Late Outcomes of Porcine and Pericardial Bioprostheses after Mitral Valve Replacement in 1162 Patients.

BACKGROUND: Debate continues regarding the superiority of porcine versus pericardial bioprostheses, and data relevant to this comparison are scant. We therefore compare late survival and structural valve deterioration of porcine and pericardial mitral valve prostheses. METHODS: Adults undergoing mitral valve replacement with one first-generation porcine valve model and one pericardial valve line were reviewed from our 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=0.5) and cumulative incidence (CI) of mitral valve structural deterioration (porcine 18±2%, pericardial 19±3%, P=0.3) were similar. The structural failure mode was more likely severe mitral stenosis in pericardial valves (35/50(70%) versus 38/106(36%), P<0.001), and more likely severe mitral regurgitation in porcine valves (80/106(75%) versus 19/50(38%), P<0.0001). After adjustment, structural deterioration was associated with younger patient age (P<0.001), but not valve type. At 10 years, porcine valves demonstrated a higher CI of mitral reoperation (19±2% vs 9±2%, P<0.001) and reoperation for structural deterioration (15±1% vs 6±2%, P=0.007). CONCLUSIONS: We demonstrate similar rates of 10-year survival and structural deterioration with porcine and pericardial bioprosthetics in mitral valve replacement. This study suggests a lack of major improvement in durability of mitral bioprosthetic valves over time. Failure mode may have greater influence on surgeon decision-making of valve choice.

Late Survival After Redo Mitral Operation With Minithoracotomy Compared With Sternotomy.

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.

The outcome of mitral repair for degenerative versus ischemic mitral regurgitation using a single complete ring.

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.

Late Durability of Mitral Repair for Ischemic Versus Nonischemic Functional Mitral Regurgitation.

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.

Sustained results of robotic mitral repair in a lower volume center with extensive minimally invasive mitral repair experience.

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.

Robotic versus port-access mitral repair: A propensity score analysis.

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.