Rheumatic mitral valve repair or replacement in the valve-in-valve era.

OBJECTIVE: For degenerative mitral disease, repair is superior to replacement; however, the best operative strategy for rheumatic mitral disease remains unclear. We evaluated the association between decision-making in choosing repair versus replacement and outcomes across 2 decades of rheumatic mitral surgery. METHODS: Patients undergoing isolated, first-time rheumatic mitral surgery were identified. Era 1 (1997-2008) and Era 2 (2009-2018) were distinguished by intraoperative assessment of anterior leaflet mobility/calcification (Era 2) in deciding between mitral repair versus replacement. Primary outcome was a composite of death, reoperation, and severe valve dysfunction. RESULTS: Among 180 patients, age was 59 ± 14 years, and ejection fraction was 58% ± 10%. A higher proportion in Era 1 (n = 56) compared with Era 2 (n = 124) had preoperative atrial fibrillation (68% vs 46%; P = .006); the groups were otherwise similar. Primary indication was mitral stenosis in 69% (124 out of 180; pure = 35, mixed = 89) and did not differ by era (P = .67). During Era 1, 70% (39 out of 56) underwent repair, compared with 33% (41 out of 124) during Era 2 (P < .001). Freedom from death, reoperation, or severe valve dysfunction at 5 years was higher in Era 2 (72% ± 9%) than Era 1 (54% ± 13%; P = .04). Five-year survival was higher in Era 2 than Era 1, but did not differ between repair versus replacement. Five-year cumulative incidence of reoperation with death as a competing risk did not differ by era, but was higher after repair than replacement. CONCLUSIONS: Careful assessment of anterior leaflet mobility/calcification to determine mitral repair or replacement was associated with improved outcomes. This decision-making strategy may alter the threshold for rheumatic mitral replacement in the current valve-in-valve era.

Treatment options for ischemic mitral regurgitation: A meta-analysis.

BACKGROUND: Treatment of ischemic mitral regurgitation (IMR) is in evolution, as percutaneous procedures and complex surgical repair have been recently investigated in randomized clinical trials and matched studies. This study aims to review and compare the current treatment options for IMR. METHODS: A comprehensive literature search was conducted using electronic databases. The primary outcome was all-cause long-term mortality. The secondary outcomes were perioperative mortality, unplanned rehospitalization, reoperation, and composite end points as defined in the original articles. RESULTS: A total of 12 articles met the inclusion criteria and were included in the final meta-analysis. The MitraClip procedure did not confer a significant benefit in mortality and repeated hospitalization compared with medical therapy alone. In patients with moderate IMR, the adjunct of mitral procedure over coronary artery bypass graft is not associated with clinical improvements. When evaluating mitral valve (MV) replacement versus repair, hospital mortality was greater among patients undergoing replacement (odds ratio [OR], 1.91; P = .009), but both reoperation and readmission rates were lower (OR, 0.60, P = .05; and OR, 0.45, P < .02, respectively). Comparing restrictive annuloplasty alone with adjunctive subvalvular repair, subvalvular procedures resulted in fewer readmissions (OR, 0.50; P = .06) and adverse composite end points (P = .009). CONCLUSIONS: MitraClip procedure is not associated with improved outcomes compared with medical therapy. MV replacement is associated with increased early mortality but reduced reoperation rate and readmission rate compared with MV repair using annuloplasty in moderate-to-severe IMR. Despite no significant benefit in isolated outcomes comparing annular and adjunct subvalvular procedures, the adjunct of subvalvular procedures reduces the risk of major postoperative adverse events.

Women Undergoing Mitral Valve Replacement: A Retrospective Analysis

Abstract Background Although cardiovascular disease is the leading cause of death in women, few data exist on risk factors and treatment of these diseases in women. This leads to a delay in the institution of appropriate therapies and worse outcomes in this population. Objective We aimed to identify predictors of morbidity and mortality in women undergoing isolated mitral valve replacement. Methods This was a retrospective cohort study with 104 women who underwent isolated mitral valve replacement at a referral hospital for treatment of cardiovascular diseases, performed from January 2011 to December 2016. Data were obtained from medical records. Statistical analysis was performed to calculate odds ratio, unpaired Student's t-test, and binary logistic regression. P values <0.05 were considered statistically significant. Results Mean age of patients was 43.73 (±13.85) years. Most patients had a diagnosis of rheumatic disease prior to surgery (76%; N=79). Mortality rate was 4.9% (N = 5). There was a statistically higher risk of death among patients with reduced ejection fraction (EF) (<50%) (OR = 14.833, 95% CI 2.183 - 100.778, P=0.001) and older age (P = 0.009). There was an inverse association between a previous diagnosis of rheumatic disease and death (OR = 0.064, 95% CI 0.007 - 0.606, P=0.002). Logistic regression showed reduced EF at preoperative evaluation as a predictor of death and a diagnosis of rheumatic disease as a protective factor. Conclusion Older age and reduced EF were associated with postoperative mortality. Reduced EF was a predictor of death, and rheumatic disease was associated with better surgical outcomes.

Trends in MitraClip, mitral valve repair, and mitral valve replacement from 2000 to 2016.

OBJECTIVE: The dissemination of mitral valve repair as the first-line treatment and the introduction of MitraClip for patients who have a prohibitive risk for surgery have changed the landscape of mitral valve intervention. The aim of this study is to provide current and generalizable data regarding the trend of mitral valve interventions and outcomes from 2000 to 2016. METHODS: Patients ≥18 years of age who underwent mitral-valve interventions were identified using the National Inpatient Sample database. National estimates were generated by means of discharge weights; comorbid conditions were identified using Elixhauser methods. All trends were analyzed with JoinPoint software. RESULTS: A total of 656,030 mitral valve interventions (298,102 mitral valve replacement, 349,053 mitral valve repair, and 8875 MitraClip) were assessed. No changes in rate of procedures (per 100,000 people in the United States) were observed over this period (annual percent change, -0.4; 95% confidence limit, -1.1 to 0.3; P = .3). From 2000 to 2010, the number of replacements decreased by 5.6% per year (P < .001), whereas repair increased by 8.4% per year from 2000 to 2006 (P < .001). MitraClip procedures increased by 84.4% annually from 2013 to 2016 (P < .001). The burden of comorbidities increased throughout the study for all groups, with the greatest score for MitraClip recipients. Overall, length of stay has decreased for all interventions, most significantly for MitraClip. In-hospital mortality decreased from 8.5% to 3.7% for all interventions, with MitraClip having the most substantial decrease from 3.6% to 1.5%. CONCLUSIONS: Over a 17-year period, mitral-valve interventions were associated with improved outcomes despite being applied to an increasingly sicker population.

Multicenter experience: early outcome of mitral valve repair in patients with ischemic mitral regurgitation.

BACKGROUND: Ischemic mitral regurgitation is associated with poor outcomes. The optimal surgical strategy for management of ischemic mitral regurgitation is still debated. The objective of this study was to evaluate the early mortality and morbidity of mitral valve repair in patients with ischemic mitral regurgitation undergoing coronary artery bypass grafting. METHODS: We performed a retrospective, observational, cohort study on prospectively collected data on 136 consecutive coronary artery bypass graft patients with ischemic mitral regurgitation undergoing mitral valve repair between January 2016 and January 2020. Perioperative echocardiogram findings, operative procedures, and outcomes were analyzed. RESULTS: The overall mortality rate was 4.4%. Mitral valve repair with a low ejection fraction had a 4-fold increase in the risk of death compared to mitral valve repair with preserved ejection fraction > 30%. However, after adjusting for preoperative risk factors, the number of grafts was not an independent risk factor for mortality (odds ratio = 0.18, 95% confidence interval: 0.03-2.81, p = 0.84). Multivariable analysis showed that preoperative ejection fraction (odds ratio = 1.14, 95% confidence interval: 0.82-4.86, p < 0.01), preoperative left ventricular end-systolic dimension (odds ratio = 1.03, 95% confidence interval: 0.65-3.51, p < 0.01) and preoperative left ventricular end-diastolic dimension (odds ratio = 0.99, 95% confidence interval: 0.64-3.28, p = 0.04) were independent risk factors for mortality. CONCLUSIONS: Mitral valve repair can be performed safely concomitantly with coronary artery bypass grafting in patients with moderate, moderately severe, and severe ischemic mitral regurgitation.

Long-term outcomes of rheumatic mitral valve repair: Is it worthwhile to do it?

AIM: This retrospective study was undertaken to evaluate the long-term outcomes of mitral valve repair in rheumatic patients. METHODS: From 2003 to 2019, 151 patients (mean age 26.5 ± 14.9 years; 68.9% female) underwent mitral valve repair. Fifty-three (35.1%) had atrial fibrillation, and 79 (52.3%) were in New York Heart Association class III/IV. Pure mitral regurgitation was present in 109 (72.2%) patients, pure stenosis in 9 (6%), and mixed regurgitation and stenosis in 33. RESULTS: Three (2%) patients died postoperatively and 4 (2.6%) were lost during follow-up. Mean follow-up was 90.5 ± 55.6 months. There were 22 (14.8%) late deaths. Actuarial survival at 5, 10, and 15 years was 90.7% ± 2.5%, 83.5% ± 3.6%, and 76.5 ± 6.1%, respectively. Twelve (8.5%) patients underwent reoperation. Freedom from reoperation at 5, 10, and 15 years was 96.1% ± 1.7%, 89.8% ± 3.2%, and 82.3% ± 6.1%, respectively. Forty-two (29.2%) patients developed recurrent mitral regurgitation. Freedom from recurrence of mitral regurgitation at 5, 10, and 15 years was 70.9% ± 4.3%, 56% ± 5.9%, and 53.3% ± 6.4%, respectively. Eighty-one (56.6%) patients were and free from all events during follow-up. Freedom from all events at 5, 10, and 15 years was 64.8% ± 4.1%, 48.6% ± 5.3%, and 43.7% ± 5.8%, respectively. CONCLUSIONS: Although rheumatic mitral valve repair is associated with late recurrence of mitral regurgitation, it has benefits in selected patients, especially children and young patients who want to avoid the lifelong risks of anticoagulation. Long-term follow-up is essential in these patients.

Clinical Outcomes of a Customized Mitral Valve Plasty for Functional Mitral Regurgitation with a Low Ejection Fraction and Implications for Preoperative Right Ventricular Function.

PURPOSE: To evaluate clinical outcomes of customized mitral valve plasty (MVP) for the treatment of functional mitral regurgitation (FMR) with a low ejection fraction (EF) and to determine which preoperative factors affected the clinical outcome. METHODS AND RESULTS: MVP was adjusted according to the degree of left ventricle (LV) remodeling. We performed mitral annuloplasty (MAP) alone in 14 patients and added subvalvular procedures (SVPs) in 22 patients at a high risk of recurrent MR. During follow-up, reverse LV remodeling was obtained and the 3-year and 5-year non-recurrence rates of MR grade ≥2 were 94% and 89%, respectively. Two patients died during their hospital stay, and four more patients died of cardiac causes during follow-up. The 3-year and 5-year rates of freedom from cardiac-related mortality were 86% and 81%, respectively; no significant difference was observed between the two treatment groups. Right ventricular fractional area change (RVFAC) was a significant predictor of cardiac mortality. Patients with an RVFAC of <26% had significantly poorer cardiac-related mortality (71% at 3 years) than those with an RVFAC of ≥26% (95% at 3 years). CONCLUSION: Customized MVP provided durable mitral competence and reverse LV remodeling. Preoperative RV function was associated with cardiac-related mortality.

Minimally invasive mitral valve surgery: a systematic safety analysis.

OBJECTIVE: Minimally invasive surgery is increasingly adopted as an alternative to conventional sternotomy for mitral valve pathology in many centres worldwide. A systematic safety analysis based on a comprehensive list of pre-specified 30-day complications defined by the Mitral Valve Academic Consortium (MVARC) criteria is lacking. The aim of the current study was to systematically analyse the safety of minimally invasive mitral valve surgery in our centre based on the MVARC definitions. METHODS: All consecutive patients undergoing minimally invasive mitral valve surgery through right mini-thoracotomy in our institution within 10 years were studied retrospectively. The primary outcome was a composite of 30-day major complications based on MVARC definitions. RESULTS: 745 patients underwent minimally invasive mitral valve surgery (507 repair, 238 replacement), with a mean age of 62.9±12.3 years. The repair was successful in 95.8%. Overall 30-day mortality was 1.2% and stroke rate 0.3%. Freedom from any 30-day major complications was 87.2%, and independent predictors were left ventricular ejection fraction <50% (OR 1.78; 95% CI 1.02 to 3.02) and estimated glomerular filtration rate <60 mL/min/1.73 m2 (OR 1.98; 95% CI 1.17 to 3.26). CONCLUSIONS: Minimally invasive mitral valve surgery is a safe technique and is associated with low 30-day mortality and stroke rate.

Outcomes of emergency or urgent mitral valve repair in patients with papillary muscle rupture and active infective endocarditis.

BACKGROUND: Emergency or urgent surgery is often required in patients with papillary muscle rupture and active mitral valve infective endocarditis. The aim of this study was to analyze the outcomes of patients with active endocarditis who underwent emergency or urgent mitral valve repair. METHODS: From 2005 to 2014, 154 ischemic mitral regurgitation patients and 41 infective endocarditis patients underwent mitral valve repair in our institution; 23 had emergency operations due to papillary muscle rupture, and 18 with active infective endocarditis underwent urgent surgery. RESULTS: Cardiopulmonary bypass time (141.4 ± 43.3 versus 145.3 ± 46.5 min) and crossclamp time (77.7 ± 34.1 versus 79.2 ± 33.0 min) were similar in the papillary muscle rupture and elective ischemic mitral regurgitation subgroups, and major postoperative complications were comparable. Hospital mortality was 17.4% in the papillary muscle rupture subgroup and 8.4% in the elective ischemic mitral regurgitation subgroup. Cardiopulmonary bypass time (103.6 ± 37.0 versus 75.5 ± 20.8 min) and crossclamp time (61.7 ± 21.2 versus 45.3 ± 18.0 min) were significantly longer in infective endocarditis patients. There were no major complications or hospital deaths. Eight years postoperatively, overall survival was 94.4% and 86.5% in the papillary muscle rupture and elective ischemic mitral regurgitation subgroups, respectively (p = 0.730). Overall survival was 100% in both infective endocarditis subgroups. CONCLUSION: The feasibility and effectiveness of emergency or urgent mitral valve repair in patients with papillary muscle rupture and active infective endocarditis are satisfactory. Early and mid-term outcomes are comparable to those of elective operations.

Presentation and outcomes of mitral valve surgery in France in the recent era: a nationwide perspective.

OBJECTIVES: Unbiased information regarding the surgical management of patients with mitral regurgitation (MR) at the nationwide level are scarce and mainly US-based. The Programme de Médicalisation des Systèmes d'Information, a mandatory national database, offers the unique opportunity to assess the presentation and outcomes of all consecutive mitral valve (MV) surgeries performed in France in the contemporary era. METHODS: We collected all MV surgeries performed for MR in France in 2014-2016. MR aetiology was classified as degenerative (DMR), secondary (SMR) or Other (rheumatic or congenital disease and infective endocarditis). RESULTS: During the 3-year period, 18 167 MV surgeries were performed in France (55% repair and 45% replacement; 52% isolated). Age was 66±12 years and 59% were male. Aetiology was DMR in 42%, SMR in 16% and other in 42% including 19% with uncertain aetiologies. Overall, in-hospital mortality was 6.5% and increased with age, female gender, Charlson Comorbidity Index, type of surgery (replacement vs repair), associated surgery (combined vs isolated) and MR aetiology (all p<0.01). In-hospital mortality and rate of death/readmission for heart failure (HF) at 1 year were 3.4% and 13%, respectively for DMR (2.4% and 11% for isolated DMR) and 7.8% and 27%, respectively for SMR (5.5% and 23% for isolated SMR). Repair rate was 55% overall, 68% in DMR and 72% for isolated DMR surgery (70% of all DMR). Repair rates decreased with age, Charlson Comorbidity Index and female sex (all p<0.0001). CONCLUSION: In this cross-sectional contemporary prospective nationwide database, in-hospital mortality and 1 year rate of death and HF readmission were considerable overall and in all subsets. Repair rates were suboptimal overall especially in the elderly and women subsets. These results underline the need to develop strategies to improve management and outcomes of patients with both DMR and SMR.

Heart team approach in treatment of mitral regurgitation: patient selection and outcome.

OBJECTIVE: A multidisciplinary heart valve team is recommended for the evaluation of treatment in patients with valvular heart disease, but evidence supporting this concept is lacking. In patients with severe mitral regurgitation, we thought to analyse the patient selection process by the heart team for different treatment options and the outcome after treatment. METHODS: In this single-centre cohort study, all patients treated for mitral regurgitation between July 2013 and September 2018 were included. Primary end points during follow-up were all-cause mortality and a combined end point, consisting of all-cause mortality, cardiovascular rehospitalisation and mitral valve reintervention. RESULTS: 179 patients (44.8%) were treated using Mitraclip, 185 (46.2%) by surgical repair and 36 (9.0%) by surgical replacement. The mortality risk according to EuroScore II differed significantly between treatment groups (6.6%±5.6%, 1.7%±1.5% and 3.6%±2.7% for Mitraclip, surgical repair and replacement, respectively, p<0.001). In-hospital mortality for the 3 groups were 3.4%, 1.6% and 8.3%, respectively (p=0.091). Overall, surgical repair patients had higher 4-year survival (HR 0.40 (95% CI 0.26 to 0.63), p<0.001) and fewer combined end points (HR 0.51 (95% CI 0.32 to 0.80), p<0.001) compared with surgical replacement and Mitraclip patients. However, patients undergoing Mitraclip for isolated, primary mitral regurgitation achieved very good long-term survival. CONCLUSION: The multidisciplinary heart team assigned only low-risk patients with favourable anatomy to surgical repair, while high-risk patients underwent Mitraclip or surgical replacement. This strategy was associated with lower than expected in-hospital mortality for Mitraclip patients and high 4-year survival rates for patients undergoing surgical or percutaneous repair of isolated primary mitral regurgitation.

Contemporary trends in mitral valve surgery in East China: a 10-year experience.

BACKGROUND: Contemporary nationwide data from mainland China on trends in mitral valve surgery are scarce. The purpose of the present study was to review a single-center experience with mitral valve surgery over a 10-year period in East China. METHODS: Between July 2009 and June 2019, 3238 consecutive patients who underwent mitral valve surgery in our center were retrospectively reviewed. The patients were evenly divided into three periods: July 2009 to October 2012 (period I), November 2012 to February 2016 (period II), March 2016 to June 2019 (period III). RESULTS: The 3238 patients included 536 (16.6%) who had mitral valve repair and 2702 (83.4%) who had mitral valve replacement. Early mortalities for mitral valve repair and mitral valve replacement were 0.2% and 0.9%, respectively. There were trends towards a higher proportion of degenerative valve lesions (24.6%, 35.8%, 54.7% in periods I, II, and III, respectively) and a lower proportion of rheumatic valve lesions (71.0%, 62.6%, 38.0%) in more recent years. The proportions of minimally invasive surgery (0.7%, 2.1%, 30.2%), mitral valve repair (8.3%, 15.4%, 27.5%), use of a bioprosthesis (10.1%, 17.0%, 23.1%), and concomitant tricuspid valve procedures (13.2%, 28.5%, 46.0%) increased dramatically, while early mortality remained constant during the 10-year period (1.0%, 0.3%, 0.9%). CONCLUSIONS: In the past 10 years, the spectrum of mitral valve disease experienced a trend towards more degenerative valve lesions and less rheumatic valve lesions in East China. Mitral valve repair, bioprostheses, tricuspid valve repair, and minimally invasive surgery have been more often applied in recent years.

Severe Mitral Annular Calcification and Mitral Valve Surgery: An Algorithmic Approach to Management.

The management of mitral valve dysfunction in the setting of substantial mitral annular calcification (MAC) remains controversial and is one of the most challenging problems in mitral valve surgery. The physiopathology of severe MAC is related to a combination of progressive, degenerative and active calcium deposition in the annulus that is often multifactorial, but largely attributable to aging and chronic disease conditions. Given the fact that overall life expectancy in the elderly population are increasing, it is imperative to understand contemporary and future therapeutic options since this MAC is likely going to be a frequent problem faced by the next generation of cardiac surgeons. This review provides a relevant synthesis of existing literature and aims to assess the efficacy of existing therapeutic choices for patients with mitral valve dysfunction and 'big' MAC with a goal of minimizing postoperative complications (e.g. left ventricular outflow tract obstruction, prosthetic paravalvular leak, valve embolization, and stroke) that can be achieved via a multidisciplinary heart team approach.

Mitral Valve Surgical Volume and Transcatheter Mitral Valve Repair Outcomes: Impact of a Proposed Volume Requirement on Geographic Access.

Background There is an open Centers for Medicare and Medicaid Services National Coverage Decision for Transcatheter Mitral Valve Repair (TMVr) and a recent multisociety consensus document suggesting that TMVr centers should achieve prespecified mitral valve replacement or repair (MVRr). Yet, little is known about the MVRr volume-TMVr outcome relationship. Methods and Results Using Centers for Medicare and Medicaid Services administrative claims from January 1, 2016 to December 31, 2018, we computed the Pearson correlation coefficient and performed multivariable hierarchical modeling to estimate the MVRr volume to TMVr outcome relationship for mortality and heart failure hospitalization. Additionally, we assessed the impact of the consensus recommendations on geographic access to care by hospital referral region. Total annualized MVRr volume was <11 to 1552 (median 96, interquartile range 53, 167). One-year survival, 1-year heart failure hospitalization after TMVr were not correlated with MVRr volume. After patient risk-adjustment for age, sex, and significant Elixhauser Comorbidities, there remained no significant correlation between institutional MVRr volume and 1-year mortality (estimate -0.010, SE 0.047, P=0.834) or heart failure hospitalization (estimate -0.011, SE 0.045, P=0.808) after TMVr. Raising the restriction on TMVr from 20 to 40 MVRr/y results in ≈30 million individuals having to travel outside of their hospital referral region to undergo TMVr, with a disproportionate impact in the Midwest and Southeast. Conclusions There is no relationship between MVRr volumes and TMVr outcomes. Additionally, adoption of an annual MVRr volume ≥40 for performance of TMVr disproportionately impacts geographic access in the Midwest and Southeast and their large black and Hispanic populations.

Thirty-Day Outcomes of Transcatheter Mitral Valve Replacement for Degenerated Mitral Bioprostheses (Valve-in-Valve), Failed Surgical Rings (Valve-in-Ring), and Native Valve With Severe Mitral Annular Calcification (Valve-in-Mitral Annular Calcification) in the United States: Data From the Society of Thoracic Surgeons/American College of Cardiology/Transcatheter Valve Therapy Registry.

BACKGROUND: Transcatheter mitral valve replacement using aortic transcatheter heart valves has recently become an alternative for patients with degenerated mitral bioprostheses, failed surgical repairs with annuloplasty rings or severe mitral annular calcification who are poor surgical candidates. Outcomes of these procedures are collected in the Society of Thoracic Surgeons/American College of Cardiology/Transcatheter Valve Therapy Registry. A comprehensive analysis of mitral valve-in-valve (MViV), mitral valve-in-ring (MViR), and valve-in-mitral annular calcification (ViMAC) outcomes has not been performed. We sought to evaluate short-term outcomes of early experience with MViV, MViR, and ViMAC in the United States. METHODS: Retrospective analysis of data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. RESULTS: Nine hundred three high-risk patients (median Society of Thoracic Surgeons score 10%) underwent MViV (n=680), MViR (n=123), or ViMAC (n=100) between March 2013 and June 2017 at 172 hospitals. Median age was 75 years, 59.2% female. Technical and procedural success were higher in MViV. Left ventricular outflow tract obstruction occurred more frequently with ViMAC (ViMAC=10%, MViR=4.9%, MViV=0.7%; P<0.001). In-hospital mortality (MViV=6.3%, MViR=9%, ViMAC=18%; P=0.004) and 30-day mortality (MViV=8.1%, MViR=11.5%, ViMAC=21.8%; P=0.003) were higher in ViMAC. At 30-day follow-up, median mean mitral valve gradient was 7 mm Hg, most patients (96.7%) had mitral regurgitation grade ≤1 (+) and were in New York Heart Association class I to II (81.7%). CONCLUSIONS: MViV using aortic balloon-expandable transcatheter heart valves is associated with a low complication rate, a 30-day mortality lower than predicted by the Society of Thoracic Surgeons score, and superior short-term outcomes than MViR and ViMAC. At 30 days, patients in all groups experienced improvement of symptoms, and valve performance remained stable. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02245763.

Very long-term outcomes of twisted auto-pericardial mitral annuloplasty.

OBJECTIVES: During mitral annuloplasty, we twisted the harvested auto-pericardium to enable adequate ring sizing and implanted it to prevent ring-related complications. Indication for twisted auto-pericardial band (APB) was limited to patients with less than severe annular dilation to ensure high reproducibility and durability. The aim of this study was to investigate the long-term outcomes of twisted APB annuloplasty. METHODS: From 1999 to 2009, 107 patients (62 ± 12 years, degenerative 92 and infective endocarditis 15) with isolated posterior mitral leaflet (PML) prolapse with inter-commissural distance of 32 mm or smaller underwent twisted APB annuloplasty. Of these, 104 patients without early leaflet repair failure were studied. Leaflet repairs were predominantly performed by quadrangular resection. Median APB size was 28 mm. RESULTS: Follow-up rate was 98.1% and duration was 10.9 ± 4.8 years. There were two early and 34 late deaths. Survival and freedom from cardiac-related death at 15 years were 61.7% ± 5.6% and 83.8% ± 4.7%, respectively. Age and male sex were independent predictors of mortality. There were four late reoperations for recurrent severe mitral regurgitation (MR), three of which were due to new chordal rupture. Freedom from reoperation and freedom from moderate or severe MR at 15 years were 93.1% ± 3.5% and 81.3% ± 6.2%, respectively. No patients developed hemolysis, ring dehiscence, or infective endocarditis. CONCLUSIONS: The long-term outcomes of twisted APB for isolated PML prolapse without severe annular dilation are satisfactory. Twisted APB annuloplasty may be a preferable option to reduce ring-related complications with sufficient durability.

Mitral Valve Surgery in Neonates, Infants, and Children: Surgical Approach, Outcomes, and Predictors.

The surgical treatment of mitral disease in pediatrics is challenging. Managing diversity in patient anatomy, growth, and the need for long-term anticoagulation requires trade-offs between imperfect solutions. We sought to assess our approach to pediatric mitral valve surgery and identify predictors associated with mortality and recurrent mitral disease. The medical records, echocardiograms, and operative reports of all patients who underwent surgical intervention on the mitral valve from January 2000 to April 2016 were reviewed. A total of 143 patients underwent mitral valve surgery, 64 of which were neonates or infants (ages 10-355 days) and 79 of which were children (ages 1-17.8 years). Neonates and infants had a higher preoperative New York Heart Association heart failure classification in comparison to children (P < 0.001) with a less severe degree of mitral valve insufficiency (P = 0.007). Postoperative outcomes for primary repair patients (n = 133) demonstrated significant differences in recurrence of mitral valve disease, with 38% of neonates/infants and 21% of children affected (P = 0.028). Five-year rates of mortality or transplant were 22% (8%, 33%) in neonates and infants compared to 4% (0%, 10%) in children, P = 0.013. Mitral valve surgery in neonates and infants is particularly high risk and is associated with higher rate of recurrence and reintervention early. However, if successful early, mitral valve repair in neonates and infants can result in a durable freedom from reintervention that parallels freedom from reintervention in older children undergoing repair. Further understanding of mechanisms of failure and better matching of anatomic substrate to strategy is needed.

Concomitant Tricuspid Valve Repair during Minimally Invasive Mitral Valve Repair.

BACKGROUND: Concomitant use of tricuspid valve (TV) surgery and minimally invasive mitral valve (MV) repair is debatable due to a prolonged time of surgery with presumably elevated operative risk. Herein, we examined cardiopulmonary bypass times and 30-day mortality in patients who underwent MV repair with and without concomitant TV surgery. METHODS: We retrospectively evaluated 3,962 patients with MV regurgitation who underwent minimally invasive MV repair without (n = 3,463; MVr group) and with (n = 499; MVr + TVr group) concomitant TV surgery between 1999 and 2014. Preoperative parameters between the groups were significantly different; therefore, propensity score matching was performed. RESULTS: Mean cardiopulmonary bypass time for all patients was 125.5 ± 55.8 minutes in MVr and 162.0 ± 58.0 minutes in MVr + TVr (p < 0.001). Overall 30-day mortality was significantly different between these groups (4.8 vs. 2.1%; p < 0.001); however, after adjustment, there was no significant difference (3.3 vs. 1.2%; p = 0.07). Backward logistic regression revealed that cardiopulmonary bypass time was not a significant predictor for early mortality within the MVr + TVr cohort. CONCLUSION: Concomitant TV repair using prosthetic rings through a minimally invasive approach is safe and does not lead to elevated early mortality in our patient cohort. Therefore, prolonged cardiopulmonary bypass time should not be the sole reason to rule out MV repair with concomitant TV repair and to prefer the use of suture techniques, which saves only a few minutes compared with prosthetic ring implantation.

Interventions for Secondary Mitral Regurgitation in Patients With Heart Failure: A Network Meta-Analysis of Randomized Controlled Comparisons of Surgery, Medical Therapy and Transcatheter Intervention.

BACKGROUND: Mitral regurgitation (MR) in heart failure (HF) notoriously carries a poor prognosis. While there are multiple interventional options for treatment, the optimal intervention remains controversial. Therefore, we aimed to evaluate the efficacy and safety of surgery, medical therapy, and transcatheter intervention in secondary MR. METHODS: A systematic database search was performed to identify all randomized controlled trials (RCTs) that evaluate various interventions for secondary MR. We performed a Bayesian network meta-analysis to calculate odd ratios (ORs) and 95% credible intervals (CIs). The primary endpoint was all-cause mortality. Secondary endpoints were moderate-severe MR, HF-hospitalizations, and freedom from severe HF symptoms. RESULTS: We identified 12 RCTs (2316 total patients; age 67.6 ±â€¯11; 63% males, and 74% with ischemic cardiomyopathy). There was a significant reduction of mortality at 24-months with transcatheter leaflet repair compared with medical therapy (OR = 0.57; 95% CI = 0.34-0.96). However, there were no significant differences among the competing treatments in all-cause mortality at the earlier time points of 30-days or 12-months (P > 0.05). Recurrent moderate-severe MR was significantly less with valvular interventions compared with medical therapy (P < 0.05), but there were no differences in the rates of HF-hospitalizations or persistent severe HF symptoms between the competing interventions (P > 0.05). CONCLUSIONS: Among patients with HF and secondary MR, transcatheter leaflet repair was associated with significantly reduced 24-month mortality compared with medical therapy. Valvular interventions were associated with lower rates of recurrent moderate-severe MR, but non-significant improvements in clinical outcomes. Further long-term studies are needed to identify the best route of intervention for secondary MR.