Ischemic mitral regurgitation: current trends and treatment.

PURPOSE OF REVIEW: Ischemic mitral regurgitation (MR) is a common finding in patients with coronary artery disease. In this review, we summarize the current literature describing the treatment of ischemic mitral regurgitation. RECENT FINDINGS: Recent publications have focused on describing outcomes following the treatment of ischemic mitral regurgitation based on the specific mechanism of regurgitation. New therapies such as remodeling rings and percutaneous approaches, along with insights into mitral valve replacement, have advanced the treatment of ischemic mitral regurgitation. SUMMARY: Mitral valve surgery and concomitant coronary artery bypass grafting represent the most effective strategy for the treatment of severe symptomatic ischemic mitral regurgitation. Overall, the survival of patients with ischemic mitral regurgitation is poor. Advances in mitral valve repair may improve long-term durability of surgery, whereas evolving percutaneous therapies may be a treatment option for patients with functional mitral regurgitation who are not surgical candidates.

Repair of quadricuspid aortic valve associated with ascending aorta dilatation.

Quadricuspid aortic valve is a rare congenital anomaly that may require surgical intervention because of valvular dysfunction. Rarely, it may be associated with enlargement of the ascending aorta. Here, the case is presented of a quadricuspid aortic valve-associated enlargement of the ascending aorta and functional aortic annulus dilatation in a 36-year-old patient. The patient subsequently underwent a successful aortic valve repair and replacement of the ascending aorta.

Left ventricular outflow tract-right atrial fistula following aortic valve replacement.

A 59-year-old male, undergoing outpatient treatment of a sternal wound infection following elective aortic valve replacement surgery, presented with decompensated heart failure. The patient required emergency redo surgery after investigations revealed a left ventricular outflow tract to right atrial fistula due to endocarditis with right ventricular dysfunction. Echocardiography, in particular transesophageal echocardiography, was essential for the diagnosis of this rare event.

Is bilateral internal thoracic artery use safe in the elderly?

BACKGROUND: The strategy of bilateral mammary artery grafting is often not considered for elderly patients due to perceived concerns of increased morbidity and mortality. The objective of this study is to explore the safety of bilateral mammary in elderly patients. METHODS: Out of 7746 patients who underwent coronary artery bypass grafting using at least one internal thoracic artery (ITA), there were 3940 patients aged 65 years or greater, and of those, 3581 patients had a single ITA (SITA) and 359 patients had bilateral ITAs (BITAs). The primary outcome was the incidence of major adverse cardiac or cerebrovascular events (MACCEs). Secondary outcomes included re-exploration for bleeding, blood transfusions, sternal wound infections, and intensive care unit and hospital length of stay. RESULTS: The incidence of mortality and MACCE were similar in both groups (mortality BITA 2.6%, SITA 3.6%, p = 0.25, MACCE BITA 8.5%, SITA 6.1%, p = 0.13). Superficial and deep sternal site infections were significantly more prevalent in the BITA group than the SITA group [superficial OR 0.42, 95% CI [0.23-0.75] (p = 0.003) and deep OR 0.29, 95% CI [0.14-0.58 (p = 0.0005)]. CONCLUSION: Use of BITA is safe in the elderly with respect to mortality and early cardiovascular outcome. BITA use in the elderly is associated with an increased risk of sternal wound infection. Our experience in this situation suggests that there is a maximum age (approximately 74 years) beyond which the combined risk of MACCE and wound complications supersedes the benefits in terms of sternal infections.

Minimally Invasive Coronary Artery Bypass Grafting in a Patient With Chronic Tracheostoma: Alternative to Reduce Sternal Wound Complication Risk.

Patients with chronic tracheostoma present a challenge when they require coronary bypass surgery due to an elevated risk of sternal wound infections (SWI). Minimally invasive coronary artery bypass grafting (MICS CABG) is a robust technique that allows complete surgical revascularization while mitigating the risks of sternal complications and functional decline associated with sternotomy. In such patients at elevated risk for SWI, MICS CABG may represent a viable revascularization strategy to avoid sternotomy. Here, we present a case of a frail, comorbid patient with a chronic tracheostomy and symptomatic multivessel coronary artery disease not amenable to percutaneous therapy referred for MICS CABG.

Systematic Approach to the Calcified Mitral Valve Apparatus at Time of Mitral Valve Replacement.

Mitral annular calcification (MAC) represents a surgical challenge to mitral valve replacement. The presence of MAC at the time of mitral valve replacement is associated with perivalvular leak and atrial-ventricular groove injury. Although percutaneous and hybrid approaches may offer alternatives to surgical mitral valve replacement, the early and late results from these techniques remain unknown. As such, the surgical management of MAC remains relevant in the contemporary treatment of patients with MAC. Herein, we present a systematic approach to the management of MAC at the time of mitral valve replacement.

Recurrent cardiac constriction after complete pericardiectomy.

We present a patient with recurrent constrictive physiology resulting from exuberant post-operative fibrosis after complete pericardiectomy. The patient underwent a repeat stripping procedure. At surgery, there was an extensive fibrotic and calcified rind around the heart. The recurrence of constriction physiology after complete pericardiectomy in non-tuberculous pericarditis is a rarely reported in literature. The management supports repeat surgery and the potential value of steroid administration.

Correction of Bileaflet Mitral Valve Prolapse Through Reduction of Posterior Leaflet Height.

Mitral regurgitation due to bileaflet prolapse can be corrected with height reduction of the posterior leaflet through detachment at its base, division of accompanying secondary chordae, and leaflet-annular reapproximation. This technique lowers the posterior leaflet height to approximately 1.5 cm, thereby displacing the line of coaptation posteriorly to achieve symmetry without the need for additional artificial chordae. Of 37 patients who underwent this type of repair at our institution, no patient had recurrent mitral regurgitation ≥ 2 at an average follow-up of 1.9 years (range, 0.2-4.5).

Respiratory Distress and Chest Pain in an Airplane Passenger With Radiolucent Left Hemithorax.

CASE PRESENTATION: A 43-year-old man experienced sudden onset of chest pain and shortness of breath onboard a domestic flight. After consultation with the airline's operations center, a decision was made to land the plane in its destination airport. After landing, an ambulance was ready, and the patient was transferred to the ED in our facility. Patient evaluation was immediately started, and oxygen supply and venous access were secured.

Is concomitant surgery for moderate functional mitral regurgitation indicated during aortic valve replacement for aortic stenosis? A systematic review and evidence-based recommendations.

BACKGROUND: Mitral regurgitation (MR) is associated with poor clinical outcomes. Functional MR is often associated with aortic stenosis (AS) and may resolve after aortic valve replacement (AVR). The objective of this study was to derive evidence-based recommendations regarding surgical intervention for moderate functional MR at the time of AVR for AS. METHODS: An exhaustive literature search strategy including Medline, Embase, the Cochrane library, and meeting abstracts was performed. Studies meeting inclusion criteria were critically appraised and data pooled according to accepted meta-analysis techniques. The primary outcome was change in moderate MR after isolated AVR. Secondary outcomes were the impact of functional MR on survival and identifying factors that predict progression of MR, in patients undergoing isolated AVR for AS. RESULTS: Thirteen nonrandomized studies including 2113 patients were reviewed. A total of 268 patients had preoperative moderate functional MR and AS. All studies were appraised as poor methodological quality. After isolated AVR a trend toward improvement in MR was observed. Left ventricular dysfunction, left atrial enlargement, and atrial fibrillation were associated with progression of MR after AVR. However, the impact of residual MR on late survival was not consistent. CONCLUSION: Pooling current evidence provided inconclusive evidence to make clinical practice recommendations for or against routine surgical intervention of moderate MR at the time of AVR for AS. The incidence of this pathology makes further clinical trial studies warranted.

Headscarf pin, a sharp foreign body aspiration with particular clinical characteristics.

The process of wearing head scarf is very complex; girls used to hold a number of pins in the mouth and utilize them one by one to fix the scarf. Loss of concentration results in pin aspiration. We presented our experience with scarf pin aspiration and discussed the unique clinical characteristics of this problem. We reviewed the records of 73 patients who underwent bronchoscopy for scarf pin inhalation during the period from January 1995 to May 2009. The following data were collected, history of aspiration, time lag before presentation, symptoms and signs, radiological findings, bronchoscopic findings, number of repeated bronchoscopy, complications, need for thoracotomy and time of discharge. All patients were female, mean age 13.4 years. The time lag before admission was <12 h for 59 (81%) patients. Positive history was present in all cases. Chest radiography identified the pins in all cases. The foreign bodies were seen in the left bronchial system in 37 (50.7%) patients, in the right bronchial system in another 24 (32.9%), and in the trachea in 12 (16.4%) patients. In 66 (90.4%) patients, the foreign body was removed in the first bronchoscopic trial; a second trial was needed in 5 (6.8%) patients, and thoracotomy was performed in two patients. In conclusion, head scarf pin aspiration occurs in adolescent Islamic girls. The clinical presentation and radiological findings are diagnostic in all cases. Rigid bronchoscopy is the preferred treatment modality. Health education is the key issue in the prevention of this problem.

Is Late Left Ventricle Remodeling After Repair of Degenerative Mitral Regurgitation Worse in Women?

BACKGROUND: Recent data suggest sex-specific differences in left ventricle (LV) remodeling in patients with ventricular dysfunction or volume overload. Data describing LV remodeling in patients after repair of degenerative mitral regurgitation (MR) is scarce. METHODS: Between 2002 and 2017, 1012 patients underwent repair of MR due to myxomatous degeneration and were monitored serially in a dedicated clinic. Patients were a mean age of 63.8 ± 12.7 years, and 277 (27%) were women. Mean preoperative indexed LV end-systolic dimension was 19.0 ± 4.3 mm/m2. Clinical and echocardiographic follow-up averaged 5.1 years and extended to 14.7 years. There were 3112 postoperative echocardiograms performed for these patients. RESULTS: Overall, freedom from recurrent MR exceeding 2+ was 98.3% ± 5.5% at 5 years and 86.9% ± 2.0% at 10 years. After a mean of 5.1 years, the mean postoperative indexed LV end-systolic dimension was 17.3 ± 4.2 mm/m2. Postoperative indexed LV end-systolic dimension decreased compared with their preoperative measurement in 63% of patients. Notably, women were less likely to experience a postoperative decrease in indexed LV end-systolic dimension than men (hazard ratio, 0.7 ± 0.1; P = .04), even after adjusting for differences in age, preoperative atrial fibrillation status, preoperative right ventricle systolic pressure, and the subsequent development of recurrent MR. Similar results were also obtained in a propensity analysis of 275 matched female-male pairs (hazard ratio, 0.7 ± 0.1; P = .03). CONCLUSIONS: Few data are available describing LV remodeling after repair of degenerative MR. In a large population registry, we have observed sex-specific differences in late LV remodeling. These data therefore raise equipoise that earlier surgical intervention of women with degenerative MR may be warranted.

When Should the Mitral Valve Be Repaired or Replaced in Patients With Ischemic Mitral Regurgitation?

BACKGROUND: Data comparing outcomes after repair versus replacement of chronic ischemic mitral regurgitation (MR) is evolving. Recent data suggest that repair is associated with recurrent MR, but not survival, when compared with replacement. However, it remains unclear when either surgical strategy should be applied based on preoperative mitral valve anatomy. METHODS: Between 2001 and 2013, 161 patients underwent repair or replacement of chronic ischemic MR. The mean age of these patients was 68.2 ± 9.0 years, 44 (27%) were female, and concomitant coronary artery bypass grafting was performed in 126 (78%). The mean preoperative posterior leaflet angle was 27.7 ± 14.2 degrees, and the left ventricular ejection fraction was 41.2 ± 12.4%. Detailed preoperative assessments of mitral valve anatomy were determined by transesophageal echocardiography. Clinical and echocardiographic follow-up was for 4.6 ± 3.2 years and extended to 11.7 years. RESULTS: Overall, perioperative death occurred in 6 (3.3%) patients; 2 patients died after valve repair and 4 after valve replacement. Five-year survival and freedom from recurrent MR (≥2+) rates were 74.0 ± 5.6% and 57.8 ± 8.0%, respectively, after valve repair and 69.4 ± 6.2% and 87.1 ± 7.0%, respectively, after valve replacement. Valve repair was associated with recurrent MR (≥2+) (hazard ratio [HR], 5.3 ± 3.3; p = 0.007), but not survival (HR, 0.9 ± 0.3; p = 0.8). Preoperative posterior leaflet tethering angle was associated with survival (HR, 1.09 ± 0.04; p = 0.005) and also recurrent MR (≥2+) (HR, 1.04 ± 0.02; p = 0.03) after valve repair. Based on a receiver operator curve describing the relationship between recurrent MR (≥2+) and posterior leaflet tethering angle, a threshold of 22 degrees was determined. CONCLUSIONS: Surgical correction of chronic ischemic MR can be performed with favorable early and late results, although recurrent MR occurred more often after repair. Among patients who underwent repair of ischemic MR, a preoperative posterior leaflet tethering angle of 22 degrees or greater was associated with worse late outcomes.

Determinants of late outcomes in women undergoing mitral repair of myxomatous degeneration.

OBJECTIVES: Studies have consistently shown that women have worse perioperative outcomes following mitral surgery compared with men. Few data are available that explain these divergent outcomes. This study was conducted to determine whether women with degenerative mitral valve disease present to surgery with more advanced disease than men, and to determine whether these differences influence long-term clinical outcomes. METHODS: Seven hundred and forty-three patients underwent repair of mitral regurgitation due to myxomatous degeneration between 2001 and 2014. Of these, 208 (28%) were females and concomitant coronary bypass grafting was performed in 103 (14%). The mean clinical follow-up was for 3.1 years, and extended to 11.9 years. RESULTS: Perioperative mortality was 0.1%. Preoperatively, women had a larger indexed left atrial diameter (27.9 ± 5.7 vs 25.3 ± 4.7 mm/m2, P = 0.0001), larger indexed left ventricle end-systolic dimension (20.6 ± 5.5 vs 18.7 ± 5.1 mm/m2, P = 0.028) and higher right ventricular systolic pressure (44.4 ± 14.4 vs 41.7 ± 13.3 mmHg, P = 0.026) compared with men. Five-year survival and freedom from recurrent MR ≥2+ were 88.7 ± 1.8 and 90.7 ± 1.6%, respectively. Although gender was not associated with survival (hazard ratio: 1.04 ± 0.4, P = 0.91), women were more likely to develop recurrent MR ≥2+ at follow-up compared with men (hazard ratio: 1.9 ± 0.5, P = 0.007). CONCLUSIONS: In this large series, women with degenerative mitral valve disease presented with echocardiographic markers suggestive of more advanced disease at the time of surgery. Although there was no difference in early or late survival between groups, women were more likely to develop recurrent MR ≥2+ over the course of follow-up. Earlier surgical referral of women may, therefore, be advised.

How Does Mitral Valve Repair Fail in Patients With Prolapse?-Insights From Longitudinal Echocardiographic Follow-Up.

BACKGROUND: Repair of mitral regurgitation (MR) caused by prolapse has been well validated. Although favorable early and late results after repair have been reported, few data are available that mechanistically describe how a mitral repair fails beyond the mere need for mitral valve reoperation. We therefore sought to determine the modes of valve repair failure in patients who underwent surgical correction of MR caused by prolapse. METHODS: Between 2001 and 2015, 855 patients underwent repair of MR caused by prolapse. Patients were a mean age of 63.7 ± 12.7 years, and 380 (44%) had bileaflet prolapse. The overall repair rate was 97.2%. These patients were monitored as part of a cohort initiative and underwent serial clinical and echocardiographic assessments at 1, 3 to 6, and 12 months after the operation. Beyond the first year of the MR repair, patients were assessed by echocardiography every 1 to 2 years or when clinically indicated. Clinical and echocardiographic follow-up averaged 4.3 ± 3.5 years. RESULTS: Freedom from recurrent MR of 2+ or higher was 92.4% ± 1.3% at 5 years and 86.6% ± 2.4% at 10 years. Overall, recurrent MR of 2+ or higher developed in 49 patients (5.7%) at a mean of 3.1 ± 2.5 years after the repair, of whom 14 (1.6%) had recurrent MR of 3+ or 4+. Among patients with bileaflet prolapse, recurrent MR of 2+ or higher was observed in 24, of whom 9 had 3+ or 4+ MR., The development of recurrent MR of 2+ or higher was categorized as prolapse in 6 and nonprolapse in 43. Severe mitral stenosis occurred in 3 patients at 8.2 years after the MR repair. Mitral reoperation was ultimately performed in 21 patients. Patients who had recurrent MR 2+ or higher within the first year after the operation were more likely to undergo a subsequent mitral valve reoperation (incident rate ratio, 5.2 ± 2.9; p = 0.003), although no association between recurrent MR and reoperation was observed after the first year. CONCLUSIONS: Severe MR after repair is rare, although some may have recurrent moderate MR. Patients who required a subsequent mitral valve reoperation were most likely to have recurrent MR of 2+ or higher within the first year after the operation.

Clinical and mechanical factors associated with the removal of temporary epicardial pacemaker wires after cardiac surgery.

BACKGROUND: Temporary pacemaker wires are placed in the majority of patients after cardiac surgery. There is no information on mechanical factors related to wire removal. METHODS: Clinical information related to temporary wire use and removal was prospectively collected from a large cardiac surgical unit over one year. Measurements of maximal tension that nurses and doctors would apply to remove temporary wires was determined using a hand-held portable scale. In a prospective trial, patients (n = 41) had their wires extracted in series to the portable scale to determine the maximal tension required for safe removal. RESULTS: Ventricular wires were placed in 86.5 % of patients during the observed year. Pacing facilitated weaning from CPB in over 15 % of patients and pacer dependence was seen in 2.1 %. No patients suffered major complications after wire removal. There was no difference in the tension that physicians or nurses would apply to comfortably extract temporary wires. In the prospective trial, there was no difference in the tension required for removal of atrial or ventricular wires (atrial 18.3 ± 17.9 oz versus 14.5 ± 14.2 oz, p = 0.430). There were no patient factors that correlated with the degree of resistance and there was no significant difference between the tension required to remove wires with (21.0 ± 22.5 oz) or without (14.1 ± 5.1 oz) an atrial button. CONCLUSIONS: Temporary epicardial wire removal is innocuous and was not associated with any complications. In some patients tension required for safe removal exceeded 20 ounces. Strategies to standardize wire removal may prevent complications and may minimize unnecessary wire retention.

Mitral valve repair in acquired dextrocardia.

Surgical correction of valvular heart disease in patients with dextrocardia is extremely rare. We report a surgical case of mitral valve repair in a patient with acquired dextrocardia. Successful mitral valve repair was performed through a right lateral thoracotomy. We describe our surgical strategy and summarize the literature.

Determinants of left ventricular dysfunction after repair of chronic asymptomatic mitral regurgitation.

BACKGROUND: The evidence supporting early surgical intervention in patients with chronic asymptomatic mitral regurgitation (MR) is steadily accumulating. Although left ventricular (LV) enlargement and preoperative pulmonary hypertension are considered when deciding on surgical intervention, the threshold above which these factors influence clinical outcomes remains poorly defined. METHODS: One-hundred fifty asymptomatic patients of aged 59.3 ± 13.4 years underwent mitral valve repair of severe MR caused by myxomatous degeneration between 2001 and 2012. Mean preoperative left atrial diameter, LV end-systolic diameter (LVESD), and right ventricular systolic pressure were 41.2 ± 6.9 mm, 34.6 ± 5.4 mm, and 38.4 ± 11.8 mm Hg, respectively. Preoperative LV ejection fraction (LVEF) was greater than 60% in 136 (91%) patients, and none had preoperative atrial fibrillation. Clinical and echocardiographic follow-up averaged 3.3 years and extended to 9.1 years. RESULTS: There were no perioperative deaths. Five-year survival and freedom from recurrent MR greater than or equal to 2+ were 93.4% ± 3.2% and 94.0% ± 3.2%, respectively. A threshold LVESD indexed to body surface area greater than 19 mm/m(2) (hazard ratio [HR], 3.5 ± 2.0; p = 0.03) and a preoperative right ventricular systolic pressure greater than 45 mm Hg (HR, 3.8 ± 12.1; p = 0.01) were independently associated with postoperative LV dysfunction, defined as a LVEF less than 60%. CONCLUSIONS: Mitral valve repair can be performed with favorable early and late outcomes in patients with asymptomatic severe MR. The presence of minimal LV enlargement and preoperative pulmonary hypertension were associated with postoperative LV dysfunction in this otherwise healthy population. Mitral valve repair may be considered in asymptomatic patients with an indexed LVESD (ILVESD) greater than 19 mm/m(2) or preoperative right ventricular systolic pressure greater than 45 mm Hg.