Mitral valve repair for endocarditis.

Many authors have reported their results of mitral valve (MV) repair (MVr) in acute and healed endocarditis. However, the results published by different authors highlight the fact that the reparability rate for this indication remains low. Over the last three decades, our group has adopted an early and repair-oriented approach to infective endocarditis with the objective to improve the repair rate and the long-term results.‬ ‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬ In this paper, we describe our institutional experience on mitral valve repair for infective endocarditis.‬‬‬‬‬‬‬‬‬‬‬‬ Data for this paper were extracted from our institutional database on heart valve disease. From 1991 to 2015, 160 consecutive patients in our institution underwent MV surgery for active IE on native MV. The median follow-up was 122 months. This study was approved by the institutional ethics review board, and written informed consent was waived for this study given its retrospective design. Hospital mortality was 11.6% (n = 18). Early MV reoperation before hospital discharge was required in five (3.1%) patients. At 5, 10, and 15 years, overall survival in the MVr for endocarditis in the group was 79% ± 4%, 65% ± 5%, 57% ± 6%, respectively. Freedom from reoperation at 5, 10, and 15 years was 95% ± 2%, 88% ± 4%, and 81% ± 6%, respectively. Mitral infective endocarditis is an insidious pathology and his surgical approach can be challenging. An early and repair-oriented surgical approach can allow to improve reparability rates with good long-term durability and a low recurrence rate of endocarditis.

Congenital unicuspid aortic valve repair without cusp patch augmentation.

Unicuspid aortic valves are rare congenital malformations. Surgical repair is feasible in aortic regurgitation, and in some cases of aortic stenosis. The standard surgical approach is a bicuspidization and symmetrization with pericardial patch augmentation of valve leaflets. Herein, we are describing our original technique for bicuspidization of a unicuspid aortic valve in adults without leaflet patch augmentation. We also address the surgical management of a commissural diastasis.

Aortic annulus elevation for aortic valve and root replacement.

Aortic valve and root replacements require an in-depth understanding of the aortic root and annulus. Both structures can be asymmetric at times, and this needs to be recognized and taken into consideration when performing valve-sparing operations or other root-replacement procedures. Moreover, the geometry of the aortic annulus can be altered, and when performing an aortic root replacement this can distort the geometry of a neoaortic valve for instance, and lead to valve dysfunction, which is difficult to reverse. We are describing an altered aortic annulus, which required modification through annulus elevation before proceeding with aortic root replacement with a graft-reinforced pulmonary-autograft.

Robotic mitral valve repair: A single center experience over a 7-year period.

BACKGROUND: We report the clinical and echocardiographic results of our experience in robotic mitral valve repair over a 7-year period. The outcomes of the earliest and the latest patients will be compared. METHODS: Between March 2012 and October 2019, 226 patients underwent robotic mitral valve repair for severe mitral regurgitation in a single institution. The first 113 patients (Group 1) were operated between March 2012 and September 2015 and the last 113 patients (Group 2) between October 2015 and October 2019. Conventional techniques employed in open surgery were used. Clinical and echographic follow-up were 96.0% and 94.2% complete, respectively. RESULTS: Successful mitral repair was achieved in all cases with no hospital mortality. The overall survival rate was 92.7 ± 2.8% and 91.0 ± 3.2% at 3 and 7 years, respectively, with no in between groups difference (p = 0.513). The overall freedom from mitral reoperation was 97.4 ± 1.2% at 3 and 7 years and was similar in both groups (p = 0.276). Freedom from mitral regurgitation Grade 2+ at 3 and 7 years were 89.1 ± 2.6% and 87.9 ± 2.8%, respectively, with no significant difference between groups (p = 0.056). CONCLUSIONS: Developing a robotic mitral repair program can be done without compromising the safety and efficacy of repair. After a well-conducted training, robotic approach allows to perform simple and complex mitral repair using similar techniques as in conventional approach and without additional risk for the patient.

Mitral Valve Repair is Feasible Following Extensive Decalcification and Reconstruction of the Atrioventricular Groove.

BACKGROUND AND AIM OF THE STUDY: Mitral annular calcification (MAC) represents a significant challenge in mitral valve (MV) surgery. Techniques to decalcify the mitral annulus significantly increase operative complexity and risk. MV repair can be particularly difficult in this setting. Mid-term outcomes following MV surgery with extensive annular decalcification were examined, with attention focused on the feasibility and outcomes of MV repair in this setting. METHODS: Among 1,485 patients undergoing MV surgery between 1999 and 2008 at the authors' institutions, 24 (1.6%) underwent complete posterior MV annular decalcification associated with either MV repair (n = 19) or replacement (n = 5). Extensive decalcification was performed from commissure to commissure in all patients. The annulus was reconstructed with pledgeted compression sutures in 17 patients, and with a bovine pericardial patch in seven. RESULTS: In-hospital mortality was 12.5%. One patient died in the operating room from atrioventricular groove rupture, and two patients died from low cardiac output postoperatively. During a mean follow up of 4.4 ± 2.7 years, eight patients died; five of these deaths were cardiovascular in nature. After five years the actuarial survival was 56 ± 11%, and freedom from cardiac death 63 ± 11%. Four patients underwent' reoperation because of failure of MV repair (n = 2), endocarditis (n = 1) or hemolysis (n = 1). All survivors were in NYHA class ≤ 2, with none to trivial mitral regurgitation in all MV repairs. The five-year freedom from MV reoperation was 82 ± 8%. CONCLUSION: After aggressive decalcification of the posterior MV annulus, both MV repair and replacement were feasible, with acceptable procedure-related mortality. It was clear however, that decalcification increased both complexity and risk. In well-selected patients, an aggressive approach to MV repair might facilitate a high rate of repair with acceptable midterm outcome in this patient population.

Aortic valve repair: indications and outcomes.

Aortic valve replacement has traditionally been the treatment of choice for patients with aortic valve insufficiency with or without aortic root pathology. Aortic valve repair is emerging as an attractive treatment alternative that avoids the long-term risks associated with prosthetic valve implantation including thromboembolism, endocarditis, prosthetic valve deterioration, and anticoagulation related hemorrhage. Important achievements in this discipline have occurred over the past decade including development and refinement of valve preserving aortic root replacement techniques, development of a classification system for aortic insufficiency, surgical approaches to cusp disease with varying cusp anatomy. As surgical techniques for aortic valve repair continue to evolve, clinical outcomes up to and beyond the first decade are promising with excellent survival and low risk of valve related events.

Tricuspid valve repair for infective endocarditis.

OBJECTIVES: The progressive increase in the use of implantable electronic devices, vascular access for dialysis and the increased life expectancy of patients with congenital heart diseases has led in recent years to a considerable number of right-side infective endocarditis, especially of the tricuspid valve (TV). Although current guidelines recommend TV repair for native tricuspid valve endocarditis (TVE), the percentage of valve replacements remains very high in numerous studies. The aim of our study is to analyse our experience in the treatment of TVE with a reparative approach. METHODS: This case series includes all the patients who underwent surgery for acute or healed infective endocarditis on the native TV, at the Cliniques Universitaires Saint-Luc (Bruxelles, Belgium) between February 2001 and December 2020. RESULTS: Thirty-one patients were included in the study. Twenty-eight (90.3%) underwent TV repair and 3 (9.7%) had a TV replacement with a mitral homograft. The repair group was divided into 2 subgroups, according to whether a patch was used during surgery or not. Hospital mortality was 33.3% (n = 1) for the replacement group and 7.1% (n = 2) for repair (P = 0.25). Overall survival at 10 years was 75.6% [95% confidence interval (CI): 52-89%]. Further, freedom from reoperation on the TV at 10 years was 59.3% (95% CI: 7.6-89%) vs 93.7% (95% CI: 63-99%) (P = 0.4) for patch repair and no patch use respectively. Freedom from recurrent endocarditis at 10 years was 87% (95% CI: 51-97%). CONCLUSIONS: Considering that TVE is more common in young patients, a repair-oriented approach should be considered as the first choice. In the case of extremely damaged valves, the use of pericardial patch is a valid option. If repair is not feasible, the use of a mitral homograft is an additional useful solution to reduce the prosthetic material.

Native Aortic Valve Resection Using a Novel Blade-Based Device.

OBJECTIVE: The aim of this study was to validate the use of a new resection device in patient candidates for surgical aortic valve replacement. We evaluated the efficacy of this new circular blade to resect the aortic valve and the efficacy to collect the debris during the resection. METHODS: For this study, a single size instrument was used, with an external diameter of 22 mm, and patients were selected on the basis of the preoperative assessment of the aortic diameters. RESULTS: From October 2018 to June 2019, 10 patient candidates for surgical aortic valve replacement were selected to undergo native aortic valve resection using a new device, before surgical valve implantation. The mean age of the patients was 74 ± 7.6 years, and 8 of 10 were male. The mean aortic annulus diameter, measured before the procedure, was 25.7 ± 1.57 mm. The resection was complete in 9 (90%) patients. In 1 patient, due to an imprecise positioning of the device, the valve resection was partial. None of the patients showed signs or symptoms due to debris embolism. In all patients, the postoperative course was uneventful. CONCLUSIONS: These preliminary results show that resection of the aortic valve using a circular foldable blade is feasible. This prototype, used during conventional surgery even through a small incision, provided an efficient tool to easily resect the valve without debris release.

Aortic root anatomy: insights into annular and root enlargement techniques.

The introduction of the Y(ang)-technique for aortic root enlargement has sparked a renewed interest in annular and root enlargement procedures world-wide. In order to execute these procedures proficiently however, it's important to understand the complex three-dimensional structure of the aortic root and left ventricular outflow tract, and also be familiar with the different enlargement techniques. Herein, we are providing a description of the aortic root anatomy and the most commonly utilized root enlargement procedures. This should facilitate clinical decision making and guidance of patients towards the most appropriate procedure, which should not only treat the patients' acute symptoms, but should also set the patient up for potentially needed future procedures and respective life-time management of aortic valve disease.

[Summary: International consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional and research purposes]. / Resumen: Consenso internacional para la nomenclatura y clasificación de la válvula aórtica bicúspide congénita y su aortopatía, con fines clínicos, quirúrgicos, intervencionistas y de investigación.

This consensus of nomenclature and classification for congenital bicuspid aortic valve and its aortopathy is evidence-based and intended for universal use by physicians (both pediatricians and adults), echocardiographers, advanced cardiovascular imaging specialists, interventional cardiologists, cardiovascular surgeons, pathologists, geneticists, and researchers spanning these areas of clinical and basic research. In addition, as long as new key and reference research is available, this international consensus may be subject to change based on evidence-based data1.

Este consenso de nomenclatura y clasificación para la válvula aórtica bicúspide congénita y su aortopatía está basado en la evidencia y destinado a ser utilizado universalmente por médicos (tanto pediatras como de adultos), médicos ecocardiografistas, especialistas en imágenes avanzadas cardiovasculares, cardiólogos intervencionistas, cirujanos cardiovasculares, patólogos, genetistas e investigadores que abarcan estas áreas de investigación clínica y básica. Siempre y cuando se disponga de nueva investigación clave y de referencia, este consenso internacional puede estar sujeto a cambios de acuerdo con datos basados en la evidencia1.

Reoperative reimplantation procedure after previous remodeling in a patient with Marfan syndrome.

A 43-year-old man with Marfan syndrome presented with recurrent aortic root dilatation and aortic regurgitation at ten years after a remodeling (Yacoub) procedure. Herein is described a reoperative valve-sparing procedure employing the reimplantation technique (David procedure) used in the treatment of this patient.

Tricuspid annular dynamics, not diameter, predicts tricuspid regurgitation after mitral valve surgery: Results from a prospective randomized trial.

Objective: Current guidelines advise using prophylactic tricuspid valve annuloplasty during mitral valve surgery, especially in the presence of annular diameter enlargement. However, several retrospective studies and a prospective randomized study from our department could not confirm that diameter enlargement is predictive of late regurgitation. We examined whether 2- and 3-dimensional echocardiographic and clinical characteristics could identify patients who will develop moderate or severe recurrent tricuspid regurgitation. Methods: Patients with less than severe functional tricuspid regurgitation (FTR) were randomized not to receive tricuspid annuloplasty, and 11 of 53 of them were excluded from the study because 3-dimensional echocardiographic analysis was not possible. Cox regression was used to estimate the model-based probability of moderate or severe FTR (vena contracta ≥3 mm) or progression of TR and FTR regression using valve dimensions (annulus area, diameter perimeter, nonplanar angle, and sphericity index), dynamics (annulus contraction, annulus displacement, and displacement velocity), and clinical parameters as possible predictors. Results: At a median follow-up of 3.8 years (range, 3-5.6 years), 17 patients had moderate or severe FTR or progression, and 13 had FTR regression. Our models identified annular displacement velocity as a significant predictor for FTR recurrence and nonplanar angle as a significant predictor for FTR regression. Conclusions: Annular dynamics, not the dimension, predict recurrence and regression of FTR. Annular contraction should be systematically investigated as a possible surrogate of right ventricle function to prophylactically treat the tricuspid valve.

Functional and pathomorphological anatomy of the aortic valve and root for aortic valve sparing surgery in tricuspid and bicuspid aortic valves.

The aortic valve (AV) is a three-dimensional structure, with leaflets that are suspended within the functional aortic annulus (FAA). These structures (AV and FAA) are therefore intrinsically connected and disease of just one component can independently lead to AV dysfunction. Hence, AV dysfunction can occur in the setting of entirely normal valve leaflets. However, as these structures are functionally inter-connected, disease of one component can lead to abnormalities of the other over time. Thus, AV dysfunction is often multifactorial. Valve-sparing root procedures require an in-depth understanding of these inter-relationships, and herein we are providing a detailed account of some of the most pertinent anatomical relationships.

Three decades of reimplantation of the aortic valve-the Brussels experience.

Background: Over the last three decades, the importance of native valve preservation has increasingly become evident. Valve-sparing root replacement procedures, such as the reimplantation or remodeling technique, are therefore being progressively used for aortic root replacement and/or aortic valve repair. Herein, we are summarizing our single-center experience with the reimplantation technique. Methods: We queried our prospective database for aortic valve repair and recruited all adult (≥18 years) patients who have undergone valve-sparing root replacement with the reimplantation technique between March 1998 and January 2022. We subcategorized the patients into three distinct groups: root aneurysm without aortic regurgitation (AR) (grade ≤1+), root aneurysm with AR (grade >1+) and isolated chronic AR (root <45 mm). Univariable logistic regression analysis was performed to identify variables of interest, which were further analyzed by multivariable Cox-regression analysis. Survival, freedom from valve reintervention, and freedom from recurrent regurgitation, were analyzed with the Kaplan-Meier method. Results: A total of 652 patients were recruited for this study; 213 patients underwent reimplantation for aortic aneurysm without AR, 289 patients for aortic aneurysm with AR, and 150 patients with isolated AR. Cumulative survival was 95.4% (95% CI: 92.9-97.0%) after 5 years, 84.8% (80.0-88.5%) after 10 years, and 79.5% (73.3-84.5%) after 12 years, which was comparable to the age-matched Belgian population. Older age (HR 1.06, P≤0.001) and male gender (HR 2.1, P=0.02) were associated with late mortality. Freedom from reoperation on the aortic valve at 5 years was 96.2% (95% CI: 93.8-97.7%), and 90.4% (95% CI: 87.4-94.2%) at 12 years. Age (P=0.001) and preoperative left ventricular end-diastolic dimension (LVEDD) (P=0.03) were associated with late reoperation. Conclusions: Our long-term data supports our reimplantation approach as a viable option for aortic root aneurysms and/or aortic regurgitation, with long-term survival that mirrors that of the general population.

Valve-sparing operations after Ross procedure: a single-center experience.

Background: The Ross procedure has demonstrated excellent long-term results, with restoration of life-expectancy in patients with severe aortic valve dysfunction. However, reintervention after Ross can occur, and herein we describe our center's experience with redo surgery after previous Ross procedures. Methods: We searched our prospective database for aortic valve-repair and recruited all adult (≥18 years) patients who have undergone valve-sparing root replacements (VSRRs) and/or aortic valve-repair after Ross procedure between July 2001 and July 2022. Univariable logistic regression analysis was performed to identify variables affecting early mortality. Survival, freedom-from-valve-reintervention and freedom-from-aortic regurgitation (AR) grade ≥3 were analyzed with the Kaplan-Meier method. Results: A total of 63 patients were recruited for this study. Indication for reoperation after Ross was aortic aneurysm without AR in 17 (27%), aortic aneurysm with AR in 27 (43%), and isolated AR in 19 (30%) patients. Median follow-up time was 7.82 years. The majority of patients (76%) had undergone the free root technique during their index Ross operation. Cumulative survival, after redo surgery following Ross, was 98.4% [95% confidence interval (CI): 89.3-99.8%] at 1 year, 96.3% (95% CI: 88.2-98.3%) at 5 years, and 92.4% (95% CI: 87.1-98.0%) at 10 years. Freedom-from-reoperation on the aortic valve at 1 year was 98.4% (95% CI: 97.0-99.8%), at 5 years was 96.7% (95% CI: 87.6-99.0%), and 79.7% (95% CI: 71.1-88.3%) at 10 years. Conclusions: Long-term survival after redo surgery following the Ross operation is excellent. The data support our aggressive valve-sparing approach after Ross.

A multicentre, propensity score matched analysis comparing a valve-sparing approach to valve replacement in aortic root aneurysm: Insight from the AVIATOR database.

OBJECTIVES: Our goal was to evaluate the outcome of valve-sparing root replacement (VSRR) and to compare the outcomes to those of patients having composite valve-graft conduit aortic root replacement (CVG-ARR) in a cohort of patients with aortic root aneurysm ± valve insufficiency, without valvular stenosis. Although valve-sparing procedures are preferable in young patients, there is a lack of comparative data in comparable patients. METHODS: The VSRR procedures were performed in 2005 patients, and 218 patients underwent a CVG-ARR procedure. Exclusion criteria included aortic dissection, endocarditis and valvular stenosis. Propensity score matching (3:1 ratio) was applied to compare VSRR (reimplantation 33% and remodelling 67%) and CVG-ARR. RESULTS: We matched 218 patients with CVG-ARR to 654 patients with VSRR (median age, 56.0; median follow-up was 4 years in both groups; interquartile range 1-5 years). Early mortality was 1.1% of those who had VSRR versus 2.3% in those who had CVG-ARR. Survival was 95.4% [95% confidence interval (CI) 94-97%] at 5 years in patients who had VSRR versus 85.4% (95% CI 82-92%) in those who had CVG-ARR; P = 0.002. Freedom from reintervention at 5 years was 96.8% (95% CI 95-98%) with VSRR and 95.4% (95% CI 91-99%) with CVG-ARR (P = 0.98). Additionally, there were more thromboembolic, endocarditis and bleeding events in the patients who had CVG-ARR (P = 0.02). CONCLUSIONS: This multicentre study shows excellent results after valve-sparing root replacement in patients with an ascending aortic aneurysm with or without valve insufficiency. Compared to composite valve-graft aortic root replacement, survival is better and valve-related events are fewer. Consequently, valve-sparing procedures should be considered whenever a durable repair is feasible. We advocate a valve-sparing strategy even in more complex cases when performed in experienced centres.

Aortic valve insufficiency: leaflet reconstruction techniques.

The introduction of effective and durable leaflet repair techniques have enabled repair of the regurgitant aortic valve. Aortic valve repair is favored to avoid the placement of a prosthesis that the patient will likely outgrow. Furthermore, repair has the potential to reduce the incidence of prosthesis-related complications, including endocarditis, thromboembolism, anticoagulant-related hemorrhage, and reoperation. The primary goal of all aortic valve repair is to restore a durable surface of coaptation to the regurgitant valve. The key to successful leaflet repair for aortic insufficiency is a thorough understanding of the mechanism of dysfunction. We have developed a systematic approach to the assessment and repair of aortic insufficiency because of leaflet disease. The combination of leaflet repair and functional aortic annulus annuloplasty can restore the proper geometry of the aortic valve complex and allow for successful repair of aortic insufficiency caused by both restriction and prolapse.