Anterior leaflet-oriented tricuspid annuloplasty using a flexible ring for severe tricuspid regurgitation.

We describe our concept and method of tricuspid annuloplasty using flexible ring for patients with severe tricuspid regurgitation accompanied by a severe tethering and a wide separation of the leaflets between the anterior leaflet and septal leaflet. The goal for our tricuspid ring annuloplasty using a flexible ring is to match the patient's own anterior leaflet configuration. We reduce the size of the tricuspid annulus respecting the individual configuration of the anterior leaflet to create a sufficient coaptation area of the leaflets. We performed this method in a 78-year-old female patient with very severe tricuspid regurgitation accompanied by a severe tethering. The anterior leaflet almost covered the orifice of the flexible ring during systole and intraoperative transesophageal echo examination revealed only trivial tricuspid regurgitation. We believe the anterior leaflet-oriented tricuspid ring annuloplasty using a flexible ring is useful for patients with severe TR accompanied by a severe tethering.

Aortic root geometry following valve-sparing root replacement with reimplantation or remodeling: experimental investigation under static continuous pressure.

The differences in aortic root geometry associated with various valve-sparing root replacement (VSRR) techniques have not fully been understood. We evaluated the root configuration of current VSRR techniques by developing in vitro test apparatus. Six fresh porcine hearts were used for each model. The aortic root remodeling control group involved replacement of the ascending aorta with diameter reduction of sino-tubular junction (STJ) (C1). The aortic valve reimplantation control group involved replacement of the ascending aorta alone (C2). VSRR included remodeling without (RM) or with annuloplasty (RM + A) and reimplantation with a tube (RI) or a handmade neo-Valsalva graft (RI + V). The root geometry of each model in response to closing hydraulic pressures of 80 and 120 mmHg was investigated using echocardiography. Among the VSRR models, RM yielded the largest aorto-ventricular junction (AVJ), which was similar to those in non-VSRR models [mean AVJ diameter (mm) at 80 mmHg; RM = 25.1 ± 1.5, RM + A = 20.9 ± 0.7, RI = 20.7 ± 0.9, RI + V = 20.8 ± 0.4]. RI + V yielded the largest Valsalva size and largest ratio of Valsalva/AVJ, which was similar to the control group [mean Valsalva diameter (mm) at 80 mmHg; RM = 28.4 ± 1.4, RM + A = 25.8 ± 1.3, RI = 23.6 ± 1.0, RI + V = 30.5 ± 0.8, ratio of Valsalva/AVJ at 80 mmHg; RM = 1.14 ± 0.06, RM + A = 1.24 ± 0.06, RI = 1.15 ± 0.06, RI + V = 1.47 ± 0.05]. The STJ diameter at 80 mmHg was numerically smaller with RM + A (22.4 ± 1.2 mm) than with RM (24.8 ± 2.3 mm, p = 0.11). There were no significant differences in AVJ, Valsalva, or STJ distensibility or ellipticity between procedures. Current modifications, including annuloplasty for remodeling or reimplantation in the setting of neo-Valsalva graft, yield near-physiological root geometries.

Early Clinical Outcome of Mitral Valve Replacement Using a Newly Designed Stentless Mitral Valve for Failure of Initial Mitral Valve Repair.

Here we report the early outcome of mitral valve replacement using a newly designed stentless mitral valve for failure of initial mitral valve repair. Mitral valve plasty (MVP) for mitral regurgitation is currently a standard technique performed worldwide. However, whether mitral valve repair should be performed for patients with advanced leaflet damage or complicated pathology remains controversial. Mitral valve replacement might be feasible for patients who have undergone failed initial MVP; however, it is not an optimal treatment because of poor valve durability and the need for anticoagulative therapy. We report two cases of successful mitral valve replacement using a newly designed stentless mitral valve made of fresh autologous pericardium, which may have a potential benefit over mitral valve repair or mitral valve replacement with a mechanical or bioprosthetic valve.

In vivo assessment of novel stentless valve in the mitral position.

BACKGROUND: We conducted in vivo examinations of a newly designed stentless mitral valve (SMV), formed by suturing 2 leaflets with the "legs" serving as chorda tendinea, made from bovine pericardium, to a flexible ring. METHODS AND RESULTS: Seven pigs underwent implantation of the SMV constructed with a 23-mm (n=5) or 25-mm (n=2) Duran ring. Baseline echocardiography examinations were used to evaluate the annular anteroposterior diameter, and distance between the mitral annulus (MA) and papillary muscles (PMs) to determine SMV-leg length. After removing the native valve, the SMV-legs were fixed to the anterior and posterior PMs, followed by fixation of the ring to the native MA. Immediately after surgery, all animals presented none or trivial mitral regurgitation, with mean and peak trans-SMV pressure gradient values of 1.9±0.8 and 6.0±3.1 mmHg, respectively. The mean length of the SMV-leg was 19.4±3.9 mm, which correlated with the distance between anterior and posterior MA-PM (r=0.96 and 0.94, respectively, P<0.01 for both). The discrepancy between the anteroposterior diameter of the ring (outside diameter) and that of the native valve was 1.0±2.9 mm, which correlated with the trans-SMV pressure gradient (r=0.81, P=0.025). CONCLUSIONS: In our preliminary study, the SMV demonstrated excellent diastolic inflow dynamics and closing function in vivo. Preoperative precise assessment of MV configuration may serve as a basis for selection of appropriate ring size and SMV-leg length.

Long-term follow-up of repair-like replacement of mitral valve using autologous pericardium.

Objectives: The present study assessed the late results of the operation, which consisted of the construction of a stentless mitral valve using autologous pericardium and valve implantation. Methods: Between 2011 and 2018, among 1617 consecutive patients who underwent mitral valve operation at our institution, 15 adult patients (0.9%) with unrepairable mitral valves who wished to avoid conventional mitral valve replacement underwent this operation. Ten patients (67%) had a history of valve repair. After discharge, patients were prospectively followed-up with a echocardiographic evaluation up to the end point. The mean follow-up term was 70.8 ± 42.5 months. Results: There were no hospital deaths or thromboembolic events and only 1 late noncardiac death. Intraoperative transesophageal echocardiography of all patients revealed no or trivial mitral regurgitation. Eight patients (53.3%) underwent redo valve replacement within 12 years. Except 1 late death, the postoperative course was divided into 3 groups depending on the occurrence of redo surgery, as follows: an early reoperation group (reoperation within 4 years; n = 4), a late reoperation group (reoperation after 4 years; n = 4), and a free from reoperation group (n = 6). The latest transthoracic echocardiographic examination performed 7.2 ± 2.9 years after the operation revealed the grade of mitral regurgitation to be none in 2 patients, mild in 2 patients, mild to moderate in 1 patients, and moderate in 1 patient in the free from reoperation group. Conclusions: Despite the high incidence of reoperation, Normo operation can be a viable option during valve replacement, especially for young patients.

Do semi-rigid prosthetic rings affect left ventricular function after mitral valve repair?

BACKGROUND: After reports of cardiac impairment caused by mitral annuloplasty with rigid rings, several prosthetic rings with semi-rigidity were introduced. The influence of semi-rigid rings on postoperative cardiac function remains unknown. This study compared postoperative cardiac function between patients receiving a semi-rigid prosthetic ring and those receiving a flexible ring or band. METHODS AND RESULTS: Transthoracic echocardiographic data of 305 patients who underwent mitral valve repair for degenerative mitral regurgitation (227 patients receiving a semi-rigid ring and 78 receiving a flexible ring or band) were retrospectively reviewed. The imbalance in the preoperative characteristics between groups was adjusted with propensity score matching. Left ventricular ejection fraction, end-diastolic dimension, and end-systolic dimension were compared at 1 week, 6 months, and 1 year after surgery. Propensity score matching yielded 68 matched pairs of patients for whom there were few group differences in preoperative covariates. Between patients receiving a semi-rigid ring and those receiving a flexible ring or band in the propensity-matched cohorts, there were no significant differences in ejection fraction (P=0.322), end-diastolic dimension (P=0.576), or end-systolic dimension (P=0.567). CONCLUSIONS: There was little difference in the influence on postoperative cardiac function between semi-rigid rings and flexible rings or bands.

Long-term outcomes of early surgery for asymptomatic severe chronic mitral regurgitation.

BACKGROUND AND AIM OF THE STUDY: The long-term outcomes of early surgery in patients with asymptomatic severe chronic mitral regurgitation (MR) and the impact of preoperative left ventricular dysfunction, atrial fibrillation (AF) and/or pulmonary hypertension (PH) on outcomes in this patient group, were evaluated. METHODS: Between 1992 and 2007, a total of 212 patients (mean age 50 +/- 15 years) with asymptomatic severe chronic degenerative MR underwent early mitral valve surgery within 12 months after echocardiographic diagnosis at the authors' institution. Mitral valve repair was attempted in all cases. The mean follow up period was 82 +/- 36 months. The patients were allocated to two groups; 111 with preoperative left ventricular dysfunction, AF and/or PH (group A), and 101 patients without those findings (group B). The outcomes were compared using univariate and multivariate analyses. RESULTS: Mitral valve repair was performed successfully in 211 patients (99.5%). The operative mortality was 0.5% (1/212). The 10-year actuarial survivals were 97.3% in all patients, 95.1% in group A, and 100% in group B. The 10-year cardiac adverse event-free rates (cardiac death, mitral valve reoperation or readmission with congestive heart failure) were 94.7% in all patients, 92.7% in group A, and 96.2% in group B. The seven-year freedom rates from recurrent MR were 93.1% in all patients, 90.0% in group A, and 97.0% in group B. In comparative analyses, group A had poorer late outcomes than group B, although the differences were not statistically significant. The multivariate analysis failed to show that preoperative left ventricular dysfunction, AF and/or PH were significantly associated with late cardiac adverse event (HR: 2.1, 95% CI: 0.4 to 10.8; p = 0.392). CONCLUSION: Early surgery for asymptomatic chronic MR demonstrated excellent early and late outcomes. The study results failed to confirm that preoperative left ventricular dysfunction, AF and/or PH were significantly associated with adverse outcomes of early mitral valve surgery in this patient group.

[Re-do mitral valve repair].

We describe proper indication and results of re-do mitral valve (MV) repair for recurrence of mitral regurgitation( MR) after MV repair. Among 1,163 patients who received MV repair for MV prolapsed between October 1991 and December 2010, 70 patients (6.0%) underwent redo MV operation. Only 14 patients (20%) among them received re-do MV repair and other 56 patients( 80%) underwent MV replacement. One patients of the 7 patients( 50%) who received re-do MV repair in 3 months after the operation received mitral valve replacement( MVR) for recurrence of MR 2 months after re-repair. However, in other 6 patients, postoperative echodoppler study performed after discharge revealed none or only trivial MR. In 6 of 7 patients, the cause of recurrence was detachment of the sutureline and hemolysis was present in 5 patients. Re-do repair was considered good indication for those patients who showed recurrence MR due to localize detachment of the sutureline. On the other hand, predictability of the results of re-do repair for chronic recurrent MR was low. Our newly developed stentless MV (Normo) would be a good solution for those patients who showed recurrence of MR after MV repair having low fesibility of re-do MV repair.

Assessment of a novel stentless mitral valve using a pulsatile mitral valve simulator.

BACKGROUND AND AIM OF THE STUDY: The study aim was to develop a novel stentless mitral valve (SMV) and to evaluate its performance, using an original pulsatile simulator developed specifically to analyze the hydrodynamic function of the mitral valve. METHODS: The SMV developed at the authors' institution consists of two major components: a large anterior leaflet with commissures, and a small posterior leaflet. The valve is formed by suturing the leaflets (made from bovine pericardium) to a flexible (Duran) ring. The SMV, constructed with a 27 mm flexible ring, was installed into the mitral valve simulator, after which the four papillary flaps of the two leaflets were sutured to artificial papillary muscles. The artificial ventricle was driven pneumatically at a pulse rate of 70 beats/min, with a systolic fraction of 35%. The mean flow, aortic pressure, and atrial pressure were adjusted to 4.5 1/min, 120/80 mmHg, and 10 mmHg, respectively. A 27 mm mechanical valve (MEV; St. Jude Medical Inc.) was employed as a control. The hydrodynamic performance of the SMV and MEV were investigated and compared. An echo-Doppler study was also performed. RESULTS: The waveforms of the SMV and MEV showed a similar pattern. The mean transvalvular flow was 4.7 +/- 0.4 1/min for the SMV, and 3.55 +/- 0.13 1/min for the MEV (p < 0.001). Mitral regurgitation was 5.07 +/- 1.15 and 3.78 +/- 0.35 ml/beat, respectively (p < 0.05). Echocardiographic data indicated that the regurgitant jet towards the left atrial model was none or trivial for the SMV, and trivial for the MEV. CONCLUSION: Within the environment of the mitral valve simulator, the novel SMV prepared from bovine pericardium demonstrated excellent performance characteristics, and may represent a potential future alternative for bioprosthetic stented mitral valves.

Mitral valve repair for extreme billowing and prolapsing valve.

Objectives: We describe our method and results of mitral valve repair up to 20 years in a defined group of patients with mitral regurgitation caused by an extreme billowing and prolapsing valve. Methods: An extreme billowing and prolapsing valve was defined by the presence of excess tissue on both leaflets and prolapse of 2 or more of the 3 segments of each leaflet. Among 1344 consecutive patients who underwent mitral valve repair for degenerative mitral regurgitation between 1991 and 2012 at the Sakakibara Heart Institute, 73 patients met our definition of an extreme billowing and prolapsing valve. From these 73 patients, 67 patients who underwent mitral valve repair based on the surgical strategy we developed in July 1996 were enrolled in this study. Our strategy of mitral valve repair for extreme billowing and prolapsing valves consists of (1) volume reduction of the leaflets, (2) physiologic remodeling annuloplasty for long anterior leaflet, and (3) wide usage of artificial chordae. Results: Mean age of the patients was 46.6 ± 12.9 years. There were no hospital deaths and 6 late deaths in this series. Kaplan-Meier survival at 10 years was 96.8 ± 2.2%. There were 2 reoperations. Cumulative incidence rate of mitral valve reoperation and moderate or severe mitral regurgitation at 10 years was 1.8 ± 1.8% and 11.2 ± 4.0%. Number of artificial chordal replacement was associated with decreased risk of recurrent moderate mitral regurgitation (hazard ratio, 0.60; P = .03). Conclusions: Long-term echo follow-up demonstrates good results of mitral valve repair for extreme billowing and prolapsing valves using our strategy.

The efficacy of sinus plication in aortic valvuloplasty for bicuspid aortic valve: experiments in a pulsatile flow simulation model.

OBJECTIVES: Sinus plication has emerged as a promising tool that can lead to better stability in bicuspid aortic valve (BAV) repair. However, the mechanisms underlying the efficacy of this technique are unclear. We evaluated the hydrodynamic effect of sinus plication using the experimental pulsatile flow simulator and our original BAV model in vitro. METHODS: Based on the computed tomography data of a BAV patient who had undergone aortic valvuloplasty, a BAV model (group C, n = 6) was developed with bovine pericardium and vascular prosthesis (J-graft Shield Neo Valsalva 24 mm). We performed sinus plication (group SP, n = 6) in the BAV model and compared hydrodynamic data with the control model in the pulsatile flow simulator. Non-fused cusp angle, annulus diameter and effective height were measured by ultrasonography. RESULTS: The average flow was significantly increased in group SP compared to group C (4.24 ± 0.14 l/min vs 4.14 ± 0.15 l/min, respectively, P = 0.034). The mean transvalvular pressure gradient and regurgitant fraction were significantly decreased in group SP compared to group C (11.6 ± 4.3 mmHg vs 16.6 ± 5.0 mmHg, respectively, P = 0.009 and 14.1 ± 2.0% vs 17.4 ± 2.1%, respectively, P = 0.001). Ultrasound measurement indicated that non-fused cusp angle was significantly increased in group SP compared to group C (163.8° ± 9.2° vs 153.0° ± 4.6°, respectively, P = 0.012). CONCLUSIONS: Sinus plication in the BAV model significantly increased the commissural angle. It was effective in not only controlling regurgitation but also improving valve opening. These finding should be confirmed by evaluating cusp stress and/or long-term durability in the future studies.

The fate of bioprostheses in middle-aged patients: the Japanese experience.

BACKGROUND AND AIM OF THE STUDY: Although the trend of bioprosthesis use has been evaluated extensively, the durability of currently available bioprostheses has not been determined in middle-aged patients. The study aim was to determine the long-term fate of bioprostheses implanted in patients aged < 60 years. METHODS: Valve implantation data were collected from 43 centers in Japan. The data included patient age at implantation, type of valve, implant position, follow up period, and cause of reoperation including structural valve deterioration (SVD) and non-SVD. Between 1975 and 2005, a total of 697 bioprostheses was implanted in the mitral position, and 247 in the aortic position. The mean follow up period was 9.2 years. Rates of freedom from SVD and reoperation were determined using an actuarial method. RESULTS: The mean age at implantation was 45 +/- 10.9 years. The 15-year freedom from SVD was 39% for those with valves implanted in the aortic position, and 27% in the mitral position (p = 0.004). For the same period, the actuarial freedom from reoperation was 31% for valves in the aortic position, and 24% in the mitral position (p = 0.178). The difference in actuarial freedom from SVD was not significant between age groups in the mitral position. However, there were differences in actuarial freedom from SVD in the aortic position for patients aged < 10 years when compared to the other age groups (p < 0.001). New-generation valves showed better long-term durability than older valves (p = 0.05). CONCLUSION: The long-term freedom from SVD in middle-aged patients was unfavorable for bioprostheses implanted in the aortic and mitral positions. Middle-aged patients must be made aware that reoperation will be necessary; consequently, the choice of bioprosthesis should be dictated by patient-surgeon preference.

Long-term echocardiography results of mitral valve repair for mitral valve prolapse.

BACKGROUND AND AIM OF THE STUDY: The study aim was to assess the long-term durability of mitral valve (MV) repair for MV prolapse using echo-Doppler evaluation. METHODS: Between July 1991 and December 2006, MV repair was performed in 603 patients with nonischemic, severe mitral regurgitation (MR). A subset of 517 patients (mean age 56.3 +/- 12.0 years) with MR caused by leaflet prolapse resulting from degeneration of the MV was subsequently investigated. The main techniques used for MV repair included chordal replacement with ePTFE sutures for 274 of 278 patients with anterior leaflet (AL) prolapse, and leaflet resection for 239 patients with posterior leaflet (PL) prolapse. A prosthetic ring or band was used for annuloplasty in 340 patients, and a band of autologous pericardium in 161; no ring or band was used in the remaining 16 cases. Postoperative serial transthoracic echocardiography was performed for all hospital survivors before discharge, and on at least one occasion after discharge in 507 patients. Echocardiographic follow up was available for up to 15 years (mean 4.4 +/- 3.6 years). Residual MR flow detected by color Doppler echocardiography was classified according to the maximum regurgitant jet area (MRA). RESULTS: The 30-day mortality was 0.57% (three deaths). There were 21 late deaths and 22 reoperations (five of which were re-repair for hemolysis). Kaplan-Meier survival and freedom from reoperation at 14 years were 79.0 +/- 6.0% and 74.5 +/- 9.6%, respectively. Estimates of freedom from severe MR (MRA > or = 7.0 cm2) at five, 10 and 14 years were 94.2 +/- 1.5%, 82.8 +/- 3.6% and 77.5 +/- 5.5%, respectively. Freedom from severe MR at 14 years for 239 patients with isolated PL prolapse was 98.4 +/- 1.6%. CONCLUSION: Echocardiographic follow up of MV repair for MV prolapse demonstrates good long-term results. In particular, the results of MV repair for isolated PL prolapse were excellent.

Management of systolic anterior motion of the mitral valve: a mechanism-based approach.

Although the mechanism of systolic anterior motion (SAM) of the mitral valve is unknown, it is known to have a multifactorial pathophysiology. Echocardiographic analysis of the mitral leaflet revealed the step-wise progression of SAM, and intraventricular flow analysis revealed the contribution of drag force generated by the misled flow below the posterior leaflet. Although several diverse clinical features of SAM are already known, some key features need to be abstracted from among them to understand the regulation of SAM establishment. This paper reviews past articles that have investigated the mechanism of SAM and proposes a mechanism-based concept to provide insights for better comprehension of SAM recognition.

Causes of repair failure for degenerative mitral valve disease and reoperation outcomes.

OBJECTIVES: This study aimed to evaluate the causes of initial mitral valve (MV) repair failure, the details of reoperation and the long-term outcomes of mitral valve re-repair (Re-MVP). METHODS: We retrospectively reviewed 86 patients who underwent reoperation after MV repair for MR due to degenerative disease from October 1991 to December 2015. First, we analysed the initial MV repair data, causes of MV repair failure, reoperation data and long-term outcomes including survival. Second, the patients were classified into 2 groups based on valve related failure or procedure related failure , and the differences between the groups were analysed. RESULTS: Leaflet prolapse at the initial operation affected the bilateral leaflets in 37 (43%) patients, the anterior leaflet in 30 (35%) patients and the posterior leaftlet in 19 (22%) patients. Median duration from first operation to reoperation was 47.5 (interquartile range 4.8-85.8) months. Reoperation indication included recurrent mitral regurgitation alone in 59 patients, haemolysis combined with recurrent mitral regurgitation in 15 patients, infectious endocarditis combined with recurrent mitral regurgitation in 8 patients, mitral stenosis in 2 patients and left ventricular pseudoaneurysm in 2 patients. The cause of MV repair failure was valve-related in 61 (71%) patients, procedure-related in 20 (23%) patients and both in 5 (6%) patients. Re-MVP was successful in 23 (27%) patients. Re-MVP was more common in patients with procedure-related failure, which occurred earlier than valve-related failure. Freedom from all-cause death was significantly better after Re-MVP. The 5-year freedom from reoperation after Re-MVP was 95.7%. CONCLUSIONS: Re-MVP was more common in patients with procedure-related failure, which occurred earlier than valve-related failure. Durability of re-repaired MVs and survival of re-repaired patients were acceptable.

The echocardiographic determinants of functional mitral regurgitation differ in ischemic and non-ischemic cardiomyopathy.

BACKGROUND: Functional mitral regurgitation (MR) is one of the common and severe complications in patients with dilated cardiomyopathy. The detailed mechanisms that cause functional MR remain to be elucidated. Using two-dimensional transthoracic echocardiography, we investigated the differences in major determinants of MR severity between ischemic cardiomyopathy (ICM) and non-ICM patients. METHODS: We enrolled 103 patients (91 males; age 64+/-12 years) with significant left ventricular (LV) dilatation. They were divided into ICM group (n=69) with significant coronary disease, and non-ICM (n=34) group without coronary disease. We devised a novel and simple parameter; the short-axis sphericity index (SI), to evaluate global LV remodeling, and used coaptation depth (CD) and tenting area (TA) to evaluate mitral deformity. RESULTS: In all cases, CD, TA and left atrium diameter (LAD) correlated positively with maximum regurgitation area (MRA) (r=0.54, 0.57, 0.57; P<0.0001). A negative correlation was observed between MRA and SI (r=-0.33, P=0.0008). There was no significant relationship between MRA and LV ejection fraction (EF). In non-ICM cases, SI tended to be lower with reduced EF. Multivariate stepwise linear regression analysis showed the following equations; ICM: MRA=-9.4+0.81CD+0.21LAD (r2=0.47, P<0.0001), non-ICM: MRA=-7.2+0.17LVDs (LV end systolic diameter) -8.7SI+0.27LAD (r2=0.63, P<0.0001). CONCLUSIONS: The strongest determinants of functional MR severity differ in ICM and non-ICM. While LV diameter and SI (global LV remodeling index) mainly determine the severity in non-ICM, CD that reflects mitral deformity is the major determinant in ICM.

Echocardiographic prediction of left ventricular dysfunction after mitral valve repair for mitral regurgitation as an indicator to decide the optimal timing of repair.

OBJECTIVES: This study sought to determine whether echocardiography before mitral valve repair (MVR) for mitral regurgitation (MR) was predictive of postoperative left ventricular (LV) dysfunction and useful for deciding the optimal timing of repair. BACKGROUND: Some reports have shown that the preoperative echocardiographic data of left ventricular ejection fraction (LVEF) and left ventricular end-systolic diameter (LVDs) were good predictors of postoperative LV dysfunction. However, few reports were based on long-term follow-up data of large numbers of patients who underwent MVR in the last decade. METHODS: A total of 274 patients with moderate or severe MR underwent MVR between October 1, 1991, and September 30, 2000. Among them, 171 patients who had both an operation for isolated MR due to degenerative pathology and a postoperative echocardiogram were studied. Postoperative echocardiograms were performed 3.9 +/- 2.4 years after the operation. The LVEF decreased from 66 +/- 10% before surgery to 63 +/- 11% after surgery (p < 0.0001). On univariate analysis, preoperative LVEF and LVDs correlated with postoperative LVEF (r = 0.41 and r = -0.39, respectively). Overall, postoperative LV dysfunction (defined as LVEF <50%) was not frequent (12%). However, the incidence of postoperative LV dysfunction was high in patients with preoperative LVEF <55% (38%) or LVDs > or =40 mm (23%). CONCLUSIONS: In patients with MR, the echocardiographic data of LVEF and LVDs were good predictors of postoperative LV dysfunction. When a decrease in LVEF or an increase in LVDs is detected, MVR should be considered to preserve postoperative LV function.

Impact of preoperative and postoperative atrial fibrillation on outcome after mitral valvuloplasty for nonischemic mitral regurgitation.

OBJECTIVE: We sought to determine the impact of preoperative or postoperative atrial fibrillation on survival, stroke, and cardiac function after mitral valvuloplasty for mitral regurgitation. METHODS: Between 1991 and 2003, 1026 patients with nonischemic/noncardiomyopathy mitral valve regurgitation underwent mitral valve plasty in 3 centers; 663 patients remained in sinus rhythm (group A), and 363 patients had atrial fibrillation or flutter preoperatively (group B) with concomitant maze procedures (group BM, n = 163) or without maze procedures (group BN, n = 200). RESULTS: Eight-year freedom from cardiovascular-related death was better in group A (99.3%) than group B (BM: 96.9%, BN: 81.6%) ( P < .001) and also better in group BM than group BN ( P = .007). The adjusted hazard ratio of group B versus group A for preoperative differences was 5.1 (95% confidence interval: 1.8-14.8). Eight-year freedom from stroke was better in group A (99.2%) than group B (BM: 98.2%, BN: 82.6%) ( P < .001) and also better in group BM than group BN ( P < .001). Patients with preoperative atrial fibrillation had larger left atria and left ventricular systolic dimensions. The adjunct maze procedure improved left ventricular systolic dimensions over mitral repair alone (group A vs B: P = .359; group BM vs BN: P = .001). CONCLUSION: Preoperative permanent/persistent atrial fibrillation was associated with a dilated left atrium and reduced left ventricular function in patients with mitral regurgitation. Including the maze procedure with mitral repair improved survival, late cardiac function, and freedom from late stroke.

Mechanism of hemolysis after mitral valve repair and new surgical management: prosthetic annuloplasty ring covered with autologous pericardium.

BACKGROUND AND AIMS OF THE STUDY: Hemolysis after mitral valve repair is a rare occurrence, but is one of the complications leading to reoperation. Since 1999, mitral valve repair at the authors' institution has been performed using a prosthetic annuloplasty ring covered with autologous pericardium to prevent this complication. The study aims were to investigate the mechanism of hemolysis after mitral valve repair and to describe the surgical management of this complication. METHODS: This retrospective study comprised 204 consecutive patients who underwent mitral valve repair using an annuloplasty ring between October 1991 and April 2000 at the authors' institution. Patients were allocated to the non-covered ring group (n = 174) and the covered ring group (n = 30), and compared for the degree of mitral regurgitation (MR), serum levels of lactate dehydrogenase (LDH), and occurrence of hemolysis. The degree and flow pattern of MR, and patient prognoses were described for hemolytic patients. RESULTS: Postoperative MR and serum LDH were not significantly high in either group. A total of seven patients presented with hemolysis; postoperative echocardiography revealed MR to be mild in two patients, moderate in three and severe in two. Collision of the regurgitant jet into the artificial ring was evident in all seven patients. A beta-blocker proved effective in treating hemolysis in three patients, mitral re-repair was performed in three, and a prosthetic mitral valve was inserted in one patient. None of the patients in the covered ring group presented with hemolysis. CONCLUSION: The major cause of hemolysis after mitral repair was collision of the regurgitant jet into the artificial ring. The simple technique used herein prevented contact of the regurgitant jet with the rough surface of the ring, and may in turn have prevented hemolysis. In selected patients, hemolysis was improved by beta-blocker administration.