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BACKGROUND: Debate persists regarding the outcomes of leaflet resection (RESECT) vs chordal replacement (CHORD) for degenerative mitral regurgitation. Our aim was to compare early and late outcomes of the RESECT vs CHORD techniques for degenerative mitral regurgitation. METHODS: A total of 1066 consecutive patients undergoing mitral repair for degenerative regurgitation with the RESECT vs CHORD techniques were evaluated from a prospectively maintained database. Propensity score matching was used to compare outcomes in RESECT vs CHORD repairs. RESULTS: Patients who underwent CHORD had later operative dates, more flail leaflet, and more anterior leaflet disease. With the switch to predominant use of the CHORD technique in 2010, the percentage of repair for all degenerative valves improved significantly from 83% to 91% (P = .002). A total of 467 patients were matched for baseline characteristics. Patients in the CHORD group had larger rings (34 mm vs 32 mm; P < .001) and greater use of an Alfieri stitch (66% vs 22%; P < .001) in matched patients. The 10-year survival was similar for matched patients (RESECT vs CHORD, 86% ± 3% vs 84% ± 4%; P = .5).Patients in the RESECT group had a lower 10-year cumulative incidence of mitral reoperation (RESECT vs CHORD, 1% ± 1% vs 8% ± 3%; P = .002) and severe mitral regurgitation (RESECT vs CHORD, 1% ± 1% vs 9% ± 5%; P = .05) compared with matched patients in the CHORD group. The late ejection fraction and mitral gradient were not different between the 2 groups in matched patients, respectively (P = .9 and P = .2, respectively). CONCLUSIONS: The use of the CHORD technique for degenerative mitral regurgitation increased the repair rates, but the CHORD technique had slightly lower repair durability at 10 years compared with the RESECT technique. These results could be related to more complex disease in CHORD group.
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BACKGROUND: Debate continues regarding the superiority of porcine vs pericardial bioprostheses, and data relevant to this comparison are scant. This study compared late survival and structural valve deterioration of porcine and pericardial mitral valve prostheses. METHODS: Adults undergoing mitral valve replacement with 1 first-generation porcine valve model and 1 pericardial valve line were reviewed from a prospectively maintained institutional database between 1976 and 2020. Multivariable regression and Cox proportional hazards analysis were used to compare late outcomes. RESULTS: Of 1162 consecutive patients, 612 (53%) received porcine valves and 550 (47%) received pericardial valves. At 10 years, patient survival (porcine, 36% ± 2%; pericardial, 38% ± 3%; P = .5) and cumulative incidence of mitral valve structural deterioration (porcine, 18% ± 2%; pericardial, 19% ± 3%; P = .3) were similar. The structural failure mode was more likely severe mitral stenosis in pericardial valves (35 of 50 [70%] vs 38 of 106 [36%]; P < .001), and it was more likely severe mitral regurgitation in porcine valves (80 of 106 [75%] vs 19 of 50 [38%]; P < .0001). After adjustment, structural deterioration was associated with younger patient age (P < .001) but not valve type. At 10 years, porcine valves demonstrated a higher cumulative incidence of mitral reoperation (19% ± 2% vs 9% ± 2%; P < .001) and reoperation for structural deterioration (15% ± 1% vs 6% ± 2%; P = .007). CONCLUSIONS: This study demonstrated similar rates of 10-year survival and structural deterioration with porcine and pericardial bioprostheses in mitral valve replacement. The study suggests a lack of major improvement in durability of mitral bioprosthetic valves over time. The failure mode may have a greater influence on surgeon decision making regarding valve choice.
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BACKGROUND: The long-term effectiveness of minithoracotomy over redo median sternotomy for reoperative mitral operation is not well described. Here we present long-term survival after reoperative mitral operation based on operative approach. METHODS: Adults undergoing mitral valve operation with previous sternotomy by redo sternotomy and minithoracotomy were reviewed from our prospectively maintained institutional database from 1997 to 2022. Propensity score matching was performed to compare short- and long-term outcomes. RESULTS: Of 750 consecutive patients, thoracotomy was performed in 503 (67%). Median follow-up was 5.0 years (interquartile range, 0-23 years). Intraoperatively, sternotomy patients were more likely to have central aortic cannulation (205 of 223 [93%] vs 265 of 481 [56%]), cardioplegic arrest (220 of 223 [99%] vs 124 of 481 [26%]), and mitral valve replacement (190 of 223 [85%] vs 358 of 481 [74%]). Thoracotomy patients were older (63 ± 13 vs 58 ± 14 years) with elective presentation (387 of 503 [77%] vs 128 of 247 [52%]). Sternotomy patients were more likely to have endocarditis (52 of 247 [21%] vs 45 of 503 [9%], P < .001). At 10 years, thoracotomy patients experienced improved survival (52% ± 3% vs 46% ± 4%, P = .004). After propensity matching, 10-year survival was significantly higher for thoracotomy patients compared with sternotomy patients (60% ± 5% vs 42% ± 5%, P = .0006). The greatest difference in survival was at the first 6 months after operation (96% ± 1% vs 81% ± 3%, P < .001). CONCLUSIONS: For patients undergoing reoperative mitral valve operation, minimally invasive right anterior thoracotomy can significantly decrease risk of death in the first 6 months, with durable survival benefit out to 10 years. We present a large single-center series to suggest an important opportunity to durably improve outcomes after reoperative mitral operation through wider use of right minithoracotomy.
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Procedimentos Cirúrgicos Cardíacos , Esternotomia , Adulto , Humanos , Toracotomia , Valva Mitral/cirurgia , Reoperação , Estudos Retrospectivos , Resultado do Tratamento , Procedimentos Cirúrgicos Minimamente InvasivosRESUMO
BACKGROUND: The durability of surgical repair for degenerative versus ischemic mitral regurgitation (MR) is thought to be markedly different. We, therefore, examined late outcomes and durability for mitral repair in a large cohort of patients receiving a single annuloplasty device. METHODS: A total of 749 consecutive patients receiving mitral repair for degenerative mitral regurgitation (DMR) or ischemic mitral regurgitation (IMR) were evaluated from a prospective database. Patients with tricuspid or maze surgery were included. Papillary muscle rupture and mixed valve etiologies were excluded. Outcomes were compared for IMR versus DMR. RESULTS: Patients with DMR were younger and less urgent. Patients with IMR had mean end-systolic diameter 4.5 ± 1.1 cm. All patients received the same complete semirigid annuloplasty device with median ring size 32 mm for DMR and 24 mm for IMR. New York Heart Association failure class improved from 2.8 to 1.5 (p < .001). Patients with DMR had lower operative mortality (1/384 [0.3%] vs. 26/365 [7%], p < .0001) and shorter length of stay. A 15-year survival was better with DMR (63% ± 3% vs. 13% ± 2%, p < .001). At 10 years, the incidence of recurrent ≥2+ MR (10% ± 2% vs. 16% ± 2%, p = .16) was not significantly different. Predictors of recurrent ≥2+ MR were female gender (odds ratio [OR]: 3.0 (1.9-4.8, p < .0001), and prior operation (OR: 2.4 [1.3-4.5], p = .02) but not IMR (OR: 1.4 [0.9-2.3], p = .15). CONCLUSIONS: In this series, where patients with IMR had relatively preserved ventricular dimensions, the primary determinants of late recurrent MR were female gender and prior operation but not IMR versus DMR. Selected patients with IMR can obtain relatively durable mitral repair despite higher operative risk and lower survival compared to DMR.
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Anuloplastia da Valva Mitral , Insuficiência da Valva Mitral , Feminino , Seguimentos , Humanos , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/cirurgia , Resultado do Tratamento , Valva TricúspideRESUMO
BACKGROUND: Concerns regarding long-term durability of surgical repair for functional mitral regurgitation are based on short-term data, with few comparisons of ischemic mitral regurgitation (IMR) versus nonischemic functional mitral regurgitation (NIFMR) etiology. METHODS: Consecutive patients (N = 788) receiving mitral repair for functional mitral regurgitation were evaluated from a prospectively maintained database. Patients with other surgical procedures were included. Propensity score matching was used to compare outcomes in IMR versus NIFMR. RESULTS: Unmatched IMR patients tended to be older men with greater comorbidities. One hundred ninety-eight matched pairs of IMR versus NIFMR patients had similar demographics with a relatively preserved ejection fraction of 40% ± 13% and an end-systolic diameter of 4.3 ± 1.1 cm. Concomitant coronary revascularization occurred in 70% of matched IMR patients. All patients received an annuloplasty ring, usually 24 to 26 mm. Heart failure class improved from 2.8 preoperatively to 1.5 at 5 years (P < .0001). Survival at 15 years was worse with IMR (12% ± 3% vs 43% ± 5%, P < .0001). At 10 years the cumulative incidence of moderate or more (≥2+) mitral regurgitation (27% ± 4% vs 26% ± 4%, P = .4), severe regurgitation (10% ± 3% vs 8% ± 2%, P = .5), and mitral reoperation (3% ± 1% vs 3% ± 1%, P = .4) was not different between IMR versus NIFMR. Recurrent moderate regurgitation was associated with heart failure readmission but not with mortality. CONCLUSIONS: In propensity-matched patients IMR versus NIFMR had worse survival but similar repair durability, with moderate regurgitation in 27% at 10 years and rare severe regurgitation or mitral reoperation. In selected patients with relatively preserved function, mitral repair for IMR or NIFMR can improve symptoms with durable mild regurgitation in most patients out to 10 years.
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Insuficiência Cardíaca , Anuloplastia da Valva Mitral , Insuficiência da Valva Mitral , Isquemia Miocárdica , Idoso , Insuficiência Cardíaca/complicações , Humanos , Isquemia/complicações , Masculino , Valva Mitral/cirurgia , Anuloplastia da Valva Mitral/efeitos adversos , Insuficiência da Valva Mitral/etiologia , Isquemia Miocárdica/complicações , Isquemia Miocárdica/cirurgia , Resultado do TratamentoRESUMO
The literature for robotic mitral repair is dominated by a small number of large volume institutions, and intermediate-term outcomes out to 5 years are rare. Whether and under what circumstances a lower volume institution could obtain durable outcomes is not known. A retrospective review was performed on all 133 patients undergoing robotically assisted mitral repair from 2011 to 2019 at a single institution. Mean volume of robotic mitral repair was 16 ± 7 cases per year, while mean institutional total volume of mitral repair was 116 ± 16 cases per year. Mean age was 58 ± 12 years, 77% were men, and mitral etiology was prolapse in 90%. Comorbidity was infrequent with atrial fibrillation in 20% and moderate tricuspid regurgitation in 14%. Central aortic cannulation was used in 97% with concurrent tricuspid operation in 5% and concurrent maze in 14%. Median clamp time, pump time, and length of stay were 146 min, 265 min, and 5 days, respectively, but none improved with experience. There were no deaths or stroke. At 5 years, the cumulative incidence of moderate mitral regurgitation was 18 ± 6% (prolapse patients 11 ± 5%), severe regurgitation 4 ± 3%, and mitral replacement 9 ± 5% (prolapse patients 5 ± 3%). 5-year survival was 96 ± 3%. At centers with significant mitral repair volume, a volume of 16 robotic mitral cases/year can yield good clinical outcomes durable out to 5 years. A case volume of 16 cases per year was not sufficient to improve pump time or length of stay over time.
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Insuficiência da Valva Mitral , Procedimentos Cirúrgicos Robóticos , Robótica , Idoso , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/cirurgia , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/métodos , Resultado do TratamentoRESUMO
BACKGROUND: Techniques and results of aortic valve repair remain challenging. AIMS: Safari et al. seek to improve aortic valve repair by either aortic patching or valve sparing root replacement. MATERIALS AND METHODS: The results of bicuspid aortic valve (BAV) repair in 142 patients were examined withor without valve sparing root replacement. RESULTS: Isolated BAV repair with or without valve sparing root replacement provided goodclinical outcomes with relatively low reoperation rate and durable valve function. DISCUSSION: While clinical outcome from BAV repair was generally good, the authors have stopped pericardial patch augmentation of BAV leaflets due to suboptimal durability. CONCLUSION: Thelack of a durable valve patch material and the modest durability of BAV repairin general point out that aortic valve repair remains an ongoing struggle inmaterial science.
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Insuficiência da Valva Aórtica , Doença da Válvula Aórtica Bicúspide , Procedimentos Cirúrgicos Cardíacos , Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/cirurgia , Humanos , Ciência dos Materiais , Reoperação , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Zubarevich et al. present the 30 day and 1-year outcomes of redo mitral valve replacement in 58 high-risk patients. The authors conclude that careful patient selection and risk stratification provides acceptable surgical results in this cohort. This series reminds us that increased use of bioprostheses, increased use of mitral replacement instead of repair, and an aging population drive the volume of high-risk redo mitral replacement. It remains to be seen whether redo mitral mortality is getting better or worse, but the risk and the patients will be with us for some time.
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Bioprótese , Implante de Prótese de Valva Cardíaca , Idoso , Humanos , Valva Mitral/cirurgia , Reoperação , Resultado do TratamentoRESUMO
Habertheuer et al. present a risk scoring system for predicting morbidity and mortality in 1181 patients undergoing surgery for drug associated endocarditis. The authors conclude that drug-related endocarditis is associated with significant morbidity and mortality and that an easily-applied risk stratification score may aid in clinical decision making. The authors demonstrate excellent predictive accuracy in a multi-institutional dataset, and the system is applicable to multivalve patients. Time will tell if application of this or other risk scoring systems can truly provide a roadmap to improved outcomes.
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Endocardite , Tomada de Decisão Clínica , Endocardite/cirurgia , Humanos , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Resultado do TratamentoRESUMO
BACKGROUND: Infective endocarditis (IE) involving the aortic valve and root is associated with high risk requiring thoughtful surgical decision-making. The impact of valve and conduit choices and patient factors on long-term outcomes in this patient population is poorly documented. METHODS: From January 1976 to December 2013, 485 patients underwent aortic root and valve replacement at a single institution. Cox's proportional hazard model identified predictors of long-term survival and cumulative incidence functions were compared to assess need for reoperation with death as a competing risk. RESULTS: Median age at time of operation was 56.6 years (interquartile range: 23.1) with the indication for operation being endocarditis in 14.6% (n = 71). Stentless root replacement was used in 70% IE versus 34% non-IE (p < .001). Endocarditis at time of root replacement did not have a significant impact on survival through 15 years (IE: 37.3% vs. non-IE: 42.5%; log-rank; p = .13). After multivariable adjustment, survival was similar between patients with and without endocarditis (hazard ratio: 1.1; 95% confidence interval: [0.77, 1.62]; p = .57). Freedom from reoperation at 15 years did not vary significantly by endocarditis status (IE: 95.9% vs. non-IE: 73.6%; p = .07). Among endocarditis patients, freedom from reoperation at 10 years was similar between homograft and stentless bioprosthetic conduits (95.3% vs. 88.5%; log-rank; K-sample; p = .46). CONCLUSIONS: In a sample with frequent use of stentless prostheses, aortic root replacement for infective endocarditis had acceptable risk and long-term survival similar to root replacement for other indications. In the setting of endocarditis, root replacement with homograft or stentless bioprosthetic root has excellent durability through 15 years.
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Bioprótese , Endocardite , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Valva Aórtica/cirurgia , Endocardite/cirurgia , Humanos , Reoperação , Estudos RetrospectivosRESUMO
BACKGROUND: Port-access (PORT) and robotic (ROBO) mitral repair are well established, but differences in patient selection and outcomes are not well documented. METHODS: A retrospective analysis was performed on 129 ROBO and 628 PORT mitral repairs at one institution. ROBO patients had 4 cm nonrib spreading incisions with robotic assistance, while PORT patients had 6-8 cm rib spreading incisions with thoracoscopic assistance. Propensity score analysis matched patients for differences in baseline characteristics. RESULTS: Unmatched ROBO patients were younger (58 ± 11 vs. 61 ± 13, p = .05), had a higher percentage of males (77% vs. 63%, p = .003) and had less NYHA Class 3-4 symptoms (11% vs. 21%, p < .01), less atrial fibrillation (19% vs. 29%, p = .02) and less tricuspid regurgitation (14% vs. 24%, p = .01). Propensity score analysis of matched patients showed that pump time (275 ± 57 vs. 207 ± 55, p < .0001) and clamp time (152 ± 38 vs. 130 ± 34, p < .0001) were longer for ROBO patients. However, length of stay, postoperative morbidity, and 5-year survival (97 ± 1% vs. 96 ± 3%, p = .7) were not different. For matched patients with degenerative valve disease, 5-year incidence of mitral reoperation (3 ± 2% vs. 1 ± 1%), severe mitral regurgitation (MR) (6 ± 4% vs. 1 ± 1%), or ≥2 + MR (12 ± 5% vs. 12 ± 4%), were not significantly different between ROBO versus PORT approaches. Predictors of recurrent moderate MR were connective tissue disease, functional etiology, and non-White race, but not surgical approach. CONCLUSIONS: In this first comparison out to 5 years, robotic versus port-access approach to mitral repair had longer pump and clamp times. Perioperative morbidity, 5-year survival, and 5-year repair durability were otherwise similar.
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Insuficiência da Valva Mitral , Valva Mitral , Procedimentos Cirúrgicos Robóticos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/cirurgia , Pontuação de Propensão , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Maeda et al. present what may be the second reported case of transcatheter aortic valve replacement (TAVR) followed by staged open surgical aortic valve replacement (SAVR) in a high-risk patient. The authors propose that TAVR may serve as a bridge procedure before SAVR for aortic stenosis in selected younger patients with high surgical risk. Further experience may clarify how long to wait after TAVR to perform SAVR. Timing will be a balance between improving surgical risk versus increasing difficulty removing the prosthesis. Knowledge of TAVR durability will ultimately be needed to decide between "destination" TAVR versus bridging to SAVR with a more durable device.