Reoperation after failure of mitral valve repair for degenerative disease: A single surgeon experience.

Background: With an increasing number of patients undergoing mitral valve repair, more patients are presenting for reoperation. This study aimed to evaluate factors influencing mortality and survival of patients undergoing reoperation for mitral valve surgery after previous mitral valve repair under a single surgeon. Methods: We retrospectively collected data from 117 patients who underwent reoperation after previous mitral valve repair between 2010 and 2022. We aimed to identify preoperative, operative, and postoperative factors affecting outcomes. The primary outcome was overall survival, and the secondary outcomes included prolonged hospital stay and in-hospital mortality. The mean follow-up was 9.13 ± 10.36 years (median, 6.50 years). Results: Out of 117 patients, 85 underwent mitral valve replacement (MVR) and 32 underwent mitral valve repair (MVr). The mean age was 64.7 ± 12.7 years (65.5 ± 12.2 years in the MVR group and 62.7 ± 14.0 years in the MVr group), and 66 (56.4%) were men. On a standard multivariate analysis of the overall factors influencing mortality, advanced age was associated with a higher risk of overall mortality (hazard ratio [HR], 1.07; 95% confidence interval [CI], f1.03-1.12; P = .001). The urgency of surgical intervention also played a role, with a higher risk of in-hospital mortality in patients undergoing emergency reoperation (HR, 1.55; 95% CI, 1.60-149.05; P = .02). Furthermore, the presence of mixed lesions, encompassing both mitral regurgitation and stenosis, was strongly linked to increased overall mortality (HR, 17.09; 95% CI, 4.06-71.94; P < .001) and in-hospital mortality (HR, 1.75; 95% CI, 15.83-1925.61; P < .001). Infective endocarditis emerged as a prominent risk factor for overall mortality (HR, 992.08; 95% CI, 85.74-11,479.08; P < .001) and in-hospital mortality (HR, 5.83; 95% CI, 514.81-65,932.99; P < .001). Additionally, chronic obstructive pulmonary disease was associated with a significantly increased risk of overall mortality (HR, 4.3; 95% CI, 1.24-14.97; P = .02). Conclusions: Our single surgeon experience demonstrates that mitral valve reoperation after a previous repair is associated with good outcomes and survival.

Amaze: a randomized controlled trial of adjunct surgery for atrial fibrillation.

OBJECTIVES: Atrial fibrillation (AF) reduces survival and quality of life (QoL). It can be treated at the time of major cardiac surgery using ablation procedures ranging from simple pulmonary vein isolation to a full maze procedure. The aim of this study is to evaluate the impact of adjunct AF surgery as currently performed on sinus rhythm (SR) restoration, survival, QoL and cost-effectiveness. METHODS: In a multicentre, Phase III, pragmatic, double-blinded, parallel-armed randomized controlled trial, 352 cardiac surgery patients with >3 months of documented AF were randomized to surgery with or without adjunct maze or similar AF ablation between 2009 and 2014. Primary outcomes were SR restoration at 1 year and quality-adjusted life years at 2 years. Secondary outcomes included SR at 2 years, overall and stroke-free survival, medication, QoL, cost-effectiveness and safety. RESULTS: More ablation patients were in SR at 1 year [odds ratio (OR) 2.06, 95% confidence interval (CI) 1.20-3.54; P = 0.009]. At 2 years, the OR increased to 3.24 (95% CI 1.76-5.96). Quality-adjusted life years were similar at 2 years (ablation - control -0.025, P = 0.6319). Significantly fewer ablation patients were anticoagulated from 6 months postoperatively. Stroke rates were 5.7% (ablation) and 9.1% (control) (P = 0.3083). There was no significant difference in stroke-free survival [hazard ratio (HR) = 0.99, 95% CI 0.64-1.53; P = 0.949] nor in serious adverse events, operative or overall survival, cardioversion, pacemaker implantation, New York Heart Association, EQ-5D-3L and SF-36. The mean additional ablation cost per patient was £3533 (95% CI £1321-£5746). Cost-effectiveness was not demonstrated at 2 years. CONCLUSIONS: Adjunct AF surgery is safe and increases SR restoration and costs but not survival or QoL up to 2 years. A continued follow-up will provide information on these outcomes in the longer term. Study registration: ISRCTN82731440 (project number 07/01/34).

Atrial function as a guide to timing of intervention in mitral valve prolapse with mitral regurgitation.

OBJECTIVES: The purpose of this study was to determine the clinical utility of left atrial (LA) functional indexes in patients with mitral valve prolapse (MVP) and mitral regurgitation (MR). BACKGROUND: Timing of surgery for MVP remains challenging. We hypothesized that assessment of LA function may provide diagnostic utility in these patients. METHODS: We studied 192 consecutive patients in sinus rhythm with MVP, classified into 3 groups: moderate or less MR (MOD group, n = 54); severe MR without surgical indication (SEV group, n = 52); and severe MR with ≥1 surgical indication (SURG group, n = 86). Comparison was made with 50 control patients. Using 2D speckle imaging, average peak contractile, conduit, and reservoir atrial strain was recorded. Using Simpson's method we recorded maximal left atrial volume (LAVmax) and minimal left atrial volume (LAVmin), from which the total left atrial emptying fraction (TLAEF) was derived: (LAVmax-LAVmin)/LAVmax × 100%. RESULTS: TLAEF was similar in the MOD and control groups (61% vs. 57%; p = NS), was reduced in the SEV group (55%; p < 0.001 vs. control group), and markedly lower in the SURG group (40%; p < 0.001 vs. other groups). Reservoir strain demonstrated a similar pattern. Contractile strain was similarly reduced in the MOD and SEV groups (MOD 15%; SEV 14%; p = NS; both p < 0.05 vs. control group 20%) and further reduced in the SURG group (8%; p < 0.001 vs. other groups). By multivariate analysis, TLAEF (odds ratio [OR]: 0.78; p < 0.001), reservoir strain (OR: 0.91; p = 0.028), and contractile strain (OR: 0.86; p = 0.021) were independent predictors of severe MR requiring surgery. Using receiver-operating characteristic analysis, TLAEF <50% demonstrated 91% sensitivity and 92% specificity for predicting MVP with surgical indication (area under the curve: 0.96; p < 0.001). CONCLUSIONS: We report the changes in left atrial function in humans with MVP and the relationship of LA dysfunction to clinical indications for mitral valve surgery. We propose that the findings support the utility of quantitative assessment of atrial function by echocardiography as an additional tool to guide the optimum timing of surgery for MVP.

Mechanisms of atrial mitral regurgitation: insights using 3D transoesophageal echo.

AIMS: Functional mitral regurgitation (FMR) is a consequence of mitral annular enlargement, leaflet tethering and reduced co-aptation. The importance of the left atrium (LA) as a cause of mitral regurgitation (MR) is less clear. We applied a co-aptation index using three-dimensional (3D) transoesophageal echocardiography to FMR and MR secondary to LA dilatation (atrial mitral regurgitation, AMR). METHODS AND RESULTS: Seventy-two patients underwent comprehensive 3D echo studies: FMR (n = 19); AMR (n = 33); and 20 controls. We recorded: LV size and function; LA dimensions; mitral annular area (MVA); and leaflet area in early and late systole. MVA fractional change was defined: (MVA late systole - MVA early systole)/MVA late systole × 100%; the co-aptation index was defined: (leaflet area early systole - leaflet area late systole)/leaflet area early systole × 100%. Despite normal LV size and function in AMR, MVA was increased similarly to FMR (AMR 12.86 cm(2) vs. FMR 12.33 cm(2), P = ns; both P < 0.01 vs. controls 8.83 cm(2)), and MVA fractional change similarly reduced (AMR 5.1% vs. FMR 6.3%; P = ns; both P < 0.001 vs. controls 14.6%). The co-aptation index was reduced in both MR groups (FMR 6.6% vs. AMR 7.0%, P = ns; both P < 0.001 vs. controls 19.6%). After multivariate analysis, the co-aptation index (χ(2) = 41.2) and MVA fractional change (χ(2) = 22.1) remained the strongest predictors of MR (both P < 0.001 for the model). A co-aptation index of ≤13% was 96% sensitive and 90% specific for the presence of MR. CONCLUSION: LA dilatation leads to MVA enlargement, reduced leaflet co-aptation and MR even without LV dilatation. A co-aptation index describes this in vivo. This work provides insights into the mechanism of AMR.

The prevalence and impact of deep clefts in the mitral leaflets in mitral valve prolapse.

AIMS: Deep clefts are a cause of early failure of mitral valve repair, but it is not known whether clefts represent normal morphology, or whether they occur more frequently in mitral valve prolapse (MVP). METHODS AND RESULTS: Deep clefts were defined as indentations extending ≥ 50% of the depth of the mitral valve leaflet. Using trans-oesophageal echo (TOE), 3D zoom images were acquired of the mitral valve in 176 patients: 76 patients with MVP, 43 patients with alternative causes of mitral regurgitation (MR), and 57 controls. Three-dimensional TOE results were corroborated with findings made at surgery for a subset of patients who subsequently underwent mitral valve surgery. An assessment of the proportion of the valve that was prolapsing was documented, and correlated to the number of clefts. The relationship of clefts to the region of prolapse or flail was recorded. Three-dimensional TOE was 93% sensitive and 92% specific for detecting clefts. Clefts were documented in 84% of patients with MVP, but significantly less frequently in patients with alternative MR (16%; P < 0.001) and controls (12%, P < 0.001). Clefts always appear in prolapsing regions or framing them, and the number of clefts increased in patients with more extensive prolapse. CONCLUSION: Clefts are frequently seen in MVP, but are uncommon in patients without this diagnosis. They occur in greater numbers as a larger proportion of the valve prolapses. They may play an important role in the development of MVP.

Stage migration: results of lymph node dissection in the era of modern imaging and invasive staging for lung cancer.

OBJECTIVES: Lung cancer staging has improved in recent years. Assuming that contemporary detailed preoperative staging may yield a lower rate of stage change after surgery, we were interested to determine the impact of our lymph node dissections performed at the time of surgical resection. METHODS: We retrospectively analysed a database in our surgical unit that prospectively captured information on all patients assessed and treated for lung cancer. We reviewed the data on patients who underwent lung cancer surgery with curative intent between January 2006 and August 2010 so as to reflect contemporary practice. Prior to potentially curative treatment, patients systematically underwent staging computerized tomography (CT), integrated positron emission tomography (PET) with CT and brain imaging. Enlarged and/or PET-positive nodes were subject to invasive evaluation to establish the nodal status in line with the current guidelines. This was performed by needle aspiration or biopsy usually with ultrasound guidance, endobronchial or endo-oesophageal ultrasound with needle biopsy; mediastinoscopy; mediastinotomy; video-assisted or open surgery. RESULTS: Three hundred and twelve lung cancer resections were performed (a mean age of 68 years [range 42-86] and a male-to-female ratio of 1.14:1). Despite thorough preoperative evaluations, 25.3% of patients had a change in nodal status after lung resection and lymph node dissection; of which 20.8% of patients had a nodal status upstaging. Occult N2 disease was identified in 31 (9.9%) of 312 patients. Patients with cT1 tumours showed a nodal upstaging of 12.3% compared with 25.3% in cT2 tumours. There was no difference in the rate of N2 disease for different tumour histological types. CONCLUSIONS: Despite systematic preoperative staging, there continues to be a high rate of nodal status change following surgical resection and lymph node dissection. If considering non-surgical treatments for the early stage lung cancer, the impact of this discrepancy should be considered. If not, errors in prognosis and in determining correct adjuvant treatment may arise.

Role of concomitant tricuspid surgery in moderate functional tricuspid regurgitation in patients undergoing left heart valve surgery.

Functional tricuspid regurgitation (FTR) is frequently present in patients undergoing aortic, and particularly mitral valve, surgery. Untreated FTR may lead to right heart failure. Reoperative cardiac surgery for late FTR is associated with high morbidity and mortality. Therefore, severe FTR has emerged as a Class I indication for concomitant tricuspid valve surgery in patients undergoing left valve surgery. Concomitant tricuspid valve surgery during left heart valve surgery to address moderate and mild FTR is controversial. This review addresses this issue and proposes an algorithm for the treatment of FTR in patients undergoing left heart valve surgery.

Clinical demonstration of efficiency and reversibility of hypoxic pulmonary vasoconstriction in a patient presenting with unilateral incomplete bronchial occlusion.

Although hypoxic pulmonary vasoconstriction is a well-recognized physiological phenomenon it is unusual to observe and assess its efficiency in clinical practice. Here, we report the case of a 50-year-old female who presented with unilateral incomplete bronchial occlusion due to a carcinoid tumor involving the left main bronchus in the absence of atelectasis. Ventilation-perfusion imaging revealed absent ventilation and perfusion to the left lung. She underwent bronchotomy and removal of the tumor. One month after the operation a further ventilation-perfusion lung scan revealed complete restoration of ventilation to the left lung and almost complete recovery of the perfusion. This unusual case demonstrates the marked efficiency of hypoxic pulmonary vasoconstriction at the level of a single lung and its reversible nature following relief of regional hypoxia.

Intermediate outcome and dynamic computerised tomography after chest wall reconstruction with the STRATOS titanium rib bridge system: video demonstration of preserved bucket-handle rib motion.

We report the intermediate clinical outcome following resection of a chest wall sarcoma and layered reconstruction with a deep expanded polytetrafluroethylene patch, four STRATOS titanium rib bridges and an overlying muscle flap. After 21 months there is no evidence of recurrence. The reconstruction remains intact despite trauma sufficient to fracture the ipsilateral scapula and elbow. Exercise capacity, pain control and quality of life are good. We developed a functional computed tomography (CT) algorithm which allowed dynamic imaging. Video images for the first time demonstrate preserved physiological type bucket-handle movement of the ribs in continuity with the rib bridges.

Transannular pulmonary enlargement and bioprostheses for carcinoid disease.

A diminutive pulmonary artery and right ventricular outflow tract in a 46-year-old woman with a 10-year history of carcinoid syndrome required transannular pulmonary patch enlargement to allow replacement of the pulmonary and tricuspid valves with bioprostheses. The avoidance of anticoagulation permitted further hepatic arterial embolization without an increased risk of bleeding.

A novel titanium rib bridge system for chest wall reconstruction.

Chest wall resection for liposarcoma was performed. To reconstruct the chest wall we used a novel titanium rib bridge system and preserved anatomically equivalent layers.

Transthoracic real-time three-dimensional echocardiography offers additional value in the assessment of mitral valve morphology and area following mitral valve repair.

AIMS: The accurate postoperative assessment of mitral valve repair is important not only to document operative outcome, but also to confirm the functional morphology of the repaired valve. METHODS AND RESULTS: We assessed 25 consecutive patients following mitral valve repair with transthoracic real-time 3-dimensional echocardiography (RT3DE) and 2-dimensional echocardiography (2DE). We compared the adequacy of the visualization of the mitral valve Carpentier segments, the site of the repair, and the accuracy of planimetry by RT3DE and 2DE in estimating the postoperative mitral valve area (MVA), compared to the Doppler-derived pressure half-time (PHT) value. Inter-observer variability and feasibility were also assessed for RT3DE. Adequate visualization of the mitral valve segments was more frequently obtained by 3DE imaging (163/170 by 3DE vs. 121/170 by 2DE, P < 0.001). In particular, the mitral valve commissures were more clearly identified with 3DE. 3DE also was significantly better at correctly identifying the site of the repaired segment (26/30 by 3DE vs. 19/30 by 2DE, P < 0.05). The difference in MVA (mean difference +/- SD) determined by 3DE planimetry, when compared to PHT was -0.21 +/- 0.46 cm(2) and -0.44 +/- 0.95 cm(2) for 2DE (P = 0.014). Planimetry by 3DE more closely correlated with the MVA calculated by PHT than 2DE planimetry (r = 0.89 for 3DE vs. r = 0.6 for 2DE). Imaging with RT3DE was both feasible, with a mean acquisition time of 4.02 +/- 1.68 min, and data analysis time of 15.82 +/- 3.9 min, and reproducible, with good inter-observer variability for segment scoring with 3DE (kappa = 0.79) and mean inter-observer difference in assessing MVA by 3DE planimetry of 0.18 +/- 0.12 cm(2) (P = NS). CONCLUSION: This study suggests that RT3DE offers additional morphological postoperative data of repaired mitral valves, and increases the accuracy of MVA estimation by planimetry. It is both feasible in a busy echocardiography department and reproducible.

Predicting survival in potentially curable lung cancer patients.

Lung cancer is the most common cause of cancer death with unchanged mortality for 50 years. Only localized nonsmall-cell lung cancer (NSCLC) is curable. In these patients it is essential to accurately predict survival to help identify those that will benefit from treatment and those at risk of relapse. Despite needing this clinical information, prospective data are lacking. We therefore prospectively identified prognostic factors in patients with potentially curable lung cancer. Over 2 years, 110 consecutive patients with confirmed localized NSCLC (stages 1-3A) were recruited from a single tertiary center. Prognostic factors investigated included age, gender, body mass index (BMI), performance status, comorbidity, disease stage, quality of life, and respiratory physiology. Patients were followed up for 3-5 years and mortality recorded. The data were analyzed using survival analysis methods. Twenty-eight patients died within 1 year, 15 patients died within 2 years, and 11 patients died within 3 years postsurgery. Kaplan-Meier survival estimates show a survival rate of 51% at 3 years. Factors significantly (p < 0.05) associated with poor overall survival were age at assessment, diabetes, serum albumin, peak VO(2) max, shuttle walk distance, and predicted postoperative transfer factor. In multiple-variable survival models, the strongest predictors of survival overall were diabetes and shuttle walk distance. The results show that potentially curable lung cancer patients should not be discriminated against with respect to weight and smoking history. Careful attention is required when managing patients with diabetes. Respiratory physiologic measurements were of limited value in predicting long-term survival after lung cancer surgery.

Preservation of the mitral valve apparatus: evidence synthesis and critical reappraisal of surgical techniques.

Sub-valvular apparatus preservation after mitral valve replacement is not a new concept, yet to date there has been no quantification of its clinical effectiveness as a procedure and no consensus as to which surgical preservation technique should be adopted to achieve the best immediate and midterm clinical outcomes. This systematic review of current available literature aims to use an evidence synthesis and meta-analytic approach to compare outcomes following replacement of the mitral valve with (MVR-P) or without preservation (MVR-NP) of its apparatus. It considers all the relevant anatomical, experimental, echocardiographic, and clinical studies published in the literature and appraises all reported mitral valve sub-valvular apparatus preservation techniques. The results of this review strongly suggest that MVR-P is superior to MVR-NP with regards to the incidence of early postoperative low-cardiac output requiring inotropic support, and early or mid-term survival. They also suggest that the operative decision should be individualised based on patient's anatomy, pathology and ventricular function and therefore surgeons should be familiar with more than one surgical preservation technique. Finally, this paper highlights the need for further high quality research focusing particularly on the long-term assessment of quality of life and health utility following MVR-P.

Outcome of ligation of the persistently patent arterial duct in neonates as performed by an outreach surgical team.

AIM: Our aim was to review the outcome of ligation of the persistently patent arterial duct in neonates as performed outside a paediatric cardiothoracic centre by an outreach surgical team. METHODS: A retrospective observational study of all ligations of the persistently patent arterial duct performed in Cambridge between January, 1988, and December, 2002. RESULTS: Over the period of 15 years studied, a persistently patent arterial duct was ligated in 43 neonates. The median gestational age at birth was 26 weeks, with a range from 23 to 35 weeks, and median weight at birth was 722 grams, with a range from 500 to 2100 grams. Median age at ligation, was 25 days, with a range from 10 to 89 days, and their weight was 963 grams, with a range from 568 to 2221 grams. Ligation was successful in 42 babies (98%), mortality at 30 days of 5%, and 29 of the babies (67%) surviving to be discharged from the hospital. The late deaths were due to complications of prematurity, rather than the procedure of ligation. CONCLUSION: The persistently patent arterial duct can successfully be ligated by an outreach surgical team outside a paediatric cardiothoracic centre. There was an excellent 30 day survival.