A.); University of Modena, Italy (A.B.); and Cleveland Clinic, Department of Thoracic and Cardiac Surgery, OH (R.M.S.)
| | - Joseph Maalouf
- From Université Catholique de Louvain, Brussels, Belgium (S.L., J.-L.V., C.d.M., A.P.); Mayo Clinic College of Medicine, Rochester, MN (H.I.M., M.H., J.M., M.-A.C., M.E.-S.); University of Bologna, Italy (F.G., A.R.); Inserm, ERI-12, University Hospital, Amiens, France (C.T., D.R., C.S.); Aix-Marseille Université, Marseille, France (J.-F.A.); University of Modena, Italy (A.B.); and Cleveland Clinic, Department of Thoracic and Cardiac Surgery, OH (R.M.S.)
| | - Marie-Annick Clavel
- From Université Catholique de Louvain, Brussels, Belgium (S.L., J.-L.V., C.d.M., A.P.); Mayo Clinic College of Medicine, Rochester, MN (H.I.M., M.H., J.M., M.-A.C., M.E.-S.); University of Bologna, Italy (F.G., A.R.); Inserm, ERI-12, University Hospital, Amiens, France (C.T., D.R., C.S.); Aix-Marseille Université, Marseille, France (J.-F.A.); University of Modena, Italy (A.B.); and Cleveland Clinic, Department of Thoracic and Cardiac Surgery, OH (R.M.S.)
| | - Catherine Szymanski
- From Université Catholique de Louvain, Brussels, Belgium (S.L., J.-L.V., C.d.M., A.P.); Mayo Clinic College of Medicine, Rochester, MN (H.I.M., M.H., J.M., M.-A.C., M.E.-S.); University of Bologna, Italy (F.G., A.R.); Inserm, ERI-12, University Hospital, Amiens, France (C.T., D.R., C.S.); Aix-Marseille Université, Marseille, France (J.-F.A.); University of Modena, Italy (A.B.); and Cleveland Clinic, Department of Thoracic and Cardiac Surgery, OH (R.M.S.)
| | - Maurice Enriquez-Sarano
- From Université Catholique de Louvain, Brussels, Belgium (S.L., J.-L.V., C.d.M., A.P.); Mayo Clinic College of Medicine, Rochester, MN (H.I.M., M.H., J.M., M.-A.C., M.E.-S.); University of Bologna, Italy (F.G., A.R.); Inserm, ERI-12, University Hospital, Amiens, France (C.T., D.R., C.S.); Aix-Marseille Université, Marseille, France (J.-F.A.); University of Modena, Italy (A.B.); and Cleveland Clinic, Department of Thoracic and Cardiac Surgery, OH (R.M.S.)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - J. Boulif
- Université Catholique de Louvain, Belgium
| | | | - B. Gerber
- Université Catholique de Louvain, Belgium
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Russell EA, Reid CM, Walsh WF, Brown A, Maguire GP. Outcome following valve surgery in Australia: development of an enhanced database module. BMC Health Serv Res 2017; 17:43. [PMID: 28095841 PMCID: PMC5240444 DOI: 10.1186/s12913-017-2002-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 01/11/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Valvular heart disease, including rheumatic heart disease (RHD), is an important cause of heart disease globally. Management of advanced disease can include surgery and other interventions to repair or replace affected valves. This article summarises the methodology of a study that will incorporate enhanced data collection systems to provide additional insights into treatment choice and outcome for advanced valvular disease including that due to RHD. METHODS An enhanced data collection system will be developed linking an existing Australian cardiac surgery registry to more detailed baseline co-morbidity, medication, echocardiographic and hospital separation data to identify predictors of morbidity and mortality outcome following valve surgery. DISCUSSION This project aims to collect and incorporate more detailed information regarding pre and postoperative factors and subsequent morbidity. We will use this to provide additional insights into treatment choice and outcome.
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Affiliation(s)
- E. Anne Russell
- Clinical Research Domain, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004 Australia
- School of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC Australia
| | - Christopher M Reid
- School of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC Australia
- School of Public Health, Curtin University, Perth, WA Australia
| | | | - Alex Brown
- Wardliparingga Aboriginal Research Unit, South Australia Health and Medical Research Institute, Adelaide, SA Australia
- School of Population Health, University of South Australia, Adelaide, SA Australia
| | - Graeme P Maguire
- Clinical Research Domain, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004 Australia
- School of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC Australia
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Abstract
Acute rheumatic fever and rheumatic heart disease remain major global health problems. Although strategies for primary and secondary prevention are well established, their worldwide implementation is suboptimum. In patients with advanced valvular heart disease, mechanical approaches (both percutaneous and surgical) are well described and can, for selected patients, greatly improve outcomes; however, access to centres with experienced staff is very restricted in regions that have the highest prevalence of disease. Development of diagnostic strategies that can be locally and regionally provided and improve access to expert centres for more advanced disease are urgent and, as yet, unmet clinical needs. We outline current management strategies for valvular rheumatic heart disease on the basis of either strong evidence or expert consensus, and highlight areas needing future research and development.
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Affiliation(s)
| | - Ahmed ElGuindy
- Department of Cardiology, Aswan Heart Centre, Aswan, Egypt
| | - Sidney C Smith
- Heart and Vascular Center, University of North Carolina, Chapel Hill, NC, USA
| | - Magdi Yacoub
- Cardiothoracic Surgery, Imperial College London, London, UK
| | - David R Holmes
- Department of Cardiology, Mayo Clinic, Rochester, MN, USA.
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Russell EA, Tran L, Baker RA, Bennetts JS, Brown A, Reid CM, Tam R, Walsh WF, Maguire GP. A review of outcome following valve surgery for rheumatic heart disease in Australia. BMC Cardiovasc Disord 2015; 15:103. [PMID: 26399240 PMCID: PMC4580994 DOI: 10.1186/s12872-015-0094-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 09/14/2015] [Indexed: 11/15/2022] Open
Abstract
Background Globally, rheumatic heart disease (RHD) remains an important cause of heart disease. In Australia it particularly affects younger Indigenous and older non-Indigenous Australians. Despite its impact there is limited understanding of the factors influencing outcome following surgery for RHD. Methods The Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database was analysed to assess outcomes following surgical procedures for RHD and non-RHD valvular disease. The association with demographics, co-morbidities, pre-operative status, valve(s) affected and operative procedure was evaluated. Results Outcome of 1384 RHD and 15843 non-RHD valve procedures was analysed. RHD patients had longer ventilation, experienced fewer strokes and had more readmissions to hospital and anticoagulant complications. Mortality following RHD surgery at 30 days was 3.1 % (95 % CI 2.2 – 4.3), 5 years 15.3 % (11.7 – 19.5) and 10 years 25.0 % (10.7 – 44.9). Mortality following non-RHD surgery at 30 days was 4.3 % (95 % CI 3.9 - 4.6), 5 years 17.6 % (16.4 - 18.9) and 10 years 39.4 % (33.0 - 46.1). Factors independently associated with poorer longer term survival following RHD surgery included older age (OR1.03/additional year, 95 % CI 1.01 – 1.05), concomitant diabetes (OR 1.7, 95 % CI 1.1 – 2.5) and chronic kidney disease (1.9, 1.2 – 2.9), longer invasive ventilation time (OR 1.7 if greater than median value, 1.1– 2.9) and prolonged stay in hospital (1.02/additional day, 1.01 – 1.03). Survival in Indigenous Australians was comparable to that seen in non-Indigenous Australians. Conclusion In a large prospective cohort study we have demonstrated survival following RHD valve surgery in Australia is comparable to earlier studies. Patients with diabetes and chronic kidney disease, were at particular risk of poorer long-term survival. Unlike earlier studies we did not find pre-existing atrial fibrillation, being an Indigenous Australian or the nature of the underlying valve lesion were independent predictors of survival.
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Affiliation(s)
- E Anne Russell
- Baker IDI, Melbourne, VIC, 3004, Australia. .,School of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Lavinia Tran
- School of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Robert A Baker
- Department of Cardiac and Thoracic Surgery, Flinders Medical Centre, Adelaide, South Australia.
| | - Jayme S Bennetts
- Department of Cardiac and Thoracic Surgery, Flinders Medical Centre, Adelaide, South Australia. .,Department of Surgery, School of Medicine, Flinders University, Adelaide, South Australia.
| | - Alex Brown
- Wardliparingga Aboriginal Research Unit, South Australia Health and Medical Research Institute, Adelaide, South Australia. .,School of Population Health, University of South Australia, Adelaide, South Australia.
| | - Christopher M Reid
- School of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia. .,School of Public Health, Curtin University, Perth, Western Australia.
| | - Robert Tam
- Director of Surgery, Department of Cardiothoracic Surgery, Townsville Hospital, Queensland, Australia.
| | | | - Graeme P Maguire
- Baker IDI, Melbourne, VIC, 3004, Australia. .,School of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia. .,School of Medicine, James Cook University, Cairns, QLD, Australia.
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Khamooshian A, Buijsrogge MP, De Heer F, Gründeman PF. Mitral Valve Annuloplasty Rings: Review of Literature and Comparison of Functional Outcome and Ventricular Dimensions. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2014; 9:399-415. [DOI: 10.1177/155698451400900603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In the past decades, more than 40 mitral valve annuloplasty rings of various shapes and consistency were marketed for mitral regurgitation (MR), although the effect of ring type on clinical outcome remains unclear. Our objective was to review the literature and apply a simplification method to make rings of different shapes and rigidity more comparable. We studied relevant literature from MEDLINE and EMBASE databases related to clinical studies as well as animal and finite element models. Annuloplasty rings were clustered into 3 groups as follows: rigid (R), flexible (F), and semirigid (S). Only clinical articles regarding degenerative (DEG) or ischemic/dilated cardiomyopathy (ICM) MR were included and stratified into these groups. A total of 37 rings were clustered into R, F, and S subgroups. Clinical studies with a mean follow-up of less than 1 year and a reported mean etiology of valve incompetence of less than 60% were excluded from the analysis. Forty-one publications were included. Preimplant and postimplant end points were New York Heart Association class, left ventricular ejection fraction (LVEF), left ventricular end-systolic dimension (LVESD), and left ventricular end-diastolic dimension (LVEDD). Statistical analysis included paired-samples t test and analysis of variance with post hoc Bonferroni correction. P < 0.05 indicated statistical difference. Mean ± SD follow-up was 38.6 ± 27 and 29.7 ± 13.2 months for DEG and ICM, respectively. In DEG, LVEF remained unchanged, and LVESD decreased in all subgroups. In our analysis, LVEDD decreased only in F and R, and S did not change; however, the 4 individual studies showed a significant decline. In ICM, New York Heart Association class improved in all subgroups, and LVEF increased. Moreover, LVESD and LVEDD decreased only in F and S; R was underpowered (1 study). No statistical difference among R, F, and S in either ICM or DEG could be detected for all end points. Overall, owing to underpowered data sets derived from limited available publications, major statistical differences in clinical outcome between ring types could not be substantiated. Essential end points such as recurrent MR and survival were incomparable. In conclusion, ring morphology and consistency do not seem to play a major clinical role in mitral valve repair based on the present literature. Hence, until demonstrated otherwise, surgeons may choose their ring upon their judgment, tailored to specific patient needs.
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A new ex vivo beating heart model to investigate the application of heart valve performance tools with a high-speed camera. ASAIO J 2014; 60:38-43. [PMID: 24270227 DOI: 10.1097/mat.0000000000000008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
High-speed camera examination of heart valves is an established technique to examine heart valve prosthesis. The aim of this study was to examine the possibility to transmit new tools for high-speed camera examination of heart valve behavior under near-physiological conditions in a porcine ex vivo beating heart model. After explantation of the piglet heart, main coronary arteries were cannulated and the heart was reperfused with the previously collected donor blood. When the heart started beating in sinus rhythm again, the motion of the aortic and mitral valve was recorded using a digital high-speed camera system (recording rate 2,000 frames/sec). The image sequences of the mitral valve were analyzed, and digital kymograms were calculated at different angles for the exact analysis of the different closure phases. The image sequence of the aortic valve was analyzed, and several snakes were performed to analyze the effective orifice area over the time. Both processing tools were successfully applied to examine heart valves in this ex vivo beating heart model. We were able to investigate the exact open and closure time of the mitral valve, as well as the projected effective orifice area of the aortic valve over the time. The high-speed camera investigation in an ex vivo beating heart model of heart valve behavior is feasible and also reasonable because of using processing feature such as kymography for exact analysis. These analytical techniques might help to optimize reconstructive surgery of the mitral valve and the development of heart valve prostheses in future.
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Ward AF, Grossi EA, Galloway AC. Minimally invasive mitral surgery through right mini-thoracotomy under direct vision. J Thorac Dis 2014; 5 Suppl 6:S673-9. [PMID: 24251027 DOI: 10.3978/j.issn.2072-1439.2013.10.09] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 10/14/2013] [Indexed: 11/14/2022]
Abstract
In the 1990s, the success of 'minimally invasive' laparoscopic operations in other surgical subspecialties sparked an interest in minimally-invasive approaches for cardiac surgery, specifically for mitral valve repair. In 1996 at New York University (NYU) we began our experience with minimally invasive mitral valve repair performed through a small right anterior mini-thoracotomy incision using the Port-Access system in a phase I clinical trial. This was the beginning of our extensive right mini-thoracotomy experience for mitral valve repair at NYU. Currently at our institution the preferred approach for the right mini-thoracotomy mitral valve surgery is through the 3rd or 4th interspace mini-thoracotomy incision. Perfusion is accomplished with direct aortic or femoral cannulation, long femoral venous cannula drainage, and a retrograde cardioplegia catheter placed trans-atrialy in the coronary sinus under TEE guidance. An antegrade cardioplegia and venting needle is placed in the ascending aorta and direct external aortic clamping is achieved with one of several specialized crossclamps. With over four decades of experience, more than 4,000 patients have undergone mitral valve repair at NYU including 1,922 performed through a right mini-thoracotomy. We have reported an overall operative mortality of 1.3%, 8-year freedom from reoperation of 95%, freedom from reoperation or severe recurrent mitral regurgitation of 93%, and freedom from all valve-related complications of 90% for our initial series of 1,071 right mini-thoracotomy mitral valve repair. Based on our extensive experience we believe that mitral valve repair through a right mini-thoracotomy provides a durable and safe alternative to a traditional sternotomy with the benefits of improved cosmesis, reduced post-operative pain, less blood loss with fewer blood transfusions, fewer infections, shorter length of stay, and faster return to activity. It is our standard of care approach for mitral valve surgery.
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Affiliation(s)
- Alison F Ward
- Department of Cardiothoracic Surgery, New York University School of Medicine, New York, NY 10016, USA
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MacHaalany J, Sénéchal M, O'Connor K, Abdelaal E, Plourde G, Voisine P, Rimac G, Tardif MA, Costerousse O, Bertrand OF. Early and late mortality after repair or replacement in mitral valve prolapse and functional ischemic mitral regurgitation: A systematic review and meta-analysis of observational studies. Int J Cardiol 2014; 173:499-505. [DOI: 10.1016/j.ijcard.2014.02.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 02/13/2014] [Indexed: 11/28/2022]
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Vengen ØA, Abdelnoor M, Westheim AS, Smith G, Fjeld NB. Outcome of mitral valve plasty or replacement: atrial fibrillation an effect modifier. J Cardiothorac Surg 2013; 8:142. [PMID: 23724788 PMCID: PMC3673869 DOI: 10.1186/1749-8090-8-142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 05/27/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Advances in the understanding of mitral valve pathology have laid to mitral valve plasty (MPL) as the procedure of choice of all the mitral intervention as compared to mitral valve replacement (MVR). MATERIAL AND METHODS A cohort of 355 patients with mitral valve disease operated between January 1993 to January 2007 with closing date first of mars 2011. There were 214 MPL and 141 MVR at the Hospital discharge. This retrospective cohort had the design of exposed (MPL) versus non-exposed (MVR) with outcome total mortality and reoperation during follow up. Also echocardiography follow-up was undertaken to estimate the true long-term failure rate of repair. RESULTS The mean follow up was 5.3 years SE (3.82) maximum follow up was 14.1 years. Considering the patient time model the association between repair/replacement and total mortality RR = 0.43 95% (0.28-074) p = 0.002 controlling for the confounding effect of 3-vessels disease. Those results were confirmed by propensity score analysis. CONCLUSION In a cohort of patient with mitral valve disease undergoing MPL/MVR was examined. MPL was associated with better survival, and lower reoperation rate for patients without AF but same rate for patients with AF. We advocate more attention in controlling risk factors of AF in the clinical management of mitral disease. Long-term failure rate of MPL was low during follow up time. A replication of our results by a randomized clinical trial is mandatory.
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Affiliation(s)
- Øystein A Vengen
- Dept of Cardiothoracic Surgery, Oslo University Hospital, Ullevaal, Norway
| | - Michael Abdelnoor
- Centre of Clinical Research: Unit of Epidemiology and Biostatistics, Oslo University Hospital, Ullevaal, Norway
- Centre for Clinical Heart Research, Oslo University Hospital, Ullevaal, Norway
| | - Arne S Westheim
- Dept of Cardiology, Oslo University Hospital, Ullevaal, Norway
| | - Gunnar Smith
- Dept of Cardiology, Oslo University Hospital, Ullevaal, Norway
| | - Nils Bj Fjeld
- Dept of Cardiothoracic Surgery, Oslo University Hospital, Ullevaal, Norway
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Vassileva CM, Shabosky J, Boley T, Markwell S, Hazelrigg S. Cost Analysis of Isolated Mitral Valve Surgery in the United States. Ann Thorac Surg 2012; 94:1429-36. [DOI: 10.1016/j.athoracsur.2012.05.100] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 05/17/2012] [Accepted: 05/25/2012] [Indexed: 10/28/2022]
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Vassileva CM, Boley T, Markwell S, Hazelrigg S. Mitral valve repair is underused in patients with hypertrophic obstructive cardiomyopathy. Heart Surg Forum 2012; 14:E376-9. [PMID: 22167765 DOI: 10.1532/hsf98.20111067] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The optimal surgical approach for patients with hypertrophic obstructive cardiomyopathy (HOCM) with concomitant mitral valve (MV) regurgitation has remained controversial. The purpose of this study was to use the largest all-payer database in the United States to examine the strategy most commonly used for the correction of mitral valve pathology in the setting of HOCM. METHODS The Nationwide Inpatient Sample (NIS) database was searched from 2005 to 2008 to identify patients with a diagnosis of HOCM (ICD-9-CM code 425.1) who underwent MV repair (ICD-9-CM code 35.12) or replacement (ICD-9-CM codes 35.23 and 35.24). HOCM patients who underwent MV repair and those who underwent MV replacement were compared with respect to baseline characteristics, repair rates, hospital mortality, and length of stay (LOS). RESULTS MV repair was performed in 17.2% of cases (219/1255). Repair rates did not show a significantly increasing trend over time (P = .1419). The median LOS was significantly longer for replacement than for repair (11 days versus 7 days, P = .0001). The mortality rate for patients who underwent repair was 0.00%, compared with 11.18% for those who underwent replacement (P < .05). CONCLUSIONS The majority of patients with a HOCM diagnosis underwent MV replacement for the correction of MV pathology. Referral to centers with special expertise in treating patients with HOCM may positively affect the operative outcomes of this patient subset.
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Affiliation(s)
- Christina M Vassileva
- Division of Cardiothoracic Surgery, Southern Illinois University School of Medicine, Springfield, Illinois 62794-9638, USA.
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De Bonis M, Ferrara D, Taramasso M, Calabrese MC, Verzini A, Buzzatti N, Alfieri O. Mitral replacement or repair for functional mitral regurgitation in dilated and ischemic cardiomyopathy: is it really the same? Ann Thorac Surg 2012; 94:44-51. [PMID: 22440363 DOI: 10.1016/j.athoracsur.2012.01.047] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Revised: 01/13/2012] [Accepted: 01/16/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND This was a study to compare the results of mitral valve (MV) repair and MV replacement for the treatment of functional mitral regurgitation (MR) in advanced dilated and ischemic cardiomyopathy (DCM). METHODS One-hundred and thirty-two patients with severe functional MR and systolic dysfunction (mean ejection fraction 0.32 ± 0.078) underwent mitral surgery in the same time frame. The decision to replace rather than repair the MV was taken when 1 or more echocardiographic predictors of repair failure were identified at the preoperative echocardiogram. Eighty-five patients (64.4%) received MV repair and 47 patients (35.6%) received MV replacement. Preoperative characteristics were comparable between the 2 groups. Only ejection fraction was significantly lower in the MV repair group (0.308 ± 0.077 vs 0.336 ± 0.076, p = 0.04). RESULTS Hospital mortality was 2.3% for MV repair and 12.5% for MV replacement (p = 0.03). Actuarial survival at 2.5 years was 92 ± 3.2% for MV repair and 73 ± 7.9% for MV replacement (p = 0.02). At a mean follow-up of 2.3 years (median, 1.6 years), in the MV repair group LVEF significantly increased (from 0.308 ± 0.077 to 0.382 ± 0.095, p < 0.0001) and LV dimensions significantly decreased (p = 0.0001). On the other hand, in the MV replacement group LVEF did not significantly change (from 0.336 ± 0.076 to 0.31 ± 0.11, p = 0.56) and the reduction of LV dimensions was not significant. Mitral valve replacement was identified as the only predictor of hospital (odds ratio, 6; 95% confidence interval, 1.1 to 31; p = 0.03) and overall mortality (hazard ratio, 3.1; 95% confidence interval, 1.1 to 8.9; p = 0.02). CONCLUSIONS In patients with advanced dilated and ischemic cardiomyopathy and severe functional MR, MV replacement is associated with higher in-hospital and late mortality compared with MV repair. Therefore, mitral repair should be preferred whenever possible in this clinical setting.
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Affiliation(s)
- Michele De Bonis
- Department of Cardiac Surgery, San Raffaele University Hospital, Milan, Italy.
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Cikirikcioglu M, Cherian S, Kalangos A. Mitral annuloplasty using an intra-annular ring. Multimed Man Cardiothorac Surg 2012; 2012:mms019. [PMID: 24414722 DOI: 10.1093/mmcts/mms019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The final step in mitral valve repair is usually the implantation of an annuloplasty ring which remodels the dilated annulus and improves the long-term durability of repair. Conventional annuloplasty rings remain as a permanent foreign body on the atrio-ventricular annulus, thus presenting an increased risk for thromboembolic complications. Furthermore, currently available conventional rings are adapted for the adult population, with no annuloplasty ring specifically developed for the paediatric population. A new intra-annular ring that undergoes gradual degradation by hydrolysis has been developed for use both in adults and in children. The resultant inflammatory reaction induces fibrosis, thereby remodelling the posterior mitral annulus. Contrary to the conventional rings that are implanted 'onto' the annulus, the intra-annular ring is implanted 'into' the annulus, and hence prevents direct contact with the circulating blood, thereby reducing the risk of thrombo-embolic complications and negating the need for anticoagulation. This annuloplasty ring also permits normal growth of the valve orifice in the paediatric population. This article aims to present the intra-annular implantation technique and the rationale for a biodegradable annuloplasty ring in mitral valve repair.
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Affiliation(s)
- Mustafa Cikirikcioglu
- Division of Cardiovascular Surgery, University Hospitals and Medical Faculty of Geneva, Switzerland
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Kassem S, Othman M. Annulus-edge-papillary stitch to repair P2 of the mitral valve posterior leaflet. J Thorac Cardiovasc Surg 2011; 141:e45-7. [PMID: 21420105 DOI: 10.1016/j.jtcvs.2011.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2010] [Revised: 01/11/2011] [Accepted: 02/09/2011] [Indexed: 11/26/2022]
Affiliation(s)
- Samer Kassem
- Department of Cardiovascular Surgery, Centro Cardiologico Monzino IRCCS, Milan, Italy.
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Gupta A, Gharde P, Kumar AS. Anterior mitral leaflet length: predictor for mitral valve repair in a rheumatic population. Ann Thorac Surg 2011; 90:1930-3. [PMID: 21095338 DOI: 10.1016/j.athoracsur.2010.07.035] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Revised: 07/11/2010] [Accepted: 07/14/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND The length and mobility of the anterior mitral leaflet (AML) are considered important for mitral valve reparability. In this study, we looked at AML length as a predictor of mitral valve reparability in a rheumatic population. METHODS Between May and November 2008, 44 patients underwent mitral valve repair for pure mitral regurgitation, pure mitral stenosis, and mixed lesions. The mean age was 26.5 ± 10.4 years (range, 9 to 50; median 23.5), and 15 patients were less than 20 years old. There were 28 female patients. The mean body surface area was 1.37 ± 0.13 (range, 0.97 to 1.62). In all patients, we measured AML length at the A2 segment, both by transesophageal echocardiography and intraoperative direct measurement. These measurements were indexed to the body surface area. RESULTS Thirty-five patients had successful repair. Nine patients underwent mitral valve replacement after failed repair. The AML lengths were significantly higher in the successful repair group as compared with the failed repair group (AML length measured by transesophageal echocardiography was 31.4 ± 4.9 mm versus 24.1 ± 2.2 mm, p = 0.001; AML length measured intraoperatively was 30.8 ± 4.4 mm versus 22.3 ± 1.5 mm, p = 0.001). An intraoperatively measured AML length of 26 mm or more predicts reparability with 97.1% sensitivity and 100% specificity. Transesophageal echocardiography can reliably judge AML length and can also predict reparability. Indexed AML lengths are an even stronger predictor of mitral valve reparability, especially in a pediatric population. CONCLUSIONS Indexed AML length is a strong predictor of mitral valve reparability. With a value of 18 mm/m(2) or more, repair can be accomplished in all cases.
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Affiliation(s)
- Anubhav Gupta
- Department of Cardiovascular and Thoracic Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
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Schwartz CF, Grossi EA, Ribakove GH, Ursomanno P, Mirabella M, Crooke GA, Galloway AC. Ten-Year Results of Folding Plasty in Mitral Valve Repair. Ann Thorac Surg 2010; 89:485-8. [DOI: 10.1016/j.athoracsur.2009.10.055] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2008] [Revised: 10/21/2009] [Accepted: 10/23/2009] [Indexed: 10/19/2022]
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Reddy PK, Dharmapuram AK, Swain SK, Ramdoss N, Raghavan SS, Murthy KS. Valve Repair in Rheumatic Heart Disease in Pediatric Age Group. Asian Cardiovasc Thorac Ann 2008; 16:129-33. [DOI: 10.1177/021849230801600210] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Valve repair in children is technically demanding but more desirable than valve replacement. From April 2004 to September 2005, 1 boy and 8 girls with rheumatic heart disease, aged 2–13 years (median, 9 years), underwent valve repair for isolated mitral regurgitation in 5, combined mitral and aortic regurgitation in 2, mitral stenosis in 1, and mitral regurgitation associated with atrial septal defect in 1. Chordal shortening in 7, annular plication in 6, commissurotomy in 1, reconstruction of commissural leaflets in 7 were performed for mitral valve disease. Plication and reattachment of the aortic cusps was carried out in 2 patients. Annuloplasty rings were not used. All patients survived the operation, 8 had trivial or mild residual mitral regurgitation, and 1 had trivial aortic regurgitation. Mean left atrial pressure decreased from 14 to 7 mm Hg postoperatively. During follow-up of 3–18 months, all children were asymptomatic and enjoyed normal activity. None required reoperation. In addition to chordal shortening and annular plication, reconstruction of the commissural leaflets is considered the most important aspect of valve repair. It can be achieved without annuloplasty rings, giving good early and midterm results.
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Affiliation(s)
- Pramod K Reddy
- Department of Pediatric Cardiac Surgery Apollo Children's Heart Hospital Hyderabad, India
| | - Anil K Dharmapuram
- Department of Pediatric Cardiac Surgery Apollo Children's Heart Hospital Hyderabad, India
| | - Sunil K Swain
- Department of Pediatric Cardiac Surgery Apollo Children's Heart Hospital Hyderabad, India
| | - Nagarajan Ramdoss
- Department of Pediatric Cardiac Surgery Apollo Children's Heart Hospital Hyderabad, India
| | - Sreekanth S Raghavan
- Department of Pediatric Cardiac Surgery Apollo Children's Heart Hospital Hyderabad, India
| | - Kona S Murthy
- Department of Pediatric Cardiac Surgery Apollo Children's Heart Hospital Hyderabad, India
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Adult Heart Disease. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Miller AP, Nanda NC. Live/real-time three-dimensional transthoracic assessment of mitral regurgitation and mitral valve prolapse. Cardiol Clin 2007; 25:319-25. [PMID: 17765112 DOI: 10.1016/j.ccl.2007.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Evaluation of the mitral valve requires appreciation of its complex geometry. To accurately guide surgical interventions and describe pathology, three-dimensional transthoracic echocardiography (TTE) is an immense improvement over the cumbersome mental reconstruction required by two-dimensional approaches. Here we describe real-time, three-dimensional transthoracic techniques for assessing mitral regurgitation and mitral valve prolapse.
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Affiliation(s)
- Andrew P Miller
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, Heart Station SWB/S102, 619 19th Street South, Birmingham, AL 35249, USA
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31
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Zhao L, Kolm P, Borger MA, Zhang Z, Lewis C, Anderson G, Jurkovitz CT, Borkon AM, Lyles RH, Weintraub WS. Comparison of recovery after mitral valve repair and replacement. J Thorac Cardiovasc Surg 2007; 133:1257-63. [PMID: 17467438 DOI: 10.1016/j.jtcvs.2006.12.048] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2006] [Revised: 11/27/2006] [Accepted: 12/12/2006] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We sought to examine the comparative improvement in health status after primary mitral valve repair versus replacement in patients with mitral valve regurgitation in a longitudinal setting. METHODS We prospectively followed 267 patients with mitral valve regurgitation who underwent primary mitral valve repair (n = 163) and replacement (n = 104) between January 2002 and January 2005. Health status was evaluated at baseline and 1, 3, and 12 months after surgery with the validated short-form 36 and analyzed using generalized estimating equations with adjustment for propensity scores. RESULTS Compared with patients undergoing mitral valve replacement, patients requiring valve repair were younger and more likely to be male. The probability of postsurgical readmission because of cardiac events was low and similar between the two treatment groups. New York Heart Association functional class was significantly improved after both procedures, with better improvement achieved by mitral valve repair (P < .01). For both treatment groups, scores for most of the short-form 36 domains were depressed at 1 month; however, after 3- and 12-month lags, dramatic improvements were achieved in most of the domains. Adjusted changes in the physical component score were similar between the two arms at each follow-up. For the mental component score, patients who underwent repair showed significant improvements compared with patients who underwent replacement at both 3 months (difference: 4.84 points, P = .005) and 12 months (difference: 5.92 points, P < .001). CONCLUSIONS Our study suggests that after mitral valve surgery, there is significant improvement in New York Heart Association functional class and health status, especially in patients undergoing mitral valve repair.
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Affiliation(s)
- Liping Zhao
- Christiana Care Health System, Newark, Del 19713, USA.
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Abstract
Three-dimensional echocardiography (3DE) is a valuable tool to be used in addition to and not instead of two-dimensional echocardiography by providing complementary information and improved quantitative accuracy and reproducibility compared with two-dimensional techniques. 3DE has the potential to become the standard echocardiographic examination procedure for the assessment of valvular disease. This article describes applications of 3DE.
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Affiliation(s)
- Bernhard Mumm
- TomTec Imaging Systems GmbH, Edisonstrasse 6, Unterschleissheim 85716, Germany.
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Suri RM, Schaff HV, Dearani JA, Sundt TM, Daly RC, Mullany CJ, Enriquez-Sarano M, Orszulak TA. Recurrent mitral regurgitation after repair: Should the mitral valve be re-repaired? J Thorac Cardiovasc Surg 2006; 132:1390-7. [PMID: 17140963 DOI: 10.1016/j.jtcvs.2006.07.018] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2006] [Revised: 06/30/2006] [Accepted: 07/12/2006] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We sought to evaluate the clinical and echocardiographic outcomes of reoperation for failed mitral valve repair. METHODS One hundred forty-five patients with recurrent mitral regurgitation after primary mitral valve repair of degenerative leaflet prolapse underwent mitral valve reoperations between January 1, 1970, and January 1, 2005. The mean age was 66 years, and 102 (70%) were men. RESULTS The mean duration from initial repair to reoperation was 4.1 years (standard deviation = +/- 5.1 years). Indications for reoperation were regurgitation alone (n = 109 [75%]), hemolysis (n = 27 [19%]), obstruction from systolic anterior motion (n = 3 [2%]), endocarditis (n = 3 [2%]) and stenosis-other (n = 3 [2%]). New pathology was found in 80 (55%) patients, and failure of the initial repair was found in 61 (42%) patients. The mitral valve was re-repaired in 64 (44%) patients and replaced in 81 (56%) patients. Early operative mortality was similar after re-repair and replacement (1.6% vs 4.9%, P = .38). Independent predictors of improved survival on multivariate analysis were mitral re-repair (hazard ratio = 0.44, P = .03), younger age (hazard ratio = 1.06, P = .001), and an operative indication of mitral regurgitation alone (hazard ratio = 0.31, P = .005). Seven patients had a third mitral operation (all replacements), 6 after re-repair and 1 after replacement. At last follow-up echocardiogram (n = 96), ejection fraction was greater (P < .001) and left ventricular end-systolic dimension was smaller (P = .009) in patients undergoing re-repair compared with values in those undergoing valve replacement. CONCLUSION Recurrent mitral regurgitation after prior repair is frequently caused by new valve pathology. Mitral re-repair is performed in almost half of patients and is associated with superior survival, improved ejection fraction, and greater regression in ventricular dimension compared with valve replacement.
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Affiliation(s)
- Rakesh M Suri
- Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA.
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Sedrakyan A, Vaccarino V, Elefteriades JA, Mattera JA, Lin Z, Roumanis SA, Krumholz HM. Health related quality of life after mitral valve repairs and replacements. Qual Life Res 2006; 15:1153-60. [PMID: 17004004 DOI: 10.1007/s11136-006-0055-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2006] [Indexed: 11/24/2022]
Abstract
BACKGROUND The decision to replace or repair mitral valves is often a difficult decision, and outcomes from the patients' perspective should guide decision-making. We investigated whether the change in health related quality of life (HRQOL) after mitral valve surgery is different after valve repairs compared with replacements. METHODS We prospectively studied 25 patients with mitral valve replacement and 45 patients with valve repairs performed in 1998-99. We measured HRQOL at baseline and at 18 months using the Medical Outcomes Trust Short Form 36-item Health Survey (SF-36) questionnaire. We compared mean HRQOL scores of the groups with age-adjusted U.S. population scores. We used analysis of covariance to determine a change in HRQOL within groups (repair or replacement) and if the change in HRQOL was different between the groups. RESULTS We found few differences between the groups, with more men and simultaneous coronary artery bypass graft surgery in the valve repair group and more prior operation in the valve replacement group. HRQOL improved after surgery in most domains, and was comparable to age-adjusted U.S. norms in the valve repair group. In the multivariable analysis, mitral valve repair recipients reported higher social functioning compared with patients who received valve replacement (p = 0.04). We did not find other statistically significant differences. However, the adjusted improvements in the component scales of physical functioning (PCS) and mental functioning (MCS) were substantial in the valve repair group (mean changes: PCS = 6.8, p = 0.003; MCS = 8.1, p = 0.014) and less pronounced in the replacement group (mean changes: PCS = 3.6, p = 0.09; MCS = 4.3, fsp = 0.16). CONCLUSIONS While many considerations influence the decision to repair or replace mitral valves, these findings suggest that repair may be better from the health status perspective. Further studies are necessary to validate this finding.
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Affiliation(s)
- Artyom Sedrakyan
- Center for Outcomes and Evidence, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850, USA
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Dreyfus GD, Souza Neto O, Aubert S. Papillary muscle repositioning for repair of anterior leaflet prolapse caused by chordal elongation. J Thorac Cardiovasc Surg 2006; 132:578-84. [PMID: 16935113 DOI: 10.1016/j.jtcvs.2006.06.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2006] [Revised: 05/30/2006] [Accepted: 06/07/2006] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Anterior leaflet prolapse is still a challenge. Various techniques have been described, but very little is known of the long-term outcome. We describe the long-term results of papillary muscle repositioning, with up to 15 years' follow-up. METHODS From 1989 through 2005, 120 patients with anterior leaflet prolapse (97 bileaflet and 23 isolated anterior leaflet) were treated with papillary muscle repositioning when chordae were elongated. All patients had severe mitral regurgitation. The mean left ventricular end-systolic diameter on echocardiography was 39.4 +/- 5.2 mm. The predominant cause was degenerative: dystrophic disease in 62 and Barlow's disease in 43. Papillary muscle repositioning was carried out on the posterior papillary muscle in 92.5% and on the anterior papillary muscle in 31.7%. A ring annuloplasty was performed in 117 cases. Fifty-seven (47.5%) patients had a tricuspid annuloplasty. RESULTS There were no in-hospital deaths or patients lost to follow-up. Mean follow-up was 6.3 +/- 0.4 years (maximum, 15.6 years). Cumulative actuarial survival at 5, 10, and 15 years was 97.2%, 94.1%, and 81.4%, respectively. Two (1.7%) patients required reoperation at 1 and 5 years after repair. No significant risk factor was identified for late mortality or reoperation. At the latest assessment, 88 (73.3%) patients were asymptomatic. Echocardiography showed no or trivial mitral regurgitation in 89 (74.2%) patients, mild mitral regurgitation in 8 patients, and moderate mitral regurgitation in 9 patients. CONCLUSIONS Anterior leaflet prolapse caused by elongated chordae can always be addressed with papillary muscle repositioning. Results indicate that it is a safe and durable technique, providing good long-term results in the management of degenerative pathology of the anterior leaflet.
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Affiliation(s)
- Gilles D Dreyfus
- Department of Cardiothoracic Surgery, Royal Brompton and Harefield NHS Trust London, Harefield Hospital, Harefield, Middlesex, United Kingdom.
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Suri RM, Schaff HV, Dearani JA, Sundt TM, Daly RC, Mullany CJ, Enriquez-Sarano M, Orszulak TA. Survival Advantage and Improved Durability of Mitral Repair for Leaflet Prolapse Subsets in the Current Era. Ann Thorac Surg 2006; 82:819-26. [PMID: 16928491 DOI: 10.1016/j.athoracsur.2006.03.091] [Citation(s) in RCA: 308] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2006] [Revised: 03/28/2006] [Accepted: 03/29/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND Factors predicting long-term survival and reoperative risk after mitral valve repair for subsets with prolapse involving the anterior leaflet in the current era are unclear. METHODS Between January 1, 1980 and December 31, 1999, surgical correction of mitral regurgitation was performed in 2,219 patients. We analyzed a subset of 1,411 patients with isolated mitral regurgitation due to leaflet prolapse undergoing mitral repair or replacement (+/- coronary bypass). RESULTS Mean age was 64 years, and 1,003 (71%) were men. Mitral repair was performed in 1,173 (83%) patients. Factors independently predicting overall long-term survival included valve repair, younger age, better functional class, and the absence of significant coronary artery disease. After adjusting for these, smaller preoperative left ventricular end-systolic dimension and greater preoperative ejection fraction were associated with superior survival. Mitral reoperation occurred in 97 patients (75 repairs, 22 replacements), at a mean of 4.8 years after initial procedure. Cumulative risk of reoperation was similar for patients having valve repair or replacement. Factors predictive of need for reoperation after initial repair were younger age, anterior leaflet prolapse, chordal shortening, no leaflet resection, no prosthetic annuloplasty, greater than mild residual mitral regurgitation, and coronary artery disease. After valve replacement, the sole determinant of reoperation was use of a biological prosthesis. The durability of repair for prolapse of the anterior leaflet improved significantly during the second decade of the study. CONCLUSIONS Mitral repair affords superior long-term survival, with permanence comparable with mechanical valve replacement. In all categories of mitral leaflet prolapse, durability of valve repair has improved over the past decade.
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Affiliation(s)
- Rakesh M Suri
- Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA.
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Patel V, Hsiung MC, Nanda NC, Miller AP, Fang L, Yelamanchili P, Mehmood F, Gupta M, Duncan K, Singh A, Rajdev S, Fan P, Naftel DC, McGiffin DC, Pacifico AD, Kirklin JK, Lin CC, Yin WH, Young MS, Chang CY, Wei J. Usefulness of Live/Real Time Three-Dimensional Transthoracic Echocardiography in the Identification of Individual Segment/Scallop Prolapse of the Mitral Valve. Echocardiography 2006; 23:513-8. [PMID: 16839393 DOI: 10.1111/j.1540-8175.2006.00252.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
In this report, we present 34 patients in whom surgical intervention was undertaken for severe mitral insufficiency due to mitral valve prolapse (MVP). Location and severity of MVP and regurgitation were assessed preoperatively by live/real time three-dimensional transthoracic echocardiography and closely agreed with the surgical findings.
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Affiliation(s)
- Vinod Patel
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, Alabama 35249, USA
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Tomita Y, Yasui H, Iwai T, Nishida T, Tatewaki H, Morita S, Masuda M, Yasutsune T, Nishimura Y. Surgical Application for a Prolapse of the Anterior Mitral Leaflet by Replacing Artificial Chordae with Polytetrafluoroethylene Grafts. Surg Today 2005; 35:812-8. [PMID: 16175460 DOI: 10.1007/s00595-005-3043-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2004] [Accepted: 01/18/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE There are an increasing number of reports concerning mitral valve repair by a reconstruction of the chordae tendinae using expanded polytetrafluoro-ethylene (PTFE) sutures. However, little information is available about extended application or results of this technique for an extended prolapse of the anterior mitral leaflets. METHODS Between July 1991 and August 2003, 28 patients with moderate to severe mitral regurgitation as a result of a prolapse of anterior leaflets (age range, 15-73 years) underwent mitral valve repair by reconstruction of the artificial chordae with 4-CV expanded polytetrafluoroethylene sutures without a leaflet resection. Either Kay's suture technique or ring annuloplasty was also performed to correct annular dilatation in all patients. RESULTS No operative death or late mortality was observed. The prolapsed segment, which was successfully repaired, was within 33% of the anterior mitral leaflet (AML) in 6 patients, from 33% to 50% in 5, from 50% to 99% in 11, and 100% in 6 patients. Before discharge, immediate postoperative echocardiography showed less than moderate mitral regurgitation in 28 of 28 patients. The follow-up, consisting of a clinical examination and serial echocardiograms, was complete in all cases and the mean follow-up period was 80.6 months (range, 12-146). There were two failures that required a reoperation because of a worsening mitral regurgitation and hemolytic anemia (elongation of anchored side of papillary muscle). The other two patients required mitral valve replacement due to a progressive regression of the left ventricular function, although the regurgitation worsened from a mild level to a moderate one. When the reoperated patients were excluded from the following data, the degree of mitral regurgitation, estimated by echocardiography performed at recent follow-up period, was none in 10 patients, trivial in 13 patients, and mild in 1 patient. In addition, the systolic and diastolic dimensions of the left ventricle decreased significantly (P < 0.01). CONCLUSIONS The replacement of artificial chordae was not complicated and it seemed to help to preserve a good relationship among leaflet tissues, chordae, and papillary muscles. We therefore suggest that the extensive use of PTFE artificial chordae appears to be a promising procedure for the repair of all kinds of mitral lesions causing mitral regurgitation.
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Affiliation(s)
- Yukihiro Tomita
- Department of Cardiovascular Surgery, Faculty of Medicine, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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Talwar S, Rajesh MR, Subramanian A, Saxena A, Kumar AS. Mitral valve repair in children with rheumatic heart disease. J Thorac Cardiovasc Surg 2005; 129:875-9. [PMID: 15821657 DOI: 10.1016/j.jtcvs.2004.11.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the long-term results of mitral valve repair in children with chronic rheumatic heart disease. METHODS From January 1988 through December 2003, 278 children (153 male children) underwent mitral valve repair. Mean age was 11.7 +/- 2.9 years (range, 2-15 years). One hundred seventy-three children (62%) were in the New York Heart Association functional class III or IV. Congestive heart failure was present in 24 (8.6%). Reparative procedures included posterior collar annuloplasty (n = 242), commissurotomy (n = 187), cusp-level chordal shortening (n = 94), cusp thinning (n = 71), cleft suture (n = 65), and cusp excision or plication (n = 10). Associated procedures included atrial septal defect closure (n = 22), aortic valve repair/replacement (n = 13), and tricuspid valve repair (n = 3). RESULTS Early mortality was 2.2% (6 patients). Preoperative left ventricular dysfunction was associated with greater mortality. Median follow-up was 56.5 months (mean, 58.9. +/- 32.3 months; range, 5 to 180 months). One hundred seventy-seven survivors (65%) had no or trivial mitral regurgitation. Sixteen patients (6%) required reoperation for valve dysfunction. There were 7 late deaths (2.6%). Actuarial, reoperation-free, and event-free survivals at a median follow-up of 56.5 months were 95.2% +/- 1.5%, 91.6% +/- 2.2%, and 55.9% +/- 3.5%, respectively; at 15 years, they were 95.2% +/- 1.5%, 85.9% +/- 5.9%, and 46.7% +/- 4.7%, respectively. CONCLUSION Mitral valve repair in children with chronic rheumatic heart disease is feasible and provides acceptable long-term results.
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Affiliation(s)
- Sachin Talwar
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
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Tomita Y, Yasui H, Iwai T, Nishida T, Morita S, Masuda M, Sano T, Nishimura Y, Tatewaki H. Extensive use of polytetrafluoroethylene artificial grafts for prolapse of posterior mitral leaflet. Ann Thorac Surg 2004; 78:815-9. [PMID: 15336998 DOI: 10.1016/j.athoracsur.2004.03.036] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2004] [Indexed: 11/19/2022]
Abstract
BACKGROUND There are an increasing number of reports concerning mitral valve repair by means of reconstruction of the chordae tendinae with expanded polytetrafluoroethylene (e-PTFE) sutures. However little information is available about extended application or results of this technique for extended prolapse of posterior mitral leaflets. METHODS Between March 1994 and December 2000, 22 patients with moderate-to-severe mitral regurgitation (MR) as the result of a prolapse of posterior leaflets (age range, 39-73 years) underwent mitral valve repair by means of reconstruction of artificial chordae with 4-CV e-PTFE sutures without leaflet resection. Either Kay's suture or ring annuloplasty was also performed to correct annular dilatation in all patients. RESULTS No operative death or late mortality was observed. Before discharge immediate postoperative echocardiography indicated less than moderate MR in 20 out of 22 patients. The follow-up was complete in all cases by clinical examination and serial echocardiograms and the median follow-up period was 87 months (range 24-108). There were two failures that required reoperation because of unsuccessful repair and worsening MR (elongation of the anchored side of the papillary muscle). When the reoperated patients were excluded from the follow-up data, the degree of MR, estimated by echocardiography that was performed at a recent follow-up period, was nonexistent in 6 patients, trivial in 10 patients, and mild in 4 patients. The systolic and diastolic dimensions of the left ventricle decreased significantly (p < 0.01). CONCLUSIONS Replacement of the artificial chordae was not complicated and seemed to preserve favorable relationships among leaflet tissues, chordae, and papillary muscles. We therefore suggest that the extensive use of PTFE artificial chordae seems to be a promising procedure regarding the repair of many kinds of mitral lesions causing MR.
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Affiliation(s)
- Yukihiro Tomita
- Department of Cardiovascular Surgery, Faculty of Medicine, Kyushu University, Fukuoka, Japan.
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Gaudiani VA, Grunkemeier GL, Castro LJ, Fisher AL, Wu Y. Mitral valve operations through standard and smaller incisions. Heart Surg Forum 2004; 7:E337-42. [PMID: 15454389 DOI: 10.1532/hsf98.20041023] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Evaluate the operative results of mitral valve repair (MVV) and mitral valve replacement (MVR) performed through standard and smaller incisions. METHODS From January 1997 through December 2002, 821 consecutive patients underwent mitral valve operation. Of these procedures, 475 were MVV and 346 were MVR. A logistic regression model was developed to identify the risk factors for early mortality and to evaluate the effect of replacement versus repair and standard versus small incision. RESULTS Replacement patients were older, more likely New York Heart Association (NYHA) class III or IV, more likely female, and had more frequent previous median sternotomy and stroke (all P <.05). The mitral diagnoses in the 2 groups were markedly different. Prolapse and ischemia dominated the repairs, whereas calcific and rheumatic diagnoses required replacement. There were 667 concomitant procedures performed on these patients, most commonly coronary artery bypass graft (229), aortic valve replacement (170), maze (79), and tricuspid valve (TV) repair/replacement (73). Thirty-three patients (4.0%) died in the postoperative period, 2.3% after repair and 6.4% after replacement ( P <.01). Endocarditis (4/17), calcific disease (7/73), and ischemic disease (9/121) accounted for 26% of patients and 60% of deaths. Multivariate regression analysis identified NYHA class, emergent status, concomitant TV operation, and history of renal failure, but not repair versus replacement, as independent risk factors predicting mortality. We estimated that 356 of the 821 patients (43%) were candidates for small-incision operations, the others were excluded by the need for concomitant procedure or other cause. A total of 205/356 (57%) actually underwent small-incision operations, all with central cannulation and standard techniques. From 1997-1999, 32% of eligible patients were so treated, but from 2000-2002, with increasing surgeon experience, this percentage rose significantly to 71% ( P <.01). Eligible patients who underwent small-incision operation were younger and had lower NYHA classifications, lower preoperative creatinine, and shorter length of stay (all P <.01) than those who had standard incisions. Cross-clamp time, perfusion time, and mortality rate were not significantly different. CONCLUSIONS The mortality rate for MV operations is concentrated among a few diagnoses. In some patients surgery may be approached safely through smaller incisions without introducing new elements of operative risk.
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Affiliation(s)
- Vincent A Gaudiani
- Pacific Coast Cardiac & Vascular Surgeons, Sequoia Hospital, Redwood City, California 94062, USA.
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Aronson S, Heller L. Transesophageal Echocardiography and Evaluation of Valvular Heart Disease. Int Anesthesiol Clin 2004; 42:83-96. [PMID: 14716198 DOI: 10.1097/00004311-200404210-00007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Solomon Aronson
- University of Chicago Hospital and Clinics, Chicago, IL 60617, USA.
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Arom KV, Grover FL. Adult cardiac surgery during the first 50 years of the Southern Thoracic Surgical Association. Ann Thorac Surg 2003; 76:S17-46. [PMID: 14596979 DOI: 10.1016/s0003-4975(03)01598-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This is a review of some of the outstanding adult cardiac surgical papers presented during the first 50 years of the Southern Thoracic Surgical Association to commemorate the 50th Anniversary meeting. Since the founding of the Southern Thoracic Surgical Association in 1954 there have been a total 512 adult cardiac surgery and great vessels papers presented, 138 from 1954 to 1970, 157 from 1971 to 1986, and 217 from 1987 to 2002. Since 1964 most of these papers have been published in The Annals of Thoracic Surgery. Forty-three papers were reviewed, the first having been presented in 1956 and the last in 2002. Not all of the papers could be located but the vast majority were retrievable and reviewed. This paper presents a broad spectrum of adult cardiac surgery beginning with early pump technology, early myocardial revascularization including the Vineberg procedure followed by coronary bypass as we know it today, valvular surgery, including several papers on aortic valve homograft and autograft procedures, ventricular aneurysms, aortic aneurysms and aortic dissections. Evaluations of various valve prostheses, cardiac transplantation, mitral valve reconstruction, quality assurance in cardiac surgery, neurobehavioral outcome after cardiac surgery, endocarditis and off-pump coronary bypass surgery were reviewed. We hope that this article is representative of the broad spectrum of issues that have characterized the specialty of cardiothoracic surgery over the second half of the 20th century and the beginning of the 21st century.
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Affiliation(s)
- Kit V Arom
- Bangkok Heart Institute, Bangkok, Thailand
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44
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Thourani VH, Weintraub WS, Guyton RA, Jones EL, Williams WH, Elkabbani S, Craver JM. Outcomes and long-term survival for patients undergoing mitral valve repair versus replacement: effect of age and concomitant coronary artery bypass grafting. Circulation 2003; 108:298-304. [PMID: 12835220 DOI: 10.1161/01.cir.0000079169.15862.13] [Citation(s) in RCA: 151] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND A paucity of literature is available on the effects of age and coronary artery bypass grafting (CABG) on the outcomes of patients undergoing mitral valve (MV) repair versus replacement. METHODS AND RESULTS A matched study was performed using prospectively collected data from the Emory cardiovascular database from 1984 to 1997 comparing 625 MV repair patients with 625 MV replacement patients. Mean age was significantly higher in the replacement group (56+/-14 versus 55+/-14 years). Preoperative demographics and postoperative outcomes were similar between groups. Length of stay (LOS) was significantly less in the repair group (9.5+/-9.4 versus 12.3+/-13.1 days). In-hospital mortality was significantly less in the repair group (4.3% versus 6.9%), and overall 10-year survival was significantly higher in the repair group (62% versus 46%). Ten-year survival of patients <60 years of age was significantly higher in repair patients (81% versus 55%) but similar in patients > or =60 years of age (33% versus 36%, respectively). Ten-year survival of MV repair without CABG was significantly higher compared with MV replacement patients (74% versus 51%) but similar to patients with concomitant CABG (28% versus 34%, respectively). Independent predictors of long-term mortality included increasing age, urgent/emergent status, female sex, diabetes mellitus, increasing weight, heart failure, decreasing ejection fraction, concomitant CABG, and MV replacement. CONCLUSIONS Mitral valve repair has reduced LOS and improved in-hospital and 10-year survival. However, in the present series, MV repair does not provide significant long-term survival benefit over MV replacement in patients older than 60 years of age or those requiring concomitant CABG.
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Affiliation(s)
- Vinod H Thourani
- Joseph B. Whitehead Department of Surgery, Division of Cardiothoracic Surgery, Carlyle Fraser Heart Center, Atlanta, Ga, USA
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45
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Gillinov AM, Faber C, Houghtaling PL, Blackstone EH, Lam BK, Diaz R, Lytle BW, Sabik JF, Cosgrove DM. Repair versus replacement for degenerative mitral valve disease with coexisting ischemic heart disease. J Thorac Cardiovasc Surg 2003; 125:1350-62. [PMID: 12830055 DOI: 10.1016/s0022-5223(02)73274-1] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We sought to compare mitral valve repair and replacement as treatments for degenerative mitral valve disease with coexisting ischemic heart disease. Specifically, we sought to (1) identify differences between patients undergoing repair and replacement, (2) determine whether the choice of mitral valve procedure affected survival after adjusting for those differences, and (3) discover which patients were predicted to benefit from mitral valve repair and which from replacement. METHODS From 1973 to 1999, 679 patients (mean age, 67 +/- 9.1 years; 73% men) with degenerative mitral valve and ischemic heart diseases underwent combined coronary artery bypass grafting and either mitral valve repair (66%) or replacement (34%). Factors associated with repair and replacement were used for multivariable propensity matching. Risk factors for death were identified by means of multivariable, multiphase hazard-function analysis. RESULTS Patients more likely to undergo repair had isolated posterior chordal rupture (P <.0001) or more recent date of operation (P <.0001); those more likely to undergo replacement were older (P =.0003) or had bileaflet prolapse (P <.0001). Unadjusted survival at 30 days and 1, 5, and 10 years was 97%, 92%, 79%, and 59% after repair and 94%, 88%, 70%, and 37% after replacement. After adjusting for comorbid factors, the extent and effect of ischemic heart disease, and propensity score, the survival benefit of repair became evident after 2 years (P =.01). Eighty-nine percent of patients were predicted to benefit from repair. CONCLUSIONS In patients with degenerative mitral valve and ischemic heart diseases, mitral valve repair confers a survival advantage over replacement that becomes evident about 2 years after the operation.
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Affiliation(s)
- A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Dounis G, Matsakas E, Poularas J, Papakonstantinou K, Kalogeromitros A, Karabinis A. Traumatic tricuspid insufficiency: a case report with a review of the literature. Eur J Emerg Med 2002; 9:258-61. [PMID: 12394624 DOI: 10.1097/00063110-200209000-00010] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Traumatic tricuspid insufficiency, a rare complication of blunt chest trauma, has been reported with increasing frequency during the last 40 years. Automobile accidents are the leading cause of traumatic tricuspid valve regurgitation. The most frequently reported injury is chordal rupture, followed by rupture of the anterior papillary muscle and leaflet tear, primarily of the anterior leaflet. In the acute phase of the injury, the traumatic lesion may go undetected. In the chronic phase many patients remain asymptomatic and others exhibit symptoms and signs of moderate to severe right heart failure. Clinically overt right heart failure has been the traditional indication for surgery, which usually consisted of tricuspid valve replacement. More recently, a more aggressive strategy, with surgical repair of the valve performed before deterioration of the right ventricular function occurs, has been advocated.
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Affiliation(s)
- G Dounis
- Intensive Care Unit, Athens General Hospital, Athens, Greece
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47
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Galloway AC, Grossi EA, Bizekis CS, Ribakove G, Ursomanno P, Delianides J, Baumann FG, Spencer FC, Colvin SB. Evolving techniques for mitral valve reconstruction. Ann Surg 2002; 236:288-93; discussion 293-4. [PMID: 12192315 PMCID: PMC1422582 DOI: 10.1097/00000658-200209000-00005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To analyze the effectiveness of new techniques of mitral valve reconstruction (MVR) that have evolved over the last decade, such as aggressive anterior leaflet repair and minimally invasive surgery using an endoaortic balloon occluder. SUMMARY BACKGROUND DATA MVR via conventional sternotomy has been an established treatment for mitral insufficiency for over 20 years, primarily for the treatment of patients with posterior leaflet prolapse. METHODS Between June 1980 and June 2001, 1,195 consecutive patients had MVR with ring annuloplasty. Conventional sternotomy was used in 843 patients, minimally invasive surgery in 352 (since June 1996). Anterior leaflet repair was performed in 374 patients, with increasing use over the last 10 years. Follow-up was 100% complete (mean 4.6 years, range 0.5-20.5). RESULTS Hospital mortality was 4.7% overall and 1.4% for isolated MVR (1.1% for minimally invasive surgery vs. 1.6% for conventional sternotomy; =.4). Multivariate analysis showed the factors predictive of increased operative risk to be age, NYHA functional class, concomitant procedures, and previous cardiac surgery. The 5-year results for freedom from cardiac death, reoperation, and valve-related complications among the 782 patients with degenerative etiology are, respectively, as follows ( >.05 for all end points): for anterior leaflet repair, 93%, 94%, 90%; for no anterior leaflet repair, 91%, 92%, 91%; for minimally invasive surgery, 97%, 89%, 93%; and for conventional sternotomy, 93%, 94%, 90%. CONCLUSIONS These findings indicate that late results of MVR after minimally invasive surgery and after anterior leaflet repair are equivalent to those achievable with conventional sternotomy and posterior leaflet repair. These options significantly expand the range of patients suitable for mitral valve repair surgery and give further evidence to support wider use of minimally invasive techniques.
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Affiliation(s)
- Aubrey C Galloway
- Department of Surgery, New York University School of Medicine, New York 10708, USA.
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Abstract
The rationale of early surgery for severe chronic mitral regurgitation (MR) due to mitral valve prolapse (MVP) has been developed over the past decade on the basis of the understanding of the natural history of this disease and the predictors of outcomes after surgical correction of MR. The important decrease in operative mortality associated with the advancements in myocardial preservation, and more importantly the improved reparability of the myxomatous mitral valve, were an additional incentive to develop the concept of early surgery. Previous studies showed that mitral valve repair offers a survival advantage at short- and 10-year follow-up, and therefore suggested that it should be the treatment of choice for severe MR due to MVP. Moreover, very recent data provided new insight on the very long-term follow up, ie, beyond the usual first 10 years in which the initial survival benefit of repair may be negated by a late deterioration.
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Affiliation(s)
- Dania Mohty
- Mayo Foundation, 200 1st Street SW, Rochester, MN 55905, USA
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49
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Onnasch JF, Schneider F, Mierzwa M, Mohr FW. [Mitral valve repair versus mitral valve replacement]. ZEITSCHRIFT FUR KARDIOLOGIE 2001; 90:75-80. [PMID: 24445792 DOI: 10.1007/s003920170012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Over the past 40 years mitral valve surgery has changed dramatically. After initial enthusiasm with the introduction of valve prostheses in the 1960s, a renewed interest in repair techniques began in the 1970s with the introduction of annuloplasty rings. These repair techniques revealed that the integrity of the subvalvular apparatus plays an important role in left ventricular function. When considering the major series comparing early and late results of mitral valve repair versus prosthetic mitral valve replacement, operative mortality rate is lower for patients with mitral valve repair. Long-term results also show a superior survival rate after mitral valve reconstruction. In addition, several problems can occur with the prosthetic valve, such as thromboembolism and endocarditis. All of these factors favor valve repair over replacement. The success of mitral valve repair depends on many factors: etiology of the mitral valve disease and the resultant pathomorphology of the valve, patient's circumstances such as age or contraindication for anticoagulation, and the experience of the surgeon. The decision whether to repair or replace the mitral valve depends on these factors. Data in the literature and in large collective databases reflect the advantages of mitral valve repair, with over 75 % of current mitral valve surgeries being repairs.In the past 5 years the exposure of the mitral valve through a right lateral minithoracotomy using video assistance has developed into a widespread technique. This approach allows complex mitral valve repair as well as mitral valve replacement even with biological stentless prostheses, with decreased morbidity. The addition of radiofrequency ablation for restoration of sinus rhythm enhances the outcome after mitral valve surgery, and can also be easily performed through a minithoracotomy technique.
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Affiliation(s)
- J F Onnasch
- Klinik für Herzchirurgie, Herzzentrum Universität Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany,
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Grossi EA, Goldberg JD, LaPietra A, Ye X, Zakow P, Sussman M, Delianides J, Culliford AT, Esposito RA, Ribakove GH, Galloway AC, Colvin SB. Ischemic mitral valve reconstruction and replacement: comparison of long-term survival and complications. J Thorac Cardiovasc Surg 2001; 122:1107-24. [PMID: 11726886 DOI: 10.1067/mtc.2001.116945] [Citation(s) in RCA: 245] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study reviews the 223 consecutive mitral valve operations for ischemic mitral insufficiency performed at New York University Medical Center between January 1976 and January 1996. The results for mitral valve reconstruction are compared with those for prosthetic mitral valve replacement. METHODS From January 1976 to January 1996, 223 patients with ischemic mitral insufficiency underwent mitral valve reconstruction (n = 152) or prosthetic mitral valve replacement (n = 71). Coronary artery bypass grafting was performed in 89% of cases of mitral reconstruction and 80% of cases of prosthetic replacement. In the group undergoing reconstruction, 77% had valvuloplasty with a ring annuloplasty and 23% had valvuloplasty with suture annuloplasty. In the group undergoing prosthetic replacement, 82% of patients received bioprostheses and 18% received mechanical prostheses. RESULTS Follow-up was 93% complete (median 14.6 mo, range 0-219 mo). Thirty-day mortality was 10% for mitral reconstruction and 20% for prosthetic replacement. The short-term mortality was higher among patients in New York Heart Association functional class IV than among those in classes I to III (odds ratio 5.75, confidence interval 1.25-26.5) and was reduced among patients with angina relative to those without angina (odds ratio 0.26, confidence interval 0.05-1.2). The 30-day death or complication rate was similarly elevated among patients in functional class IV (odds ratio 5.53; confidence interval 1.23-25.04). Patients with mitral valve reconstruction had lower short-term complication or death rates than did patients with prosthetic valve replacement (odds ratio 0.43, confidence interval 0.20-0.90). Eighty-two percent of patients with mitral valve reconstruction had no insufficiency or only trace insufficiency during the long-term follow-up period. Five-year complication-free survivals were 64% (confidence interval 54%-74%) for patients undergoing mitral valve reconstruction and 47% (confidence interval 33%-60%) for patients undergoing prosthetic valve replacement. Results of a series of statistical analyses suggest that outcome was linked primarily to preoperative New York Heart Association functional class. CONCLUSIONS Initial mortalities were similar among patients undergoing prosthetic replacement and valve reconstruction. Poor outcome was primarily related to preexisting comorbidities. Patients undergoing valve reconstruction had fewer valve-related complications. Valve reconstruction resulted in excellent durability and freedom from complications. These findings suggest that mitral valve reconstruction should be considered for appropriate patients with ischemic mitral insufficiency.
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Affiliation(s)
- E A Grossi
- Division of Cardiothoracic Surgery, Department of Surgery, Division of Biostatistics, New York University School of Medicine, New York, NY, USA.
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