Contemporary techniques for mitral valve repair-the Mayo Clinic experience

Mitral valve repair for patients with degenerative or functional mitral valve regurgitation improves symptoms and prognosis, and several techniques have been described. Important principles in operation are simplicity, reproducibility, and durability of repair. At Mayo Clinic, we have operated on more than 6000 patients with degenerative mitral valve disease and valve prolapse, and this review details our approach to mitral valve repair, including robotic and minimally invasive techniques. Most patients with isolated leaflet prolapse can be managed with leaflet plication or triangular resection, and chordal replacement is reserved for repair of anterior leaflet prolapse. Posterior annuloplasty with a standard-sized flexible band is used to reduce annular circumference and improve leaflet coaptation. With these methods, early risk of mortality for mitral valve repair is low in the current era (< 1%), and rate of recurrent valve leakage is 1.5 per 100 patient-years during the first year post-repair and 0.9 per 100 patient-years thereafter. This paper also briefly summarizes important considerations for patients with mitral valve regurgitation and severe calcification, perforations due to endocarditis, and rheumatic heart disease.

Outcomes of surgical treatment for active infective endocarditis of mitral valve compared using complexity scoring

OBJECTIVE

The aim of this study was to evaluate our surgical treatment outcomes of active infective endocarditis (IE) of mitral valve in relation to the patients' complexity scores.

METHODS

We reviewed 51 patients who underwent surgical treatment for active IE on the mitral valve, in our hospital between September 2002 and November 2016. We adapted a complexity scoring scale to describe the range of parts suffering vegetation and damage, assigning the following weighting: weight 1 for each posterior segment; weight 2 for each anterior segment, commissural segment, left atrium, or left ventricle; weight 3 if the annulus was involved or if pathology extended to a prior mitral operation site. A total of 51 patients were identified and categorized by complexity score into two groups: 1-2: Simple (n = 19); ≥ 3: Complex (n = 32).

RESULTS

MV repair was achieved in 18 patients (95%) in the Simple group and 26 patients (81%) in the Complex group. In the Complex there were 2 in-hospital deaths (6%). There were none in the Simple. The 5-year survival rates were 100% in the Simple and 79.6% in the Complex (P < 0.05). The 5-year rates of freedom from mitral regurgitation were 77.8% in the Simple and 91.5% in the Complex (P = 0.63). The 5-year rates of freedom from recurrence of IE were 93.3% in the Simple and 92.2% in the Complex (P = 0.76).

CONCLUSIONS

We found consistent outcomes in terms of recurrent mitral regurgitation and recurrence of IE, regardless of lesion complexity.

Long-term outcomes of mitral valve endocarditis: improved survival through collaborative management

BACKGROUND

Infective endocarditis (IE) of the mitral valve is an illness associated with significant morbidity and mortality. We describe the long-term outcomes of mitral valve endocarditis at a single centre.

METHODS

All patients who presented with IE to the study institution between 2000 and 2015 were included. Data were obtained by retrospective review of the medical records.

RESULTS

There were 163 patients who presented with mitral valve IE. Mean age was 58 ± 16.8 years. A history of intravenous drug use was present in 18% (30/163) of patients. The most common infective agents were Staphylococcus aureus in 42% (69/163) (7% (5/69) were methicillin resistant), Streptococcus viridans species in 15% (25/163) and Enterococcus faecalis in 10% (17/163). Surgery was performed in 29% (47/163) of patients. Hospital mortality was 23% (38/163). Survival was 71% (95% confidence interval (CI) 63.1-77.6%) at 1 year, 56% (95% CI 46.0-64.9%) at 5 years and 44% (95% CI 36.4-59.7%) at 10 years follow-up. There was no survival difference between medical and surgical management (P = 0.55). On multivariate Cox regression analysis, need for renal replacement therapy (P = 0.003) and increasing age (P = 0.014) were found to be risk factors while infectious diseases consult during index admission (P = 0.007) was found to be protective.

CONCLUSION

Mitral valve endocarditis is associated with survival of <50% at 10 years follow-up. Surgical and medical management were associated with similar outcomes. Increasing age and need for renal replacement therapy were associated with mortality, and infectious diseases consultation was associated with improved survival.

Outcome of early vs delayed surgery for infective mitral endocarditis

BACKGROUND AND AIM OF THE STUDY

Timing of surgery for infective endocarditis is controversial. The objective of this study was to report the outcomes of early vs delayed surgery (DS) of mitral endocarditis.

METHODS

We retrospectively reviewed all patients treated surgically for mitral endocarditis between 2005 and 2016 in a single center. We analyzed midterm outcomes of early surgery (ES; surgery within 7 days or less of prior directed antibiotic treatment) in comparison to DS (surgery after more than 7 days of prior directed antibiotic treatment).

RESULTS

Survival of all patients was 87% at one and 72% at 5 years. Mean follow-up time was 4.0 ± 3.1 years. Thirty-three (36.3%) patients were in the ES and 58 (63.7%) were in the DS group. Patients with ES were younger (47.4 vs 55.3 years), were in New York Heart Association class III or IV more frequently (97.0 vs 65.5%), and had higher EuroScore2 (15.6 vs 8.6%). The ES group had lower freedom from valve reoperation (98.2 vs 87.2%; P = .035) and the composite endpoint of >2 + regurgitation or reoperation at 5 years (98.2 vs 72.7%; P = .004).

CONCLUSIONS

ES was associated with a higher rate of reoperations and the composite endpoint of recurrent MR or reoperation.

Early results for active infective endocarditis

Introduction

Cardiac surgery is frequently needed during active phase of infective endocarditis (IE). The purpose of this study was to analyze the immediate and late results and determine the risk factors for death.

Methods

We retrospectively reviewed 101 patients with IE operated in the active phase. The mean age was 40.5 ± 12.5 years. 16 patients (15.8%) were diagnosed with prosthetic valve endocarditis (PVE). 81 (80.9%) were in NYHA functional class III-IV. Blood cultures were positive in only 24 cases (23.9%).

Results

in-hospital mortality rate was 17.9% (18 cases). Multivariate analysis indentified five determinant predictor factors: congestive heart failure (CHF), renal insufficiency, high Euroscore, prolonged cardiopulmonary bypass time (> 120 min) and long ICU stay. The median follow-up period was 4.2 (2-6.5) years. Overall survival rate for all patients who survived surgery was 97% at 5 years and 91% at 10 years.

Conclusion

Despite high in-hospital mortality rate, when patients receive operation early in the active phase of their illness, late outcome may be good.

Nationwide cohort study of mitral valve repair versus replacement for infective endocarditis

OBJECTIVES

The feasibility and long-term outcomes of mitral valve (MV) repair in patients with infective endocarditis (IE) remain unclear.

METHODS

Using Taiwan's National Health Insurance Research Database, we identified 1999 patients who underwent MV surgery for IE during 2000 to 2013. The patients were more likely to have undergone valve replacement (1575 patients; 78.8%) than valve repair (424 patients; 21.2%). After 1:1 propensity score matching, 352 patients in each group were included for analysis. Perioperative outcomes and late composite end points, comprising all-cause mortality, MV reoperation, any stroke, major bleeding, and readmission for heart failure, were compared.

RESULTS

Patients who received MV repair had fewer perioperative complications, lower in-hospital mortality rates (6.3% vs 10.8%; P = .031), and lower risks of late mortality (hazard ratio [HR], 0.59; 95% confidence interval [CI], 0.44-0.80), and composite end point (HR, 0.67; 95% CI, 0.52-0.87) during a mean follow-up of 4.8 years. Subgroup analysis revealed a trend in which the beneficial effect of MV repair was not apparent when surgeries were performed in hospitals within the lowest volume quartile (P for interaction = .091). In patients who underwent surgery during active IE, MV repair was also related to a lower rate of late mortality (HR, 0.64; 95% CI, 0.48-0.85).

CONCLUSIONS

Mitral repair for IE has better perioperative and late outcomes than mitral replacement. Mitral repair performed by an experienced team is recommended for IE patients instead of MV replacement whenever possible, even with an active infection status.

Long-Term Results of Mitral Valve Repair

Introduction

Current guidelines state that patients with severe mitral regurgitation should be treated in reference centers with a high reparability rate, low mortality rate, and durable results.

Objective

To analyze our global experience with the treatment of organic mitral regurgitation from various etiologies operated in a single center.

Methods

We evaluated all surgically treated patients with organic mitral regurgitation from 2004-2017. Patients were evaluated clinically and by echocardiography every year. We determined early and late survival rates, valve related events and freedom from recurrent mitral regurgitation and tricuspid regurgitation. Valve failure was defined as any mitral regurgitation ≥ moderate degree or the need for reoperation for any reason.

Results

Out of 133 patients with organic mitral regurgitation, 125 (93.9%) were submitted to valve repair. Mean age was 57±15 years and 52 patients were males. The most common etiologies were degenerative disease (73 patients) and rheumatic disease (34 patients). Early mortality was 2.4% and late survival was 84.3% at 10 years, which are similar to the age- and gender-matched general population. Only two patients developed severe mitral regurgitation, and both were reoperated (95.6% at 10 years). Freedom from mitral valve failure was 84.5% at 10 years, with no difference between degenerative and rheumatic valves. Overall, late ≥ moderate tricuspid regurgitation was present in 34% of the patients, being more common in the rheumatic ones. The use of tricuspid annuloplasty abolished this complication.

Conclusion

We have demonstrated that mitral regurgitation due to organic mitral valve disease from various etiologies can be surgically treated with a high repair rate, low early mortality and long-term survival that are comparable to the matched general population. Concomitant treatment of atrial fibrillation and tricuspid valve may be important adjuncts to optimize long-term results.

Early and late results of surgical treatment for isolated active native mitral valve infective endocarditis

OBJECTIVES

Native mitral valve infective endocarditis (IE) is a complicated disease with high mortality and morbidity rates. Mitral valve repair (MVRep) is feasible when limited valve destruction is present. However, recurrent valve dysfunction and reintervention are common.

METHODS

Between January 2000 and March 2016, 83 patients underwent surgery for isolated active native mitral valve IE. We applied an early surgery, MVRep-oriented approach with progressive utilization of patch techniques to secure a durable repair; MVRep was attempted in 67% of patients. Fifty-one (61%) patients underwent MVRep (including full-ring annuloplasty in 94%) and 32 (39%) patients underwent mitral valve replacement.

RESULTS

Early mortality was 13%. No cases of early recurrent IE occurred. Predischarge echocardiography demonstrated good MVRep function in all, except 1 patient with residual (Grade 2+) regurgitation. The mean duration of follow-up was 3.7 years (interquartile range 1.5-8.4). For hospital survivors, 8-year overall survival rates were 92.4% (95% confidence interval 84.0-100%) and 74.2% (95% confidence interval 53.8-94.6%) for the MVRep and mitral valve replacement groups, respectively. Propensity score-adjusted Cox regression analysis revealed no significant difference in survival between the 2 groups (hazard ratio 0.359, 95% confidence interval 0.107-1.200; P = 0.096). Four reinterventions occurred, 2 in each group. Echocardiographic follow-up demonstrated excellent MVRep durability; no cases of mitral regurgitation and 1 case of mitral valve stenosis were seen.

CONCLUSIONS

Native mitral valve IE is linked to high mortality and morbidity rates. A durable MVRep is feasible in most patients and provides excellent mid-term durability. Mitral valve replacement is a reasonable alternative when a durable repair is not likely.

Role of mitral valve repair in active infective endocarditis: long term results

BACKGROUND

Although mitral valve repair is at present the technique of choice in mitral regurgitation (MR) due to degenerative valve disease, long term results in patients with active mitral infective endocarditis (IE) are still under evaluation.

METHODS

In the study were included 34 consecutive patients (22 males; mean age, 60 years; range 32-84 years) referred to our institution between January 1, 2005 to December 31, 2011 who were treated with valve repair for mitral valve (MV) active infective endocarditis. Eighteen patients underwent isolated MV repair. Aortic valve replacement and respectively repair were performed in 9 and 2 patients with concomitant aortic involvement. Blood cultures were positive in 30 (17 Staphylococcus, 13 Streptococcus, 1 g negative, 2 enterococcus).

RESULTS

Four patients died during hospital stay (11%) due to multi system organ failure as a consequence of severe septic shock (2 patients), cardiogenic shock (1 case) and respiratory failure (1 patient). At an average follow up of 48 months in patients discharged alive from hospital survival was 96.7% (29 out of 30). None developed more than mild- to moderate mitral valve regurgitation during follow-up and we found a significant improvement in functional capacity and left ventricular ejection fraction associated with a significant decrease of pulmonary artery pressure. The only recurrence of endocarditis occurred in a drug addict patient.

CONCLUSIONS

Present investigation suggest that in patients with active mitral valve endocarditis MV repair, when technically feasible, is associated with a favorable clinical long term outcome. None of the patients alive at the end of follow-up developed severe mitral regurgitation. Moreover mortality and reinfection rate are uncommon and functional improvement.