Long-term follow-up of posterior mitral leaflet extension for Type IIIb ischemic mitral regurgitation

Objective

Ischemic mitral regurgitation (MR) is generally associated with very poor outcomes and disappointing results, despite a seemingly perfect initial repair and optimal revascularization. We previously published our intermediate-term results of posterior leaflet augmentation without follow-up extending beyond 4 years. Our objective is to assess long-term durability of the repair, survival, and the causes of late mortality.

Methods

Ninety-one patients with severe (4+) Carpentier Type IIIb ischemic MR underwent repair in a single center between 2003 and 2022 by method of posterior leaflet extension using a patch of bovine pericardium and a true-sized remodeling annuloplasty ring, with or without surgical revascularization. Serial echocardiography was performed over the years to ascertain valve competence and degree of ventricular remodeling, in addition to telephone follow-up and chart reviews.

Results

The average age of patients was 67 ± 9.6 years. Mean follow-up was 8 ± 5 years with some extending to almost 20 years. One-, 5-, and 10-year freedom from recurrent significant MR, characterized as moderate or severe MR, was 98.6%, 85.5%, and 71.3%, respectively. Thirty-day mortality was 6.5%. One-, 5-, and 10-year survival was 85.5%, 64.4%, and 43.3%, respectively. Of all the mortalities, only 17.5% were proven to be directly cardiac related.

Conclusions

The suggested repair technique offers satisfactory long-term outcomes with minimal residual regurgitation in surviving patients when used in context of ischemic MR. Despite durable repair, we have discovered that poor long-term survival is not directly related to cardiovascular causes.

Mitral valve repair with patch augmentation for atrial functional mitral regurgitation complicated with giant left atrium

OBJECTIVE

We aimed to assess the results of posterior leaflet augmentation with an autologous pericardial patch in atrial functional mitral regurgitation.

METHODS

Data of 16 patients with atrial functional mitral regurgitation who underwent posterior leaflet patch augmentation for mitral valve repair were retrospectively analyzed. This procedure was applied to a short posterior leaflet with a height of < 10 mm in P2. The median age was 72.5 [67.8-78.3] years. Preoperative New York Heart Association functional class was II in 7 (43.8%) and III or IV in 9 (56.2%) patients. Mitral regurgitation was moderate in 2 (12.5%) and severe in 14 (87.5%) patients.

RESULTS

Operative mortality occurred in 1 (6.2%) patient due to cerebral infarction. One patient required valve replacement because of patch perforation early after operation. Mitral regurgitation was reduced to less than mild in 15 (93.8%) patients and less than trivial in 11 (68.8%) patients (P < 0.01) postoperatively. As for mid-term results, New York Heart Association functional class improved to I or II in 12 (75%) patients (P < 0.01). Two cases of thrombotic complication were observed. Remote recurrent regurgitation occurred in one case due to small patch size. The 3-year free rate of valve-related morbidity and regurgitation recurrence was 65.6% and 87.1%, respectively. The 5-year survival rate was 93.8%.

CONCLUSIONS

Pericardial patch augmentation in atrial functional mitral regurgitation leads to good survival and mitral regurgitation recurrence-free rates. Steady anticoagulation and the use of larger patches would be necessary to reduce thrombotic complications and recurrent MR.

Patch augmentation vs. valve replacement for patients with atrial functional mitral regurgitation and long-standing atrial fibrillation

BACKGROUND

Long-standing atrial fibrillation is associated with atrial functional mitral regurgitation (AFMR) with atriogenic tethering. We compared the outcomes of patch augmentation (PA) and valve replacement (VR) for AFMR.

METHODS

We retrospectively compared the data of 16 patients who underwent PA for AFMR with the data of 15 patients who underwent VR between 2008 and 2021. Patients with a left ventricular ejection fraction (LVEF) of <50% were excluded. We also performed atrial plication and left appendage closure if the patients had no weak atrial wall that led to severe bleeding.

RESULTS

The median age was 72.5 and 76.0 years in the PA and VR groups, respectively. The PA group had a longer cardiopulmonary bypass time (206 vs. 172 min, P=0.012). Although there were no differences in hospital morbidity and mortality between the PA and VR groups, one patient underwent reoperation for patch perforation in the PA group. The overall 3-year survival rate was 93.8% and 100% in the PA and VR groups, respectively (P=0.878). The 3-year rate of freedom from major adverse cardiac events was 75.0% and 53.6% in the PA and VR groups, respectively (P=0.181). Three and six patients were readmitted for congestive heart failure in the PA and VR groups, respectively. Two patients in the PA group developed severe recurrent regurgitation, including one patient who required reoperation. No patients in the VR group required reoperation. The postoperative left atrial volume index (LAVI) was associated with thromboembolic events (P=0.016).

CONCLUSIONS

PA may achieve comparable outcomes to those of VR for AFMR. Operative procedures should be chosen based on each patient's background. Atrial reduction could be considered to prevent thromboembolic events.

Early and late results of mitral valve repair with anterior leaflet patch augmentation

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.

Clinical Outcomes Following Durable Mitral Valve Repair for Ischemic Mitral Regurgitation

BACKGROUND

This study aimed to clarify the incidence and determinants of postoperative adverse events in patients with ischemic cardiomyopathy who achieved long-term durable mitral valve repair.

METHODS

Between 1999 and 2015, 166 patients with chronic ischemic mitral regurgitation (MR) and left ventricular (LV) ejection fraction ≤40% underwent restrictive mitral annuloplasty. During follow-up (65±34 months), echocardiographic assessments were performed 809 times (mean, 4.9±2.4 times) and 20 patients who had developed postoperative recurrent MR (≥moderate) were excluded. Finally, 146 patients (68±9 years) whose MR was well controlled over time were included.

RESULTS

A total of 61 mortalities and/or 27 readmissions for heart failure were observed in 76 patients (52%). Among hospital survivors, age (adjusted hazard ratio: 1.05; P=0.001), and estimated glomerular filtration rate (adjusted hazard ratio: 0.61; P=0.001) were identified as independent predictors of long-term mortality and/or readmission for heart failure. The degree of LV function recovery after surgery was comparable between patients with and without adverse events. However, the former group showed greater values for systolic pulmonary artery pressure, tricuspid regurgitation severity, inferior vena cava dimension, and plasma brain natriuretic peptide level throughout the follow-up period (group effect p<0.05 for all).

CONCLUSIONS

Approximately 50% of patients died or were hospitalized for heart failure even in the absence of recurrent mitral regurgitation during the 5-year follow-up, indicating that durable mitral repair does not always lead to favorable clinical outcomes. The adverse events might be related to volume overload secondary to impaired renal function and less favorable pulmonary hemodynamics.

Double leaflet technique for mitral regurgitation with the small or tethered posterior leaflet

Small leaflets make mitral valve repair procedures challenging. Our double leaflet technique creates a new autologous pericardial leaflet attached to the papillary muscle, annuloplasty ring and neighboring scallops above the small or tethered posterior leaflet. This simple additional technique provides deep coaptation after mitral valve repair for both degenerative and functional mitral regurgitation with the small or tethered posterior leaflet.

Initial Clinical Experience With Mitral Valve Translocation for Secondary Mitral Regurgitation

BACKGROUND

Functional (secondary) mitral regurgitation (FMR) results from altered geometry of the mitral valve apparatus. Repair with restrictive mitral annuloplasty is associated with high rates of recurrent mitral regurgitation (MR). We developed a novel operative repair for FMR that translocates the intact mitral valve towards the apex.

METHODS

The mitral valve was detached circumferentially and translocated into the ventricle with a frustum-shaped glutaraldehyde-treated autologous pericardial patch. Clinical and echocardiographic follow-up was performed.

RESULTS

Fifteen consecutive patients with FMR (mean age, 59 years; 67% female) had mitral valve translocation between 2018 and 2020. Preoperative mean ejection fraction, left ventricular end-diastolic dimension, and systolic pulmonary artery pressure were 40% ± 11%, 59 ± 8 mm, and 49 ± 21 mm Hg, respectively; 33% had atrial fibrillation. Cardiomyopathy was ischemic in 4 and nonischemic in 11. Concomitant procedures included tricuspid valve operation (n = 8), coronary artery bypass grafting (n = 4), and atrial fibrillation ablation (n = 5). Post bypass transesophageal echocardiogram demonstrated none/trace MR in all patients and mean gradient of 3 mm Hg (interquartile range, 2-4 mm Hg). Mean leaflet extent of coaptation was 14 ± 2 mm (range, 11-17 mm). There was no postoperative mortality, stroke, or renal failure. Predismissal echocardiography showed none/trace MR in 14 patients and mild MR in 1. One patient underwent successful late rerepair of a suture line leak. Twelve patients were alive at latest follow-up and MR at 1 and 6 months was mild or less in all patients with mean leaflet extent of coaptation of 14 ± 2 mm (range, 12-16 mm) at 6 months.

CONCLUSIONS

Mitral valve translocation creates a large surface of coaptation and effectively corrects FMR. Further study is needed to demonstrate the long-term durability and clinical utility of this operation.

An observational, prospective study on surgical treatment of secondary mitral regurgitation: The SMR study. Rationale, purposes, and protocol

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.