1
|
Loulmet DF, Grossi EA. Two decades of experience with robotic mitral valve repair: What have we learned? JTCVS Tech 2024; 24:76-81. [PMID: 38835581 PMCID: PMC11145349 DOI: 10.1016/j.xjtc.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/05/2024] [Accepted: 01/18/2024] [Indexed: 06/06/2024] Open
Affiliation(s)
- Didier F. Loulmet
- NYU Grossman School of Medicine, NYU Langone Health, New York, NY
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY
| | - Eugene A. Grossi
- NYU Grossman School of Medicine, NYU Langone Health, New York, NY
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY
| |
Collapse
|
2
|
Moore RA, Wierup P, Tappuni S, Houghtaling PL, Burns DJP, Chemtob R, Blackstone EH, Svensson LG, Gillinov AM. Reoperation after early and late failure of mitral valve repair for degenerative disease. J Thorac Cardiovasc Surg 2024; 167:1251-1262.e8. [PMID: 36323616 DOI: 10.1016/j.jtcvs.2022.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 08/25/2022] [Accepted: 09/11/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To determine mechanisms of early and late failure after mitral valve repair for degenerative disease, identify factors associated with re-repair, and evaluate durability of re-repair. METHODS From January 2008 to July 2020, 330 reoperations were performed for recurrent mitral valve dysfunction after initial valve repair for degenerative disease. Mechanisms of repair failure were determined by review of preoperative imaging and operative reports. Multivariable analysis was performed to identify factors associated with likelihood of re-repair or replacement. Durability of re-repair was assessed using longitudinal analysis of postoperative echo data. RESULTS Eighty-five of 330 (26%) reoperations were performed for early repair failure within 1 year and 245/330 (74%) for late failure thereafter. Suture/annuloplasty dehiscence, systolic anterior motion, hemolysis, and ventricular remodeling were more common mechanisms of early failure and disease progression and fibrosis late failure. Forty percent (34/85) of early failures were re-repaired versus 24% (59/245) of late failures. Re-repair was more common than replacement in recent years and was associated with earlier reoperation (median 1.5 vs 3.9 years; P = .0001). No in-hospital deaths occurred after re-repair; 2 patients (0.8%) died after valve replacement. Freedom from severe mitral regurgitation after re-repair was 93% at 7 years. CONCLUSIONS Mitral valve re-repair can be performed with low rates of mortality and morbidity for early and late valve dysfunction. Mechanisms of early repair failure differ from those of late failure and are generally more amenable to re-repair. In selected patients who present after failed repair, we prefer mitral re-repair to valve replacement whenever technically feasible.
Collapse
Affiliation(s)
- Ryan A Moore
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Per Wierup
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shahed Tappuni
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Penny L Houghtaling
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Daniel J P Burns
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Raphaelle Chemtob
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
| |
Collapse
|
3
|
Wagner CM, Fu WW, Brescia AA, Hawkins RB, Romano MA, Ailawadi G, Bolling SF. Repeat crossclamp after failed initial degenerative mitral valve repair is safe and successful. JTCVS OPEN 2023; 16:209-217. [PMID: 38204717 PMCID: PMC10775030 DOI: 10.1016/j.xjon.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 07/31/2023] [Accepted: 08/14/2023] [Indexed: 01/12/2024]
Abstract
Objective Surgical risk and long-term outcomes when re-crossclamp is required during degenerative mitral valve repair are unknown. We examined the outcomes of patients who required re-crossclamp for mitral valve reintervention. Methods Adults undergoing mitral valve repair for degenerative mitral valve disease at a single center from 2007 to 2021 who required more than 1 crossclamp for mitral valve reintervention were included. Outcomes including major morbidity and 30-day mortality were collected. Kaplan-Meier analysis characterized survival and freedom from recurrent mitral regurgitation. Results A total of 69 patients required re-crossclamp for mitral valve reintervention. Of those, 72% (n = 50) underwent successful re-repair and the remaining underwent mitral valve replacement (28%, n = 19). Major morbidity occurred in 23% (n = 16). There was no 30-day mortality, and median long-term survival was 10.9 years for those undergoing re-repair and 7.2 years for those undergoing replacement (P = .79). Midterm echocardiography follow-up was available for 67% (33/50) of patients who were successfully re-repaired with a median follow-up of 20 (interquartile range, 7-37) months. At late follow-up, 90% of patients had mild or less mitral regurgitation. Of those re-repaired, 2 patients later required mitral valve reintervention. Conclusions Patients requiring re-crossclamp for residual mitral regurgitation had low perioperative morbidity and no mortality. Most patients underwent successful re-repair (vs mitral valve replacement) with excellent valve function and long-term survival. In the event of unsatisfactory repair at the time of mitral valve repair, attempt at re-repair is safe and successful with the appropriate valvar anatomy.
Collapse
Affiliation(s)
- Catherine M. Wagner
- Department of Cardiac Surgery, University of Michigan Medicine, Ann Arbor, Mich
| | - Whitney W. Fu
- Department of General Surgery, University of Michigan Medicine, Ann Arbor, Mich
| | | | - Robert B. Hawkins
- Department of Cardiac Surgery, University of Michigan Medicine, Ann Arbor, Mich
| | - Matthew A. Romano
- Department of Cardiac Surgery, University of Michigan Medicine, Ann Arbor, Mich
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan Medicine, Ann Arbor, Mich
| | - Steven F. Bolling
- Department of Cardiac Surgery, University of Michigan Medicine, Ann Arbor, Mich
| |
Collapse
|
4
|
Longitudinal Outcomes Following Surgical Repair of Primary Mitral Regurgitation. J Cardiovasc Dev Dis 2023; 10:jcdd10030095. [PMID: 36975860 PMCID: PMC10051838 DOI: 10.3390/jcdd10030095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/21/2023] [Accepted: 02/21/2023] [Indexed: 02/25/2023] Open
Abstract
Degenerative mitral valve (MV) disease is the most common cause of organic mitral regurgitation (MR) in developed countries. Surgical mitral valve repair is the gold standard treatment for primary MR. Surgical mitral valve repair is associated with excellent outcomes in terms of survival and freedom from recurrent MR. As well, innovations in surgical repair techniques, including thoracoscopically and robotically assisted approaches, further reduce morbidity. Emerging catheter-based therapies may also provide advantages in select patient groups. Although the outcomes following surgical mitral valve repair are well described in the literature, longitudinal follow-up is heterogenous. Indeed, longitudinal follow-up and long-term data are vital to better advise treatment and counsel patients.
Collapse
|
5
|
Zhong Z, Xu H, Song W, Liu S. Re-repair vs. Replacement for Failed Mitral Valve Repair: A Systemic Review and Meta-Analysis. Front Cardiovasc Med 2022; 9:868980. [PMID: 35774370 PMCID: PMC9237322 DOI: 10.3389/fcvm.2022.868980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/12/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe objective of this study was to compare outcomes of re-repair with those of mitral valve replacement (MVR) for failed initial mitral valve repair (MVr).MethodsWe searched the Pubmed, Embase, and Cochrane Library databases for studies that compared mitral valve re-repair with MVR for the treatment of failed initial MVr. Data were extracted by two independent investigators and subjected to a meta-analysis. Odds ratio (OR), risk ratio (RR), hazard ratio (HR), ratio difference (RD), mean difference (MD), and 95% confidence interval (CI) were calculated with the Mantel-Haenszel and inverse-variance methods for mode of repair failure, perioperative outcomes, and follow-up outcomes.ResultsEight retrospective cohort studies were included, with a total of 938 patients, and mean/median follow-up ranged from 1.8 to 8.9 years. Pooled incidence of technical failure was 41% (RD: 0.41; 95% CI: 0.32 to 0.5; P = 0.00; I2 = 86%; 6 studies, 846 patients). Pooled mitral valve re-repair rate was 36% (RD: 0.36; 95% CI: 0.26–0.46; P = 0; I2 = 91%; 8 studies, 938 patients). Pooled data showed significantly lower perioperative mortality (RR: 0.22; 95% CI: 07 to 0.66; I2 = 0%; P = 0.008; 6 studies, 824 patients) and significantly lower long-term mortality (HR:0.42; 95% CI: 0.3 to 0.58; I2 = 0%; P = 0; 7 studies, 903 patients) in the re-repair group compared with MVR.ConclusionsMitral valve re-repair was associated with better immediate and sustained outcomes for failed MVr and should be recommended if technically feasible.
Collapse
|
6
|
Veerappan M, Cheekoty P, Sazzad F, Kofidis T. Mitral valve re-repair vs replacement following failed initial repair: a systematic review and meta-analysis. J Cardiothorac Surg 2020; 15:304. [PMID: 33028386 PMCID: PMC7542900 DOI: 10.1186/s13019-020-01344-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 09/28/2020] [Indexed: 11/30/2022] Open
Abstract
Background The optimal treatment strategy following a failed mitral valve repair remains unclear. This study aims to compare and analyse available studies which report the clinical outcomes post mitral valve re-repair (MVr) or replacement (MVR) after a prior mitral valve repair. Methods Based on PRISMA guidelines, a literature search was performed utilising PubMed, Cochrane and Scopus databases to identify retrospective cohort studies that reported outcomes of MVr and MVR after a prior mitral valve repair. Data regarding operative mortality, clinical outcomes and complications were extracted, synthesized and meta-analysed where appropriate. Results Eight studies with a total cohort of 1632 patients were used. After analysis, no significant differences in the short term and long-term operative mortality, incidence of stroke, congestive heart failure, Grade 1 and Grade 2 mitral regurgitation, requirement of 3rd mitral valve operation and reoperation due bleeding were found between the two groups. However, a slightly higher incidence of postoperative atrial fibrillation (OR: 0.11, CI: 0.02 to 0.17, I2 = 0%, p = 0.02) was observed in the MVR group, as compared to the MVr group. Conclusion MVr appears to be a viable alternative to MVR for mitral valve reoperation, given that they are associated with similar post-operative outcomes.
Collapse
Affiliation(s)
- Muthu Veerappan
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System-NUHS, 1E Kent Ridge Road, 9th Floor, Tower Block, Singapore, 119228, Singapore.,School of Medicine, University of Dundee, Dundee, UK
| | - Prashasth Cheekoty
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System-NUHS, 1E Kent Ridge Road, 9th Floor, Tower Block, Singapore, 119228, Singapore.,School of Medicine, Newcastle University, Newcastle, UK
| | - Faizus Sazzad
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System-NUHS, 1E Kent Ridge Road, 9th Floor, Tower Block, Singapore, 119228, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Cardiovascular Research Institute, National University of Singapore, Singapore, Singapore
| | - Theo Kofidis
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System-NUHS, 1E Kent Ridge Road, 9th Floor, Tower Block, Singapore, 119228, Singapore. .,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore. .,Cardiovascular Research Institute, National University of Singapore, Singapore, Singapore.
| |
Collapse
|
7
|
Fatehi Hassanabad A, Turcotte M, Dennehy C, Kim A, Malaisrie SC, Kent WDT. Contemporary Reoperative Mitral Valve Surgery: Technical Considerations and Clinical Outcomes. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2020; 15:425-439. [DOI: 10.1177/1556984520949955] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
As patients with cardiac disease live longer, reoperative mitral valve surgery has become more common. Although these operations are technically challenging and of high risk, outcomes continue to improve. Minimally invasive techniques, better cardioprotective strategies, and advanced perioperative care have contributed to this. In this review, we discuss surgical approaches, intraoperative strategies, novel catheter-directed devices, and clinical outcomes of contemporary reoperative mitral valve surgery.
Collapse
Affiliation(s)
- Ali Fatehi Hassanabad
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, AB, Canada
| | | | | | - Angela Kim
- Faculty of Medicine, University of Calgary, AB, Canada
| | - S. Chris Malaisrie
- Department of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - William D. T. Kent
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, AB, Canada
| |
Collapse
|
8
|
Gerosa G, Besola L, Beiras-Fernandez A, Salizzoni S, Vairo A, D'Aleo S, von Bardeleben RS, De Paulis R, Yadav R, Duncan A, Albertini A, Rinaldi M, Colli A. The Neochord Procedure After Failed Surgical Mitral Valve Repair. Semin Thorac Cardiovasc Surg 2020; 33:35-44. [PMID: 32621965 DOI: 10.1053/j.semtcvs.2020.06.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 06/19/2020] [Indexed: 11/11/2022]
Abstract
Surgical mitral valve reintervention is associated with significant morbidity and mortality, and repeat repair is not always feasible. We examine the clinical outcomes of the NeoChord procedure after failed conventional mitral valve repair. A total of 312 patients were treated with the NeoChord repair procedure between January 2014 and December 2018 at 5 European centers. Clinical and echocardiographic data were reviewed to identify patients who had a prior surgical mitral valve repair procedure. The primary endpoint (Patient Success) was a composite of placement of at least 2 neochordae and end-procedure mitral valve regurgitation (MR) ≤ mild, freedom from death, stroke, structural or functional procedure failure (MR > moderate), procedure or device-related unplanned procedures, cardiac-related rehospitalization, or worsening NYHA functional class at 1 and 2-year FU. Fifteen (15) patients were identified who required reoperation for failed surgical mitral valve repair. Mean time-to-reoperation was 2.7 years (2.2-6.1). Median intensive care unit stay was 24 hours and median hospitalization time was 7 days (6-8). No in-hospital deaths were observed. At discharge, mitral regurgitation was ≤ mild in 13 patients (86.7%). Patient success and freedom from more than mild MR were 92.3 ± 7.4% and 83.9 ± 10.4% at 1 and 2-year follow-up respectively. One high-risk patient presented with severe recurrent MR and died during surgical reintervention due to an acute aortic dissection. Selected patients can be successfully treated with the NeoChord procedure after failed surgical mitral valve repair. These results support a wider adoption of the NeoChord procedure as a first-line minimally invasive, alternative therapy to treat failed mitral valve repair.
Collapse
Affiliation(s)
- Gino Gerosa
- Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Laura Besola
- Department of Cardiovascular Surgery, Salus Hospital GVM Care and Research, Reggio Emilia, Italy
| | - Andres Beiras-Fernandez
- Department of Cardiothoracic and Vascular Surgery, University Hospital, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Stefano Salizzoni
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza di Torino, University of Turin, Torino, Italy
| | - Alessandro Vairo
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza di Torino, University of Turin, Torino, Italy
| | | | | | | | - Rashmi Yadav
- Cardiovascular Biomedical Research Unit, Royal Brompton and Harefield National Health Service Foundation Trust, London, United Kingdom
| | - Alison Duncan
- Department of Cardiothoracic Surgery, Royal Brompton and Harefield National Health Service Foundation Trust, London, United Kingdom
| | - Alberto Albertini
- Department of Cardiovascular Surgery, Maria Cecilia Hospital GVM care & research, Cotignola (RA) Italy
| | - Mauro Rinaldi
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza di Torino, University of Turin, Torino, Italy
| | - Andrea Colli
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Italy.
| |
Collapse
|
9
|
Trumello C, Giambuzzi I, Del Forno B, Bargagna M, Blasio A, Ruggeri S, Meneghin R, Schiavi D, Nascimbene S, Castiglioni A, Alfieri O, De Bonis M. Re-repair after previous mitral valve reconstruction: handle with care! Interact Cardiovasc Thorac Surg 2020; 31:35-41. [DOI: 10.1093/icvts/ivaa057] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 01/23/2020] [Accepted: 02/26/2020] [Indexed: 11/15/2022] Open
Abstract
Abstract
OBJECTIVES
Patients with recurrent mitral regurgitation after surgical repair are currently treated with a re-repair procedure or valve replacement. The aim of this study was to compare outcomes of our series of patients who underwent re-repair versus replacement in this setting.
METHODS
From 2003 to 2017, a total of 79 patients with recurrent mitral regurgitation underwent re-repair, group A (39), or replacement, group B (40). Mean follow-up was 7.4 ± 3.27 years (max 14.4). Inverse Probability of Treatment Weighting was used to create comparable distributions of the covariates; the Kaplan–Meier method was used for survival and competing risk analysis for time to cardiac death, time to recurrence of MR ≥3+ and MR ≥2+.
RESULTS
A re-repair was possible in 49.4% of patients (39/79). At hospital discharge, residual MR ≥2+ was present in 5 patients in group A, and none in group B (P < 0.001). The paired overall survival at 8 years was 100% in the re-repair group and 96.5 ± 2.34% in the replacement group (P = 0.069). The cumulative incidence function of cardiac death, with non-cardiac death as competitive event, at 8 years was 0% in group A and 3.5 ± 2.34% in group B (P = 0.077). The cumulative incidence function of MR ≥3+ at 8 years was 29.2 ± 8.81% in group A and 0% in group B (P < 0.001).
CONCLUSIONS
Recurrent significant mitral regurgitation after re-repair is not rare already at 8 years, but the survival tends to be worse after replacement. This finding calls for a very selective approach in pursuing a re-repair only when the intraoperative findings and the immediate results are very reassuring as far as long-term durability is concerned.
Collapse
Affiliation(s)
- Cinzia Trumello
- Division of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ilaria Giambuzzi
- Division of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Benedetto Del Forno
- Division of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marta Bargagna
- Division of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Blasio
- Division of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefania Ruggeri
- Division of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Roberta Meneghin
- Division of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Davide Schiavi
- Division of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Simona Nascimbene
- Division of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Castiglioni
- Division of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Ottavio Alfieri
- Division of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michele De Bonis
- Division of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| |
Collapse
|
10
|
Aphram G, De Kerchove L, Mastrobuoni S, Navarra E, Solari S, Tamer S, Baert J, Poncelet A, Rubay J, Astarci P, Noirhomme P, El Khoury G. Re-repair of the failed mitral valve: insights into aetiology and surgical management. Eur J Cardiothorac Surg 2019; 54:774-780. [PMID: 29547941 DOI: 10.1093/ejcts/ezy111] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 02/13/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Mitral valve (MV) repair is the gold standard for treatment of degenerative mitral regurgitation. A variety of surgical techniques allow surgeons to achieve a high rate of MV repair even with MV diseases of other aetiologies. However, a certain number of repairs fail over time. The aim of this study was to review our single-centre experience of MV re-repair and analyse the mode of repair failure, re-repair safety and efficiency in relation to the initial aetiology. METHODS Between 1997 and 2015, 91 patients underwent redo MV re-repair. The first MV repair was performed in our institution in 59% of cases. Follow-up information was available for 93% of our patients. The median follow-up was 56 months. RESULTS The initial aetiology was degenerative disease in 40 (44%) patients, rheumatic disease in 25 (27.5%), endocarditis in 10 (11%), ischaemic in 6 (7%), severe mitral annulus calcification in 5 (5.5%), congenital disease in 4 (4%) and unknown in 1 (1%). The mean age was 58 ± 15 years. The median delay between the 1st and 2nd repair was 49 months with 6 early re-repairs. Re-repair was urgent or emergent in 19% of cases; indications for surgery were mitral regurgitation in 48%, stenosis in 19%, endocarditis in 19%, mitral disease in 11%, ring thrombosis in 2% and systolic anterior motion in 1%. The main mechanisms of failure included technical error (30%), progression of disease (35%), new disease (29%) and unknown (6%.) Re-repair was performed through a median sternotomy in 96% of cases, and 34% of patients had concomitant procedures. Eight (9%) postoperative deaths (4 of mitral annulus calcification, 2 of endocarditis, 1 of degenerative disease, 1 of ischaemia) and 5 (6%) early failures occurred (3 of rheumatic disease, 1 of degenerative disease, 1 of a congenital condition), requiring MV replacement in 4 and new repair in 1. Overall survival at 5 and 10 years was 76% and 57%, 83% and 49% in patients with degenerative diseases and 95% and 95% in patients with rheumatic disease. Overall freedom from reoperation at 5 and 10 years was 82% and 61%, 94% and 87% with degenerative disease and 60% and 45% with rheumatic disease. CONCLUSIONS MV re-repair is feasible and has good mid-term results in patients with degenerative MV disease. Rheumatic MV disease is associated with a certain risk of failure over time; nevertheless, these patients show excellent survival after re-repair.
Collapse
Affiliation(s)
- Gaby Aphram
- Department of Thoracic and Cardiovascular Surgery, Catholic University of Louvain, Saint Luc Hospital, Brussels, Belgium
| | - Laurent De Kerchove
- Department of Thoracic and Cardiovascular Surgery, Catholic University of Louvain, Saint Luc Hospital, Brussels, Belgium
| | - Stefano Mastrobuoni
- Department of Thoracic and Cardiovascular Surgery, Catholic University of Louvain, Saint Luc Hospital, Brussels, Belgium
| | - Emiliano Navarra
- Department of Thoracic and Cardiovascular Surgery, Catholic University of Louvain, Saint Luc Hospital, Brussels, Belgium
| | - Silvia Solari
- Department of Thoracic and Cardiovascular Surgery, Catholic University of Louvain, Saint Luc Hospital, Brussels, Belgium
| | - Saadallah Tamer
- Department of Thoracic and Cardiovascular Surgery, Catholic University of Louvain, Saint Luc Hospital, Brussels, Belgium
| | - Jerome Baert
- Department of Thoracic and Cardiovascular Surgery, Catholic University of Louvain, Saint Luc Hospital, Brussels, Belgium
| | - Alain Poncelet
- Department of Thoracic and Cardiovascular Surgery, Catholic University of Louvain, Saint Luc Hospital, Brussels, Belgium
| | - Jean Rubay
- Department of Thoracic and Cardiovascular Surgery, Catholic University of Louvain, Saint Luc Hospital, Brussels, Belgium
| | - Parla Astarci
- Department of Thoracic and Cardiovascular Surgery, Catholic University of Louvain, Saint Luc Hospital, Brussels, Belgium
| | - Philippe Noirhomme
- Department of Thoracic and Cardiovascular Surgery, Catholic University of Louvain, Saint Luc Hospital, Brussels, Belgium
| | - Gebrine El Khoury
- Department of Thoracic and Cardiovascular Surgery, Catholic University of Louvain, Saint Luc Hospital, Brussels, Belgium
| |
Collapse
|
11
|
Nishida H, Fukui T, Kasegawa H, Kin H, Yamazaki M, Takanashi S. Causes of repair failure for degenerative mitral valve disease and reoperation outcomes. Eur J Cardiothorac Surg 2019; 53:1244-1250. [PMID: 29309559 DOI: 10.1093/ejcts/ezx468] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 12/02/2017] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES This study aimed to evaluate the causes of initial mitral valve (MV) repair failure, the details of reoperation and the long-term outcomes of mitral valve re-repair (Re-MVP). METHODS We retrospectively reviewed 86 patients who underwent reoperation after MV repair for MR due to degenerative disease from October 1991 to December 2015. First, we analysed the initial MV repair data, causes of MV repair failure, reoperation data and long-term outcomes including survival. Second, the patients were classified into 2 groups based on valve related failure or procedure related failure , and the differences between the groups were analysed. RESULTS Leaflet prolapse at the initial operation affected the bilateral leaflets in 37 (43%) patients, the anterior leaflet in 30 (35%) patients and the posterior leaftlet in 19 (22%) patients. Median duration from first operation to reoperation was 47.5 (interquartile range 4.8-85.8) months. Reoperation indication included recurrent mitral regurgitation alone in 59 patients, haemolysis combined with recurrent mitral regurgitation in 15 patients, infectious endocarditis combined with recurrent mitral regurgitation in 8 patients, mitral stenosis in 2 patients and left ventricular pseudoaneurysm in 2 patients. The cause of MV repair failure was valve-related in 61 (71%) patients, procedure-related in 20 (23%) patients and both in 5 (6%) patients. Re-MVP was successful in 23 (27%) patients. Re-MVP was more common in patients with procedure-related failure, which occurred earlier than valve-related failure. Freedom from all-cause death was significantly better after Re-MVP. The 5-year freedom from reoperation after Re-MVP was 95.7%. CONCLUSIONS Re-MVP was more common in patients with procedure-related failure, which occurred earlier than valve-related failure. Durability of re-repaired MVs and survival of re-repaired patients were acceptable.
Collapse
Affiliation(s)
- Hidefumi Nishida
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
| | - Toshihiro Fukui
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan.,Department of Cardiovascular Surgery, Kumamoto University, Kumamoto, Japan
| | - Hitoshi Kasegawa
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
| | - Hajime Kin
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
| | - Masataka Yamazaki
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
| | - Shuichiro Takanashi
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
| |
Collapse
|
12
|
Gardner MA, Hossack KF, Smith IR. Long-Term Results Following Repair for Degenerative Mitral Regurgitation - Analysis of Factors Influencing Durability. Heart Lung Circ 2018; 28:1852-1865. [PMID: 30377076 DOI: 10.1016/j.hlc.2018.10.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 10/04/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND The majority of patients with degenerative mitral regurgitation (DMR) are amenable to reconstructive procedures. There is debate regarding factors that influence long-term durability with respect to repair technique, valve remodelling and progressive myxomatous change. METHODS A total of 685 patients with DMR underwent mitral valve repair by a single surgeon between 1991 and 2011 with follow-up completed at 31 December 2016. Repair rate for patients undergoing surgery for DMR was over 90%. Mean age was 64 years (18-89) with 66.2% male, 47% NYHA class III-IV, and 20% had permanent atrial fibrillation (PAF). Major associated procedures were performed in 28% of patients (189); including coronary artery bypass graft (CABG) (127), aortic valve replacement (15), aortic root surgery (3) and tricuspid valve annuloplasty (61). RESULTS Operative mortality (≤30 days) occurred in four patients (0.58%). At 20 years, survival was 58%, freedom from reoperation was 90% and freedom from reoperation and non-operated recurrent MR >2+ (relapse) was 78%. Factors influencing survival were advancing age, left ventricular (LV) dysfunction (ejection fraction <60% or end systolic dimension >40mm), New York Heart Association (NYHA) III-IV and PAF. Predictors of relapse were the degree of residual intraoperative mitral regurgitation (p<0.001), anterior leaflet prolapse (p<0.001) and the addition of a sliding annuloplasty in isolated posterior leaflet repair (p=0.023). The majority of reoperations were for technical issues related to the original repair. A competent valve at 6 months to 3 years postoperatively predicted an excellent long-term result. CONCLUSION The great majority of degenerative mitral valves are repairable regardless of age with excellent long-term results achievable following surgery. Survival is reduced by significant symptoms, LV dysfunction and preoperative PAF. Repair is best performed before these features develop. Durability is largely dependent on the technical performance of the repair and degree of residual MR on the post-pump transoesophageal echocardiogram. We recommend surgery should be performed by surgeons specialising and skilled in mitral valve repair.
Collapse
Affiliation(s)
| | | | - Ian R Smith
- St Andrew's War Memorial Hospital, Brisbane, Qld, Australia
| |
Collapse
|
13
|
Outcomes of repeat mitral valve replacement in patients with prior mitral surgery: A benchmark for transcatheter approaches. J Thorac Cardiovasc Surg 2018; 156:619-627.e1. [DOI: 10.1016/j.jtcvs.2018.03.126] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 01/10/2018] [Accepted: 03/02/2018] [Indexed: 11/21/2022]
|
14
|
Tomšic A, Arabkhani B, Schoones JW, van Brakel TJ, Takkenberg JJM, Palmen M, Klautz RJM. Outcome reporting for surgical treatment of degenerative mitral valve disease: a systematic review and critical appraisal. Interact Cardiovasc Thorac Surg 2018; 26:566-572. [PMID: 29236990 DOI: 10.1093/icvts/ivx370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 10/25/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Standardized outcome reporting is of critical importance for performance monitoring, improvement of existing techniques and introduction of novel technologies. Whether outcome reporting for surgical treatment of degenerative mitral valve disease complies with the guidelines has not been assessed to date. METHODS A systematic review of PubMed, EMBASE, Web of Science and the Cochrane Library was conducted for articles published between 1 January 2009 and 7 March 2016. Inclusion criteria were adult patient population (n ≥ 200) and surgical intervention for degenerative mitral valve disease. The quality of reported outcome was compared with the standard recommended by the guidelines on reporting morbidity and mortality after cardiac valve interventions. RESULTS Forty-two non-randomized clinical studies were included: 4 provided early and 38 provided early and late outcome data. Early echocardiographic outcome was reported in 49% of studies. Freedom from reintervention, the indication for reintervention and the follow-up echocardiographic outcome were reported in 97%, 59% and 79% of studies providing late outcome data, respectively. The Kaplan-Meier method was used to assess the freedom from recurrent mitral regurgitation in 60% (18/30) of studies, whereas 7% (2/30) of studies applied a longitudinal data analysis. Recurrent mitral regurgitation was most commonly defined as moderate (Grade 2+; 60%) or severe (Grade 4+; 37%) regurgitation. CONCLUSIONS There is a significant discordance between the guidelines-based recommendations and actual reporting of outcome for surgical treatment of degenerative mitral valve disease. Better adherence to the guidelines would raise the quality and generalizability of clinical data reporting.
Collapse
Affiliation(s)
- Anton Tomšic
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Bardia Arabkhani
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Jan W Schoones
- Walaeus Library, Leiden University Medical Centre, Leiden, Netherlands
| | - Thomas J van Brakel
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Johanna J M Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Meindert Palmen
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Robert J M Klautz
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| |
Collapse
|
15
|
Kwedar K, McNeely C, Zajarias A, Markwell S, Vassileva CM. Outcomes of Early Mitral Valve Reoperation in the Medicare Population. Ann Thorac Surg 2017; 104:1516-1521. [DOI: 10.1016/j.athoracsur.2017.05.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 04/25/2017] [Accepted: 05/01/2017] [Indexed: 11/16/2022]
|
16
|
Mehaffey HJ, Hawkins RB, Schubert S, Fonner C, Yarboro LT, Quader M, Speir A, Rich J, Kron IL, Ailawadi G. Contemporary outcomes in reoperative mitral valve surgery. Heart 2017; 104:652-656. [DOI: 10.1136/heartjnl-2017-312047] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 09/11/2017] [Accepted: 09/12/2017] [Indexed: 11/04/2022] Open
Abstract
ObjectiveData suggest that redo mitral valve surgery is being performed in increasing numbers, possibly with superior results according to single-centre studies. The purpose of this study is to describe outcomes of redo mitral valve surgery and identify risk-adjusted predictors of poor outcomes.MethodsAll (11 973) open mitral valve cases were evaluated (2002–2016) from a regional Society of Thoracic Surgery (STS) database. Patients were stratified by primary versus redo mitral valve surgery. Mixed effects logistic regression models including hospital as a random effect were used to identify risk factors for patients undergoing redo mitral valve surgery.ResultsOf all mitral valve cases, 1096 (9.7%) had a previous mitral operation. Redo patients had higher rates of valve replacement and preoperative comorbidities resulting in more complications, operative mortalities (11.1%vs6.5%, p<0.0001) and higher resource utilisation. Several factors independently increased risk for composite STS major morbidity and 30-day mortality, including cardiogenic shock (OR 10.3, p=0.0001), severe tricuspid insufficiency (OR 2.3, p=0.001), urgent/emergent status (OR 1.8, p=0.001) and concurrent coronary artery bypass grafting (OR 2.4, p=0.002). The volume of redo mitral valve surgery increased 10% per year and the observed-to-expected ratios (O/E) for operative mortality in redo mitral surgery improved from 1.44 early in the study period to 0.72 in the most recent era.ConclusionsRedo mitral valve surgery accounts for approximately 10% of mitral valve operations and is associated with increased risk and resource utilisation. However, as the volume of redo mitral surgery increases, outcomes have dramatically improved and are now better than predicted.
Collapse
|
17
|
Chan V, Elmistekawy E, Ruel M, Hynes M, Mesana TG. How Does Mitral Valve Repair Fail in Patients With Prolapse?—Insights From Longitudinal Echocardiographic Follow-Up. Ann Thorac Surg 2016; 102:1459-1465. [DOI: 10.1016/j.athoracsur.2016.08.088] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2016] [Indexed: 10/20/2022]
|
18
|
McNeely CA, Vassileva CM. Long-term outcomes of mitral valve repair versus replacement for degenerative disease: a systematic review. Curr Cardiol Rev 2015; 11:157-62. [PMID: 25158683 PMCID: PMC4356723 DOI: 10.2174/1573403x10666140827093650] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Revised: 08/12/2014] [Accepted: 08/12/2014] [Indexed: 11/24/2022] Open
Abstract
The short-term advantage of mitral valve repair versus replacement for degenerative disease has been extensively documented. These advantages include lower operative mortality, improved survival, better preservation of left-ventricular function, shorter post-operative hospital stay, lower total costs, and fewer valve-related complications, including thromboembolism, anticoagulation-related bleeding events and late prosthetic dysfunction. More recent written data are available indicating the long-term advantage of repair versus replacement. While at some institutions, the repair rate for degenerative disease may exceed 90%, the national average in 2007 was only 69%. Making direct comparisons between mitral valve repair and replacement using the available studies does present some challenges however, as there are often differences in baseline characteristics between patient groups as well as other dissimilarities between studies. The purpose of this review is to systematically summarize the long-term survival and reoperation data of mitral valve repair versus replacement for degenerative disease. A PubMed search was done and resulted in 12 studies that met our study criteria for comparing mitral valve repair versus replacement for degenerative disease. A systematic review was then conducted abstracting survival and reoperation data.
Collapse
|
19
|
BAIL DOROTHEEH. (Meta)-Analysis of Safety and Efficacy Following Edge-to-Edge Mitral Valve Repair Using the MitraClip System. J Interv Cardiol 2015; 28:69-75. [DOI: 10.1111/joic.12168] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- DOROTHEE H.L. BAIL
- Competence-Center Quality Assurance; Medical Service of Statutory Healthcare Insurance; Tuebingen and Stuttgart; Germany
| |
Collapse
|
20
|
Outcome characteristics of multiple-valve surgery: comparison with single-valve procedures. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2014; 9:27-32. [PMID: 24402042 DOI: 10.1097/imi.0000000000000028] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Multiple-valve (MUV) procedures currently exhibit higher operative mortality than do single-valve procedures, but a paucity of scientific information exists to explain the observation. This topic was examined using The Society of Thoracic Surgeons Database. METHODS All patients in the The Society of Thoracic Surgeons data set undergoing valve surgery (except pulmonary valve and aortic root operations) from 1993 through 2007 were identified (N = 623,039). Baseline characteristics and postoperative outcomes were contrasted between all seven combinations of single-valve and MUV procedures involving aortic, mitral, and tricuspid valves. Seven independent logistic regression analyses were performed, based on the seven procedures, and multivariable risk factors for mortality were compared, with emphasis on single-valve versus MUV procedures. RESULTS Baseline characteristics for MUV procedures (n = 67,926) shared many similarities to those for single-valve procedures (n = 555,113), including age, ejection fraction, and comorbidities. Preoperative renal failure, New York Heart Association class III to IV, nonelective presentation, and reoperation were slightly more common in MUV subsets, and coronary bypass was less frequent. Operative mortality was almost double for MUV as compared with single-valve procedures (10.7% vs 5.7%, P = 0.0001). Categorical predictors with the largest odds ratios for mortality were emergency status, renal failure, and second reoperation. However, predictors for mortality were generally consistent in order and magnitude between the single-valve and MUV subgroups. CONCLUSIONS Despite similarities in preoperative profiles of the patients undergoing single-valve and MUV procedures, mortality for MUV surgery remains considerably higher. Determinants of operative mortality and morbidity differ little across the procedural groups, and these findings serve as a benchmark for future studies, as well as suggest a continued search for explanations of poorer MUV outcomes.
Collapse
|
21
|
Grapsa J, Zimbarra Cabrita I, Jakaj G, Ntalarizou E, Serapheim A, Demir OM, Smith B, Dawson D, Momin A, Punjabi PP, Anagnostopoulos CE, Nihoyannopoulos P. Strain balance of papillary muscles as a prerequisite for successful mitral valve repair in patients with mitral valve prolapse due to fibroelastic deficiency. Eur Heart J Cardiovasc Imaging 2014; 16:53-61. [PMID: 25187617 DOI: 10.1093/ehjci/jeu163] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Julia Grapsa
- Department of Cardiovascular Sciences, Hammersmith Hospital, Imperial College London, NHLI, Hammersmith Hospital, London W12 1NN, UK
| | - Ines Zimbarra Cabrita
- Department of Cardiovascular Sciences, Hammersmith Hospital, Imperial College London, NHLI, Hammersmith Hospital, London W12 1NN, UK
| | - Gentjan Jakaj
- Department of Cardiothoracic Surgery, Hammersmith Hospital, Imperial College London, London, UK
| | - Evangelia Ntalarizou
- Department of Cardiovascular Sciences, Hammersmith Hospital, Imperial College London, NHLI, Hammersmith Hospital, London W12 1NN, UK
| | - Andreas Serapheim
- Department of Cardiovascular Sciences, Hammersmith Hospital, Imperial College London, NHLI, Hammersmith Hospital, London W12 1NN, UK
| | - Ozan M Demir
- Department of Cardiovascular Sciences, Hammersmith Hospital, Imperial College London, NHLI, Hammersmith Hospital, London W12 1NN, UK
| | - Benjamin Smith
- Department of Cardiovascular Sciences, Hammersmith Hospital, Imperial College London, NHLI, Hammersmith Hospital, London W12 1NN, UK
| | - David Dawson
- Department of Cardiovascular Sciences, Hammersmith Hospital, Imperial College London, NHLI, Hammersmith Hospital, London W12 1NN, UK
| | - Aziz Momin
- Department of Cardiothoracic Surgery, Hammersmith Hospital, Imperial College London, London, UK
| | - Prakash P Punjabi
- Department of Cardiothoracic Surgery, Hammersmith Hospital, Imperial College London, London, UK
| | | | - Petros Nihoyannopoulos
- Department of Cardiovascular Sciences, Hammersmith Hospital, Imperial College London, NHLI, Hammersmith Hospital, London W12 1NN, UK
| |
Collapse
|
22
|
Vassileva CM, Li S, Thourani VH, Suri RM, Williams ML, Lee R, Rankin JS. Outcome Characteristics of Multiple-Valve Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2014. [DOI: 10.1177/155698451400900105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - Shuang Li
- Duke University and Duke Clinical Research Institute, Durham, NC USA
| | | | | | | | - Richard Lee
- St. Louis University School of Medicine, St. Louis, MO USA
| | | |
Collapse
|
23
|
Jassar AS, Vergnat M, Jackson BM, McGarvey JR, Cheung AT, Ferrari G, Woo YJ, Acker MA, Gorman RC, Gorman JH. Regional annular geometry in patients with mitral regurgitation: implications for annuloplasty ring selection. Ann Thorac Surg 2013; 97:64-70. [PMID: 24070698 DOI: 10.1016/j.athoracsur.2013.07.048] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 07/08/2013] [Accepted: 07/11/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND The saddle shape of the normal mitral annulus has been quantitatively described by several groups. There is strong evidence that this shape is important to valve function. A more complete understanding of regional annular geometry in diseased valves may provide a more educated approach to annuloplasty ring selection and design. We hypothesized that mitral annular shape is markedly distorted in patients with diseased valves. METHODS Real-time 3-dimensional echocardiography was performed in 20 patients with normal mitral valves, 10 with ischemic mitral regurgitation, and 20 with myxomatous mitral regurgitation (MMR). Thirty-six annular points were defined to generate a 3-dimensional model of the annulus. Regional annular parameters were measured from these renderings. Left ventricular inner diameter was obtained from 2-dimensional echocardiographic images. RESULTS Annular geometry was significantly different among the three groups. The annuli were larger in the MMR and in the ischemic mitral regurgitation groups. The annular enlargement was greater and more pervasive in the MMR group. Both diseases were associated with annular flattening, although though the regional distribution of that flattening was different between groups. Left ventricular inner diameter was increased in both groups. However, relative to the Left ventricular inner diameter, the annulus was disproportionately dilated in the MMR group. CONCLUSIONS Patients with MMR and ischemic mitral regurgitation have enlarged and flattened annuli. In the case of MMR, annular distortions may be the driving factor leading to valve incompetence. These data suggest that the goal of annuloplasty should be the restoration of normal annular saddle shape and that the use of flexible, partial, and flat rings may be ill advised.
Collapse
Affiliation(s)
- Arminder S Jassar
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania; Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mathieu Vergnat
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin M Jackson
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania; Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy R McGarvey
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania; Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Albert T Cheung
- Department of Anesthesia University of Pennsylvania, Philadelphia, Pennsylvania
| | - Giovanni Ferrari
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Y Joseph Woo
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael A Acker
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert C Gorman
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania; Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph H Gorman
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania; Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania.
| |
Collapse
|
24
|
Anyanwu AC, Itagaki S, Varghese R, Castillo J, Chikwe J, Adams DH. Re-repair of the mitral valve as a primary strategy for early and late failures of mitral valve repair. Eur J Cardiothorac Surg 2013; 45:352-7; discussion 357-8. [PMID: 23864217 DOI: 10.1093/ejcts/ezt256] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES With the expanding uptake of mitral valve repair as the primary therapy for mitral valve regurgitation, an increasing cohort of patients are presenting with failures following valve repair. These patients have traditionally been treated by mitral valve replacement. We have adopted an aggressive strategy of valve re-repair for failures of mitral valve repair and present our mid-term results. METHODS Fifty-three consecutive adults underwent reoperation by a single surgical team for failed non-rheumatic mitral valve repair. Primary valve repair had been done for degenerative (n=38), congenital (n=6), infective (n=3), functional (n=1) or unknown (n=5) mitral disease. The reoperative mitral procedure occurred at a median interval of 3 (interquartile range 0.9-6.5) years from the primary mitral valve repair. Valve re-repair was attempted if the anterior leaflet was sufficiently pliable, and lesions causing recurrence were identifiable and deemed treatable. Standard repair techniques were employed in re-repair procedures. RESULTS Valve analysis showed that the mode of failure was progression of original disease in 19 (36%), technical failure in 20 (38%) and new disease in 14 (26%) patients. Valve re-repair was successfully accomplished in 45 (85%) patients. Re-repair was most frequent when the prior aetiology was degenerative (34 of 38, 90%) as opposed to non-degenerative (11 of 15, 73%). There were no hospital deaths. Four-year patient survival was 97%. Freedoms from moderate mitral regurgitation were 100, 95, 88 and 80% at discharge and at 1, 3, and 4 years, respectively. There were no reoperations in the follow-up period. CONCLUSIONS Re-repair of the mitral valve is feasible in most of the cases of failed mitral valve repair of non-rheumatic aetiology and has acceptable mid-term outcomes. The relatively high prevalence of technical failures as the mechanism of failure of the primary mitral valve repair suggests the need for ongoing surgical education and continuing development and refinement of repair techniques.
Collapse
Affiliation(s)
- Anelechi C Anyanwu
- Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY, USA
| | | | | | | | | | | |
Collapse
|
25
|
Rankin JS, He X, O'Brien SM, Jacobs JP, Welke KF, Filardo G, Shahian DM. The Society of Thoracic Surgeons Risk Model for Operative Mortality After Multiple Valve Surgery. Ann Thorac Surg 2013; 95:1484-90. [DOI: 10.1016/j.athoracsur.2012.11.077] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 11/08/2012] [Accepted: 11/12/2012] [Indexed: 12/14/2022]
|
26
|
Rankin JS, Thourani VH, Suri RM, He X, O'Brien SM, Vassileva CM, Shah AS, Williams M. Associations between valve repair and reduced operative mortality in 21 056 mitral/tricuspid double valve procedures. Eur J Cardiothorac Surg 2013; 44:472-6; discussion 476-7. [DOI: 10.1093/ejcts/ezt077] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
27
|
Xu C, Jassar AS, Nathan DP, Eperjesi TJ, Brinster CJ, Levack MM, Vergnat M, Gorman RC, Gorman JH, Jackson BM. Augmented mitral valve leaflet area decreases leaflet stress: a finite element simulation. Ann Thorac Surg 2012; 93:1141-5. [PMID: 22397985 PMCID: PMC3462015 DOI: 10.1016/j.athoracsur.2012.01.069] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 01/17/2012] [Accepted: 01/20/2012] [Indexed: 11/20/2022]
Abstract
BACKGROUND Using human mitral valve (MV) models derived from three-dimensional echocardiography, finite element analysis was used to predict mechanical leaflet and chordal stress. Subsequently, valve geometries were altered to examine the effects on stresses of the following: (1) varying coaptation area; (2) varying noncoapted leaflet tissue area; and (3) varying interleaflet coefficient of friction (μ). METHODS Three human MV models were loaded with a transvalvular pressure of 80 mm Hg using finite element analysis. Initially leaflet coaptation was set to 10%, 50%, or 100% of actual coaptation length to test the influence of coaptation length on stress distribution. Next, leaflet surface areas were augmented by 1% overall and by 2% in the noncoapted "belly" region to test the influence of increased leaflet billowing without changing the gross geometry of the MV. Finally, the coefficient of friction between the coapted leaflets was set to μ = 0, 0.05, or 0.3, to assess the influence of friction on MV function. RESULTS Leaflet coaptation length did not affect stress distribution in either the coapted or noncoapted leaflet regions; peak leaflet stress was 0.36 ± 0.17 MPa at 100%, 0.35 ± 0.14 MPa at 50%, and 0.35 ± 0.15 MPa at 10% coaptation lengths (p = 0.85). Similarly, coaptation length did not affect peak chordal tension (p = 0.74). Increasing the noncoapted leaflet area decreased the peak valvular stresses by 5 ± 2% (p = 0.02). Varying the coefficient of friction between leaflets did not alter leaflet or chordal stress distribution (p = 0.18). CONCLUSIONS Redundant MV leaflet tissue reduces mechanical stress on the noncoapted leaflets; the extent of coaptation or frictional interleaflet interaction does not independently influence leaflet stresses. Repair techniques that increase or preserve noncoapted leaflet area may decrease mechanical stresses and thereby enhance repair durability.
Collapse
Affiliation(s)
- Chun Xu
- Gorman Cardiovascular Research Group, University of Pennsylvania, Glenolden, Pennsylvania, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Pouch AM, Xu C, Yushkevich PA, Jassar AS, Vergnat M, Gorman JH, Gorman RC, Sehgal CM, Jackson BM. Semi-automated mitral valve morphometry and computational stress analysis using 3D ultrasound. J Biomech 2012; 45:903-7. [PMID: 22281408 DOI: 10.1016/j.jbiomech.2011.11.033] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2011] [Indexed: 11/16/2022]
Abstract
In vivo human mitral valves (MV) were imaged using real-time 3D transesophageal echocardiography (rt-3DTEE), and volumetric images of the MV at mid-systole were analyzed by user-initialized segmentation and 3D deformable modeling with continuous medial representation, a compact representation of shape. The resulting MV models were loaded with physiologic pressures using finite element analysis (FEA). We present the regional leaflet stress distributions predicted in normal and diseased (regurgitant) MVs. Rt-3DTEE, semi-automated leaflet segmentation, 3D deformable modeling, and FEA modeling of the in vivo human MV is tenable and useful for evaluation of MV pathology.
Collapse
Affiliation(s)
- Alison M Pouch
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Ibrahim M, Rao C, Ashrafian H, Chaudhry U, Darzi A, Athanasiou T. Modern management of systolic anterior motion of the mitral valve. Eur J Cardiothorac Surg 2012; 41:1260-70. [DOI: 10.1093/ejcts/ezr232] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
30
|
Pandis D, Grapsa J, Athanasiou T, Punjabi P, Nihoyannopoulos P. Left ventricular remodeling and mitral valve surgery: Prospective study with real-time 3-dimensional echocardiography and speckle tracking. J Thorac Cardiovasc Surg 2011; 142:641-9. [DOI: 10.1016/j.jtcvs.2010.11.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Revised: 11/04/2010] [Accepted: 11/20/2010] [Indexed: 10/18/2022]
|
31
|
Ghoreishi M, Dawood M, Stauffer CE, Gammie JS. Mitral regurgitation: current trends in diagnosis and management. Hosp Pract (1995) 2011; 39:181-92. [PMID: 21441774 DOI: 10.3810/hp.2011.02.389] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Mitral regurgitation is the most prevalent heart valve disorder in the United States. Individuals with mitral regurgitation may be asymptomatic or may present with dyspnea, orthopnea, fatigue, and/or heart rhythm disturbances. Long-standing mitral regurgitation causes chronic left ventricular volume overload, which leads to left ventricular dilation and contractile dysfunction. Without treatment, mitral regurgitation results in biventricular failure and death. Echocardiography is the preferred diagnostic test to assess the presence and severity of mitral regurgitation. Mitral valve surgery, the only effective treatment for patients with severe mitral regurgitation, is recommended early in the course of the disease to prevent the development of heart failure. Early recognition of mitral regurgitation and timely referral for mitral valve surgery significantly improve symptoms and long-term survival.
Collapse
Affiliation(s)
- Mehrdad Ghoreishi
- Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, MD 21201, USA
| | | | | | | |
Collapse
|
32
|
Mechanisms of recurrent regurgitation after valve repair for prolapsed mitral valve disease. Ann Thorac Surg 2011; 91:1433-8; discussion 1438-9. [PMID: 21435629 DOI: 10.1016/j.athoracsur.2011.01.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2010] [Revised: 12/31/2010] [Accepted: 01/04/2011] [Indexed: 11/22/2022]
Abstract
BACKGROUND We assessed mitral valve (MV) function using serial echocardiography as an indicator of the durability of MV repair. The aim of this study was to analyze the mechanisms of recurrent regurgitation after MV repair for degenerative disease. METHODS From 1991 to 2007, 736 patients had valve repair for mitral regurgitation caused by leaflet prolapse: 346 patients had posterior and 390 had anterior leaflet prolapse. The mean age was 54.6±14.6 years, with 495 males. The durability and mechanisms of recurrent regurgitation were evaluated by the findings of echocardiography and reoperation. Follow-up and late echocardiography averaged 5.7±3.9 and 5.1±3.6 years, respectively. RESULTS Survival was 91.9%±1.5% at 10 years. Freedom from reoperation and moderate or severe regurgitation at 10 years were 91.2%±1.7% and 84.5%±2.1%, respectively. Reoperations were performed for recurrent regurgitation in 29 patients, hemolysis in 5, and endocarditis in 1. Based on the findings of reoperation, the mechanisms of repair failure were procedure related in 9 (25.7%), valve related in 25 (71.4%), and unknown in 1. Late echocardiography revealed none to trivial regurgitation in 511 patients, mild in 153, moderate in 26, and severe in 40. Anterior leaflet prolapse, preoperative atrial fibrillation, and no use of annuloplasty ring were independent predictors of recurrent regurgitation. The main causes of moderate or severe regurgitation were leaflet thickening in 34 patients, leaflet prolapse in 20, dehiscence in 10, and unknown in 2. CONCLUSIONS The main mechanism of recurrent regurgitation after MV repair is progressive degeneration that is characterized by leaflet thickening and prolapse, especially in patients with anterior leaflet prolapse.
Collapse
|
33
|
Shimokawa T, Kasegawa H, Matsuyama S, Seki H, Manabe S, Fukui T, Morita S, Takanashi S. Long-Term Outcome of Mitral Valve Repair for Infective Endocarditis. Ann Thorac Surg 2009; 88:733-9; discussion 739. [DOI: 10.1016/j.athoracsur.2009.05.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2009] [Revised: 05/08/2009] [Accepted: 05/13/2009] [Indexed: 10/20/2022]
|