Augmentation of the posterior mitral leaflet in secondary mitral valve insufficiency, mid-term results.

OBJECTIVES: We evaluate the mid-term results of mitral valve (MV) repair with patch augmentation of the posterior leaflet in secondary mitral regurgitation. METHODS: Patients were included after diagnosis of a severe symptomatic secondary MV insufficiency with grade III and IV according to the Carpentier classification IIIb. Indication for a patch augmentation technique was a dilatation of the left ventricle leading to a displacement of the papillary muscles, causing restricted leaflet motion and a marked leaflet tenting height. Data were collected prospectively between December 2011 and March 2020. RESULTS: In total, 174 patients (mean age: 65 ± 12 years) received an MV repair with patch augmentation of the posterior leaflet and a true-sized remodelling annuloplasty (mean size 30.8 mm). Causes of the MV incompetence were dilatative cardiomyopathy in 126 patients and ischaemic myocardial disease in 48 patients. Concomitant bypass surgery was performed in 28 patients, and the tricuspid valve was repaired in 68 patients. The mean follow-up was 40 ± 28.2 months. There was no 30-day mortality. In-hospital mortality was 1.2% (n = 2); late mortality was 10.9% (n = 19). At 8 years, overall survival was 62.48%, freedom from moderate or severe recurrent mitral regurgitation was 91.9% and freedom from reoperation due to MV insufficiency was 97.1%. CONCLUSIONS: Augmentation of the posterior MV leaflet in addition to remodelling annuloplasty is a safe and reproducible mitral reconstruction technique that renders sustainable MV competence.

Mitral valve repair for degenerative mitral valve regurgitation.

In industrialized countries, the most common etiology of mitral regurgitation (MR) is degenerative mitral valve (MV) disease. The natural history of severe degenerative MR is poor. However, its appropriate and timely correction is associated with a life expectancy similar to that of the normal population. Surgical MV repair is the gold-standard treatment. This review will focus on the most recent evidence with a specific emphasis on surgical indications, timing of treatment, contemporary surgical techniques, Heart Teams, and Centers of Excellence.

Bentall procedure after previous aortic valve or complete root replacement: Usefulness of self-assembled aortic valve conduit.

OBJECTIVES: The aim of this study was to evaluate surgical results of complete aortic root replacement using self-assembled valve composite graft in the setting of destroyed aortic annulus after previous valve replacement. METHODS: Aortic root pathology being addressed by complete root replacement was combined with partial or complete absence of annular tissue in 112 consecutive patients. Eighty-eight had undergone a previous replacement of the aortic valve and 24 had undergone root replacement with a valved conduit. Altogether, 31 patients (27.7%) presented with acute endocarditis, which was the indication for surgery in 75% of patients with prior root replacement. In all patients, the root replacement or re-replacement was performed with a self-assembled valved conduit using mechanical (n = 74) or, in patients with an advanced age, biological (n = 38) valve prostheses. RESULTS: In-hospital mortality was 11.6%, including a 30-day mortality of 6.3%. Resternotomy for bleeding was necessary in 5.4% of patients and about one-quarter did not need any blood transfusion. Estimated survival at 1, 5, and 10 years was 84.8% ± 3.4%, 75.7% ± 4.3%, and 57.1% ± 6.5%, respectively. Freedom from any valve-related events at 10 years was 86.2% ± 4.1%. During the follow-up time (mean, 63 ± 47 months), there was only 1 reoperation necessary 9 years after surgery (replacement of deteriorated biological valve prosthesis within the vascular tube leaving the conduit untouched). CONCLUSIONS: A self-assembled composite graft allows safe proximal fixation of the conduit in patients with destroyed aortic annulus, resulting in sufficient proximal anastomosis and a very low incidence of aorta-related reoperations.

Aortic Valve Leaflet Perforation After Minimally Invasive Mitral Valve Repair.

We report on 3 consecutive patients who suffered significant aortic leaflet injury during minimally invasive mitral valve reconstruction procedures and who subsequently underwent reoperation in our institution. In all cases, aortic valves were preserved, and the perforated leaflets were repaired using autologous pericardial patches.

Prolapse of the posterior leaflet: resect or respect.

Prolapse of the posterior leaflet (PPL) is the most frequent dysfunction of the mitral valve in the western world. Quadrangular resection, first proposed by Alain Carpentier, has progressed to become the gold standard modality to repair posterior leaflet prolapse. Although this "resection technique" is safe, reproducible, and offers favorable long term results, it presents major drawbacks. Firstly, it leads to a reduced surface of coaptation, the ultimate goal of mitral valve repair; secondly, it does not respect the anatomy of the mitral valve; thirdly, it leads to a deformation of the base of the ventricle; and finally, degenerative disease of the mitral valve is a spectrum of lesions depending on the amount of excess tissue, and hence, a one technique-fits-all strategy cannot meet the absolute necessity to repair all mitral valve patients with PPL. Therefore, new approaches which have been proposed place greater emphasis on respecting, rather than only resecting, the leaflet tissue in order to avoid the drawbacks of the "resection" approach. The use of artificial chordae to correct the leaflet prolapse restores the normal anatomy and physiology of the mitral valve, thus producing an optimal surface of coaptation. However, this approach is limited by anatomical variances. As a community, we should expand our vision and define a clear and helpful strategy for PPL: to obtain a high, smooth and regular surface of coaptation located in the inflow of the left ventricle. To achieve this goal, it is necessary to have a high level of respect for the leaflet tissue in order to obtain the best surface of coaptation. Nonetheless, a limited resection may be needed to remodel the posterior leaflet, so that it will be smooth and regular.

Totally endoscopic set-up for mitral valve repair.

Minimally invasive mitral surgery is increasingly recognized as routine. We describe here the financially economical set-up for totally endoscopic surgery, which also represents currently the smallest surgical access, limited only by prosthesis and retractor size. This allows the full range of repairs to be performed. Cannulation for cardiopulmonary bypass is performed via the groin. A cosmetic, periareolar (in males) or inframammary fold (in females) incision is made and the chest entered on bypass. An aortic cross-clamp and crystalloid cardioplegia are used via the aortic root prior to atriotomy and surgical repair. This method gives the highest level of cosmesis available and minimal discomfort, without compromising on the extremely good published results.

Surgical one-stage approach for coronary artery disease and occlusive disease of all aortic arch branches.

A 52-year-old man, who presented with two-vessel coronary artery disease and severe arterial occlusive disease with occlusions and/or stenoses of all aortic arch branches, underwent simultaneously coronary artery bypass grafting and bilateral aortic-subclavian as well as left-sided aortic-carotidal bypass grafting.

Rate of repair in minimally invasive mitral valve surgery.

BACKGROUND: Valve repair has been shown to be the method of choice in the treatment of patients with severe mitral valve regurgitation. Minimally invasive surgery has raised skepticism regarding the rate of repair especially for supposedly complex lesions, when anterior leaflet involvement or bileaflet prolapse is present. We sought to review our experience of all our patients presenting with degenerative mitral valve regurgitation and operated on minimally invasively. METHOD: From September 2006 to December 2012, 842 patients (mean age 56.12±11.62 years old) with degenerative mitral valve regurgitation and anterior leaflet (n=82, 9.7%), posterior leaflet (n=688, 81.7%) and bileaflet (n=72, 8.6%) prolapses were operated on using a minimally invasive approach. RESULTS: 836 patients had a valve repair (99.3%) and received a concomitant ring annuloplasty (mean size, 33.7; range, 28-40). Six patients (0.7%) underwent valve replacement. Two patients had a re-repair due to MR progression or infective endocarditis. Thirty-day mortality was 0.2% (two patients). There were 60 major adverse events (MAE) (7.1%). CONCLUSIONS: A minimally invasive approach allows repair of almost all degenerative valves with good short-term outcomes in a tertiary referral center, when using proven and efficient surgical techniques.

Toward a new paradigm for the reconstruction of posterior leaflet prolapse: midterm results of the "respect rather than resect" approach.

BACKGROUND: The aim of mitral valve reconstruction is restoration of good coaptation surface. Resection of the prolapsed area has been the accepted technique to repair prolapse of the posterior leaflet (PPL). However, as leaflet tissue is the basic component of coaptation surface, the logical corrective approach was thought to be the transformation of the posterior leaflet into a smooth vertical buttress without resection, the "respect rather than resect" approach. METHODS: Between 1994 and 2004, 225 patients underwent a PPL repair for severe mitral regurgitation with the respect rather than resect approach, in which the prolapse was corrected with artificial chordae. In 193 patients, the prolapse was limited to the posterior leaflet; in the remaining 32 patients, both leaflets were involved. All patients received ring annuloplasty. Associated procedures included myocardial revascularization (21 patients) and tricuspid repair (19 patients). Patient demographics were as follows: mean age, 60.7 +/- 12.9 years; male, 150 (67%); asymptomatic, 102 (45%). RESULTS: Three patients died postoperatively (1.3%). Survival at 10 years (88% +/- 6%) was similar to expected survival rate (97% +/- 2% for asymptomatic patients and 82% +/- 10% for symptomatic patients (p < 0.005)). Ten patients were reoperated on, for a freedom from reoperation rate of 93% +/- 3% at 10 years. At echocardiographic follow-up, 172 patients of 195 (88%) showed mitral regurgitation of 1 or less; and 195 of 203 patients (96%) were in New York Heart Association functional class I or II. CONCLUSIONS: The respect rather than resect approach is safe, effective, and durable, and increases technical repair possibilities. Surgical strategy focuses on restoration of surface coaptation instead of location and extent of leaflet resection.

Femoral versus aortic cannulation for surgery of chronic ascending aortic aneurysm.

BACKGROUND: Femoral artery cannulation and retrograde arterial perfusion have been postulated to increase the risk of cerebral embolism. In this study, the impact of the arterial cannulation site on the perioperative results after proximal aortic surgery is evaluated. METHODS: Between January 1996 and December 2002, a total of 327 patients underwent proximal aortic repair for chronic non-dissected aortic disease. The arterial inflow was established by cannulation of the aortic arch (group A) or the femoral artery (group F) in 166 and 161 patients, respectively. RESULTS: The early 30-day mortality was 0.9% (3 patients [1 patient in group A and 2 patients in group F]). The overall rate of early focal neurologic dysfunction (permanent and transient) was 4% (13 patients) and there was no significant difference between the two groups (4.2% vs 3.7%). Due to an intraoperative injury of the arterial wall, there were 6 repairs (3.6%) of the aortic arch in group A and 1 repair (0.6%) of the femoral artery in group F. The univariable examination of preoperative and intraoperative variables demonstrated that hypertension and increased cholesterol level could be possible independent risk factors for neurologic morbidity. In the following stepwise logistic regression, only the preoperative hypercholesterolemia was identified as an independent predictor for postoperative focal neurologic dysfunction. CONCLUSIONS: The arterial inflow via the femoral artery and the subsequent retrograde perfusion during cardiopulmonary bypass do not increase the risk of neurologic complications in patients who undergo proximal aortic repair due to chronic non-dissected aortic aneurysm. Because there is an increased risk of aortic wall injury during cannulation, the femoral artery seems to be more suitable in these cases for cannulation than the proximal aorta.

Prospective Evaluation of the St. Jude Medical Aortic Connector for Aortic-to-Autologous Vessel Graft Anastomoses.

BACKGROUND: : Evolving technologies of proximal anastomosis devices meet the endeavor of surgeons to minimize manipulation of the ascending aorta during surgical myocardial revascularization. The objective of this study was to compare the patency rate of the saphenous vein coronary bypass grafts in which the proximal anastomoses were performed with automatic connector devices to the suture technique. METHODS: : From September 2002 through July 2003, 86 patients underwent coronary artery bypass grafting with at least 1 vein graft anastomosed to the ascending aorta with the Symmetry G2 connector. Six-month clinical and angiographic follow-up, including Core-Lab quantitative coronary angiography (QCA) and corrected TIMI frame count (CTFC), was performed. RESULTS: : Eighty patients had at least 1 connector successfully implanted. Freedom from MACE (cardiac mortality myocardial infarction and target vessel reintervention) was 72/80 (90%). Six patients underwent a target vessel reintervention on the connector grafts. Six-month (mean 193 ± 36 days) angiography patency rates for the connector grafts were 72/81 (88.89%), 37/40 (92.5%) in sutured grafts, and 60/62 (96.8%) in arterial grafts. By QCA, 64/65 (98.5%) patent connector-grafts were free from more than 50% stenosis (1 connector-graft with a 51% stenosis). CTFC showed 65/65 (100%) patent connector-grafts with nonrestrictive flow. CONCLUSIONS: : Saphenous vein grafts anastomosed to the aorta with the Symmetry G2 connector have early and midterm patency rates comparable to the conventional sutured anastomoses. These results support the efficiency of the second generation of symmetry aortic connectors.