Long-term results of suture annuloplasty for degenerative mitral valve disease: a propensity-matched analysis.

AIMS: Ring annuloplasty is the gold standard of surgical repair in degenerative mitral valve disease. However, prosthetic annuloplasty has some drawbacks and potential hazards. Suture annuloplasty theoretically is able to preserve annular leaflet dynamics and left ventricular performance, but experience is limited. The aim of the study was to review the early and long-term outcome of the posterior double-suture annuloplasty (DSA) technique for degenerative mitral valve repair. METHODS: From January 2002 to December 2008, 400 patients underwent primary mitral valve repair for degenerative disease either with posterior DSA [n = 147 (37%)] or with flexible posterior annuloplasty band [n = 253 (63%)]. Differences in patient characteristics were addressed by propensity-score matching (132 pairs). A composite end-point of mitral valve failure (MVF) was calculated as the incidence of mitral valve regurgitation greater than 2+ or need for mitral valve replacement at follow-up. RESULTS: After propensity-score matching, the distribution of preoperative variables among matched pairs was, on average, equal. Isolated annuloplasty and leaflet repair techniques were similarly performed in both groups (P = 0.20). In-hospital mortality was comparable between the two study groups (P = 0.48). Predischarge echocardiography showed excellent results regarding valve hemodynamics (P = 0.71). At a mean follow-up of 11 ±â€Š3 years, all-cause mortality (P = 0.12), need for mitral valve replacement (P = 0.49), and cardiac re-hospitalization rate (P = 0.57) resulted comparable between the two groups. Ten-year survival (75 vs. 71%, P = 0.51) and freedom from MVF (92 vs. 84%, P = 0.39) were similar between posterior annuloplasty band and DSA groups. CONCLUSION: Suture annuloplasty demonstrated comparable results with posterior flexible band repair and could be a viable option for mitral valve surgery in selected patients, such as in the minimally invasive approach, in endocarditis, and in developing countries.

Aortic valve decalcification for severe aortic valve stenosis in the elderly: medium-term results.

AIMS: To present the results of a novel technique of aortic valve decalcification (AVD) in a consecutive population of elderly patients with severe aortic valve stenosis (AVS) and small aortic annulus. METHODS: Between January 2008 and December 2012, a consecutive series of 34 patients (mean age 80 ±â€Š13 years) with severe AVS were operated on using AVD. They were compared with a matched population of 68 patients (mean age 82 ±â€Š7 years) submitted to aortic valve replacement (AVR) with bioprosthesis. The two groups were comparable for cardiac risk factors and admission symptoms. Preoperatively, all patients presented with severe AVS, small aortic annulus (19 mm) and preserved left ventricular function. RESULTS: Thirty-day mortality was 8.8 vs. 7.5% in the AVD and AVR groups, respectively (P = 0.88). Actuarial 2 and 5-year survival rates were 80 vs. 82% and 64 vs. 78% in the AVD and AVR groups, respectively (P = 0.27). Long-term valve-related events incidence was significantly higher in the AVD group (12%) compared with that in the AVR group (4%; P = 0.01). However, in the AVD group, patients with no or mild residual AR experienced 2 and 5 years of freedom from valve-related events, which is not significantly different from the patients submitted to the AVR group (P = 0.76). After AVD, a significant increase in the aortic valve area (from 0.8 to 1.9 cm) and a parallel reduction in the mean gradient (from 40 to 12 mmHg) was observed in all patients (P = 0.01). Postoperative aortic valve area (1.9 vs. 1.26 cm), as well as mean gradient (12 vs. 21 mmHg), were significantly better in the AVD group compared with that in the AVR group (P = 0.01). CONCLUSION: In this preliminary experience, AVD seems a good therapeutic option for elderly patients with severe AVS. Further studies with longer follow-up are needed in order to confirm these preliminary results and to ascertain the valve durability over time.

Longitudinal Strain by Automated Function Imaging Detects Single-Vessel Coronary Artery Disease in Patients Undergoing Dipyridamole Stress Echocardiography.

BACKGROUND: The aim of this study was to investigate the incremental value of global longitudinal strain (GLS) by automated function imaging in respect to wall motion (WM) for the detection of coronary artery disease (CAD) during dipyridamole stress echocardiography. METHODS: Fifty-two patients (mean age, 65.3 ± 8.7 years; 22 men) underwent dipyridamole stress echocardiography followed by coronary angiography within 1 week. Diagnostic accuracy for the identification of single-vessel CAD was evaluated for WM and GLS. The study population was divided into two groups according to coronary angiographic findings: those with CAD (n = 38; mean age, 67.2 ± 5.9 years; 19 men) and those without CAD (n = 14; mean age, 63.3 ± 6.4 years; three men). RESULTS: A trend toward lower resting GLS values was found in patients with CAD than in those without (-18.7 ± 2.2% vs -20 ± 2.8%, P = .061). In patients without CAD, GLS progressively increased up to peak dose (from -20 ± 2.8% at rest to -20.7 ± 1.9% at low dose, P = .045; from -20.7 ± 1.9% at low dose to -21.5 ± 3.1% at peak dose, P = .032), whereas in patients with CAD, an increase of GLS from rest to low dose (from -18.7 ± 2.2% to -19.2 ± 3.9%, P = .046) followed by a decrease from low to peak dose (from -19.2 ± 3.9% to -17.5 ± 2.4%, P = .007) was observed. In addition, with regard to diagnostic accuracy in detecting CAD, WM yielded sensitivity of 44%, specificity of 55%, positive predictive value of 73%, and negative predictive value of 26%, whereas GLS, alternatively evaluated as the difference between peak dose and resting values or between peak and low-dose values, provided sensitivity of 61%, specificity of 90%, positive predictive value of 94%, and negative predictive value of 47% (respectively, P = .020, P = .001, P = .023, and P = .031, all vs WM) and sensitivity of 84%, specificity of 92%, positive predictive value of 96%, and negative predictive value of 68% (respectively, P < .001, P < .001, P = .001, P < .001, all vs WM). CONCLUSIONS: GLS analysis, particularly performed by comparing peak-dose with low-dose values, improves the accuracy of dipyridamole stress echocardiography in the detection of single-vessel CAD compared with the sole assessment of WM changes.

In patients with post-infarction left ventricular dysfunction, how does impaired basal rotation affect chronic ischemic mitral regurgitation?

BACKGROUND: The aim of this study was to explore the contribution of left ventricular (LV) basal rotation to the mechanism of chronic ischemic mitral regurgitation (MR). METHODS: Fifty-seven patients (52 men; mean age, 68.3 ± 11.8 years) with postinfarction LV dysfunction (defined as an ejection fraction ≤ 45%) were prospectively enrolled. Each invariably had functional MR. To assess MR degree, the effective regurgitant orifice area (EROA) was quantified by echocardiography using the proximal isovelocity surface area method. Furthermore, mitral valve deformation (valve tenting and annular function) and LV global (systolic and diastolic volumes, function, and sphericity) and local remodeling (displacement of papillary muscles, regional strain, and rotation by speckle-tracking) were assessed. The patients were subsequently subdivided into two groups according to the absence (group A) or presence (group B) on transthoracic echocardiography of infarct area in the inferior and/or posterior basal segments. RESULTS: A larger EROA was found in group B than in group A (P = .034) and in subjects with asymmetric rather than symmetric tethering in either group (P = .036 and P = .040 for groups A and B, respectively). Basal radial (P = .009), circumferential (P = .042), and longitudinal (P = .005) strain and rotation (P = .021) were lower in group B than in group A. There was also a significant inverse correlation between EROA and basal rotation in group B (r = -0.75, P < .001). Furthermore, using multivariate linear regression analysis, we found that the independent determinants of EROA were end-diastolic volume (P < .001) and tenting area (P = .004) in group A and asymmetric tethering (P = .029) and basal rotation (P < .001) in group B. CONCLUSIONS: Impaired basal rotational mechanics occurring after an inferior-posterior myocardial infarction is associated with increased MR.