Surgical redo mitral valve replacement in high-risk patients: The real-world experience

Management of Prosthetic Mitral Valve Infective Endocarditis in a Patient With Congenital Heart Disease

We present the case of an adult patient with Kartagener's syndrome, multiple prior sternotomies, and recurrent prosthetic valve endocarditis, a scenario without clear guidelines to direct management. Ultimately, the team elected for medical management given the high mortality risk associated with surgery; the patient responded to antibiotic therapy.

Transcatheter Therapy for Mitral Valve Stenosis

Mitral valve stenosis remains highly prevalent among the US population although with dramatically shifting demographics. The significance of rheumatic mitral disease in developing nations persists, despite improvements in preventative measures and early detection, and its presence in developed countries is still evident as observed through international migration. In addition, the substantial growth in the aging population with a heightened occurrence of concurrent cardiovascular risk factors is leading to an increased prevalence of chronic calcific degeneration and degeneration of previously repaired or replaced valves. This article aims to review various transcatheter therapies in the treatment of mitral valve stenosis.

Myocardial Injury After Transcatheter Mitral Valve Replacement Versus Surgical Reoperation

This study aimed to evaluate the incidence and clinical implications of myocardial injury, as determined by cardiac biomarker increase, in patients who underwent mitral bioprosthesis dysfunction treatment with transcatheter mitral valve replacement (TMVR) versus surgical mitral valve replacement reoperation (SMVR-REDO). Between 2014 and 2023, 310 patients with mitral bioprosthesis failure were included (90 and 220 patients for TMVR and SMVR-REDO, respectively). Multivariable analysis and propensity score matching were performed to adjust for the intergroup differences in baseline characteristics. Creatinine kinase-MB (CK-MB) and cardiac troponin I (cTn) were collected at baseline and 6 to 12, 24, 48, and 72 hours after intervention. The cardiac biomarkers values were evaluated in relation to their reference values. The outcomes were determined according to the Mitral Valve Academic Research Consortium criteria. CK-MB and cTn increased above the reference level in almost all patients after SMVR-REDO and TMVR (100% vs 94%, respectively), with the peak occurring within 6 to 12 hours. SMVR-REDO was associated with a two- to threefold higher increase in cardiac biomarkers. After 30 days, the mortality rates were 13.3% in the TMVR and 16.8% in the SMVR-REDO groups. At a median follow-up of 19 months, the mortality rates were 21.1% in the TMVR and 17.7% in the SMVR-REDO groups. Left ventricular ejection fraction, estimated glomerular filtration rate, CK-MB, and cTn were predictors of mortality. In conclusion, some degree of myocardial injury occurred systematically after the treatment of mitral bioprosthetic degeneration, especially after SMVR, and higher CK-MB and cTn levels were associated with increased cumulative late mortality, regardless of the approach.

Outcomes of minimally invasive versus conventional sternotomy for redo mitral valve surgery according to Mitral Valve Academic Research Consortium: A systematic review and meta-analysis

A minimally invasive approach through right mini-thoracotomy for redo mitral valve surgery may improve patients' outcomes compared to median sternotomy. This study aims to evaluate the outcomes of both procedures according to the Mitral Valve Academic Research Consortium (MVARC). This systematic review and meta-analysis were performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Literature searching was performed in several databases including PubMed, EBSCOhost, Scopus, and Proquest up to 28 February 2022. Meta-analysis using proportions or means was applied. A total of 13 retrospective cohort articles were included in this study. The incidence of in-hospital mortality (3% vs 9.2%, OR = 0.35; 95% CI: 0.21-0.58; P ≤ 0.0001), reintervention for bleeding (3.8% vs 5.9%, OR = 0.56; 95% CI: 0.32-0.97; P = 0.04), and acute renal failure (5% vs 12%, OR = 0.29; 95% CI: 0.23-0.65; P = 0.0003) was significantly lower in mini-thoracotomy (MINI) group compared to median sternotomy (STER) group. The incidence of neurologic events (3.4% vs 5.5%, OR = 0.66; 95% CI: 0.4-1.08; P = 0.1) and arrhythmia (19.5% vs 25.5%, OR = 0.64; 95% CI: 0.38-1.09; P = 0.1) were also lower in MINI group compared to STER group but was not significant statistically. No significant differences were found in myocardial infarct (1% vs 1%, OR = 0.71; 95% CI: 0.06-8.85; P = 0.79) between MINI and STER group. A minimally invasive surgery through right mini-thoracotomy is associated with a lower incidence of in-hospital mortality, reintervention for bleeding, and acute renal failure. It is a safe alternative to median sternotomy for redo mitral valve surgery.

Special issues regarding redo mitral valve procedures in the developing countries

Redo mitral valve replacement remains the standard treatment for recurrent mitral valve disease. Most patients referred for a redo surgery in the western world are older and present with multiple comorbidities. With the successful broad implementation of anti-infective treatment, rheumatic mitral valve disease has become highly uncommon. Nonetheless, rheumatic heart disease is still thriving in developing countries causing the most severe mitral valve conditions. The guidelines are there to help us in our decision-making process, but the actual decision has to be made based on each patients' individual criteria.