Advent of severe mitral regurgitation in surgical ventricular restoration and ventricular septal rupture repair.

BACKGROUND: Per-procedural severe mitral regurgitation is a rare complication in concomitant surgical ventricular restoration and postinfarction ventricular septal rupture repair. It is challenging to discover the underlying etiology and adopt an appropriate strategy, in particular, in a high-risk patient. CASE PRESENTATION: Semi-emergent surgical ventricular restoration combined with ventricular septal rupture closure and coronary artery bypassing was performed in a 67-year-old male patient. Severe mitral regurgitation was detected after the weaning of cardiopulmonary bypass. Two key questions arose in the management of this condition: did the regurgitation exist previously and was dissimulated by significant left-to-right shunt, or it occurred secondarily to the Dor procedure? Which was the better management strategy, chordal-sparing mitral valve replacement or mitral plasty? We believed that severe mitral regurgitation was under-estimated pre-operatively and we performed an downsizing annuloplasty to treat mitral regurgitation. The outcomes were promising and the patient did well in follow-up. CONCLUSIONS: Our case brought out an open discussion on the etiology and therapeutic strategies of this complicated condition.

Fifteen-Year Outcomes Following Valve-Sparing Aortic Root Replacement in Elderly Patients.

BACKGROUND: Valve-sparing aortic root replacement (VSRR) techniques have several advantages such as preservation of physiological haemodynamics of the native aortic valve and avoidance of prosthetic valve-related complications. However, VSRR procedures are generally performed in young patients and the long-term results in elderly patients (≥65 years) are scarce. METHODS: Fifty-six (56) consecutive patients underwent VSRR surgery by a single surgeon at the current centre between January 2006 and December 2013; a modified "remodelling technique" was typically performed. The mean age was 58.86±12.5 years; Marfan syndrome and bicuspid aortic valve were both present in six patients (10.7%); 38 patients (67.8%) presented with greater than moderate aortic regurgitation; and 17 patients (30.4%) were in New York Heart Association (NYHA) class III before surgery. They were divided into two groups according to their ages receiving VSRR surgery: Group E (elderly patients aged ≥65 years, n=24) and Group Y (young patients aged <65 years, n=32). The primary outcomes were aortic valve-related reoperation, cardiovascular reoperation, all-cause mortality, and functional status. RESULTS: One (1) patient in Group E was converted to aortic valve replacement as a result of a failed aortic valve repair. No perioperative mortality was observed. The mean follow-up was 11.5±2.9 years. Aortic valve-related reoperation was noted in two patients of each group (one with endocarditis, one with severe aortic regurgitation). Cardiovascular reoperations were observed in three and six patients, and all-cause deaths in seven and two patients in Group E and Group Y, respectively. The 10-year freedom from aortic valve-related reoperation was estimated to be 91.7±5.6% and 92.7±5.0% (p=0.594), the 10-year freedom from cardiovascular reoperation was 86.4±7.3% and 81.1±7.7% (p=0.781), and the cumulative 10-year survival rates were 74.0±9.2% and 93.8±4.3% (p=0.018) in Group E and Group Y, respectively. During follow-up, 6.7% of patients were in NYHA class III and 6.4% of patients developed moderate-to-severe aortic regurgitation. Cox regression analysis failed to identify predictors for primary outcomes. CONCLUSION: Valve-sparing aortic root replacement can safely be performed in elderly patients with low early mortality and satisfactory long-term freedom from aortic valve-related and cardiovascular re-intervention.