Contemporary cardiac surgery for adults with congenital heart disease.

OBJECTIVE: Advances in early management of congenital heart disease (CHD) have led to an exponential growth in adults with CHD (ACHD). Many of these patients require cardiac surgery. This study sought to examine outcome and its predictors for ACHD cardiac surgery. METHODS: This is an observational cohort study of prospectively collected data on 1090 consecutive adult patients with CHD, undergoing 1130 cardiac operations for CHD at the Royal Brompton Hospital between 2002 and 2011. Early mortality was the primary outcome measure. Midterm to longer-term survival, cumulative incidence of reoperation, other interventions and/or new-onset arrhythmia were secondary outcome measures. Predictors of early/total mortality were identified. RESULTS: Age at surgery was 35±15 years, 53% male, 52.3% were in New York Heart Association (NYHA) class I, 37.2% in class II and 10.4% in class III/IV. Early mortality was 1.77% with independent predictors NYHA class ≥ III, tricuspid annular plane systolic excursion (TAPSE) <15 mm and female gender. Over a mean follow-up of 2.8±2.6 years, 46 patients died. Baseline predictors of total mortality were NYHA class ≥ III, TAPSE <15 mm and non-elective surgery. The number of sternotomies was not independently associated with neither early nor total mortality. At 10 years, probability of survival was 94%. NYHA class among survivors was significantly improved, compared with baseline. CONCLUSIONS: Contemporary cardiac surgery for ACHD performed at a single, tertiary reference centre with a multidisciplinary approach is associated with low mortality and improved functional status. Also, our findings emphasise the point that surgery should not be delayed because of reluctance to reoperate only.

Strain balance of papillary muscles as a prerequisite for successful mitral valve repair in patients with mitral valve prolapse due to fibroelastic deficiency.

AIMS: The aim of this study was to assess the papillary muscle strain as a contributor to recurrent mitral regurgitation (MR) after mitral valve repair for fibroelastic deficiency. METHODS AND RESULTS: Sixty-four patients with isolated posterior mitral valve prolapse and severe MR referred for surgery were prospectively recruited between 2008 and 2012. Two- and three-dimensional echocardiography and speckle tracking were performed in all patients. The longitudinal strain of the anterolateral (AL) and posteromedial (PM) papillary muscles was individually calculated as well as the global longitudinal strain of both papillary muscles was measured before and after mitral repair and normalized to left ventricle end-diastolic volume. Eight patients (12.5%) had at least moderate MR 6 months after mitral repair. The longitudinal strain of the AL (preop -4.94 ± 2.2 vs. postop -3.28 ± 1.3, P < 0.001) and the PM papillary muscles (preop -12.64 ± 5.3 vs. postop -4.12 ± 6.77, P < 0.001) as well as the global strain of both papillary muscles (preop -7.59 ± 3.48 vs. postop -1.07 ± 6, P < 0.001) were all reduced after surgical repair. The longitudinal strain of the PM papillary muscle was the strongest predictor of recurrent MR (when less than or equal to -14.78). The global preoperative papillary muscle strain was also a determinant of recurrent MR when the global strain was greater than -9.05% (area under the curve: 0.895, sensitivity: 100%, and specificity: 76.8%). CONCLUSIONS: Patients with isolated posterior mitral leaflet prolapse are less likely having any residual MR post repair when the global papillary muscle strain of both papillary muscles is close or equal to zero. Strain of the papillary muscles may be an important determinant in predicting residual MR in patients who undergo mitral valve repair.

Mitral valve repair results in better right ventricular remodelling than valve replacement for degenerative mitral regurgitation: a three-dimensional echocardiographic study.

INTRODUCTION: Right ventricular (RV) remodelling may be an important determinant of clinical outcome in patients undergoing mitral valve surgery for mitral regurgitation. In the present study we hypothesised that, compared to valve replacement, mitral valve repair for degenerative mitral regurgitation may result in better RV remodelling, as assessed by real-time, three-dimensional echocardiography (RT3DE). METHODS: Forty unselected patients with degenerative mitral valve regurgitation were recruited prospectively. Two-dimensional (2DE) and RT3DE studies were performed prior to surgery and 6 months postoperatively. RV volumes, stroke volume, ejection fraction and mass, as well as RV pressures were calculated. Regression analysis was used to demonstrate the effect of surgical mitral repair and replacement on reverse RV remodelling. RESULTS: Twenty-one patients underwent mitral valve repair and 19 valve replacement. Mean age was 59.5 ± 15.4 years. Five patients who underwent repair (23.8%) developed recurrent MR within 6 months postoperatively. RV systolic pressure was reduced from 39.3 ± 11.9 mmHg, to 25.4 ± 8.3 mmHg after surgery (p=0.027). Compared to preoperative volumes, 6 months after surgery there was a significant reduction in RV diastolic volume and stroke volume (from 106.4 ± 16.3 ml to 80.4 ± 12.1 ml and from 69.2 ± 15.4 ml to 52.2 ± 14.1 ml, respectively, p<0.001), and an increase in RV ejection fraction (from 54.5 ± 9.2% to 67.3 ± 8.5%, p<0.001). Over a 6-month follow-up period there were no deaths. Overall, the functional class was significantly improved in 39/40 patients (97.5%) but there was no difference between the repair and replacement groups. Using a multivariate regression analysis model including all parameters composing RV remodelling postoperatively, mitral valve repair was the strongest predictor of reverse RV remodelling (reduction of RV end-diastolic volume, p<0.01; reduction of RV mass, p<0.01; reduction of tricuspid regurgitant velocity, p=0.019). CONCLUSIONS: Mitral valve repair leads to more favourable reverse RV remodelling, assessed by RT3DE, compared to valve replacement. This may have important clinical implications.