Impact of different annuloplasty rings on geometry of the mitral annulus with fibroelastic deficiency: the significance of aorto-mitral angle

High- versus low-gradient aortic stenosis: Is our evaluation limited by aorto-mitral angle on cardiovascular CT?

BACKGROUND

Accurate assessment of aortic valve (AV) stenosis (AS) on transthoracic echocardiogram is crucial for appropriate clinical management. However, discordance between aortic valve area (AVA) and Doppler can complicate the diagnosis of severe AS in low-gradient (LG) AS phenotypes.

METHODS

We reviewed 220 consecutive patients with suspected severe AS and AVA ≤1.0 cm2 on transthoracic echocardiogram who were evaluated for transcatheter AV replacement (TAVR) within a large health system from 2015 to 2019. We compared AV calcium score and aorto-mitral angle (AMA) on 3-chamber views from ECG-gated cardiovascular CT among patients with high-gradient (HG) AS (N = 19), paradoxical low-flow low-gradient (PLFLG) AS (N = 24) and normal-flow low-gradient (NFLG) AS (N = 14).

RESULTS

All groups had comparable age, comorbidities, and AV calcium scores. Compared to patients with HG AS (mean AMA 120 ± 10°), those with PLFLG AS (104 ± 12°; p < 0.001) and NFLG AS (106 ± 13°; p = 0.008) had narrower mean AMA values on cardiovascular CT.

CONCLUSION

LG AS patients have significantly narrower AMA than HG AS patients on cardiovascular CT. Due to difficulty obtaining parallel Doppler alignment, narrower AMA may contribute to AVA-Doppler discordance on echocardiogram. These findings emphasize the need for additional information in the setting of LG AS.

Efficacy and Outcomes of Para-Annular Plication in Mitral Valve Repair via Right Mini-Thoracotomy

PURPOSE

We aim to assess the efficacy and safety of left atrial plication (LAP), particularly para-annular plication, using a right mini-thoracotomy approach.

METHODS

Among 90 mitral valve repair (MVr) procedures performed at our institution between 2016 and 2023, 16 left atrial plication cases for left atrial enlargement (diameter: >50 mm) were assessed; nine cases underwent median sternotomy (conventional) (Group C), and seven cases underwent minimally invasive cardiac surgery (MICS) (Group M). The surgical protocol involved mitral valve repair via a right-sided left atrial approach, incorporating para-annular plication to suture the posterior wall. The mean follow-up duration was 3.3±2.4 years.

RESULTS

Mortality within 30 days of surgery or during hospitalization did not occur. Postoperative complications included one case in each group that required reoperation for hemorrhage originating extraneously in the left atrium. Postoperative echocardiographic assessments revealed a comparable reduction in left atrial diameter (C/M: 80.3±7.0/80.7±14.6%; p=0.94), left atrial volume index (55.6±19.3/68.3±34.1%; p=0.36), and aorto-mitral angle (AMA) enlargement (113.8±7.3/107.5±12.2%; p=0.22). The three-year survival rate (88.9%/75.0%; p=0.33) was comparable between groups.

CONCLUSION

The synergistic utilization of left atrial plication with para-annular plication via right mini-thoracotomy can enhance the postoperative outcomes of mitral valve repair.

The impact of annuloplasty ring or band implantation on post-repair mitral valve haemodynamic performance

OBJECTIVES

The clinical importance of optimal post-repair mitral valve diastolic performance is increasingly being recognized. The haemodynamic effect of a partial annuloplasty band implantation, in comparison to a full ring, remains insufficiently explored.

METHODS

Patients undergoing mitral valve repair for pure degenerative disease between 2011 and 2019 at 2 experienced heart valve centres were eligible for inclusion. Exclusion criteria were concomitant procedures other than tricuspid valve repair and ablation procedures for atrial fibrillation. Pre-discharge and follow-up echocardiograms (1-4 years after surgery) were analysed to assess haemodynamic mitral valve performance.

RESULTS

Of 535 patients meeting the inclusion criteria, 364 (68.0%) patients underwent full annuloplasty ring and 171 (31.0%) partial band implantation. On predischarge echocardiogram, post-repair mitral valve gradient and area did not differ between groups [2.89 mmHg (IQR 2.26-3.72) vs 2.60 mmHg (IQR 1.91-3.55), P = 0.19 and 1.98 cm2 (IQR 1.66-2.46) vs 2.03 cm2 (IQR 1.55-3.06), P = 0.15]. However, multivariable linear regression analysis demonstrated band annuloplasty as a determinant of larger valve area (coefficient 0.467 cm2, standard error 0.105, P < 0.001). On multivariable analysis, no significant impact on post-repair gradient was observed (-0.370 mmHg, standard error 0.167, P = 0.36). At follow-up, the differences between groups disappeared and multivariable regression analysis failed to demonstrate a significant impact of annuloplasty device type on mitral valve gradient (coefficient -0.095 mmHg, standard error 0.171, P = 1.00) or area (coefficient -0.085 cm2, standard error 0.120, P = 1.00). These results were confirmed with a linear mixed model analysis.

CONCLUSIONS

Partial band annuloplasty was related to an improved haemodynamic profile directly after valve repair for degenerative disease but the effect was short-lived. Our results suggest that the type of annuloplasty device has no durable impact on diastolic valve performance.

Aortomitral angle affects cardiovascular events after mitral valve repair for atrial functional mitral regurgitation

PURPOSE

This study aimed to elucidate the geometric parameters of the aortomitral (AM) complex affecting postoperative cardiovascular events (CVEs) in patients with atrial functional mitral regurgitation (MR).

METHODS

From October 2008 to August 2018, we performed mitral and tricuspid valve repairs in 58 patients with atrial functional MR. We examined the determinants of CVEs using preoperative and postoperative echocardiographic data. Furthermore, we analyzed the effect of left atrial (LA) plication on AM geometries after surgery. The follow-up period ranged from 56 to 3283 days (median, 1073 days).

RESULTS

All patients underwent mitral and tricuspid annuloplasty. Seventeen patients (29%) underwent additional LA plication. The AM angle was narrowed after surgery in patients with CVEs (115° ± 6.8° to 106° ± 4.2°, p = .00336), whereas it widened in patients without CVEs (115° ± 7.4° to 118° ± 8.4°, p = .0278). The postoperative AM angle was an independent predictor of postoperative CVEs (p = .000829). LA plication was not a predictor of CVEs; however, it was a predictor of the obtuse postoperative AM angle (p = .0071).

CONCLUSIONS

Our results suggest that a narrow postoperative AM angle is an independent predictor of postoperative CVEs. Additional LA plication reduces the sharpening of the AM angle, which may prevent CVEs after mitral valve repair for atrial functional MR.

Intraoperative transesophageal echocardiography following mitral valve repair: a systematic review

OBJECTIVE

We aimed to examine the recent evidence and search for novel assessments on intraoperative TEE following mitral valve repair that can impact short and long-term outcomes.

METHODS

The Ovid MEDLINE, PubMed, and EMBASE databases were searched from January 1, 2008, until January 27, 2021, for studies on patients with severe Mitral Valve Regurgitation (MR) undergoing Mitral Valve (MV) repair surgery with intraoperative Transesophageal Echocardiography (TEE) performed after the repair. Additional searches were conducted using Google search engine, Web of Science, and Cochrane Library.

RESULTS

After reviewing 302 records, 8 retrospective and 22 prospective studies were included (n = 30). Due to clinical and methodological diversity, these studies are noncomparable and data were not amenable to quantitative synthesis.

CONCLUSION

Although technological advances allowed the objective assessment of geometric and dynamic alterations of the MV, the impact of the use of these technologies on short- or long-term outcomes was not studied. There is uncertainty and conflicting evidence on the ideal method and metrics to evaluate MV patency post-repair. Few isolated studies validated methods to assess coaptation surface and LV function post-repair.

The Impact of Aorto-Mitral Angle on New-Onset Atrial Arrhythmia after Mitral Valve Repair in Patients with Mitral Regurgitation

In this study, we hypothesized that post-operative aorto-mitral angle might be associated to the occurrence of post-operative atrial arrhythmia (AA), including atrial fibrillation and atrial tachycardia, after mitral valve repair in patients with mitral regurgitation (MR). Thus, this present study aims to determine the effects of post-operative aorto-mitral angle on new-onset AA after mitral valve repair with mitral annuloplasty for the treatment of MR.In total, 172 patients without any history of AA underwent mitral valve repair with mitral annuloplasty in our institution between 2008 and 2017. Patient information, including medical records and echocardiographic data, were retrospectively studied.As per our findings, AA occurred in 15 (8.7%) patients during the follow-up period (median, 35.7 months; range, 0.5-132 months). The patients with AA were noted to have a longer cardiopulmonary bypass time and a smaller aorto-mitral angle at post-operative TTE than the others (119 ± 6° versus 125 ± 10°, P = 0.003). No significant difference was noted in the degree of post-operative residual MR or functional MS between the groups. In a multivariate Cox proportional hazards analysis, the longer cardiopulmonary bypass time and the smaller post-operative aorto-mitral angle were independent predictors of the occurrence of AA during the follow-up period (odds ratio per 10 minutes 1.11; 95% CI 1.02-1.22, P = 0.019: odds ratio 0.91; 95% CI 0.85-0.98, P = 0.012).A small aorto-mitral angle at post-operative TTE was determined to be a predictor of new-onset AA after a mitral valve repair for treating MR.