[Long-term clinical and echocardiographic follow-up of the edge-to-edge technique for surgical mitral valve repair]. / Follow-up clinico ed ecocardiografico a lungo termine dopo riparazione valvolare mitralica con tecnica "edge-to-edge".

BACKGROUND: To evaluate the long-term clinical and echocardiographic performance of mitral valve repair with the edge-to-edge technique. METHODS: In-hospital results, actuarial freedom from all-cause mortality, cumulative incidence of cardiovascular mortality, recurrent mitral regurgitation ≥3+ and reoperation on the mitral valve were assessed in 180 consecutive patients undergoing mitral repair with the edge-to-edge technique for degenerative or functional regurgitation. Exercise echocardiography was performed in 24 patients to assess valve hemodynamics in the long-term follow-up. RESULTS: The edge-to-edge repair was applied as a first strategy in 157 patients (87.2%) or as a bail-out procedure in 23 patients (12.8%). At discharge, mitral regurgitation grade was absent in 152 patients (84.4%) and trivial in 28 patients (15.6%). Mean gradient was 2.8 ± 0.6 mmHg and effective orifice area was 2.9 ± 0.4 cm2. After a median follow-up of 6.5 (interquartile range 3.5-10.2) years, 93.6% patients were in NYHA functional class I-II. Actuarial survival at 15 years was 89.2 ± 2.7%, whereas the cumulative incidence of cardiovascular mortality was 7.0%, of recurrent mitral regurgitation ≥3+ 12.6% and of reoperation on the mitral valve 3.2%. Exercise stress echocardiography revealed a significant increase of functional area (3.1 ± 0.3 vs 4.0 ± 0.6 cm2, p<0.001) and mean gradients (2.7 ± 0.4 vs 4.6 ± 1.2 mmHg, p<0.001). CONCLUSIONS: The edge-to-edge technique effectively corrects degenerative and functional mitral regurgitation and represents a valid bail-out procedure in case other approaches failed to achieve adequate intraoperative valve competence. Long-term results are sustained up to 15 years, with significant improvement in functional status. Despite an altered geometry, the occurrence of iatrogenic mitral stenosis is avoided even at high workload conditions.

[Totally endocardial surgical ablation of atrial fibrillation combined with mitral valve surgery. Our experience with the Cardioablate pen]. / L'ablazione chirurgica per via endocardica della fibrillazione atriale associata alla chirurgia valvolare mitralica. Nostra esperienza con la penna Cardioablate.

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia found in mitral valve (MV) disease, occurring in 30 to 85% of patients. Since 1999, AF has been ablated using monopolar epicardial-endocardial radiofrequency. In this study, we describe our own endocardial experience of using the Cardioablate monopolar radiofrequency irrigated pen for the ablation of AF in patients undergoing MV surgery and an analysis of the short and mid-term results. METHODS: From August 2002 to February 2004, a monopolar radiofrequency pen was used to ablate AF in 29 patients undergoing MV replacement or repair (24 females, 82.7%). Preoperative AF was paroxysmal in 27.6% of the patients, persistent in 13.8%, and permanent in 58.6%. The mean left atrial diameter was 65.8 +/- 11.4 mm (range 40-92 mm). In all the patients the ablation lines were created under conditions of extracorporeal circulation and aortic cross-clamping and carried out according to the Alfieri's set. The left atrial appendage was resected or excluded. Endocardial ablation increased the duration of the operation by a mean time of 14.8 +/- 2.7 min with an average time of 7.3 +/- 1.4 min for radiofrequency application. RESULTS: All patients left the operating room with ginus rhythm (SR) or with atrioventricular pacing. Perioperative AF was common, affecting 51.7% of patients. Six patients required electrical cardioversion. Both early postoperative death (2 patients, 6.8%) and complications were not procedure-related. At discharge, all patients were in SR. The mean follow-up was 14.8 +/- 5.2 months (range 7-25 months). Only 3 patients (11.1%) lost SR within the first 6 months of follow-up but it was recovered in all cases through the use of electrical cardioversion (2 patients) or antiarrhythmic drugs. CONCLUSIONS: The totally endocardial monopolar radiofrequency pen facilitates a quick and safe AF ablation in patients with MV disease. Its only theoric limitation concerns the transmurality of the lesions. Perioperative AF is common and should be treated aggressively. By 6 months postoperatively, 100% of patients are free of AF or atrial flutter with recovery of normal atrial contraction. More patients and longer follow-up are necessary to document the long-term results of this simple procedure.