1
|
Sugimori H, Nakao T, Okada Y, Okita Y, Yaku H, Kobayashi J, Uesugi H, Takanashi S, Ito T, Koyama T, Sakaguchi T, Yamamoto K, Yoshikawa Y, Sawa Y. Mid-term outcomes of surgical aortic valve replacement using a mosaic porcine bioprosthesis with concomitant mitral valve repair. Heart Vessels 2024; 39:252-265. [PMID: 37843552 DOI: 10.1007/s00380-023-02325-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 09/28/2023] [Indexed: 10/17/2023]
Abstract
This study retrospectively evaluated the mid-term outcomes of surgical aortic valve replacement (SAVR) using a stented porcine aortic valve bioprosthesis (Mosaic; Medtronic Inc., Minneapolis, MN, USA) with concomitant mitral valve (MV) repair. From 1999 to 2014, 157 patients (median [interquartile range] age, 75 [70-79] years; 47% women) underwent SAVR with concomitant MV repair (SAVR + MV repair), and 1045 patients (median [interquartile range] age, 76 [70-80] years; 54% women) underwent SAVR only at 10 centers in Japan as part of the long-term multicenter Japan Mosaic valve (J-MOVE) study. The 5-year overall survival rate was 81.5% ± 4.1% in the SAVR + MV repair group and 85.1% ± 1.4% in the SAVR only group, and the 8-year overall survival rates were 75.2% ± 5.7% and 78.1% ± 2.1%, respectively. Cox proportional hazards analysis showed no significant difference in the survival rates between the two groups (hazard ratio, 0.87; 95% confidence interval, 0.54-1.40; P = 0.576). Among women with mild or moderate mitral regurgitation who were not receiving dialysis, those who underwent SAVR + MV repair, were aged > 75 years, and had a preoperative left ventricular ejection fraction of 30-75% tended to have a lower mortality risk. In conclusion, this subgroup analysis of the J-MOVE cohort showed relevant mid-term outcomes after SAVR + MV repair.
Collapse
Affiliation(s)
- Haruhiko Sugimori
- Department of Cardiovascular Surgery, New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba, 270-2232, Japan.
| | - Tatsuya Nakao
- Department of Cardiovascular Surgery, New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba, 270-2232, Japan
| | - Yukikatsu Okada
- Department of Cardiovascular Surgery, Midori Hospital, 1-16 Edayoshi, Nishi-ku, Kobe, Hyogo, 651-2133, Japan
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Takatsuki General Hospital, 1-3-13 Kosobe-Machi, Takatsuki, Osaka, 569-1192, Japan
| | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibeshin-Machi, Suita, Osaka, 564-0018, Japan
| | - Hideyuki Uesugi
- Department of Cardiovascular Surgery, Saiseikai Kumamoto Hospital, 5-3-1 Chikami, Minami-ku, Kumamoto, Kumamoto, 861-4101, Japan
| | - Shuichiro Takanashi
- Department of Cardiovascular Surgery, Kawasaki Saiwai Hospital, 31-27 Omiya-Chyou, Saiwai-ku, Kawasaki, Kanagawa, 212-0014, Japan
| | - Toshiaki Ito
- Department of Cardiovascular Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, 3-35 Michishita-Chyou, Nakamura-ku, Nagoya, Aichi, 453-0046, Japan
| | - Tadaaki Koyama
- Department of Cardiovascular Surgery, Kansai Medical University, 2-5-1 Shin-Machi, Hirakata, Osaka, 573-1010, Japan
| | - Taichi Sakaguchi
- Department of Cardiovascular Surgery, Hyogo College of Medicine, 1-3-6 Minatojima, Chuo-ku, Kobe, Hyogo, 650-0045, Japan
| | - Kouji Yamamoto
- Department of Biostatistics, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Yasushi Yoshikawa
- Department of Cardiovascular Surgery, Tottori University, 4-101 Koyama-Cho, Minami, Tottori, 680-8550, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| |
Collapse
|
2
|
Xu D, McBride E, Kalra K, Wong K, Guyton RA, Sarin EL, Padala M. Undersizing mitral annuloplasty alters left ventricular mechanics in a swine model of ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2022; 164:850-861.e8. [PMID: 33288234 PMCID: PMC8099928 DOI: 10.1016/j.jtcvs.2020.09.141] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 09/23/2020] [Accepted: 09/28/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Undersizing mitral annuloplasty (UMA) is a frequently used surgical repair technique to correct ischemic mitral regurgitation in patients with heart failure. In this study, we sought to test the hypothesis that downsizing the mitral annulus can adversely affect the shape and mechanics of the left ventricle inhibiting its functional recovery. METHODS Eighteen farm swine that underwent an inferolateral myocardial infarction and developed ischemic mitral regurgitation of >2+ severity after 2 months were assigned as follows: 9 swine received an undersized mitral annuloplasty, 6 received papillary muscle approximation (PMA), and 3 animals did not receive any other intervention. Animals lived another 3 months and cardiac magnetic resonance imaging was performed before termination to assess ventricle mechanics and function. RESULTS Ejection fraction was comparable between the 2 repair groups before surgery, but was significantly lower in UMA at 38.89% ± 7.91% versus 50.83% ± 9.04% in the PMA group (P = .0397). Animals receiving UMA had lower regional peak fractional shortening and reduced systolic and diastolic radial velocities compared with PMA and in some regions were lower than sham. Animals that underwent UMA had higher circumferential strain than sham, but lower than PMA. UMA animals have lower longitudinal strain compared to sham group and lower LV torsion than PMA. CONCLUSIONS Undersizing the mitral annulus with an annuloplasty ring can restore valvular competence, but unphysiologically impair ventricle mechanics. Mitral valve repair strategies should focus not only on restoring valve competence, but preserving ventricle mechanics.
Collapse
Affiliation(s)
- Dongyang Xu
- Structural Heart Research & Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown, Atlanta, Ga
| | - Erin McBride
- Structural Heart Research & Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown, Atlanta, Ga
| | - Kanika Kalra
- Structural Heart Research & Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown, Atlanta, Ga
| | - Keawepono Wong
- Structural Heart Research & Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown, Atlanta, Ga
| | - Robert A Guyton
- Structural Heart Research & Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown, Atlanta, Ga; Division of Cardiothoracic Surgery, Department of Surgery, Emory University, Atlanta, Ga
| | - Eric L Sarin
- Structural Heart Research & Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown, Atlanta, Ga; Department of Cardiothoracic Surgery, Inova Heart and Vascular Institute, Fairfax, Va
| | - Muralidhar Padala
- Structural Heart Research & Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown, Atlanta, Ga; Division of Cardiothoracic Surgery, Department of Surgery, Emory University, Atlanta, Ga.
| |
Collapse
|
3
|
Kehara H, Minakata K, McCarthy J, Sunagawa G, Mangukia C, Brann S, Zhao H, Boova R, Toyoda Y. Early and late results of mitral valve repair with anterior leaflet patch augmentation. Interact Cardiovasc Thorac Surg 2022; 35:6595026. [PMID: 35640545 PMCID: PMC9373942 DOI: 10.1093/icvts/ivac144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 04/14/2022] [Accepted: 05/24/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
OBJECTIVES
The aim of this study was to determine the long-term results of mitral valve (MV) repair with anterior leaflet patch augmentation.
METHODS
Between 2012 and 2015, 45 patients underwent MV repair using the anterior leaflet patch augmentation technique at our institution. The mean age of the patients was 65.9 ± 13.0 years (16 males). We reviewed the MV pathology and the surgical techniques used and assessed the early and late results.
RESULTS
In terms of MV pathology, 43 patients (95.6%) had pure mitral regurgitation (MR) and 2 patients (4.4%) had mixed mitral stenosis and MR. Rheumatic changes were seen in 18 patients (40.0%). Postoperative echocardiography showed that 95.6% of patients had none to mild MR. During a median follow-up period of 5.5 years (range 0.1–8.3 years), there were 8 late deaths. Nine patients (20%) required reoperation. The mean interval between the initial operation and redo operation was 3.7 ± 3.1 years (range: 0.4–7.8 years). The causes of reoperation included patch dehiscence (n = 4), progression of mitral stenosis (n = 2), band dehiscence (n = 1), patch enlargement (n = 1) and unknown (n = 1). Eight patients underwent MV replacement and 1 underwent repeat MV repair. The freedom from reoperation at 3 and 5 years was 85.7 ± 6.7% and 81.2 ± 7.7%, respectively.
CONCLUSIONS
Anterior leaflet patch augmentation can provide excellent early results in the majority of the patients even in the presence of rheumatic pathology; however, we observed late reoperation in 20% of patients. Thus, this technique should be used with caution and careful follow-up with serial echocardiography is essential.
Collapse
Affiliation(s)
- Hiromu Kehara
- Division of Cardiovascular Surgery, Temple University and Lewis Katz School of Medicine , Philadelphia, PA, USA
| | - Kenji Minakata
- Division of Cardiovascular Surgery, Temple University and Lewis Katz School of Medicine , Philadelphia, PA, USA
| | - James McCarthy
- Division of Cardiovascular Surgery, Temple University and Lewis Katz School of Medicine , Philadelphia, PA, USA
| | - Gengo Sunagawa
- Division of Cardiovascular Surgery, Temple University and Lewis Katz School of Medicine , Philadelphia, PA, USA
| | - Chirantan Mangukia
- Division of Cardiovascular Surgery, Temple University and Lewis Katz School of Medicine , Philadelphia, PA, USA
| | - Stacey Brann
- Division of Cardiovascular Surgery, Temple University and Lewis Katz School of Medicine , Philadelphia, PA, USA
| | - Huaqing Zhao
- Center for Biostatistics and Epidemiology, Department of Biomedical Education and Data Science, Temple University and Lewis Katz School of Medicine , Philadelphia, PA, USA
| | - Robert Boova
- Division of Cardiovascular Surgery, Temple University and Lewis Katz School of Medicine , Philadelphia, PA, USA
| | - Yoshiya Toyoda
- Division of Cardiovascular Surgery, Temple University and Lewis Katz School of Medicine , Philadelphia, PA, USA
| |
Collapse
|
4
|
Surgical mitral valve repair technique considerations based on the available evidence. TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2022; 30:302-316. [PMID: 36168574 PMCID: PMC9473589 DOI: 10.5606/tgkdc.dergisi.2022.23340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 02/21/2022] [Indexed: 11/21/2022]
Abstract
Mitral valve regurgitation is the second most common valve disease in the western world. Surgery is currently the best tool for generating a long-lasting elimination of mitral valve regurgitation. However, the mitral valve apparatus is a complex anatomical and functional structure, and repair results and durability show substantial heterogeneity. This is not only due to differences in the underlying mitral valve regurgitation pathophysiology but also due to differences in repair techniques. Repair philosophies differ substantially from one surgeon to the other, and consensus for the technically best repair strategy has not been reached yet. We had previously addressed this topic by suggesting that ring sizing is "voodoo". We now review the available evidence regarding the various repair techniques described for structural and functional mitral valve regurgitation. Herein, we illustrate that for structural mitral valve regurgitation, resuspension of prolapsing valve segments or torn chordae with polytetrafluoroethylene sutures and annuloplasty can generate the most durable results paired with the best achievable hemodynamics. For functional mitral valve regurgitation, the evidence suggests that annuloplasty alone is insufficient in most cases to generate durable results, and additional subvalvular strategies are associated with improved durability and possibly improved clinical outcomes. This review addresses current strategies but also implausibilities in mitral valve repair and informs the mitral valve surgeon about the current evidence. We believe that this information may help improve outcomes in mitral valve repair as the heterogeneity of mitral valve regurgitation pathophysiology does not allow a one-size-fits-all concept.
Collapse
|
5
|
Translocation of the Mitral Valve in an Acute Large Animal Model. J Cardiovasc Transl Res 2022; 15:1100-1107. [PMID: 35175554 DOI: 10.1007/s12265-022-10215-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 02/07/2022] [Indexed: 10/19/2022]
Abstract
Current repair options for functional mitral regurgitation (FMR) are not durable and do not adequately address underlying pathophysiology including leaflet tethering and insufficient coaptation. The feasibility of mitral valve translocation as a repair strategy for FMR was examined in normal swine. Seven pigs (median 62 kg, IQR 55-65 kg) with normal cardiac function were implanted with a 1-cm frustum-shaped pericardial patch inserted between the native mitral annulus and intact mitral leaflets. Operative survival was 100% with no post-procedure mitral stenosis, systolic anterior motion, or central mitral regurgitation observed on echocardiography. Post-translocation mean gradient was 3.5 mmHg (IQR 1.5-4 mmHg); trace or mild suture line leaks on the atrial suture line were noted in 5/7 pigs. Median leaflet coaptation increased from 2.4 (IQR 2.1-4.3 mm) to 12.4 mm (IQR 10.8-13.4 mm) after translocation (P = 0.016). Translocation dramatically increases leaflet coaptation without impairing diastolic function in animals with normal left ventricular function and is a promising technique for repair of FMR. Implantation of a 1.0-cm circumferential pericardial patch (mitral valve translocation) increases leaflet coaptation in a normal animal model.
Collapse
|
6
|
Pausch J, Girdauskas E, Conradi L, Reichenspurner H. Secondary mitral regurgitation repair techniques and outcomes: Subannular repair techniques in secondary mitral regurgitation type IIIb. JTCVS Tech 2022; 10:92-97. [PMID: 34977710 PMCID: PMC8691802 DOI: 10.1016/j.xjtc.2021.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/02/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jonas Pausch
- Department of Cardiovascular Surgery University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiothoracic Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery University Heart & Vascular Center Hamburg, Hamburg, Germany
| |
Collapse
|
7
|
OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6564254. [DOI: 10.1093/ejcts/ezac125] [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: 04/21/2021] [Revised: 02/09/2022] [Accepted: 02/14/2022] [Indexed: 11/12/2022] Open
|
8
|
Zhan-Moodie S, Xu D, Suresh KS, He Q, Onohara D, Kalra K, Guyton RA, Sarin EL, Padala M. Papillary muscle approximation reduces systolic tethering forces and improves mitral valve closure in the repair of functional mitral regurgitation. JTCVS OPEN 2021; 7:91-104. [PMID: 35299626 PMCID: PMC8924981 DOI: 10.1016/j.xjon.2021.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background Undersizing mitral annuloplasty (UMA) to repair functional mitral regurgitation (FMR) lacks durability, as it forces leaflet coaptation without relieving the subleaflet tethering forces. In this biomechanical study, we demonstrate that papillary muscle approximation (PMA) before UMA can drastically relieve tethering forces and improve valve function, without the need for significant annular downsizing. Methods An ex vivo model of FMR was used, in which pig mitral valves were geometrically perturbed to induce FMR, and the repairs were performed. Nine pig mitral valves were studied in the following sequence: normal (baseline), FMR, true-sized annuloplasty to 30 mm (true-sized ring [TSR]), and undersized annuloplasty to 26 mm (down-sized ring [DSR]), along with concomitant PMA at both ring sizes. Mitral regurgitation, valve kinematics, and chordal forces were measured and compared among the groups. Results FMR geometry induced a mean regurgitant fraction of 16.31 ± 7.33% compared with 0% at baseline. TSR reduced the regurgitant fraction to 6.05 ± 5.63%, whereas DSR reduced it to 5.06 ± 6.76%. The addition of PMA before the use of these rings reduced the mean regurgitant fraction to 3.87 ± 6.79% with the TSR (TSR + PMA) and 3.71 ± 6.25% with the DSR (DSR + PMA). Mean peak anterior and posterior marginal chordal forces were elevated to 0.09 ± 0.1 N and 0.12 ± 0.1 N, respectively, with FMR and were not reduced by annuloplasty of either sizes. The addition of PMA significantly reduced these forces to 0.23 ± 0.02 N and 0.51 ± 0.04 N. Conclusions This biomechanical study demonstrates that PMA relieves tethering forces, and concomitantly with annuloplasty it mobilizes the leaflets to achieve physiological valve closure. Such a result could be achieved without the need for extensive annular downsizing.
Collapse
|
9
|
Exploring the Operative Strategy for Secondary Mitral Regurgitation: A Systematic Review. BIOMED RESEARCH INTERNATIONAL 2021; 2021:3466813. [PMID: 34258260 PMCID: PMC8245239 DOI: 10.1155/2021/3466813] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/05/2021] [Accepted: 06/16/2021] [Indexed: 01/16/2023]
Abstract
Background Mitral valve disease surgery is an evolving field with multiple possible interventions. There is an increasing body of evidence regarding the optimal strategy in secondary mitral regurgitation where the pathology lies within the ventricle. We conducted a systematic review to identify the benefits and limitations of each surgical option. Methods A systematic review of the literature was performed to identify pertinent randomized controlled trials (RCTs), propensity-matched observational series, and meta-analyses which were considered initially and followed by unmatched observational series using the MEDLINE, Ovid EMBASE, and Cochrane Library. Results We identified 6 different strategies for treating secondary mitral valve regurgitation: mitral valve replacement, restrictive mitral annuloplasty, surgical revascularization (with and without mitral annuloplasty), subvalvular procedures (papillary muscle approximation, papillary muscle relocation, ring and string procedure), and procedures directly targeting the mitral valve (edge-to-edge repair and anterior leaflet enlargement) alongside transcatheter heart valve therapy. We also highlighted the role of left ventricular assist devices in the management of this condition. The benefits and limitations of each intervention are highlighted. Conclusion There is currently no unanimous and shared strategy for the optimal treatment of patients with secondary IMR. The management of patients with secondary mitral regurgitation must be entrusted to a multidisciplinary Heart Team to ensure ideal intervention and patient matching for the best outcomes.
Collapse
|
10
|
Vinciguerra M, Grigioni F, Romiti S, Benfari G, Rose D, Spadaccio C, Cimino S, De Bellis A, Greco E. Ischemic Mitral Regurgitation: A Multifaceted Syndrome with Evolving Therapies. Biomedicines 2021; 9:biomedicines9050447. [PMID: 33919263 PMCID: PMC8143318 DOI: 10.3390/biomedicines9050447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/14/2021] [Accepted: 04/19/2021] [Indexed: 12/24/2022] Open
Abstract
Dysfunction of the left ventricle (LV) with impaired contractility following chronic ischemia or acute myocardial infarction (AMI) is the main cause of ischemic mitral regurgitation (IMR), leading to moderate and moderate-to-severe mitral regurgitation (MR). The site of AMI exerts a specific influence determining different patterns of adverse LV remodeling. In general, inferior-posterior AMI is more frequently associated with regional structural changes than the anterolateral one, which is associated with global adverse LV remodeling, ultimately leading to different phenotypes of IMR. In this narrative review, starting from the aforementioned categorization, we proceed to describe current knowledge regarding surgical approaches in the management of IMR.
Collapse
Affiliation(s)
- Mattia Vinciguerra
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (S.R.); (S.C.); (E.G.)
- Correspondence:
| | - Francesco Grigioni
- Unit of Cardiovascular Sciences, Department of Medicine Campus Bio-Medico, University of Rome, 00128 Rome, Italy;
| | - Silvia Romiti
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (S.R.); (S.C.); (E.G.)
| | - Giovanni Benfari
- Division of Cardiology, Department of Medicine, University of Verona, 37219 Verona, Italy;
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - David Rose
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool FY3 8NP, UK; (D.R.); (C.S.)
| | - Cristiano Spadaccio
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool FY3 8NP, UK; (D.R.); (C.S.)
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8QQ, UK
| | - Sara Cimino
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (S.R.); (S.C.); (E.G.)
| | - Antonio De Bellis
- Department of Cardiology and Cardiac Surgery, Casa di Cura “S. Michele”, 81024 Maddaloni, Caserta, Italy;
| | - Ernesto Greco
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (S.R.); (S.C.); (E.G.)
| |
Collapse
|
11
|
Servito M, Elbatarny M, Fremes SE. Reply: The track less travelled: Subvalvular techniques and anterior leaflet augmentation in ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2021; 163:e179-e181. [PMID: 33726907 DOI: 10.1016/j.jtcvs.2021.02.018] [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: 02/03/2021] [Revised: 02/03/2021] [Accepted: 02/04/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Maria Servito
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Malak Elbatarny
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
12
|
Reply: The issues to address when repairing ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2021; 163:e179. [PMID: 33640133 DOI: 10.1016/j.jtcvs.2021.01.133] [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: 01/27/2021] [Accepted: 01/29/2021] [Indexed: 11/23/2022]
|
13
|
Hetzer R, Javier MFDM, Wagner F, Loebe M, Javier Delmo EM. Organ-saving surgical alternatives to treatment of heart failure. Cardiovasc Diagn Ther 2021; 11:213-225. [PMID: 33708494 DOI: 10.21037/cdt-20-285] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Over time, various surgical treatment strategies have evolved to manage advanced heart failure (HF). Scientific and technological breakthroughs through the last 50 years have put forward various surgical alternatives to patients with advanced HF encompassing surgical ventricular restoration to surgical gene therapy and stem cell replacement of the diseased ventricles. Organ-saving surgical options which used to be promising included dynamic cardiomyoplasty, partial resection of ventricle and cardiac wrapping with Acorn CorCap cardiac support device. These procedures were eventually abandoned due to negative outcomes and without proven disadvantages. Another organ-saving surgical option currently being considered but still make little sense is cardiac regeneration by stem cell therapy, i.e., cardiomyocyte restoration and replacement. Presently, the organ-saving surgical alternatives to treat end-stage HF are revascularization for ischemic cardiomyopathy, mitral valve surgery (repair or replacement) for ischemic mitral incompetence (IMI), left ventricular (LV) aneurysmectomy (surgical ventricular restoration) and mitral valve repair for IMI. These aforementioned procedures have become quite established approaches and with increasing experience are continuously being modified to improve outcome. Various mechanical circulatory support systems have emerged over time to improve functional status of patients with advanced HF, either as a bridge to heart transplantation or as a bridge to myocardial recovery. Likewise offered in those with contraindications to transplantation. Ventricular assist devices (VAD) can keep patients alive until an eventual transplantation. This article reviews the variety of the myriad of alternative organ-saving surgical alternatives that have been available or are currently available provided to patients with end-stage HF, their advantages and deficiencies, as well as prospects in HF therapy.
Collapse
Affiliation(s)
- Roland Hetzer
- Department of Cardiothoracic and Vascular Surgery, Cardio Centrum Berlin, Berlin, Germany
| | | | - Frank Wagner
- Charité Research Organization, Universitätsmedizin Berlin-Charité, Berlin, Germany
| | - Matthias Loebe
- Thoracic Transplant and Mechanical Support, Miami Transplant Institute, Memorial Jackson Health System, University of Miami, Miami, FL, USA
| | | |
Collapse
|
14
|
Calafiore AM, Di Mauro M, Bonatti J, Centofanti P, Di Eusanio M, Faggian G, Fattouch K, Gaudino M, Kofidis T, Lorusso R, Menicanti L, Prapas S, Sarkar K, Stefano P, Tabata M, Zenati M, Paparella D. An observational, prospective study on surgical treatment of secondary mitral regurgitation: The SMR study. Rationale, purposes, and protocol. J Card Surg 2020; 35:2489-2494. [PMID: 32789993 DOI: 10.1111/jocs.14924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The natural history of secondary mitral regurgitation (MR) is unfavorable. Nevertheless, there are no evidence that its correction can improve the outcome. If from one side the original cause of secondary MR can be such to limit the possibilities of improvement, from the other side it is possible that the surgical technique widely applied to repair, restrictive mitral annuloplasty, is not adequate to correct the regurgitation. The addition of valvular and/or subvalvular techniques has been considered a possible technical solution. However, we do not know the prevalence of each technique, how many times mitral replacement is used to correct secondary MR. This aspect is of particular importance, as we know that a successful mitral repair causes a better left ventricular systolic remodeling than a unsuccessful repair or replacement. This study is a prospective, observational registry, conceived to understand what is done in the real world. Any surgeon will use the technique he thinks the most suitable for the patient. Every year, for 5 years, patients will have a clinical and echocardiographic follow-up, to evaluate the risk factors for a worse result (death, rehospitalization for heart failure, reoperation for MR return, moderate, or more MR return). This knowledge will give us the possibility to understand which is the technique, or the strategy, more efficient to treat this disease and the real efficacy of the surgical treatment.
Collapse
Affiliation(s)
| | - Michele Di Mauro
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, Italy
| | - Johannes Bonatti
- Department of Cardiac Surgery, Wien North Hospital, Wien, Austria
| | - Paolo Centofanti
- Department of Cardiac Surgery, Ospedale Mauriziano, Torino, Italy
| | - Marco Di Eusanio
- Department of Cardiac Surgery, Ospedali Riuniti Torrette, Ancona, Italy
| | - Giuseppe Faggian
- Department of Cardiac Surgery, Ospedale Universitario di Verona, Verona, Italy
| | - Khalil Fattouch
- Department of Cardiac Surgery, Villa Maria Eleonora, Palermo, Italy
| | - Mario Gaudino
- Department of Cardiac Surgery, Weill Cornell Medicine, New York, New York
| | - Thoedoros Kofidis
- Department of Cardiac Surgery, National University Heart Center, Singapore
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, Italy
| | - Lorenzo Menicanti
- Department of Cardiac Surgery, IRCCS, Policlinico San Donato, San Donato Milanese, Italy
| | - Sotirios Prapas
- Department of Cardiac Surgery, Henry Dunant Hospital, Athens, Greece
| | - Kunal Sarkar
- Department of Cardiac Surgery, Medica Superspecialty Hospital, Kolkata, India
| | - Pierluigi Stefano
- Department of Cardiac Surgery, Azienda Ospedaliera Universitaria Careggi, Firenze, Italy
| | - Minoru Tabata
- Department of Cardiac Surgery, Tokyo Bay Urayasu-Ichikawa Medical Center, Tokyo, Japan
| | - Marco Zenati
- Department of Cardiac Surgery, Veterans Affairs Boston Healthcare System, Harvard Medical School, Bosto, Massachusetts
| | | |
Collapse
|
15
|
Calafiore AM, Totaro A, Paparella D, Gaudino M, Prapas S, Mick SL, Di Mauro M. Mimicking natural mitral adaptation to ischaemic regurgitation: a proposed change in the surgical paradigm. Eur J Cardiothorac Surg 2020; 58:35-39. [DOI: 10.1093/ejcts/ezaa163] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
| | - Antonio Totaro
- Department of Cardiovascular Diseases, Gemelli Molise, Campobasso, Italy
| | - Domenico Paparella
- Department of Emergency and Organ Transplants, Aldo Moro University of Bari, Santa Maria Hospital, GVM Care & Research, Bari, Italy
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Sotirios Prapas
- Department of Cardiac Surgery, Henry Dunant Hospital, Athens, Greece
| | - Stephanie L Mick
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Michele Di Mauro
- Cardio-Thoracic Surgery Unit, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| |
Collapse
|
16
|
Boudoulas KD, Vallakati A, Pitsis AA, Orsinelli DA, Abraham WT. The Use of MitraClip in Secondary Mitral Regurgitation and Heart Failure. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:1606-1612. [PMID: 32461047 DOI: 10.1016/j.carrev.2020.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/02/2020] [Accepted: 05/13/2020] [Indexed: 10/24/2022]
Abstract
Secondary (also known as functional) mitral regurgitation (MR) has increased substantially over the last several decades due to an increase in the prevalence of dilated cardiomyopathy (ischemic and non-ischemic). Mortality and morbidity in patients with dilated cardiomyopathy is much greater when associated with MR as compared to without MR. MR will result in further left ventricular (LV) volume overload, LV dilation, and pupillary muscle displacement resulting in deterioration of the severity of MR leading to a vicious cycle. Optimization of heart failure medical therapy, and cardiac resynchronization therapy for those that qualify, can improve severity of MR; however, significant MR will persist in certain patients. Transcatheter mitral valve repair to treat significant MR using the MitraClip (Abbott, Menlo Park, California), which grasps and coapts the posterior and anterior mitral valve leaflets, in appropriately selected patients with dilated cardiomyopathy and secondary MR has been shown to improve quality of life and prolong survival.
Collapse
Affiliation(s)
| | - Ajay Vallakati
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH, USA
| | - Antonios A Pitsis
- Department of Cardiothoracic Surgery, St. Luke's Hospital, Thessaloniki, Greece
| | - David A Orsinelli
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH, USA
| | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH, USA
| |
Collapse
|
17
|
Calafiore AM, Totaro A, De Amicis V, Pelini P, Pinna G, Testa N, Alfonso JJ, Mazzei V, Sacra C, Gaudino M, Di Mauro M. Surgical mitral plasticity for chronic ischemic mitral regurgitation. J Card Surg 2020; 35:772-778. [PMID: 32126160 DOI: 10.1111/jocs.14487] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY The outcome of mitral valve (MV) repair for chronic ischemic mitral regurgitation (IMR) is suboptimal, due to the high recurrence rate of moderate or severe mitral regurgitation (MR) during follow-up. The MV adapts to new MR increasing its area to cover the enlarged annular area (mitral plasticity). As this process is often incomplete, we aimed to evaluate if augmenting the anterior leaflet (AL) and cutting the second-order chords (CC) together with restrictive mitral annuloplasty, a strategy we call "surgical mitral plasticity," could improve the midterm results of MV repair for IMR. MATERIALS AND METHODS From November 2017 to October 2019, 22 patients with chronic IMR underwent surgical mitral plasticity. Mean age was 73 ± 7 years and six were female. Mean ejection fraction was 32% ± 11%, IMR grade was moderate in 10 and severe in 12. Mean clinical and echocardiographic follow-up was 12 ± 6 months. RESULTS There was no early death, and one patient died 6 months after surgery. Ejection fraction improved from 32% ± 15% to 40% ± 6% (P = .031). IMR was absent or mild in all patients, and none showed recurrent moderate or more IMR. Tenting area decreased significantly from 2.5 ± 0.5 to 0.5 ± 0.3 cm² and coaptation length increased from 1.9 ± 0.7 to 7.8 ± 1.6 mm. All patients were in New York Heart Association class I or II. CONCLUSIONS Mitral plasticity, if uncomplete, is ineffective in preventing IMR to become significant. Surgical mitral plasticity, by completing incomplete process of MV adaptation, has a strong rationale, which however needs to be validated with longer follow-up.
Collapse
Affiliation(s)
| | - Antonio Totaro
- Department of Cardiovascular Diseases, Gemelli Molise, Campobasso, Italy
| | | | - Piero Pelini
- Division of Cardiac Surgery, D'Annunzio University, Chieti, Italy
| | - Giovanni Pinna
- Division of Cardiac Surgery, Federico II University, Naples, Italy
| | - Nicola Testa
- Department of Cardiovascular Diseases, Gemelli Molise, Campobasso, Italy
| | - Juan J Alfonso
- Department of Research, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Valerio Mazzei
- Department of Cardiovascular Diseases, Gemelli Molise, Campobasso, Italy
| | - Cosimo Sacra
- Department of Cardiovascular Diseases, Gemelli Molise, Campobasso, Italy
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Michele Di Mauro
- Division of Cardiac Surgery, D'Annunzio University, Chieti, Italy
| |
Collapse
|
18
|
Calafiore AM, Kofidis T, Gaudino M. Commentary: Surgical mitral plasticity: Another brick in the wall? JTCVS OPEN 2020; 1:17-19. [PMID: 36003195 PMCID: PMC9390659 DOI: 10.1016/j.xjon.2019.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 12/02/2019] [Accepted: 12/12/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Antonio M. Calafiore
- Department of Cardiac Surgery and Cardiology, Fondazione “Papa Giovanni Paolo II,” Campobasso, Italy
| | - Theodoros Kofidis
- Department of Cardiothoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
- Address for reprints: Mario Gaudino, MD, Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 E 68th St, New York, NY 10065.
| |
Collapse
|
19
|
Long-term Performance of Fresh Autologous Pericardium for Mitral Valve Leaflet Repair. Ann Thorac Surg 2020; 109:36-41. [DOI: 10.1016/j.athoracsur.2019.05.045] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/12/2019] [Accepted: 05/13/2019] [Indexed: 12/21/2022]
|
20
|
Calafiore AM, Totaro A, Sacra C, Foschi M, Tancredi F, Pelini P, Gaudino M, Di Mauro M. Unbalanced mitral valve remodeling in ischemic mitral regurgitation: Implications for a durable repair. J Card Surg 2019; 34:885-888. [DOI: 10.1111/jocs.14119] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 05/13/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Antonio M Calafiore
- Department of Cardiac Surgery and CardiologyFondazione “Papa Giovanni Paolo II” Campobasso Italy
| | - Antonio Totaro
- Department of Cardiac Surgery and CardiologyFondazione “Papa Giovanni Paolo II” Campobasso Italy
| | - Cosimo Sacra
- Department of Cardiac Surgery and CardiologyFondazione “Papa Giovanni Paolo II” Campobasso Italy
| | | | | | - Piero Pelini
- Department of Cardiac Surgery and CardiologyFondazione “Papa Giovanni Paolo II” Campobasso Italy
| | - Mario Gaudino
- Department of Cardiothoracic SurgeryWeill Cornell Medicine New York New York
| | | |
Collapse
|
21
|
Athanasuleas CL, Stanley AWH, Buckberg GD. Mitral regurgitation: anatomy is destiny. Eur J Cardiothorac Surg 2018; 54:627-634. [PMID: 29718159 DOI: 10.1093/ejcts/ezy174] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 03/18/2018] [Indexed: 11/13/2022] Open
Abstract
Mitral regurgitation (MR) occurs when any of the valve and ventricular mitral apparatus components are disturbed. As MR progresses, left ventricular remodelling occurs, ultimately causing heart failure when the enlarging left ventricle (LV) loses its conical shape and becomes globular. Heart failure and lethal ventricular arrhythmias may develop if the left ventricular end-systolic volume index exceeds 55 ml/m2. These adverse changes persist despite satisfactory correction of the annular component of MR. Our goal was to describe this process and summarize evolving interventions that reduce the volume of the left ventricle and rebuild its elliptical shape. This 'valve/ventricle' approach addresses the spherical ventricular culprit and offsets the limits of treating MR by correcting only its annular component.
Collapse
Affiliation(s)
- Constantine L Athanasuleas
- Section of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Gerald D Buckberg
- Department of Cardiothoracic Surgery, University of California Los Angeles, Los Angeles, CA, USA
| |
Collapse
|
22
|
Hung J, Mihos C. Toward a better repair for ischemic mitral regurgitation: Thinking outside the ring. J Thorac Cardiovasc Surg 2017; 154:1256-1257. [DOI: 10.1016/j.jtcvs.2017.06.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 06/12/2017] [Indexed: 11/26/2022]
|
23
|
Leaflet repair techniques in mitral valve reconstruction. Indian J Thorac Cardiovasc Surg 2017. [DOI: 10.1007/s12055-017-0584-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
|
24
|
Pedraz-Prieto Á, Rodríguez-Abella H, Sánchez-Valenzuela DF, Cuerpo-Caballero GP, Ruíz-Fernández M, Fortuny-Ribas R, González-de Diego JF, Amorós-Rivera C, Las J, Irabien-Ortiz Á, Alonso-Perarnau S, González-Pinto ÁT. Reparación de la insuficiencia mitral funcional mediante abordaje del aparato subvalvular. Resultados a medio plazo. CIRUGIA CARDIOVASCULAR 2017. [DOI: 10.1016/j.circv.2017.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
25
|
Kelley TM, Kashem M, Wang H, McCarthy J, Carroll ND, Moser GW, Guy TS. Anterior Leaflet Augmentation With CorMatrix Porcine Extracellular Matrix in Twenty-Five Patients: Unexpected Patch Failures and Histologic Analysis. Ann Thorac Surg 2017; 103:114-120. [DOI: 10.1016/j.athoracsur.2016.05.090] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 03/15/2016] [Accepted: 05/23/2016] [Indexed: 10/21/2022]
|
26
|
Wolfenden HD, Cranney G. Functional mitral valve regurgitation: repair or replacement? Med J Aust 2016; 205:438-440. [PMID: 27852175 DOI: 10.5694/mja16.00553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 09/05/2016] [Indexed: 11/17/2022]
|
27
|
Anterior Mitral Leaflet Augmentation for Ischemic Mitral Regurgitation Performed Via a Right Thoracotomy Approach. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016; 11:298-300. [PMID: 27612148 DOI: 10.1097/imi.0000000000000288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Ischemic mitral regurgitation (MR) after myocardial infarction is associated with poor long-term survival, and the optimal treatment strategy remains debated. The most common repair technique used is a restrictive annuloplasty. However, up to 15% to 30% of patients experience recurrent MR owing to progressive left ventricular remodeling and geometric distortion of the mitral valve apparatus. Anterior mitral leaflet augmentation using a pericardial patch, in combination with a true-sized mitral annuloplasty, has been proposed as an adjunctive technique to increase the durability of valve repair for ischemic MR. Herein, we describe 2 cases of anterior mitral leaflet augmentation with annuloplasty repair for severe ischemic MR via a minimally invasive right thoracotomy, and review the literature regarding patient selection and clinical outcomes of this technique.
Collapse
|
28
|
Mihos CG, Pineda AM, Horvath SA, Santana O. Anterior Mitral Leaflet Augmentation for Ischemic Mitral Regurgitation Performed via a Right Thoracotomy Approach. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016. [DOI: 10.1177/155698451601100413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Christos G. Mihos
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, MA USA
| | - Andrés M. Pineda
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL USA
| | - Sofia A. Horvath
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL USA
| | - Orlando Santana
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL USA
| |
Collapse
|
29
|
Espiritu D, Onohara D, Kalra K, Sarin EL, Padala M. Transcatheter Mitral Valve Repair Therapies: Evolution, Status and Challenges. Ann Biomed Eng 2016; 45:332-359. [DOI: 10.1007/s10439-016-1655-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 05/14/2016] [Indexed: 12/21/2022]
|
30
|
Lee CH, Rabbah JP, Yoganathan AP, Gorman RC, Gorman JH, Sacks MS. On the effects of leaflet microstructure and constitutive model on the closing behavior of the mitral valve. Biomech Model Mechanobiol 2015; 14:1281-302. [PMID: 25947879 PMCID: PMC4881393 DOI: 10.1007/s10237-015-0674-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 04/01/2015] [Indexed: 12/30/2022]
Abstract
Recent long-term studies showed an unsatisfactory recurrence rate of severe mitral regurgitation 3-5 years after surgical repair, suggesting that excessive tissue stresses and the resulting strain-induced tissue failure are potential etiological factors controlling the success of surgical repair for treating mitral valve (MV) diseases. We hypothesized that restoring normal MV tissue stresses in MV repair techniques would ultimately lead to improved repair durability through the restoration of MV normal homeostatic state. Therefore, we developed a micro- and macro- anatomically accurate MV finite element model by incorporating actual fiber microstructural architecture and a realistic structure-based constitutive model. We investigated MV closing behaviors, with extensive in vitro data used for validating the proposed model. Comparative and parametric studies were conducted to identify essential model fidelity and information for achieving desirable accuracy. More importantly, for the first time, the interrelationship between the local fiber ensemble behavior and the organ-level MV closing behavior was investigated using a computational simulation. These novel results indicated not only the appropriate parameter ranges, but also the importance of the microstructural tuning (i.e., straightening and re-orientation) of the collagen/elastin fiber networks at the macroscopic tissue level for facilitating the proper coaptation and natural functioning of the MV apparatus under physiological loading at the organ level. The proposed computational model would serve as a logical first step toward our long-term modeling goal-facilitating simulation-guided design of optimal surgical repair strategies for treating diseased MVs with significantly enhanced durability.
Collapse
Affiliation(s)
- Chung-Hao Lee
- Center for Cardiovascular Simulation, Institute for Computational Engineering and Sciences (ICES), The University of Texas at Austin, 201 East 24th Street, 1 University Station C0200, POB 5.236, Austin, TX, 78712, USA
| | - Jean-Pierre Rabbah
- Cardiovascular Fluid Mechanics Laboratory, Department of Biomedical Engineering, Georgia Institute of Technology, 387 Technology Circle NW, Atlanta, GA, 30318, USA
| | - Ajit P Yoganathan
- Cardiovascular Fluid Mechanics Laboratory, Department of Biomedical Engineering, Georgia Institute of Technology, 387 Technology Circle NW, Atlanta, GA, 30318, USA
| | - Robert C Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Joseph H Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Michael S Sacks
- W. A. "Tex" Moncrief, Jr. Simulation-Based Engineering Science Chair I, Department of Biomedical Engineering, Center for Cardiovascular Simulation, Institute for Computational Engineering and Sciences (ICES), The University of Texas at Austin, 201 East 24th Street, 1 University Station C0200, POB 5.236, Austin, TX, 78712, USA.
| |
Collapse
|
31
|
Gomibuchi T, Takano T, Wada Y, Terasaki T, Seto T, Fukui D. Patch detachment after mitral valve repair with posterior leaflet augmentation: a case report. J Cardiothorac Surg 2015; 10:118. [PMID: 26363551 PMCID: PMC4568073 DOI: 10.1186/s13019-015-0322-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 09/04/2015] [Indexed: 01/23/2024] Open
Abstract
Mitral valve (MV) repair is indicated for patients with severe MR. We report a case of acute MR caused by patch detachment after posterior leaflet augmentation in MV repair. A 65-year-old male underwent MV repair with posterior leaflet augmentation and coronary artery bypass graft 1 month prior to this study. An inverted T-shaped incision was made on the posterior mitral leaflet (PML), and a piece of autologous fresh pericardium was sewn in the PML defect. Seven days after hospital discharge, he started feeling chest pain and presented with pulseless electrical activity. Ultrasonic cardiography showed severe mitral regurgitation (MR), which was suggestive of acute MR. We performed emergency reoperation. The edge of the autologous pericardial patch was detached from the anterior papillary muscle, and MV replacement was performed. He was discharged from the hospital 55 days after the reoperation and returned to his normal daily life. We conclude that avoidance of tension focalization during MV repair may be important.
Collapse
Affiliation(s)
- Toshihito Gomibuchi
- Department of Cardiovascular Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano, 390-8621, Japan.
| | - Tamaki Takano
- Department of Cardiovascular Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano, 390-8621, Japan.
| | - Yuko Wada
- Department of Cardiovascular Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano, 390-8621, Japan.
| | - Takamitsu Terasaki
- Department of Cardiovascular Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano, 390-8621, Japan.
| | - Tatsuichiro Seto
- Department of Cardiovascular Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano, 390-8621, Japan.
| | - Daisuke Fukui
- Department of Cardiovascular Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano, 390-8621, Japan.
| |
Collapse
|
32
|
Jouan J. Mitral valve repair over five decades. Ann Cardiothorac Surg 2015; 4:322-34. [PMID: 26309841 DOI: 10.3978/j.issn.2225-319x.2015.01.07] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 11/27/2014] [Indexed: 01/13/2023]
Abstract
It has become evident that mitral valve (MV) repair is the preferable treatment for the majority of patients presenting with severe mitral regurgitation (MR). This success clearly testifies that the surgical procedure is accessible, reproducible and is carrying excellent long-lasting results. From the pre-extracorporeal circulation's era to the last percutaneous approaches, a large variety of techniques have been proposed to address the different features of MV diseases. This article aimed at reviewing chronologically the development of these dedicated techniques through their origins and the debates that they generated in the literature.
Collapse
Affiliation(s)
- Jerome Jouan
- Department of Cardiovascular Surgery, Georges Pompidou European Hospital, 75015 Paris, France
| |
Collapse
|
33
|
Hetzer R, Solowjowa N, Siniawski H, Delmo Walter EM. Posterior annulus shortening increases leaflet coaptation in ischemic mitral incompetence: a new and valid technique. Ann Cardiothorac Surg 2015; 4:238-48. [PMID: 26309825 DOI: 10.3978/j.issn.2225-319x.2015.04.07] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 03/23/2015] [Indexed: 11/14/2022]
Abstract
BACKGROUND We introduce a technique of posterior annulus shortening to augment leaflet coaptation which addresses the restrictive mitral leaflet mobility in ischemic mitral incompetence (IMI), and report its long-term outcome. METHODS Between 1992 and 2012, 75 patients (mean age, 64.6±10.4 years; median, 66.0 years; range, 35.0-86.1 years) underwent repair of IMI by posterior annulus shortening to augment leaflet coaptation surface area. This technique reduces the annular diameter to between 23 and 25 mm and decreases the valve orifice to between 3.5 to 4.5 cm(2), which is sufficient to ensure an adequate leaflet coaptation area. An untreated pericardial strip is used to reinforce the shortened annulus in order to avoid redilatation. This augments the posterior leaflet by increasing the ratio of leaflet area/valve orifice where the coaptation gap is the greatest. The tissue strip increases and heightens the area which the posterior leaflet offers to the anterior leaflet for coaptation during closure, making valve closure possible in advanced leaflet restriction. RESULTS During a mean follow-up of 7.62±0.66 (median 8.53, range, 3.6-20.9) years, New York Heart Association (NYHA) functional class significantly improved, left ventricular ejection fraction (LVEF) increased and there was a tremendous abatement of MI (P<0.01). Annular area was reduced from 9.2 to 5.8 cm(2). Coaptation area was increased from a complete lack thereof to 6.6 mm(2) post-repair. CT showed posterior annulus size reduction from 70.4 to 54 mm and an increase in posterior leaflet length from 15.9 to 19.6 mm. A remarkable CT finding was the increase in coaptation length from 5.2 to 8.2 mm. Eighteen-year freedom from moderate MI, freedom from reoperation and survival rates were 80.7%±9%, 84.9%±4.2% and 65.1%±6.3%, respectively. CONCLUSIONS Posterior annulus shortening with pericardial strip augmentation addressing the lack of leaflet coaptation is a simple, reproducible and highly effective technique to restore valve competence in IMI.
Collapse
Affiliation(s)
- Roland Hetzer
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Natalia Solowjowa
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Henryk Siniawski
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Eva Maria Delmo Walter
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| |
Collapse
|
34
|
Debonnaire P, Al Amri I, Leong DP, Joyce E, Katsanos S, Kamperidis V, Schalij MJ, Bax JJ, Marsan NA, Delgado V. Leaflet remodelling in functional mitral valve regurgitation: characteristics, determinants, and relation to regurgitation severity. Eur Heart J Cardiovasc Imaging 2014; 16:290-9. [DOI: 10.1093/ehjci/jeu216] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
35
|
Mitral valve annuloplasty and anterior leaflet augmentation for functional ischemic mitral regurgitation: quantitative comparison of coaptation and subvalvular tethering. J Thorac Cardiovasc Surg 2014; 148:1688-93. [PMID: 24820187 DOI: 10.1016/j.jtcvs.2014.04.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 03/20/2014] [Accepted: 04/04/2014] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Although restrictive mitral annuloplasty (RMA) has been the preferred surgical treatment of functional ischemic mitral regurgitation (FIMR), some patients with severely dilated left ventricles will experience recurrent mitral regurgitation (MR). Consequently, new surgical strategies have been entertained to compensate for severely dilated ventricles by maximizing coaptation and reducing subvalvular tethering. Anterior leaflet augmentation (ALA) with mitral annuloplasty has been theorized to meet these goals. We compared the mechanistic effects of RMA and adjunct ALA in the setting of FIMR. METHODS Mitral valves were mounted in a clinically relevant left heart simulator. The tested conditions included control, FIMR, RMA, and true-size annuloplasty with either a small or large ALA. The A2-P2 leaflet coaptation length, MR, and strut and intermediary chordal forces were quantified. All repairs alleviated the MR. The coaptation length was significantly increased from FIMR to RMA, small ALA, and large ALA (P<.001). Between repairs, a large ALA created the greatest length of coaptation (P<.05). Tethering forces from the posteromedial strut chordae were reduced from the FIMR condition by all repairs (P<.001). Only a large ALA reduced the intermediate chordal tethering from the FIMR condition (P<.05). CONCLUSIONS A large ALA procedure created the greatest coaptation and reduced chordal tethering. Although all repairs abolished MR acutely, the repairs that create the greatest coaptation might conceivably produce a more robust and lasting repair in the chronic stage. A clinical need still exists to best identify which patients with altered mitral valve geometries would most benefit from an adjunct procedure or RMA alone.
Collapse
|
36
|
Invited commentary. Ann Thorac Surg 2014; 97:765-6. [PMID: 24580899 DOI: 10.1016/j.athoracsur.2013.11.011] [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: 11/05/2013] [Revised: 11/05/2013] [Accepted: 11/11/2013] [Indexed: 11/22/2022]
|
37
|
Paparella D, Malvindi PG, Romito R, Fiore G, Tupputi Schinosa LDL. Ischemic mitral regurgitation: pathophysiology, diagnosis and surgical treatment. Expert Rev Cardiovasc Ther 2014; 4:827-38. [PMID: 17173499 DOI: 10.1586/14779072.4.6.827] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Ischemic mitral valve regurgitation often complicates acute myocardial infarction and also represents a negative prognostic factor for long-term survival in patients undergoing surgical myocardial revascularization. While severe mitral regurgitation should always be corrected during a coronary artery bypass operation, the decision making is more difficult in patients with a mild-to-moderate degree of regurgitation. Recent studies and experimental protocols have elucidated the pathophysiological mechanisms leading to mitral regurgitation with great interest in annular modifications and subvalvular alterations. These data suggest that new and integrated surgical approaches that address annuloplasty ring sizing, ring type selection and tethering phenomenon (i.e., chordal cutting, 'edge-to-edge' technique and left-ventricular plasty techniques) are required for a safer and durable valve repair. Transthoracic and transesophageal echocardiography are useful in determining the etiology and the degree of mitral regurgitation, to assess mitral deformation and to measure indexes of global and regional left-ventricular remodeling. Stress echocardiography may unmask higher degrees of mitral regurgitation. More data are needed in order to confirm the promising and interesting preliminary experimental findings of magnetic resonance imaging in diagnosis and clinical evaluation of ischemic mitral regurgitation.
Collapse
Affiliation(s)
- Domenico Paparella
- University of Bari, Division of Cardiac Surgery, Piazza Giulio Cesare 11, 70100 Bari, Italy.
| | | | | | | | | |
Collapse
|
38
|
Yaku H, Doi K, Okawa K. Surgical management of ischemic mitral regurgitation: indications, procedures, and future prospects. Gen Thorac Cardiovasc Surg 2013; 61:497-503. [PMID: 23775235 DOI: 10.1007/s11748-013-0277-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Indexed: 11/24/2022]
Abstract
Ischemic mitral regurgitation (IMR) is one of the most important risk factors affecting prognosis of patients who suffer from myocardial infarction. The mechanisms of IMR, the indications for surgical intervention, the operative procedures, and the limitations of surgical procedures are discussed in this review article.
Collapse
Affiliation(s)
- Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan.
| | | | | |
Collapse
|
39
|
Functional mitral regurgitation: a 30-year unresolved surgical journey from valve replacement to complex valve repairs. Heart Fail Rev 2013; 19:341-58. [DOI: 10.1007/s10741-013-9392-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
|
40
|
Badr AA, Brik A, Salem AM, Refat A, Mostafa K, Badr U, Sharawy M, Kamal ER. Midterm Results of Leaflet Augmentation in Mitral Valve Repairin Rheumatic Valves Experience in One Center. WORLD JOURNAL OF CARDIOVASCULAR SURGERY 2013; 03:90-96. [DOI: 10.4236/wjcs.2013.32016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
|
41
|
Levinson MM, Miller J. Microsizing using inside suture placement. A simple and versatile technique for precision adjustment of ring annuloplasties. Heart Surg Forum 2012; 15:E242-50. [PMID: 23092659 DOI: 10.1532/hsf98.20121068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION A new and simple technique for eliminating residual leaks during mitral annuloplasty, called microsizing, is described. METHODS Microsizing is performed by moving one or more annuloplasty sutures from the outside to the inside of the prosthetic ring. This maneuver advances discrete segments of the annulus toward the opposing leaflet by a distance equal to the thickness of the ring (approximately 3 mm). Microsizing is a simple method for precision adjustment of annular shape and size to eliminate focal gaps, regardless of the cause. RESULTS A series of 63 consecutive patients with moderate to severe mitral regurgitation (MR) were repaired over a 10 year period, all with intraoperative transesophageal echocardiography guidance. No patient required valve replacement (repair success rate 100%). Concomitant (non-mitral valve) procedures were performed in 53 patients (84.1%). Fifty patients (79.3%, Group 1) underwent successful repair using traditional suture placement in the prosthetic ring. Thirteen patients (20.6%, Group 2) had one or more sutures repositioned to the inside of the ring ("micro-sized") as a new strategy to eliminate residual leaks. Mean post repair MR grade was lower when microsizing was used (0.15 for Group 2 versus 0.30 for Group 1). No micro-sized patient experienced systolic anterior motion (SAM) or mitral stenosis. There were no repairs with greater than trace MR, late ring dehiscences, recurrent regurgitation, or reoperation in the entire series. There was one death (1.6%) in a non-micro-sized patient from intra-operative abdominal hemorrhage secondary to an IABP complication. CONCLUSION Microsizing is a simple variation of suture placement that allows custom shaping of the mitral annulus by advancing selected portions toward the opposing leaflet, eliminating gaps, and improving coaptation. This technique is safe, simple, and reproducible without causing stenosis, SAM, or late failure.
Collapse
Affiliation(s)
- Mark M Levinson
- Hutchinson Regional Medical Center, Hutchinson, KS 67502, USA.
| | | |
Collapse
|
42
|
Jassar AS, Minakawa M, Shuto T, Robb JD, Koomalsingh KJ, Levack MM, Vergnat M, Eperjesi TJ, Jackson BM, Gorman JH, Gorman RC. Posterior leaflet augmentation in ischemic mitral regurgitation increases leaflet coaptation and mobility. Ann Thorac Surg 2012; 94:1438-45. [PMID: 22795059 DOI: 10.1016/j.athoracsur.2012.05.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 05/02/2012] [Accepted: 05/03/2012] [Indexed: 01/09/2023]
Abstract
BACKGROUND Restoring leaflet coaptation is the primary objective in repair of ischemic mitral regurgitation (IMR). The common practice of placing an undersized annuloplasty ring partially achieves this goal by correcting annular dilation; however, annular reduction has been demonstrated to exacerbate posterior leaflet tethering. Using a sheep model of IMR, we tested the hypothesis that posterior leaflet augmentation (PLA) combined with standard annuloplasty sizing increases leaflet coaptation more effectively than undersized annuloplasty alone. METHODS Eight weeks after posterobasal myocardial infarction, 15 sheep with 2+ or greater IMR underwent annuloplasty with either a 24-mm annuloplasty ring (24-mm group, n = 5), 30-mm ring (30-mm group, n = 5), or 30-mm ring with concomitant augmentation of the posterior leaflet (PLA group, n = 5). Using three-dimensional echocardiography, postrepair coaptation zone and posterior leaflet mobility were assessed. RESULTS Leaflet coaptation length after repair was greater in the PLA group (4.1 ± 0.3 mm) and the 24-mm group (3.8 ± 0.5 mm) as compared with the 30-mm group (2.7 ± 0.6 mm, p < 0.01). Leaflet coaptation area was significantly greater in the PLA group (121.5 ± 6.6 mm(2)) as compared with the 30-mm group (77.5 ± 17.0 mm(2)) or the 24-mm group (92.5 ± 17.9 mm(2), p < 0.01). Posterior leaflet mobility was significantly greater in the PLA group as compared with the 30-mm group or the 24-mm group. CONCLUSIONS Posterior leaflet augmentation combined with standard-sized annuloplasty enhances leaflet coaptation more effectively than either standard-sized annuloplasty or undersized annuloplasty alone. Increased leaflet coaptation after PLA provides redundancy to IMR repair, and may decrease incidence of both recurrent IMR and mitral stenosis.
Collapse
Affiliation(s)
- Arminder S Jassar
- Department of Surgery, University of Pennsylvania, Philadelphia, PA 19036, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Ostli B, Vester-Petersen J, Askov JB, Honge JL, Levine RA, Hagège A, Nielsen SL, Hasenkam JM, Nygaard H, Jensen MO. In Vitro System for Measuring Chordal Force Changes Following Mitral Valve Patch Repair. Cardiovasc Eng Technol 2012; 3:263-268. [PMID: 26273417 DOI: 10.1007/s13239-012-0098-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Attention towards optimization of mitral valve repair methods is increasing. Patch augmentation is one strategy utilized to correct functional mitral regurgitation or systolic anterior motion in complex mitral valve repairs. This article describes a system for investigating the redistribution of chordae tendineae tension as a reflection of altered stress distribution of the valve leaflet following patch augmentation. METHODS AND MATERIALS An in vitro test setup was constructed to hold native porcine mitral valves containing an annulus and papillary muscle positioning system. The alterations caused by patch augmentation should be visual from both the atrial and ventricular views. Ventricular pressure was regulated stepwise in a range of 0-150 mmHg. To test the system, the anterior mitral leaflet was extended by a pericardial patch sutured to the mid/basal part of the leaflet, and the chordae tendineae force was measured as the ventricular pressure was applied. RESULTS The system demonstrated the capacity to hold native porcine mitral valves and introducing patch repairs according to clinical practice. The porcine mitral valve test setup indicated strong correlation between the forces in the mitral valve secondary chordae tendineae and the applied transvalvular pressure (R2 = 0.95). CONCLUSION This test setup proved the ability to obtain normal mid-systolic mitral valve function, secondary chordae force measurements, and important preservation of the visual access: Hence, obtaining the pressure-force relationship as well as identifying any shift of the secondary chordae insertion point on the anterior leaflet relative to the coaptation zone was made possible.
Collapse
Affiliation(s)
- B Ostli
- Dept. of Biomedical Engineering, Engineering College of Aarhus, Aarhus, Denmark
| | - J Vester-Petersen
- Dept. of Biomedical Engineering, Engineering College of Aarhus, Aarhus, Denmark
| | - J B Askov
- Dept. of Biomedical Engineering, Engineering College of Aarhus, Aarhus, Denmark ; Dept. of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Aarhus, Denmark
| | - J L Honge
- Dept. of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Aarhus, Denmark
| | - R A Levine
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - A Hagège
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Department of Cardiology; University Paris Descartes; INSERM U 633; Paris, France
| | - S L Nielsen
- Dept. of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Aarhus, Denmark
| | - J M Hasenkam
- Dept. of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Aarhus, Denmark
| | - H Nygaard
- Dept. of Biomedical Engineering, Engineering College of Aarhus, Aarhus, Denmark ; Dept. of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Aarhus, Denmark
| | - M O Jensen
- Dept. of Biomedical Engineering, Engineering College of Aarhus, Aarhus, Denmark ; Dept. of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Aarhus, Denmark
| |
Collapse
|
44
|
Calafiore AM, Iacò AL, Gallina S, Al-Amri H, Penco M, Di Mauro M. Surgical treatment of functional mitral regurgitation. Int J Cardiol 2012; 166:559-71. [PMID: 22633664 DOI: 10.1016/j.ijcard.2012.05.027] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2011] [Revised: 04/10/2012] [Accepted: 05/04/2012] [Indexed: 12/22/2022]
Abstract
Incidence of functional mitral regurgitation (FMR) is increasing due to aging and better survival after acute myocardial infarction, the most frequent cause of FMR. At the basis of FMR there is a displacement of one of both papillary muscle(s) and/or annular enlargement, which can be primitive or, more often, secondary. There is general agreement that its natural history is unfavorable, as witnessed by a considerable body of evidences. However, even if there is no clear evidence that surgical treatment of FMR changes consistently the outcome of patients with this disease, at least in terms of survival, there are some studies which show that function improves, as well as the global quality of life. The guidelines reflect this uncertainty, providing no clear indications, even in the gradation of severity of the FMR. Surgical techniques are variable and are mainly addressed to the annulus (restrictive annuloplasty), which is only a part of the anatomic problem related to FMR. Insertion of a prosthesis inside the native valve is appearing more and more a valuable option rather than a bail out procedure. On the other side, techniques addressed to modify the position of the papillary muscles appear to be still under investigation and not yet in the armamentarium of surgical treatment of FMR. Even after many years, rules are not established and results are fluctuating, but how and when to treat FMR is becoming more and more a topic of interest in cardiac surgery.
Collapse
Affiliation(s)
- Antonio M Calafiore
- Department of Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.
| | | | | | | | | | | |
Collapse
|
45
|
Influence of Chronic Tethering of the Mitral Valve on Mitral Leaflet Size and Coaptation in Functional Mitral Regurgitation. JACC Cardiovasc Imaging 2012; 5:337-45. [DOI: 10.1016/j.jcmg.2011.10.004] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Revised: 09/28/2011] [Accepted: 10/11/2011] [Indexed: 11/18/2022]
|
46
|
Durán D, Lugo J, Montoto J, Casais R. El tratamiento quirúrgico de la insuficiencia mitral isquémica. CIRUGIA CARDIOVASCULAR 2011. [DOI: 10.1016/s1134-0096(11)70050-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
|
47
|
Robb JD, Minakawa M, Koomalsingh KJ, Shuto T, Jassar AS, Ratcliffe SJ, Gorman RC, Gorman JH. Posterior leaflet augmentation improves leaflet tethering in repair of ischemic mitral regurgitation. Eur J Cardiothorac Surg 2011; 40:1501-7; discussion 1507. [PMID: 21546260 DOI: 10.1016/j.ejcts.2011.02.079] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Revised: 02/16/2011] [Accepted: 02/21/2011] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES Ischemic mitral regurgitation results from annular dilatation, leaflet tethering and leaflet flattening. Undersized annuloplasty corrects annular dilatation but worsens leaflet tethering and flattening. This exacerbation of abnormal leaflet geometry may contribute to poor repair results for ischemic mitral regurgitation (IMR). Using a sheep model of IMR, we hypothesized that posterior leaflet augmentation and less-extreme annular undersizing would relieve tethering and increase leaflet curvature. METHODS Eight weeks after posterolateral infarct, 10 sheep with ≥ 2+ IMR underwent either a 24-mm planar ring annuloplasty (n = 5) or a 30-mm planar ring annuloplasty with concomitant posterior leaflet augmentation (n = 5). Real-time three-dimensional echocardiography allowed measurement of indices of leaflet curvature and tethering before and after annuloplasty. RESULTS Comparing pre- and post-repair values in the P1, P2, and P3 leaflet regions, undersized 24-mm ring annuloplasty made no significant difference to mean septolateral curvature (0.23-0.26, 0.33-0.29, and 0.27-0.37 cm(-1), respectively), whereas leaflet augmentation in combination with a 30-mm ring annuloplasty increased septolateral curvature (P1 0.30-1.02, P2 0.31-1.23, and P3 0.35-0.84 cm(-1), p-values<0.05). The mean tethering angle formed between the annular plane and the posterior leaflet increased in all three posterior regions for the 24-mm ring group (P1 12-23°, P2 26-31°, and P3 16-25°), but decreased in all regions for the group undergoing leaflet augmentation (P1 +5 to -6°, P2 +13 to -13°, P3 +16-15°, all p-values < 0.05). CONCLUSIONS Undersized annuloplasty exacerbates leaflet tethering. Posterior leaflet augmentation with less severe annular reduction increases leaflet curvature and decreases tethering; this technique more completely addresses the pathogenic mechanism of IMR and may improve repair durability.
Collapse
Affiliation(s)
- J Daniel Robb
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA PA 19036, USA
| | | | | | | | | | | | | | | |
Collapse
|
48
|
Shin H, Mori M, Yamabe K, Iwanaga S. Reconstruction of the free margin of the anterior mitral leaflet with autologous pericardium in active infected endocarditis. Eur J Cardiothorac Surg 2011; 39:784-5. [PMID: 20932770 DOI: 10.1016/j.ejcts.2010.08.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Revised: 08/13/2010] [Accepted: 08/25/2010] [Indexed: 10/19/2022] Open
|
49
|
Anterior leaflet augmentation for ischemic mitral regurgitation in patients with anomalous left coronary artery from the pulmonary artery and preserved left ventricular function. J Thorac Cardiovasc Surg 2011; 142:716-8. [PMID: 21334009 DOI: 10.1016/j.jtcvs.2011.01.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Revised: 11/21/2010] [Accepted: 01/17/2011] [Indexed: 11/20/2022]
|
50
|
Characterization of Mitral Valve Annular Dynamics in the Beating Heart. Ann Biomed Eng 2011; 39:1690-702. [DOI: 10.1007/s10439-011-0272-y] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Accepted: 02/04/2011] [Indexed: 11/25/2022]
|