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Wagner CM, Brescia AA, Watt TMF, Bergquist C, Rosenbloom LM, Ceniza NN, Markey GE, Ailawadi G, Romano MA, Bolling SF. Surgical strategy and outcomes for atrial functional mitral regurgitation: All functional mitral regurgitation is not the same! J Thorac Cardiovasc Surg 2024; 167:647-655. [PMID: 35618531 DOI: 10.1016/j.jtcvs.2022.02.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 01/10/2022] [Accepted: 02/23/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Functional mitral regurgitation (FMR) is a cardiac pathology that causes the mitral valve to malfunction, leading to mitral regurgitation (MR). The optimal strategy for FMR remains unclear, and FMR outcomes are poor. All etiologies of FMR might not be the same, and subdividing patients with FMR caused by atrial (AFMR) versus ventricular FMR pathology might be important. Herein, we present outcomes of patients with AFMR to define this "new" population. METHODS Data of patients who underwent mitral valve repair for MR from 2000 to 2020 were reviewed. Patients with degenerative/myxomatous disease, ejection fraction <50% (ventricular FMR), and miscellaneous etiologies including endocarditis and rheumatic disease were excluded to isolate a population of "pure" AFMR patients. Descriptive characteristics and outcomes data were analyzed. RESULTS Among 123 total AFMR patients, mean preoperative left atrial dimensions were enlarged to 4.9 (95% CI, 4.7-5.0) cm, whereas mean preoperative left ventricular diastolic dimensions remained near normal at 5.0 (95% CI, 4.9-5.2) cm. Preoperative atrial fibrillation was noted in 61% (74/123). Echocardiogram was performed in 58% (71/123) of patients at a median of 569 (interquartile range, 75-1782) days after surgery. Of those, 72% (51/71) had trivial or no MR, 22% (16/71) mild, and only 6% (4/71) moderate or greater MR. Only 1.6% (2/123) required redo mitral valve reoperation. Estimated 5-year survival was 74%. CONCLUSIONS Patients with AFMR do well after mitral valve repair using an annuloplasty ring, with low rates of reoperation, mortality, and recurrence of MR. Mitral annuloplasty should be considered the surgical therapy of choice for AFMR.
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Affiliation(s)
| | | | - Tessa M F Watt
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Curtis Bergquist
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Liza M Rosenbloom
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Nicolas N Ceniza
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Grace E Markey
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Steven F Bolling
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.
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Kim SE, Kim DY, Seo J, Cho I, Hong GR, Ha JW, Shim CY. Left atrial strain and clinical outcome in patients with significant mitral regurgitation after surgical mitral valve repair. Front Cardiovasc Med 2022; 9:985122. [PMID: 36267639 PMCID: PMC9577607 DOI: 10.3389/fcvm.2022.985122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 09/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background This study aimed to investigate the prognostic value of left atrial (LA) strain in patients with significant mitral regurgitation (MR) after surgical mitral valve (MV) repair. Methods A total of 169 patients (age 55 ± 15 years, 88 men) with moderate or severe MR on echocardiogram at least 6 months after surgical MV repair for primary MR were studied. Two-dimensional, Doppler, and speckle tracking echocardiography including MR quantitative measures, chamber size, and LA strain were comprehensively analyzed. The primary outcome was a composite of cardiovascular death, heart failure hospitalization, and MV reoperation. Results During a median of 44.4 months [interquartile range (IQR): 18.7-70.3 months] of follow-up, 44 patients (26%) experienced clinical events; these patients had greater MR volume, elevated mean diastolic pressure gradient and pulmonary artery systolic pressure, and enlarged chamber size compared with patients who did not experience events. Patients with events showed significantly lower LA strain [13.3% (IQR: 9.3-23.8%) vs. 24.0% (IQR: 13.1-31.4%), p = 0.003] and higher MR volume/LA strain [3.09 ml/% (IQR: 2.06-5.80 ml/%) vs. 1.57 ml/% (IQR: 1.04-2.72 ml/%), p < 0.001] than those without events. MR volume/LA strain was a good predictor of clinical outcomes (cut-off 1.57 ml/%, area under the curve 0.754, p < 0.001). On multivariable Cox proportional analysis, MR volume/LA strain was independently associated with clinical outcomes (hazard ratio: 1.269, 95% confidence interval: 1.109-1.452, p < 0.001) along with pulmonary artery systolic pressure. Conclusion A measure of LA mechanical function relative to MR volume is associated with clinical outcomes in patients with significant MR after surgical MV repair.
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Affiliation(s)
- Se-Eun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Dae-Young Kim
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Jiwon Seo
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Iksung Cho
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Geu-Ru Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jong-Won Ha
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Chi Young Shim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea,*Correspondence: Chi Young Shim,
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Rong LQ, Lopes AJ, Mitlak HW, Palumbo MC, Mick S, Kim J, Levine RA, Wong SC, Reisman M, Devereux RB, Gaudino M, Weinsaft JW. Relative Impact of Surgical Mitral Repair and MitraClip on Annular Remodeling-A Potential Mechanism for Therapeutic Response to Mitral Repair for Degenerative Mitral Regurgitation. J Cardiothorac Vasc Anesth 2022; 36:1279-1287. [PMID: 34600832 PMCID: PMC9027699 DOI: 10.1053/j.jvca.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/23/2021] [Accepted: 09/03/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Three-dimensional transesophageal echocardiography (TEE) is widely used to guide decision-making for mitral repair. The relative impact of surgical mitral valve repair (MVr) and MitraClip on annular remodeling is unknown. The aim was to determine the impact of both mitral repair strategies on annular geometry, including the primary outcome of annular circumference and area. DESIGN This was a retrospective observational study of patients who underwent mitral intervention between 2016 and 2020. SETTING Weill Cornell Medicine, a single, large, academic medical center. PARTICIPANTS The population comprised 50 patients with degenerative mitral regurgitation (MR) undergoing MVr. INTERVENTIONS Elective MVr and TEE. MEASUREMENTS AND MAIN RESULTS Patients undergoing MitraClip or surgical MVr were matched (1:1) for sex and coronary artery disease. Mitral annular geometry indices were quantified on intraprocedural three-dimensional TEE. Mild or less MR on follow-up transthoracic echocardiography defined optimal response. Patients undergoing MitraClip were older (80 ± eight v 66 ± six years; p < 0.001) but were otherwise similar to surgical patients. Patients undergoing MitraClip had larger baseline left atrial and ventricular sizes, increased tenting height, and volume (p < 0.01), with a trend toward increased annular area (p = 0.23). MitraClip and surgery both induced immediate mitral annular remodeling, including decreased area, circumference, and tenting height (p < 0.001), with greater remodeling with surgical repair. At follow-up (4.1 ± 9.0 months) optimal response (≤ mild MR) was ∼twofold more common with surgery than MitraClip (81% v 46%; p = 0.02). The relative reduction in annular circumference (odds ratio [OR] 1.05 [1.00-1.09] per cm; p = 0.04) and area (OR 1.03 [1.00-1.05] per cm2; p = 0.049) were both associated with optimal response. CONCLUSIONS Surgical MVr and MitraClip both reduce annular size, but repair-induced remodeling is greater with surgery and associated with an increased likelihood of optimal response.
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Affiliation(s)
- Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY.
| | | | - Hannah W Mitlak
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Maria C Palumbo
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Stephanie Mick
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Jiwon Kim
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Robert A Levine
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - S Chiu Wong
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Mark Reisman
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Richard B Devereux
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Jonathan W Weinsaft
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
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Machine Learning Prediction Models for Mitral Valve Repairability and Mitral Regurgitation Recurrence in Patients Undergoing Surgical Mitral Valve Repair. Bioengineering (Basel) 2021; 8:bioengineering8090117. [PMID: 34562939 PMCID: PMC8469985 DOI: 10.3390/bioengineering8090117] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Mitral valve regurgitation (MR) is the most common valvular heart disease and current variables associated with MR recurrence are still controversial. We aim to develop a machine learning-based prognostic model to predict causes of mitral valve (MV) repair failure and MR recurrence. Methods: 1000 patients who underwent MV repair at our institution between 2008 and 2018 were enrolled. Patients were followed longitudinally for up to three years. Clinical and echocardiographic data were included in the analysis. Endpoints were MV repair surgical failure with consequent MV replacement or moderate/severe MR (>2+) recurrence at one-month and moderate/severe MR recurrence after three years. Results: 817 patients (DS1) had an echocardiographic examination at one-month while 295 (DS2) also had one at three years. Data were randomly divided into training (DS1: n = 654; DS2: n = 206) and validation (DS1: n = 164; DS2 n = 89) cohorts. For intra-operative or early MV repair failure assessment, the best area under the curve (AUC) was 0.75 and the complexity of mitral valve prolapse was the main predictor. In predicting moderate/severe recurrent MR at three years, the best AUC was 0.92 and residual MR at six months was the most important predictor. Conclusions: Machine learning algorithms may improve prognosis after MV repair procedure, thus improving indications for correct candidate selection for MV surgical repair.
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Blessberger H, Kellermair J, Kammler J, Steinwender C, Zierer AF. Transapical off-pump mitral valve repair following prior mitral valve surgery: A case report. Medicine (Baltimore) 2021; 100:e26148. [PMID: 34032769 PMCID: PMC8154387 DOI: 10.1097/md.0000000000026148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 05/11/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Redo surgeries after mitral valve repair are technically demanding. Procedures applying the NeoChord device (NeoChord Inc, St. Louis Park, MN) have proven to be safe and feasible in selected patients requiring mitral valve repair due to a leaflet prolapse or flail. However, its use for redo procedures after conventional surgical repair has not been well established yet. PATIENT CONCERNS We report the case of a 57-year-old man who presented with dyspnea upon exertion. The patient had undergone a minimally invasive surgical mitral valve repair because of a flail leaflet of the segments segment 2 of the posterior mitral valve leaflet (P2)/segment 3 of the posterior mitral valve leaflet (P3) 4 years before. DIAGNOSES Transesophageal echocardiography identified a relapse of severe mitral valve regurgitation. The recurring regurgitant jet was caused by a flail leaflet due to newly ruptured native chords. INTERVENTIONS After discussion in an interdisciplinary heart team, we performed a minimally invasive off-pump redo procedure applying the NeoChord device under three-dimensional transesophageal echocardiographic guidance. OUTCOMES The echocardiographic result with only trivial residual mitral regurgitation as well as the further clinical course of the patient were favorable. LESSONS As redo surgery after minimally invasive mitral valve repair is challenging, the NeoChord device represents a novel treatment option that does not require cardiopulmonary bypass.
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Affiliation(s)
- Hermann Blessberger
- Department of Cardiology, Kepler University Hospital, Medical Faculty, Johannes Kepler University, Linz
| | - Joerg Kellermair
- Department of Cardiology, Kepler University Hospital, Medical Faculty, Johannes Kepler University, Linz
| | - Juergen Kammler
- Department of Cardiology, Kepler University Hospital, Medical Faculty, Johannes Kepler University, Linz
- Department of Internal Medicine II, Paracelsus Medical University, Salzburg
| | - Clemens Steinwender
- Department of Cardiology, Kepler University Hospital, Medical Faculty, Johannes Kepler University, Linz
- Department of Internal Medicine II, Paracelsus Medical University, Salzburg
| | - Andreas F. Zierer
- Department of Cardiothoracic and Vascular Surgery, Kepler University Hospital, Medical Faculty, Johannes Kepler University, Linz, Austria
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