Minimally invasive mitral valve repair

Case Report: Persistent residual shunt after a first percutaneous PFO closure followed by minimally invasive surgical failure: third time is a charm

Background

Even though the optimal management of a moderate or large residual shunt following patent foramen ovale (PFO) closure is open to question, recent data confirmed that it is associated with an increased risk of stroke recurrence.

Case summary

A 48-year-old woman, a migraineur with visual aura, was diagnosed with a PFO associated with a huge multifenestrated atrial septal aneurysm (mfASA) and a moderate right-to-left shunt, detectable only after a Valsalva maneuver on contrast-transthoracic echocardiography. Brain magnetic resonance imaging showed a 1-mm silent white matter lesion in the right frontal lobe. Although the indication was not supported by guidelines, a transcatheter PFO closure was performed at another center with implantation of a large, equally sized, double-disc device (Figulla UNI 33/33 mm). At 6-month follow-up, a 2D/3D transesophageal echocardiography (TEE) color Doppler showed incorrect orientation of the device, which was not parallel to the interatrial septum, with two discs failing to capture the aortic muscular rim and partially protruding in the right atrium; furthermore, a 4 mm × 7 mm ASA fenestration was documented with a residual bidirectional shunt. Thereafter, the same team performed a minimally invasive cardiac surgery under femoro-femoral cardiopulmonary bypass; however, the procedure proved ineffective and was complicated by postoperative pericarditis with pericardial effusion, requiring further rehospitalization 1 month later due to persistent pericarditis, bilateral pleuritis, phrenic nerve palsy, and atrial flutter, which was treated with amiodarone. The patient asked for a second opinion, and our multidisciplinary heart team decided to offer a percutaneous redo intervention. An uneventful implantation of a regular PFO occluder (Figulla Flex II 16/18 mm) across the septal defect was performed successfully. Twelve-month follow-up with 2D TTE color Doppler and contrast transcranial Doppler showed correct position and good interaction between the two devices, with no residual shunt.

Discussion

In addition to the incorrect indication for PFO closure and the failure of minimally invasive surgery, the procedural mishap in this case could have been due to the inappropriate implantation of the first large device within the tunnel. It would have been better to deploy the same large device in the most central fenestration, covering the PFO and a greater part of the remaining mfASA at the same time.

Two-incision totally thoracoscopic mitral valve repair combined with radiofrequency atrial fibrillation ablation in rheumatic mitral valve disease: Early results of a case series of 43 consecutive patients

BACKGROUND

Few studies have reported the outcomes of two-incision total thoracoscopic mitral valve repair (MVr) and concomitant radiofrequency atrial fibrillation ablation (RAFA) in patients with rheumatic mitral valve disease and atrial fibrillation (AF).

METHODS

We retrospectively analyzed 43 consecutive patients who underwent MVr and RAFA through two-incision total thoracoscopic technique from October 2018 to June 2022. We collected data on baseline characteristics, perioperative outcomes, and early-term results.

RESULTS

The mean age was 55.67 ± 7.64 years and 29 (67.4%) patients had New York Heart Association (NYHA) class III or IV. The mean cardiopulmonary bypass (CPB) time was 115.56 ± 8.53 min and aortic clamping time was 81.42 ± 7.54 min. There were no in-hospital deaths or strokes. The mean preoperative mitral valve orifice area (MVOA) was 0.95 (0.84-1.16) cm2 and increased to 2.56 (2.41-2.87) cm2 at discharge and 2.54 (2.44-2.76) cm2 at 3 months after surgery (P < .001). At discharge, 32 (74.4%) patients were in sinus rhythm, 7 (20.9%) were in junctional or atrial flutter rhythm, and 4 (9.3%) remained in AF. At 6 months, 35 (81.4%) patients were in sinus rhythm, 5 (11.63%) were in junctional or atrial flutter rhythm, and 3 (4.7%) were in AF.

CONCLUSIONS

Two-incision total thoracoscopic MVr and RAFA is a safe and effective procedure that can improve the MVOA and promote conversion of AF to sinus rhythm in patients with rheumatic mitral valve disease and AF. Further studies with larger sample size and longer follow-up are needed to confirm the long-term benefits of this approach.

Long-Term Outcomes of Sternal-Sparing Versus Sternotomy Approaches for Mitral Valve Repair: Meta-Analysis of Reconstructed Time-to-Event Data

OBJECTIVE

Since there are concerns about the durability of mitral valve repair (MVRp) with minimally invasive techniques in patients with mitral regurgitation (MR), we aimed to evaluate the long-term outcomes of these sternal-sparing approaches when compared with conventional approaches with sternotomy in patients undergoing MVRp.

METHODS

We performed a systematic review according to a preestablished protocol and performed a pooled analysis of Kaplan-Meier-derived reconstructed time-to-event data from studies with longer follow-up comparing sternal-sparing versus sternotomy approaches for MVRp. Our outcomes of interest were survival, freedom from recurrent MR, and freedom from reoperation.

RESULTS

Eleven studies met our eligibility criteria comprising 7,596 patients with follow-up (sternal sparing, n = 4,246; sternotomy, n = 3,350). Patients who underwent sternal-sparing MVRp had a significantly lower risk of mortality over time compared with patients who underwent MVRp with sternotomy (hazard ratio [HR] = 0.29, 95% confidence interval [CI]: 0.23 to 0.36, P < 0.001) in the overall analysis. However, we found no statistically significant difference between the groups in the sensitivity analysis with adjusted populations (HR = 0.85, 95% CI: 0.63 to 1.15, P = 0.301). Regarding the outcomes freedom from recurrent MR and freedom from reoperation, we found no statistically significant differences between the groups in the follow-up in both overall and sensitivity analyses.

CONCLUSIONS

In comparison with MVRp with sternotomy approaches, sternal-sparing MVRp was not associated with worse outcomes in terms of survival, recurrent MR, and reoperations over time.

Effect of minimally invasive cardiac surgery compared with conventional surgery on post-operative physical activity and rehabilitation in patients with valvular heart disease

Background

Minimally invasive cardiac surgery (MICS) has steadily become more and more popular. MICS is less invasive and has a faster return to normality after surgery. Patients who had MICS continue to exercise more frequently than those who had the conventional median sternotomy surgery. It is generally established that physical activity lowers mortality and the risk of cardiac disease. The purpose of the study: is to evaluate and compare physical activity levels in MICS and conventional surgery.

Result

The level of preoperative physical activity did not significantly differ between the two groups. However, the MICS group significantly exceeded the conventional group in terms of postoperative progress, amount of physical activity, and 6-minute walking test. Also, Visual Analog Scale (VAS) score was significantly less.

Conclusion

Minimally invasive cardiac surgery has a higher margin of benefit, and speedy recovery to normality, which is accompanied by a lower VAS score and increased physical activity in comparison to conventional surgery.

Quantitative Biomechanical Optimization of Neochordal Implantation Location on Mitral Leaflets during Valve Repair

Objective

Methods

Results

Conclusions