Scoring model based on cardiac CT and clinical factors to predict early good mitral valve repair in rheumatic mitral disease.

OBJECTIVE: We aimed to evaluate the mitral valve calcification and mitral structure detected by cardiac computed tomography (cardiac CT) and establish a scoring model based on cardiac CT and clinical factors to predict early good mitral valve repair (EGMR) and guide surgical strategy in rheumatic mitral disease (RMD). MATERIALS AND METHODS: This is a retrospective bi-center cohort study. Based on cardiac CT, mitral valve calcification and mitral structure in RMD were quantified and evaluated. The primary outcome was EGMR. A logical regression algorithm was applied to the scoring model. RESULTS: A total of 579 patients were enrolled in our study from January 1, 2019, to August 31, 2022. Of these, 443 had baseline cardiac CT scans of adequate quality. The calcification quality score, calcification and thinnest part of the anterior leaflet clean zone, and papillary muscle symmetry were the independent CT factors of EGMR. Coronary artery disease and pulmonary artery pressure were the independent clinical factors of EGMR. Based on the above six factors, a scoring model was established. Sensitivity = 95% and specificity = 95% were presented with a cutoff value of 0.85 and 0.30 respectively. The area under the receiver operating characteristic of external validation set was 0.84 (95% confidence interval [CI] 0.73-0.93). CONCLUSIONS: Mitral valve repair is recommended when the scoring model value > 0.85 and mitral valve replacement is prior when the scoring model value < 0.30. This model could assist in guiding surgical strategies for RMD. CLINICAL RELEVANCE STATEMENT: The model established in this study can serve as a reference indicator for surgical repair in rheumatic mitral valve disease. KEY POINTS: • Cardiac CT can reflect the mitral structure in detail, especially for valve calcification. • A model based on cardiac CT and clinical factors for predicting early good mitral valve repair was established. • The developed model can help cardiac surgeons formulate appropriate surgical strategies.

Risk factors for postoperative recurrent tricuspid regurgitation after concomitant tricuspid annuloplasty during left heart surgery and the association between tricuspid annular circumference and secondary tricuspid regurgitation.

BACKGROUND: To identify the association between tricuspid annular circumference and secondary tricuspid regurgitation and analyze the risk factors of recurrent tricuspid regurgitation after concomitant tricuspid annuloplasty during left heart surgery. METHODS: From October 2018 to June 2019, a total of 117 patients receiving concomitant tricuspid annuloplasty within left heart surgery were enrolled. Severity of tricuspid regurgitation was classified as 4 subtypes: normal, mild, moderate and severe. Perioperative data and mid-term outcome were collected. Tricuspid annular circumference (TAC) was measured under cardiac arrest during surgery procedure by cardioplegia. Optimal TAC and TAC index (TAC/body surface area, BSA) cutoffs of significant tricuspid annulus dilatation (moderate and severe) were obtained. Univariable and multivariable logistic regression analyses were performed to identify the risk factors of postoperative recurrent tricuspid regurgitation. The follow up period is 13-19 months (mean 15.5 ± 3.2 months). RESULTS: There was 1 patient was excluded who died after surgery. A total of 116 patients receiving tricuspid annuloplasty were included. Optimal cutoffs of significant tricuspid annulus dilatation were recommended (TAC 11.45 cm, Sensitivity 82.89%, Specificity 73.68%, AUC 0.915; TAC index 7.09 cm/m2, Sensitivity 73.68%, Specificity 85%, AUC 0.825, respectively). Based on findings of multivariable logistic regression, it has been showed that TAC index and postoperative atrial fibrillation were the independent risk factors of recurrent regurgitation after surgery. Optimal TAC index cutoff to predict recurrent tricuspid regurgitation was 7.86 cm/m2 CONCLUSIONS: The severity of secondary tricuspid regurgitation is associated with the tricuspid annular circumference. The cut-offs of significant tricuspid regurgitation (more than moderate) were TAC 11.45 cm and TAC index 7.09 cm/m2, respectively. Clinically, concomitant tricuspid annuloplasty is relative safe and effective. TAC index ≥ 7.86 cm/m2 and postoperative atrial fibrillation are the risk factors of recurrent significant tricuspid regurgitation after concomitant tricuspid annuloplasty during left heart surgery.

Commissuroplasty as a Main Operative Technique in Rheumatic Mitral Valve Repair: Surgical Experiences and Mid-Term Results.

AIM: We aimed to evaluate the therapeutic effectiveness of commissuroplasty in mitral valve repair for rheumatic mitral valve disease. For this purpose, we summarise our experience with this technique and analyse the mid-term postoperative outcomes. METHOD: We retrospectively evaluated the records of patients with rheumatic valve disease who underwent mitral valve repair between January 2011 and January 2018 at our centre. Detailed follow-up data were collected. A Kaplan-Meier survival curve for survival free from reoperation and valve failure was constructed. Multivariate Cox regression analyses were performed to identify predictors of relevant end points (death, reoperation, and valve failure). RESULTS: A total of 362 patients underwent rheumatic mitral valve repair during the study period. Mitral valve stenosis was the primary pathological feature. Almost all surgeries were accomplished via commissuroplasty. The mean duration of follow-up was 25.57 ± 19.91 months. Twenty-two (22) endpoint events were noted during follow-up. The 2- and 7-year rates of survival free from reoperation and valve failure were 93.9%±1.4% and 91.5%±2.0%, respectively. Multivariate Cox regression analysis revealed that left atrial anteroposterior diameter >60 mm (hazard ratio, 5.2; p < 0.001) was an independent predictor of all endpoints. CONCLUSIONS: Most Chinese patients with rheumatic valve disease were treated effectively via commissuroplasty combined with other surgical procedures, and the mid-term postoperative outcomes were satisfactory.

MicroRNA profiling in the left atrium in patients with non-valvular paroxysmal atrial fibrillation.

BACKGROUND: We aimed to identify the miRNA expression profiles in left atrial appendage, with the intention of identifying miRNAs that were significantly associated with non-valvular paroxysmal AF. METHODS: The RNA samples were isolated from healthy controls (n = 5) and patients with atrial fibrillation (n = 8). To confirm the findings obtained by analyzing the miRNA profile, we measured the expression of selected miRNAs in the entire cohort by quantitative PCR. RESULTS: Ten specific miRNAs were found to be differentially expressed between atrial fibrillation and healthy controls with more than a 2-fold change (P < 0.05). Consistent with the data obtained for the profile, expression levels of miRNA-155, miRNA-146b-5p and miRNA-19b were significantly increased in patients with atrial fibrillation. Interestingly, levels of miRNA-146b-5p and miRNA-155, which are known to be associated with inflammation, were independently and positively associated with left atrium dimension, atrial fibrillation duration and high sensitivity C-reactive protein levels. By using four Databases (TargetScan, miRanda, Starbase Clip-seq and miRDB) to perform target gene prediction, there were four genes were related to the inflammatory response and fibrosis, and three others encoding cardiac ion channel proteins. As a result of TaqMan qPCR and Western analysis, the relative mRNA and protein expression level of three target genes (DIER-1, TIMP-4 and CACNA1C) were significantly lower in the atrial fibrillation group than that in the healthy control group. CONCLUSIONS: Expression of inflammation-associated miRNAs is significantly up-regulated in the left atrial appendage of patients with non-valvular paroxysmal atrial fibrillation, which may play a significant role in electrical and structural remodeling.

CH-VAD left ventricular assist implantation combined with the Bentall procedure and coronary artery bypass grafting.

Left ventricular assist device (LVAD) implantation is an effective alternative treatment to heart transplantation, especially for end-stage heart failure patients who are ineligible for or unable to await a heart transplant. This report describes a complex and innovative surgery where LVAD implantation was performed alongside multiple concomitant cardiac and aortic procedures. A 62-year-old male patient with complicated comorbidities developed acute myocardial infarction and subsequent refractory advanced heart failure. Given his critically ill condition and intractable anatomical malformations, the CH-VAD left ventricular assist system implantation was performed concomitantly with the Bentall procedure, coronary artery bypass grafting, tricuspid valvuloplasty, and foramen ovale closure. The patient was successfully discharged. This case details the medical decision-making process and surgical strategy and demonstrates the feasibility of LVAD implantation combined with multiple additional cardiac and aortic procedures in expert cardiac centres. Success relies on experienced cardiac surgeons and a multidisciplinary LVAD Heart Team, ensuring excellence in surgical techniques, preoperative evaluation, post-operative care, and rehabilitation.

[Differential expressions of miRNAs in patients with nonvalvular atrial fibrillation].

OBJECTIVE: To detect the differential expressions of miRNAs in left atrial appendage (LAA) in patients with atrial fibrillation (AF). METHODS: Left atrial samples were collected from nonvalvular AF patients and healthy controls. The miRNA transcriptome was analyzed by microarray and verified by real-time reverse transcription-polymerase chain reaction. Computational prediction identified the AF-related miRNAs and its target gene. In the meantime, construction of reporter plasmids and reporter assays were performed to test whether miRNA could represses the Luciferase activity of 3' untranslated regions of its target gene. RESULTS: MiR-155, miR-142-3p, miR-19b, miR-223, miR-146b-5p, miR-486-5p, miR-301b, miR-193b, miR-519b were found to be up-regulated by > 2 folds whereas miR-193a-5p was down-regulated. In particular, the level of miR-155 increased by 5.78 folds in AF patients versus healthy controls (9.42 ± 4.74 vs 1.63 ± 0.65). Furthermore, computational prediction identified CACNA1C encoding Cav1.2 as a direct target of miR-155. In the meantime, the construction of reporter plasmids and reporter assays showed that miR-155 repressed the Luciferase activity of 3' untranslated regions of CACNA1C. CONCLUSION: In LAA sample of nonvalvular AF, there is an expression of AF-related miRNAs including miR-155. And it reveals a potential link between the regulation of Cav1.2 and miR-155 in electric remodeling of AF.

Decade-long mitral valve surgery trends and rheumatic heart disease: a review of mitral valve surgery in a large Chinese cardiovascular center.

BACKGROUND: Despite being one of the few chronic secondary heart diseases that can be prevented, current epidemiological data on rheumatic heart disease (RHD) in China are unavailable. This study examined mitral valve (MV) surgery trends in a large Chinese cardiovascular center over the last 10 years and provided insight into the distribution of RHDs and their changes. METHODS: Medical records of patients who underwent cardiac surgery, MV surgery, and MV surgery for rheumatic MV (rMV) disease at Beijing Anzhen Hospital between January 2010 and December 2019 were retrospectively reviewed. Patients' demographic and clinical characteristics were statistically analyzed among age groups. RESULTS: Overall, 7,736 patients underwent rMV surgery and 87.5% were aged 40-70 years. The proportion of patients aged >60 years increased annually (P<0.05), and the proportion of patients in all other age groups decreased. The proportion of patients with rMV diseases among those with cardiac or mitral valve diseases decreased each year, but the absolute number of patients with rMV disease remained stable. Approximately 90% of patients who underwent rMV surgery were from northern China. The incidence of rMV disease among patients with mitral valve disease moderately correlated with the per capita gross regional product (Per-GRP), an indicator of living standards (r=-0.517, P<0.05). CONCLUSIONS: RHD still exists in northern China and requires adequate resources for its management. The number of older patients with rMV disease presents a challenge for mitral valve surgery.

Short-Term Results on Leaflet Mobility in Patients Undergoing Rheumatic Mitral Valve Repair With an Efficient 4-Step Commissuroplasty Technique.

BACKGROUND: Mitral valve stenosis (MS) is the primary pathologic feature of rheumatic mitral valve disease, and the complex repair affects its clinical outcome. This study aimed to examine the efficacy of the 4-step commisuroplasty "SCORe" procedure by assessing changes in the mobility of mitral valve leaflets and its clinical effects. METHODS: From September 1, 2018, to January 13, 2019, patients with MS who underwent mitral valve repair with the SCORe procedure in the study center were analyzed in this prospective study. Mitral valve structure was assessed by transthoracic echocardiography pre- and postoperatively as well as during follow-up. RESULTS: In total, 60 consecutive patients were examined. In 56 patients (93.3%), mitral valve orifice area (MVOA) was less than 1.5 cm2, and mean (SD) MVOA for the whole cohort was 1.20 (0.34) cm2. The mobility of the anterior leaflet was improved (P < .001) during the cardiac cycle postsurgery, but that of the posterior leaflet was not (P = .591). The mean (SD) coaptation length was increased significantly from 6.69 (1.32) mm to 7.92 (1.24) mm (P < .001) postoperatively. Mean (SD) MVOAs increased to 2.24 (0.38) cm2 postoperatively (P < .001). During the 1-year follow-up, there were no deaths or reoperations. Follow-up echocardiography revealed minor or mild regurgitation in 98.3% of patients. CONCLUSION: These findings demonstrated that the SCORe procedure can effectively improve the mobility of mitral leaflets and enlarge the valve orifice area in patients with rheumatic MS in China, with minimal complications and promising results.

Sufentanil: a risk factor for lactic acidosis in patients after heart valve surgery.

BACKGROUNDS: Hyperlactatemia is a common metabolic disorder after cardiac surgery with cardiopulmonary bypass. Epinephrine use has been identified as a potential cause of increased lactate levels after cardiac surgery. Stress can lead to an increase in catecholamines, mainly epinephrine, in the body. Exogenous epinephrine causes hyperlactatemia, whereas endogenous epinephrine released by stress may have the same effect. Opioids are the most effective anesthetics to suppress the stress response in the body. The authors sought to provide evidence through a retrospective data analysis that helps investigate the relationship between intraoperative opioid dosage and postoperative lactic acidosis after cardiac surgery. METHODS: The clinical data of 215 patients who underwent valvular heart surgery with cardiopulmonary bypass from July 2016 to July 2019 were analyzed retrospectively. Blood lactate levels were measured at 0.1 h, 2 h, 4 h, and 8 h after surgery. Patients with continuous increases in lactate levels and lactate levels exceeding 5 mmol/L at two or more time points were included in the lactic acidosis group, whereas the other patients were included in the control group. First, univariate correlation analysis was used to identify parameters that were significantly different between the two groups, and then multivariate regression analysis was conducted to elucidate the independent risk factors for lactic acidosis. Fifty-one pairs of patients were screened by propensity score matching analysis (PSM). Then, lactic acid levels at four time points in both groups were analyzed by repeated measures ANOVA. RESULTS: he EF (heart ejection fraction) (OR = 0.94, P = 0.003), aortic occlusion time (OR = 10.17, P < 0.001) and relative infusion rate (OR = 2.23, P = 0.01) of sufentanil was an independent risk factor for lactic acidosis after valvular heart surgery. The patients were further divided into two groups with the mean sufentanil infusion rate as the reference point. The data were filtered with PSM (Propensity Score Matching). Lactic acid values in both groups peaked at 4 h after surgery and then declined. The rate of lactic acid decline was significantly faster in the group with a higher sufentanil dosage than in the lower group. The difference was statistically significant (P < 0.05). There was also a significant difference in lactic acid levels at the four time points (0.1 h, 2 h, 4 h and 8 h after surgery) in both groups (P < 0.001). CONCLUSION: The inadequate intraoperative infusion rate of sufentanil is an independent risk factor for lactic acidosis after heart valve surgery. The possibility of lactic acidosis caused by this factor after cardiac surgery should be considered, which is helpful for postoperative patient management.

Clinico-pathological classification of rheumatic mitral valve damage and surgical strategy.

BACKGROUND: There is a lack of established pathological indications for rheumatic valve repair. Therefore, we summarized the pathological classifications of rheumatic heart diseases and their correlations with the surgical strategies. METHODS: This observational study enrolled patients with rheumatic heart diseases who underwent mitral valve repair (MVP) or replacement at our centre between January 2017 and January 2019. Mitral leaflet, mitral commissural, and sub-valvular apparatus were classified into three grades from mild to severe, according to their degree of pathological damage. Based on certain principles and the grade of mitral leaflet, mitral commissural, and sub-valvular apparatus damage, three pathological types were identified (types I to III), based on which all patients were classified. The features of each pathological type were summarised. Differences between the three pathological types were analysed using chi-square test of tendency. These data were used to propose a clinico-pathological classification of rheumatic mitral valve damage in Chinese patients. RESULTS: Of 398 patients, 284 (70%) underwent MVP for rheumatic mitral valve diseases. There were 58 type I (15%) patients in the study, all of whom underwent repair (repair rate, 100%). Preoperative moderate-to-severe regurgitation with mild pathological lesions was observed in 64% of these patients. In 260 type II (65%) patients, the repair rate was 76% (197/260); preoperative moderate-to-severe stenosis was observed in 88% of these patients. In 80 type III (20%) patients, the repair rate was 36% (29/80); the preoperative rates of extremely severe stenosis and moderate-to-severe regurgitation in these patients were 50% and 40%, respectively. Several preoperative parameters show the change in trend with the increase in the pathological classification severity. CONCLUSIONS: Our clinico-pathological classification of rheumatic mitral valve damage is applicable to MVP. Considering that the classification principles are based on the possibility of mitral repair, it provides a phased and achievable target ratio for MVP and a principle of screening patients who should undergo rheumatic MVP.

[Video-assisted minimally invasive radiofrequency ablation in the treatment of persistent atrial fibrillation].

OBJECTIVE: To evaluate the effectiveness of the video-assisted minimally invasive radiofrequency ablation combined irbesartan use for the treatment of the persistent atrial fibrillation (AF). METHODS: From January 2006 to December 2009, 83 patients with persistent AF having a video-assisted minimally invasive radiofrequency ablation. There were 58 males, 25 females with a mean age of (57 ± 11) years. Mean duration of preoperative AF was (61 ± 65) months. Follow-up for the whole patients ranged from 1.0 to 3.6 years [mean (2.2 ± 0.8) years]. Patients were randomly divided into irbesartan group (n = 42) and without irbesartan group (n = 41) postoperatively. RESULTS: No patient died postoperatively. During follow-up, there was 1 patient died of unknown reason. At the end of the procedure, 38 patients (45.7%) were sinus rhythm, 4 patients (4.9%) were pacing rhythm, 5 patients (6.0%) were atrial flutter or atrial tachycardia, and 36 patients (43.4%) were AF. Before discharge, 53 patients (63.9%) were sinus rhythm, 24 patients (28.9%) were AF. At late follow-up, 65 patients (80.2%) were sinus rhythm; 14 patients (17.3%) were AF or atrial flutter. After follow-up, the Kaplan-Meier analysis showed the irbesartan group had fewer patients with AF (P = 0.020). The hazard ratio for AF recurrence in patients treated with irbesartan was 0.24 (95% CI: 0.087 to 0.637, P = 0.004). CONCLUSIONS: The video-assisted minimally invasive radiofrequency ablation is safe and effective. The patients treated with irbesartan have a lower rate of recurrence of AF.

Rheumatic mitral valve repair: the Score procedure.

We have defined a standard surgical procedure for rheumatic mitral valve repair (the Score procedure) including four steps: shaving, checking, commissurotomy, and relaxing. Here, we summarize the clinical pathological classification for making a decision on repair or replacement. Given the large number of patients in China, we consider it the responsibility of Chinese cardiac surgeons to adopt a therapeutic schedule for rheumatic mitral valve disease, which includes a simple operation with reliable effects and easy to promote. This schedule would ensure that millions of patients get the best treatment to extend survival and improve their quality of life.

Repair versus replacement of mitral valves in cases of severe rheumatic mitral stenosis: mid-term clinical outcomes.

BACKGROUND: We compared and analyzed differences between repair vs. replacement of mitral valves on severe rheumatic mitral stenosis by looking at mid-term clinical outcomes. METHODS: Patients with severe rheumatic mitral stenosis (mitral valve area ≤1.5 cm2, with or without mitral valve regurgitation) from January 2011 to September 2017 were divided into two groups: a mitral valve repair group (MVP) and a mitral valve replacement group (MVR). After propensity score matching between the two groups, we compared changes in post-operation clinical outcomes. We also monitored changes in left ventricular longitudinal and circumferential strain in successfully matched patients (20 pairs) by echocardiography speckle tracing. RESULTS: A total of 921 patients were recruited (221 in MVP and 700 in MVR). After a propensity score matching, 216 cases were selected with 108 patients in each group. With a follow-up period of 3 months to 7.1 years, the incidence of heart failure was observed to be significantly higher in the MVR group than in the MVP group (P<0.05). Echocardiographic speckle tracking imaging analysis showed that left ventricular longitudinal strain decreased in the MVR group, suggesting that a change of cardiac structure may affect the cardiac function. CONCLUSIONS: Selecting suitable patients for mitral valve repair is feasible even for patients with severe rheumatic mitral stenosis. In our study, compared with prosthetic valve replacement in these patients, valve repair still significantly reduced the valve-related complications rates and improved the quality of life during the follow-up.

Structural analysis of the mitral valve in rheumatic and degenerative mitral valve diseases: implications for annuloplasty selection.

BACKGROUND: Mitral valve (MV) repair has been recommended for MV diseases. Good repair requires a full understanding of the three-dimensional (3D) structure of the MV, however, currently little is known about the 3D structure of the rheumatic MV. METHODS: A total of 82 cases underwent 3DTEE. Of these, 41 patients with rheumatic valvular disease (RVD) were studied intraoperatively (17 had severe mitral stenosis, 8 had severe mitral regurgitation, 16 had severe mitral stenosis coupled with regurgitation). There were 19 patients with degenerative MV disease (mitral valve prolapse [MVP] with severe regurgitation) and 22 cases with normal MV served as control subjects (CS). RESULTS: Compared with CS, the anteroposterior diameter, anterolateral posteromedial, annulus circumference, and annulus area of both pathological groups, i.e., the RVD and MVP groups, were understandably greater. Though the sphericity index was greater in the RVD group vis-à-vis CS, the MVP group had nearly the same sphericity index as CS. The mitral annulus of patients with RVD tended to be round. Annular unsaddling, defined as annular height to commissural width ratio (an indicator of saddle degree) less than 15%, was significantly more prevalent in the group with degenerative MV disease. Automatic dynamic analysis revealed that the parameters of annular maximum displacement and annulus area fraction (two-dimensional) were considerably decreased in the RVD group. CONCLUSIONS: Annular unsaddling was significantly more prevalent in the degenerative MV disease group. The mitral annulus of patients with RVD tended to be round and stiff.

Intraoperative method based on tricuspid annular circumference in patients with mild or no tricuspid regurgitation during left-sided cardiac valve surgery for the prophylactic tricuspid annuloplasty.

BACKGROUND: During left-sided cardiac valve surgery in patients with mild or no tricuspid regurgitation (TR), the tricuspid valve exploration plays a vital role in the decision-making of concomitant tricuspid annuloplasty. Currently lack of an appropriate standard to define tricuspid annular dilatation is a challenge. The aim of this study is to introduce and evaluate an alternative intraoperative method for Tricuspid Valve annuloplasty based on annular circumference that could trace the extent of annular dilatation and predict TR-progression, which can also guide the surgeons to intraoperative decision. METHODS: From January 2011 to December 2011, 131 patients (73 females, 58 males, and mean age 54±10.8) were selected for the study underwent left-sided cardiac valve surgery at Anzhen Hospital, all the subjects preoperatively diagnosed with non-significant TR. The enrolled subjects were followed-up over 5years for TR-progression. Tricuspid annular circumference (TAC) measurement was performed via special sizer for each patient, and the obtained values divided on the subject's body surface area (BSA) to achieve the tricuspid annular circumference index (TACI). The endpoint was set as the TR-progression by more than two grades, or a final TR grade ≥3+. RESULTS: The mean follow up period was 68±3.8 months (range, 60-77 months). In univariate, multivariate and logistic regression analysis three variables were noticed to be associated with TR progression, female gender (P<0.002), body mass index (BMI) (P<0.021), and intraoperatively measured TACI (P<0.001). But in multiple regression the TACI (OR 0.812; 95% CI: 0.748-0.883; P<0.001) was the single parameter which significantly related to TR-progression. Based on the receiver-operator curve (ROC), it was likely to derive an optimal cut-off 80.2 mm/m2 which could predict the postoperative development of TR with acceptable sensitivity and specificity 69%, 89%. CONCLUSIONS: Patients with mild or no TR undergoing left-sided valve surgery, intraoperative measurement of the TAC proved to be an ideal method to judge the tricuspid-annulus, it is capable to predict TR-progression. For prophylactic tricuspid repair a presumed TACI of 80.2 mm/m2 is recommended as an indicative threshold.

Features of rheumatic mitral valves and a grading system to identify suitable repair cases in China.

BACKGROUND: We aimed to assess the pathological characteristics of rheumatic mitral valve disease in Chinese patients and formulate a pathological grading system to identify cases suitable for rheumatic mitral valve repair (rMVP). METHODS: Nearly 5 years of follow-up data on patients who underwent rMVP were analysed. A Kaplan-Meier survival curve for freedom from reoperation and valve failure was constructed. A pathological grading system of rheumatic mitral valve lesions (PGSRMVL) was developed based on the pathological characteristics of rheumatic mitral valve disease and tested by receiver operating characteristics (ROCs) curve analysis. Predictors of endpoints for rheumatic repair were analysed. RESULTS: From January 2012 to June 2016, 179 patients underwent rMVP in our centre. The mean follow-up duration was 24±14 months. A left atrial anterior and posterior diameter >60 mm was an independent predictor for the 16 endpoints [hazard ratio (HR) =3.884, P=0.029]. Between 2015 and 2016, 126 consecutive pathological characteristics of rheumatic mitral valve were evaluated (61 and 65 repair and replacement cases, respectively). The ROCs area under the curve was 0.891 for the correlation between the pathological score and successful repair (cut-off point, 17.5; sensitivity, 78%; specificity, 85.2%). Seven lesions had higher ratios in the replacement group than the repair group. Commissural fusion/calcification and main chordae tendineae fusion/calcification were the most common severe pathological lesions. CONCLUSIONS: The main pathological characteristics of rheumatic mitral valve disease in Chinese patients are commissure and sub-valvular apparatus lesions. Most patients can be appropriately treated via commissurotomy and leaflet thinning. Severe calcification of the commissure and sub-valvular apparatus can considerably decrease the odds of a successful repair. The median follow-up results of rheumatic mitral repair are considered satisfactory for the pathological characteristics in Chinese patients.

Impact of Surgical Ablation of Atrial Fibrillation on the Progression of Tricuspid Regurgitation and Right-Sided Heart Remodeling After Mitral-Valve Surgery: A Propensity-Score Matching Analysis.

BACKGROUND: This study assessed the role of surgical ablation for atrial fibrillation (AF) in decreasing tricuspid regurgitation (TR) and right-sided heart remodeling in patients after mitral valve procedure. METHODS AND RESULTS: Between 1994 and 2014, 1568 consecutive patients with AF undergoing mitral valve procedure were identified. In 26.0% (n=408), surgical ablation of AF was used. Propensity-score matching (PSM) was performed on the basis of 41 known perioperative risk variables. Survival, reoperation, stroke, and moderate-to-severe TR, as well as echocardiography indices in long-term follow-up, were compared in 406 matched patient pairs (ablated and nonablated groups). The nonablated group showed significantly higher risks of death (hazard ratio [HR], 1.644; 95% CI, 1.081-2.501; P=0.020), reoperation (HR, 2.644; 95% CI, 1.299-5.466; P=0.008), and moderate-to-severe TR (HR, 1.436; 95% CI, 1.059-1.948; P=0.020), associated with a significantly deteriorated cardiac function, progression of TR, and right-sided heart remodeling after 5-year follow-up. In a subgroup comparison of ablated patients with sinus rhythm versus AF recurrence, a PSM analysis was performed at the 5-year follow-up. The recurrent group showed significantly higher risks of moderate-to-severe TR (HR, 2.427; 95% CI, 1.261-4.671; P=0.008). AF recurrence was associated with progressive TR and significant deterioration in right-sided heart remodeling. CONCLUSIONS: In a retrospective PSM analysis, mitral valve disease with AF was associated with TR progression as well as right-sided heart remodeling, which are alleviated by surgical ablation.

Ablation in selective patients with long-standing persistent atrial fibrillation: medium-term results of the Dallas lesion set.

OBJECTIVES: The aim of the study was to investigate the efficacy and safety of the Dallas lesion set, which mimics the Cox-maze III left atrial (LA) lesions, for long-standing persistent atrial fibrillation (LSPAF). METHODS: Over a 4-year period, 103 LSPAF patients were treated with the Dallas lesion set. Linear lesions were created at the roofline, at the anterior line and between the roofline and left atrial appendage (LAA). All patients underwent ganglionated plexi ablation and LAA excision as well as pulmonary vein isolation. Follow-up at 6, 12 and 24 months was performed by 48-h Holter recordings and real-time 3-dimensional echocardiography. RESULTS: At the 24-month follow-up, 83 of 103 (80.6%) patients were free of any atrial arrhythmia lasting >30 s, with 77 patients (74.8%) off of antiarrhythmic drugs (AADs). At 3.1 ± 0.7 years, 74 of 103 patients (71.8%) were in sinus rhythm, with 71 patients (68.9%) off AADs. The optimal cut-off value of LA dimension to discriminate atrial arrhythmia recurrence was 55 mm (receiver operating characteristic curve analysis), and the Kaplan-Meier analysis showed that patients with an LA dimension of <55 mm had less recurrence during the follow-up (log-rank test, P = 0.015). After 6 months, a significant reduction in LA volume and improvement in LA function was noted in patients without recurrence (P < 0.05). In contrast, patients with recurrence showed no improvement in LA volume or function. CONCLUSIONS: The Dallas lesion set is an effective treatment in patients with LSPAF. It resulted in significant improvement in LA volume and function after restoration of sinus rhythm.

Treatment of long-lasting persistent atrial fibrillation using minimally invasive surgery combined with irbesartan.

BACKGROUND: Recent studies have provided evidence that the renin-angiotensin system plays a key role in the onset and progression of atrial fibrillation (AF). The current study was designed to assess the efficacy and safety of video-assisted minimally invasive radiofrequency ablation for long-lasting persistent AF, as well as to evaluate the efficacy of the angiotensin-receptor blocker irbesartan for maintaining sinus rhythm. METHODS: Over a period of 4 years, 83 patients with long-lasting persistent AF underwent minimally invasive ablation at our center. The patients were randomly assigned to two groups, one group treated with ablation plus irbesartan, and the other with ablation alone. Follow-up ranged from 1 to 3.6 years. RESULTS: No patient died postoperatively. At the end of the procedure, 38 patients (45.7%) were in sinus rhythm, and 36 (43.4%) had AF. At the last follow-up, 65 patients (80.2%) were in sinus rhythm, 38 (92.7%) in group 1 and 27 (67.5%) in group 2 (p = 0.002). Patients in group 2 had a significantly higher rate of recurrent arrhythmia (Kaplan-Meier analysis, p = 0.004; hazard ratio, 0.24; 95% confidence interval: 0.087 to 0.637). Kaplan-Meier analysis also showed that patients treated with irbesartan had a significantly lower rate of use of antiarrhythmic drugs (p = 0.02). CONCLUSIONS: The video-assisted minimally invasive ablation procedure was safe and effective for patients with long-lasting persistent AF. Patients who were additionally treated with irbesartan had a significantly lower rate of AF recurrence than patients who were treated with ablation alone.