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Oezpeker UC, Hoefer D, Barbieri F, Gollmann-Tepekoeylue C, Johannes H, Clemens E, Suat E, Adel S, Sasa R, Mueller L, Grimm M, Bonaros N. Isolated annuloplasty in elderly patients with secondary mitral valve regurgitation: short- and long-term outcomes with a less invasive approach. Front Cardiovasc Med 2023; 10:1193156. [PMID: 37915742 PMCID: PMC10617676 DOI: 10.3389/fcvm.2023.1193156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 09/06/2023] [Indexed: 11/03/2023] Open
Abstract
Background Long-term outcomes of elderly and frail patients with secondary mitral valve regurgitation (MR) are inconclusive. Especially in patients with co-morbidities such as atherosclerosis who are suffering from heart failure, optimal medical therapy (OMT) is the preferred therapy relative to surgical or percutaneous interventions. It remains challenging to identify the most successful therapy to improve symptoms and increase life expectancy. To reduce surgical trauma for these patients, minimally invasive mitral valve surgery (MIMVS) was developed; this has shown promising medium-term results, but there is still a lack of evidence regarding long-term results. The aim of this investigation was to describe the long-term outcomes of less invasive mitral valve surgery (MVS) in elderly patients. Methods In this longitudinal retrospective analysis, 67 patients (aged ≥70 years) with secondary MR who underwent MV repair ± tricuspid valve repair (TVR) were identified. MVS was performed via minithoracotomy (MT) in most cases (n = 54); in patients with contraindications for MIMVS, partial upper sternotomy (PS) was the preferred route for surgical access (n = 13). The appropriate access route was chosen according to the patient's clinical condition and comorbidities. We analyzed reoperation-free long-term survival, combined operative success (lack of residual MR, conversion to MV replacement, or larger thoracic incisions), and perioperative safety (at 30 days: mortality, re-thoracotomy, ECMO, pacemaker implantation, dialysis, longer ventilation, stroke, myocardial infarction). In a subgroup analysis, we compared long-term survival in MVS patients with and without TVR. Results The median age of patients (62.7% female) was 74 years (interquartile range: 72-76 years), with a median EuroSCORE2 of 2.8% (1.5%-4.6%) and N-terminal pro-brain natriuretic peptide plasma levels of 1,434 ng/L (1035-2149 ng/L). The median follow-up period was 5.6 years (2.7-8.5 years). The reoperation-free long-term survival rate up to 10 years was 66.2%. Combined operative success and perioperative safety were achieved in 94% and 76% of patients, respectively. Additional TVR was performed in 56.7% of patients, without any significant difference in survival rates compared to the group without TVR (p = 0.417; HR 1.473, 95% CI 0.578-3.757). Conclusion Less invasive MV repair for secondary MR shows excellent operative success and safety in selected patients. Freedom from significant MR and from the need for reoperation indicates long-lasting efficacy. These results should be considered in heart team discussions regarding allocation of patients to surgical mitral procedures.
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Affiliation(s)
- Ulvi Cenk Oezpeker
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Daniel Hoefer
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Fabian Barbieri
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Berlin, Germany
| | | | - Holfeld Johannes
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Engler Clemens
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Ersahin Suat
- Department of Cardiovascular Surgery, Sakarya University, Adapazari, Türkiye
| | - Sakic Adel
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Rajsic Sasa
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Ludwig Mueller
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Grimm
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
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An Individualized, Less-Invasive Surgical Approach Algorithm Improves Outcome in Elderly Patients Undergoing Mitral Valve Surgery. J Cardiovasc Dev Dis 2023; 10:jcdd10010028. [PMID: 36661923 PMCID: PMC9862192 DOI: 10.3390/jcdd10010028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 12/30/2022] [Accepted: 01/05/2023] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND For mitral valve surgery (MVS) in elderly, frail patients with increasing life expectancy, finding the least harmful means of access is a challenge. In the complexity of MVS approach evolution, using three different approaches (mini-thoracotomy (MT), partial upper-sternotomy (PS), full-sternotomy (FS), we developed a personalized, minimized-invasiveness algorithm for MVS. METHODS In this retrospective analysis, 517 elderly patients (≥70 years) were identified who had undergone MVS ± TV repair. MVS was performed via MT (n = 274), FS (n = 128) and PS (n = 115). The appropriate access type was defined according to several clinical patient conditions. Using uni- and multivariate regression models, we analyzed combined operative success (residual MV regurgitation, conversion to MV replacement or larger thoracic incisions); perioperative success (30-days mortality, thoracotomy, ECMO, pacemaker implantation, dialysis, longer ventilation); and reoperation-free long-term survival. An additional EuroSCORE2 adjustment was performed to reduce the bias of clinical conditions between all access types. RESULTS The EuroSCORE2-adjusted Cox regression analysis showed significantly increased reoperation-free survival in the MT cohort compared to FS (HR 0.640; 95% CI 0.442-0.926; p = 0.018). Mortality was additionally reduced after the implementation of PS (p = 0.023). Combined operative success was comparable between the three access types. The perioperative success was higher in the MT cohort compared to FS (OR 2.19, 95% CI 1.32-3.63; p = 0.002). CONCLUSION Less-invasive approaches in elderly patients improve perioperative success and reoperation-free survival in those undergoing MVS procedures.
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Iwamoto SJ, Defreyne J, Kaoutzanis C, Davies RD, Moreau KL, Rothman MS. Gender-affirming hormone therapy, mental health, and surgical considerations for aging transgender and gender diverse adults. Ther Adv Endocrinol Metab 2023; 14:20420188231166494. [PMID: 37113210 PMCID: PMC10126651 DOI: 10.1177/20420188231166494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 03/13/2023] [Indexed: 04/29/2023] Open
Abstract
As the transgender and gender diverse (TGD) population ages, more transfeminine and transmasculine individuals present to clinic to initiate or continue their gender-affirming care at older ages. Currently available guidelines on gender-affirming care are excellent resources for the provision of gender-affirming hormone therapy (GAHT), primary care, surgery, and mental health care but are limited in their scope as to whether recommendations require tailoring to older TGD adults. Data that inform guideline-recommended management considerations, while informative and increasingly evidence-based, mainly come from studies of younger TGD populations. Whether results from these studies, and therefore recommendations, can or should be extrapolated to aging TGD adults remains to be determined. In this perspective review, we acknowledge the lack of data in older TGD adults and discuss considerations for evaluating cardiovascular disease, hormone-sensitive cancers, bone health and cognitive health, gender-affirming surgery, and mental health in the older TGD population on GAHT.
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Affiliation(s)
| | - Justine Defreyne
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Christodoulos Kaoutzanis
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- UCHealth Integrated Transgender Program – Anschutz Medical Campus, Aurora, CO, USA
| | - Robert D. Davies
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- CUMedicine LGBTQ Mental Health Clinic, University of Colorado Hospital, Aurora, CO, USA
- UCHealth Integrated Transgender Program – Anschutz Medical Campus, Aurora, CO, USA
| | - Kerrie L. Moreau
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Eastern Colorado Geriatric Research Education and Clinical Center, Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
| | - Micol S. Rothman
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- UCHealth Integrated Transgender Program – Anschutz Medical Campus, Aurora, CO, USA
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Oezpeker UC, Barbieri F, Hoefer D, Bonaros N, Grimm M, Mueller L. Partial Upper Sternotomy is a Safe Alternative in Mitral Annulus Decalcification. Semin Thorac Cardiovasc Surg 2021; 34:502-509. [PMID: 34089825 DOI: 10.1053/j.semtcvs.2021.04.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 04/12/2021] [Indexed: 11/11/2022]
Abstract
In patients with major annulus calcifications (MAC) requiring en-bloque decalcification anterolateral minithoracotomy is not suitable for safe and reproducible mitral valve surgery (MVS) procedures. In these cases, full sternotomy (FS) is still the preferred approach. Alternatively, less invasive MVS via partial upper sternotomy (PS) and transseptal access can be used in experienced centers. After reviewing the records of 1741 patients, who were treated with either isolated MVS or combined procedures, we identified 32 patients who had undergone en-bloque decalcification for MAC. The 2 techniques (PS-group n = 17, FS-cohort n = 15) were presented in terms of 1-year mortality as well as intra- and perioperative outcome. In the PS group, the age was 60.06 ± 7.56 patients, 64.7% were female and had a STS Predicted Risk of Mortality (PROM) score of 1.01 ± 1.06. In the FS group the patients (53.3% female) mean age was 58.47 ± 14.45 and had a STS PROM score 2.35 ± 2.73%. Rates of mitral repair were in the PS and FS cohort 64.7% and 46.7%, respectively. One-year mortality for PS-MVS was 5.9% (n = 1) and 20% (n = 3) for FS-MVS. The cardiopulmonary bypass (FS: 181.60 ± 49.99 minutes, PS: 192.83 ± 77.32 minutes and the cross-clamp times (FS: 119.67 ± 46.06, PS: 136.94 ± 54.37 minutes). The observed ventilation times in the PS and FS group were 5 hours (IQR 3.5-9) and 10 hours (IQR 5-15), respectively. A permanent pacemaker implantation was not necessary in any patient. In patients with MAC and en-bloque decalcification PS seems to be a safe access and might be a valid less invasive alternative to minithoracotomy.
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Affiliation(s)
- Ulvi Cenk Oezpeker
- Department of Cardiac Surgery, Medical University of Innsbruck, Austria.
| | - Fabian Barbieri
- Department of Cardiology, Medical University of Innsbruck, Austria
| | - Daniel Hoefer
- Department of Cardiac Surgery, Medical University of Innsbruck, Austria
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, Austria
| | - Michael Grimm
- Department of Cardiac Surgery, Medical University of Innsbruck, Austria
| | - Ludwig Mueller
- Department of Cardiac Surgery, Medical University of Innsbruck, Austria
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Noack T, Borger MA. Chordal replacement: future surgical gold standard or first-line option as bridge to definitive therapy in primary mitral regurgitation? Ann Cardiothorac Surg 2021; 10:167-169. [PMID: 33575189 DOI: 10.21037/acs-2020-mv-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Thilo Noack
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - Michael A Borger
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
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Götte J, Zittermann A, Hakim-Meibodi K, Hata M, Schramm R, Bleiziffer S, Parsa MA, Gummert J, Renner A. Long-Term Clinical Outcome in Elderly Patients Undergoing Mitral Valve Repair. Thorac Cardiovasc Surg 2020; 70:93-99. [PMID: 32998167 DOI: 10.1055/s-0040-1716324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Long-term data on patients over 75 years undergoing mitral valve (MV) repair are scarce. At our high-volume institution, we, therefore, aimed to evaluate mortality, stroke risk, and reoperation rates in these patients. METHODS We investigated clinical outcomes in 372 patients undergoing MV repair with (n = 115) or without (n = 257) tricuspid valve repair. The primary endpoint was the probability of survival up to a maximum follow-up of 9 years. Secondary clinical endpoints were stroke and reoperation of the MV during follow-up. Univariate and multivariable Cox regression analysis was performed to assess independent predictors of mortality. Mortality was also compared with the age- and sex-adjusted general population. RESULTS During a median follow-up period of 37 months (range: 0.1-108 months), 90 patients died. The following parameters were independently associated with mortality: double valve repair (hazard ratio, confidence interval [HR, 95% CI]: 2.15, 1.37-3.36), advanced age (HR: 1.07, CI: 1.01-1.14 per year), diabetes (HR: 1.97, CI: 1.13-3.43), preoperative New York Heart Association (NYHA) functional class (HR: 1.41, CI: 1.01-1.97 per class), and operative creatininemax levels (HR: 1.32, CI: 1.13-1.55 per mg/dL). The risk of stroke in the isolated MV and double valve repair groups at postoperative year 5 was 5.0 and 4.1%, respectively (p = 0.65). The corresponding values for the risk of reoperation were 4.0 and 7.0%, respectively (p = 0.36). Nine-year survival was comparable with the general population (53.2 vs. 53.1%). CONCLUSION Various independent risk factors for mortality in elderly MV repair patients could be identified, but overall survival rates were similar to those of the general population. Consequently, our data indicates that repairing the MV in elderly patients represents a suitable and safe surgical approach.
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Affiliation(s)
- Julia Götte
- Department of Cardio-Thoracic Surgery, Heart and Diabetes Center North Rhine Westphalia, Bad Oeynhausen, Nordrhein-Westfalen, 32545, Germany
| | - Armin Zittermann
- Department of Cardio-Thoracic Surgery, Heart and Diabetes Center North Rhine Westphalia, Bad Oeynhausen, Nordrhein-Westfalen, 32545, Germany
| | - Kavous Hakim-Meibodi
- Department of Cardio-Thoracic Surgery, Heart and Diabetes Center North Rhine Westphalia, Bad Oeynhausen, Nordrhein-Westfalen, 32545, Germany
| | - Masatoshi Hata
- Department of Cardio-Thoracic Surgery, Heart and Diabetes Center North Rhine Westphalia, Bad Oeynhausen, Nordrhein-Westfalen, 32545, Germany
| | - Rene Schramm
- Department of Cardio-Thoracic Surgery, Heart and Diabetes Center North Rhine Westphalia, Bad Oeynhausen, Nordrhein-Westfalen, 32545, Germany
| | - Sabine Bleiziffer
- Department of Cardio-Thoracic Surgery, Heart and Diabetes Center North Rhine Westphalia, Bad Oeynhausen, Nordrhein-Westfalen, 32545, Germany
| | - Mohammed Amin Parsa
- Department of Cardio-Thoracic Surgery, Heart and Diabetes Center North Rhine Westphalia, Bad Oeynhausen, Nordrhein-Westfalen, 32545, Germany
| | - Jan Gummert
- Department of Cardio-Thoracic Surgery, Heart and Diabetes Center North Rhine Westphalia, Bad Oeynhausen, Nordrhein-Westfalen, 32545, Germany
| | - Andre Renner
- Department of Cardio-Thoracic Surgery, Heart and Diabetes Center North Rhine Westphalia, Bad Oeynhausen, Nordrhein-Westfalen, 32545, Germany
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Mechanistic study of ventricular hook anchor for heart valve replacement or repair. MEDICINE IN NOVEL TECHNOLOGY AND DEVICES 2020. [DOI: 10.1016/j.medntd.2020.100033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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8
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Noack T, Kiefer P, Vivell N, Sieg F, Marin-Cuartas M, Leontyev S, Holzhey DM, Garbade J, Pfannmueller B, Davierwala P, Misfeld M, Seeburger J, Borger MA. Annuloplasty ring dehiscence after mitral valve repair: incidence, localization and reoperation. Eur J Cardiothorac Surg 2020; 57:300-307. [PMID: 31369069 DOI: 10.1093/ejcts/ezz219] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 06/24/2019] [Accepted: 07/02/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Mitral valve (MV) annuloplasty ring dehiscence with subsequent recurrent mitral regurgitation represents an unusual but challenging clinical problem. Incidence, localization and outcomes for this complication have not been well defined. METHODS From 1996 to 2016, a total of 3478 patients underwent isolated MV repair with ring annuloplasty at the Leipzig Heart Centre. Of these patients, 57 (1.6%) underwent reoperation due to annuloplasty ring dehiscence. Echocardiographic data, operative and early postoperative characteristics as well as short- and long-term survival rates after MV reoperation were analysed. RESULTS Occurrences of ring dehiscence were acute (<30 days), early (≤1 year) and late (>1 year) in 44%, 33% and 23% of patients, respectively. Localization of annuloplasty ring dehiscence was found most frequently in the P3 segment (68%), followed by the P2 (51%) and the P1 segments (47%). The 30-day mortality rate and 1- and 5-year survival rates after MV reoperation were 2%, 89% and 74%, respectively. During reoperation, MV replacement was performed in 38 (67%) and MV re-repair in 19 (33%) patients. CONCLUSIONS Annuloplasty ring dehiscence is clinically less common, localized more frequently on the posterior annulus and occurs mostly acutely or early after MV repair. MV reoperation can be performed safely in such patients.
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Affiliation(s)
- Thilo Noack
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Philipp Kiefer
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Nina Vivell
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Franz Sieg
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Mateo Marin-Cuartas
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Sergey Leontyev
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | | | - Jens Garbade
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Bettina Pfannmueller
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Piroze Davierwala
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Martin Misfeld
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Joerg Seeburger
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
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Rostagno C. Heart valve disease in elderly. World J Cardiol 2019; 11:71-83. [PMID: 30820277 PMCID: PMC6391621 DOI: 10.4330/wjc.v11.i2.71] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 01/13/2019] [Accepted: 01/26/2019] [Indexed: 02/06/2023] Open
Abstract
The incidence of heart valve disease increases significantly with age. Degenerative abnormalities associated with severe aortic stenosis and mitral and tricuspid regurgitation are found in not less than 10% of the population aged ≥ 75 years. Surgical treatment has been considered for years to be the treatment of choice. However, it was not uncommonly associated with high perioperative morbidity and mortality due to frequent comorbidities and overall frailty conditions of these patients. Conventional risk scores such as Society of Thoracic Surgeons and European System for Cardiac Operative Risk Evaluation may underestimate the risk of surgery in elderly patients, leading to inappropriate surgical indication. On the other hand, at least 30% of patients with severe conditions are left untreated due to prohibitive surgical risk. Interventional procedures, which are in continuous development, may be actually considered for high risk patients and, as recent results suggest, also for intermediate risk patients.
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Affiliation(s)
- Carlo Rostagno
- Department of Internal Medicine, University of Florence, Florence 50134, Italy
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10
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Lee JS, Kim KH, Choi JW, Hwang HY, Kim KB. Surgical Treatment of Degenerative Mitral Valve Regurgitation in the Elderly: Comparison of Early and Long-Term Outcomes Using Propensity Score Matching Analysis. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2018; 51:367-375. [PMID: 30588444 PMCID: PMC6301326 DOI: 10.5090/kjtcs.2018.51.6.367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 10/01/2018] [Accepted: 10/01/2018] [Indexed: 12/03/2022]
Abstract
Background It is unclear whether mitral valve (MV) repair for degenerative mitral regurgitation (MR) provides the same advantages in the elderly that it does in the general population. Methods From 1994 to 2016, 188 elderly patients (mean age, 68.3±5.50 years) underwent MV repair (n=153) or MV replacement (n=35) for primary degenerative MR. Early and long-term outcomes were compared before and after propensity score matching (PSM). Results Before PSM, there was a significant difference in operative mortality (p=0.011). Overall survival and freedom from cardiac-related death (CRD) at 5, 10, and 15 years were significantly higher in patients who underwent MV repair (p=0.039 and p=0.007, respectively). In the multivariable analysis, MV replacement was an independent risk factor of CRD. After PSM, operative mortality was not significantly lower in patients who underwent MV repair (p=0.125). Overall survival and freedom from CRD at 5, 10, and 15 years showed no significant difference between the 2 groups in the PSM cohort (p=0.207, p=0.47, respectively). There was no significant difference in freedom from reoperation before or after PSM (p=0.963 and p=0.575, respectively). Conclusion MV repair for primary degenerative MR might be a valid option in the elderly population if successful repair is possible.
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Affiliation(s)
- Joon Seok Lee
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine
| | - Kyung Hwan Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine
| | - Jae Woong Choi
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine
| | - Ho Young Hwang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine
| | - Ki-Bong Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine
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Bozkurt S, Preston-Maher GL, Torii R, Burriesci G. Design, Analysis and Testing of a Novel Mitral Valve for Transcatheter Implantation. Ann Biomed Eng 2017; 45:1852-1864. [PMID: 28374279 PMCID: PMC5527080 DOI: 10.1007/s10439-017-1828-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Accepted: 03/25/2017] [Indexed: 12/31/2022]
Abstract
Mitral regurgitation is a common mitral valve dysfunction which may lead to heart failure. Because of the rapid aging of the population, conventional surgical repair and replacement of the pathological valve are often unsuitable for about half of symptomatic patients, who are judged high-risk. Transcatheter valve implantation could represent an effective solution. However, currently available aortic valve devices are inapt for the mitral position. This paper presents the design, development and hydrodynamic assessment of a novel bi-leaflet mitral valve suitable for transcatheter implantation. The device consists of two leaflets and a sealing component made from bovine pericardium, supported by a self-expanding wireframe made from superelastic NiTi alloy. A parametric design procedure based on numerical simulations was implemented to identify design parameters providing acceptable stress levels and maximum coaptation area for the leaflets. The wireframe was designed to host the leaflets and was optimised numerically to minimise the stresses for crimping in an 8 mm sheath for percutaneous delivery. Prototypes were built and their hydrodynamic performances were tested on a cardiac pulse duplicator, in compliance with the ISO5840-3:2013 standard. The numerical results and hydrodynamic tests show the feasibility of the device to be adopted as a transcatheter valve implant for treating mitral regurgitation.
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Affiliation(s)
- Selim Bozkurt
- UCL Mechanical Engineering, Cardiovascular Engineering Laboratory, University College London, London, WC1E 7JE, UK
| | - Georgia L Preston-Maher
- UCL Mechanical Engineering, Cardiovascular Engineering Laboratory, University College London, London, WC1E 7JE, UK
| | - Ryo Torii
- UCL Mechanical Engineering, Cardiovascular Engineering Laboratory, University College London, London, WC1E 7JE, UK
| | - Gaetano Burriesci
- UCL Mechanical Engineering, Cardiovascular Engineering Laboratory, University College London, London, WC1E 7JE, UK. .,Ri.MED Foundation, Bioengineering Group, Palermo, Italy.
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12
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Figulla HR, Webb JG, Lauten A, Feldman T. The transcatheter valve technology pipeline for treatment of adult valvular heart disease. Eur Heart J 2016; 37:2226-39. [PMID: 27161617 DOI: 10.1093/eurheartj/ehw153] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 03/17/2016] [Indexed: 12/17/2022] Open
Abstract
The transcatheter valve technology pipeline has started as simple balloon valvuloplasty for the treatment of stenotic heart valves and evolved since the year 2000 to either repair or replace heart valves percutaneously with multiple devices. In this review, the present technology and its application are illuminated and a glimpse into the near future is dared from a physician's perspective.
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Affiliation(s)
- Hans R Figulla
- Universitätsklinikum Jena, Friedrich Schiller Universität Jena, Jena, Germany
| | - John G Webb
- St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Alexander Lauten
- Charité-Universitaetsmedizin Berlin, Department of Cardiology Berlin, Campus Benjamin Franklin, Germany
| | - Ted Feldman
- Cardiology Division, NorthShore University HealthSystem Evanston, Evanston, USA
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13
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Wozniak SE, Coleman J, Katlic MR. Optimal Preoperative Evaluation and Perioperative Care of the Geriatric Patient: A Surgeon's Perspective. Anesthesiol Clin 2015; 33:481-489. [PMID: 26315633 DOI: 10.1016/j.anclin.2015.05.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The elderly preoperative patient benefits from an assessment that includes more than a routine physical examination and electrocardiogram. Such an assessment includes domains likely to affect the elderly: cognition, functionality, frailty, polypharmacy, nutrition, and social support. This fosters decisions based on functional age rather than chronologic age and on each patient as an individual. One such assessment is that promulgated by the American College of Surgeons National Surgery Quality Improvement Program/American Geriatrics Society Best Practice Guidelines. We should not miss any opportunity to improve results in this growing population of surgical patients.
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Affiliation(s)
- Susan E Wozniak
- Department of Surgery, Sinai Center for Geriatric Surgery, Sinai Hospital, 2401 West Belvedere Avenue, Baltimore, MD 21215, USA
| | - JoAnn Coleman
- Department of Surgery, Sinai Center for Geriatric Surgery, Sinai Hospital, 2401 West Belvedere Avenue, Baltimore, MD 21215, USA
| | - Mark R Katlic
- Department of Surgery, Sinai Center for Geriatric Surgery, Sinai Hospital, 2401 West Belvedere Avenue, Baltimore, MD 21215, USA.
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14
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Goldstone AB, Cohen JE, Howard JL, Edwards BB, Acker AL, Hiesinger W, MacArthur JW, Atluri P, Woo YJ. A “Repair-All” Strategy for Degenerative Mitral Valve Disease Safely Minimizes Unnecessary Replacement. Ann Thorac Surg 2015; 99:1983-90; discussion 1990-1. [DOI: 10.1016/j.athoracsur.2014.12.076] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 12/15/2014] [Accepted: 12/23/2014] [Indexed: 11/29/2022]
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15
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Kathetergestützte Mitralklappenrekonstruktion. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2015. [DOI: 10.1007/s00398-014-1124-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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16
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Taramasso M, Maisano F, Denti P, Latib A, La Canna G, Colombo A, Alfieri O. Percutaneous edge-to-edge repair in high-risk and elderly patients with degenerative mitral regurgitation: midterm outcomes in a single-center experience. J Thorac Cardiovasc Surg 2014; 148:2743-50. [PMID: 24768099 DOI: 10.1016/j.jtcvs.2014.03.036] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 03/08/2014] [Accepted: 03/21/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The study objective was to report the midterm outcomes of MitraClip implantation in inoperable or high-risk surgical candidates with degenerative mitral regurgitation. METHODS From October 2008, data of all high-risk or elderly patients with severe degenerative mitral regurgitation who underwent MitraClip implantation were prospectively collected. RESULTS Forty-eight high-risk consecutive patients with severe degenerative mitral regurgitation underwent MitraClip implantation (mean age, 78.5 ± 10.8 years; 56.6% of the patients were aged ≥ 80 years). Mean Society of Thoracic Surgeons score was 12% ± 10%, and 71% were in New York Heart Association class III or IV. Mean left ventricular ejection fraction was 57% ± 11%. The device was successfully implanted in 47 of 48 patients (98%). In-hospital mortality was 2%. The median intensive care unit stay was 22 hours; patients were discharged from the hospital in an average of 4.5 ± 2.4 days. Predischarge echocardiography showed a mitral regurgitation reduction to grade 2+ or less in 43 of 47 patients (91.5%). Actuarial survival was 89% ± 5.2% and 70.2% ± 9% at 1 and 2 years, respectively (82% ± 9% in patients aged <80 years and 95% ± 4.4% in patients aged ≥ 80 years at 1 year; P = .9). Freedom from mitral regurgitation 3+ or greater was 80% ± 7% at 1 year and 76.6% ± 7% at 2 years. At 1 year, 93% of survivors were in New York Heart Association class I or II (100% of patients aged <80 years and 88% of patients aged ≥ 80 years; P = .4). Significant quality of life improvements were documented. A significant improvement in 6-minute walk test performance was observed. CONCLUSIONS MitraClip therapy is a valuable alternative to surgery in high-risk and elderly patients with degenerative mitral regurgitation. Clinical benefits also are obtained in octogenarians.
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Affiliation(s)
- Maurizio Taramasso
- Cardiac Surgery Department, San Raffaele University Hospital, Milan, Italy.
| | - Francesco Maisano
- Division of Cardiovascular Surgery, University Hospital of Zurich, Zurich, Switzerland
| | - Paolo Denti
- Cardiac Surgery Department, San Raffaele University Hospital, Milan, Italy
| | - Azeem Latib
- Interventional Cardiology Unit, San Raffaele University Hospital, Milan, Italy
| | - Giovanni La Canna
- Cardiac Surgery Department, San Raffaele University Hospital, Milan, Italy
| | - Antonio Colombo
- Interventional Cardiology Unit, San Raffaele University Hospital, Milan, Italy
| | - Ottavio Alfieri
- Cardiac Surgery Department, San Raffaele University Hospital, Milan, Italy
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17
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Misfeld M, Mohr FW. Video-atlas on minimally invasive mitral valve surgery-the Mohr technique. Ann Cardiothorac Surg 2013; 2:825-7. [PMID: 24349989 DOI: 10.3978/j.issn.2225-319x.2013.10.16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 10/29/2013] [Indexed: 11/14/2022]
Affiliation(s)
- Martin Misfeld
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Friedrich W Mohr
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
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18
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Garbade J, Davierwala P, Seeburger J, Pfannmueller B, Misfeld M, Borger MA, Mohr FW. Myocardial protection during minimally invasive mitral valve surgery: strategies and cardioplegic solutions. Ann Cardiothorac Surg 2013; 2:803-8. [PMID: 24349985 DOI: 10.3978/j.issn.2225-319x.2013.09.04] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 09/06/2013] [Indexed: 12/13/2022]
Abstract
Effective myocardial protection and perfusion strategies during minimally invasive mitral valve surgery (Mini-MV) have evolved over the last decade. Our institutional approach for right-sided Mini-MV has been standardized over the last 15 years in more than 4,500 cases. Cardiopulmonary bypass (CPB) is usually instituted by right-sided femoral arterial and venous cannulation with additional cannulation of the right jugular vein in patients with a body weight greater than 75 kg or when a concomitant tricuspid valve (TV) procedure and/or atrial septal defect closure is performed. A single dosage of crystalloid-based cardioplegia [Custodial- histidine-trypthophan-ketoglutarate (Custodial-HTK)] administered via the aortic root in combination with moderate hypothermia (34-35 °C) has become the standard of care for induction and maintenance of myocardial protection at our institution. The present article highlights and discusses the principal techniques of myocardial protection for Mini-MV.
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Affiliation(s)
- Jens Garbade
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Germany
| | - Piroze Davierwala
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Germany
| | - Joerg Seeburger
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Germany
| | | | - Martin Misfeld
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Germany
| | - Michael A Borger
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Germany
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19
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Seeburger J, Raschpichler M, Garbade J, Davierwala P, Pfannmueller B, Borger MA, Mohr FW, Misfeld M. Minimally invasive mitral valve surgery in octogenarians-a brief report. Ann Cardiothorac Surg 2013; 2:765-7. [PMID: 24349979 DOI: 10.3978/j.issn.2225-319x.2013.10.13] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Accepted: 09/17/2013] [Indexed: 11/14/2022]
Affiliation(s)
- Joerg Seeburger
- Department of Cardiac Surgery, Heart Centre Leipzig University, Leipzig, Germany
| | | | - Jens Garbade
- Department of Cardiac Surgery, Heart Centre Leipzig University, Leipzig, Germany
| | - Piroze Davierwala
- Department of Cardiac Surgery, Heart Centre Leipzig University, Leipzig, Germany
| | - Bettina Pfannmueller
- Department of Cardiac Surgery, Heart Centre Leipzig University, Leipzig, Germany
| | | | | | - Martin Misfeld
- Department of Cardiac Surgery, Heart Centre Leipzig University, Leipzig, Germany
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20
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Taramasso M, Buzzatti N, La Canna G, Colombo A, Alfieri O, Maisano F. Interventional vs. surgical mitral valve therapy. Herz 2013; 38:460-6. [DOI: 10.1007/s00059-013-3859-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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21
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Mitral valve surgery in elderly patients with mitral regurgitation: repair or replacement with tissue valve? Curr Opin Cardiol 2013; 28:164-9. [PMID: 23314759 DOI: 10.1097/hco.0b013e32835da4f8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE OF REVIEW The fastest growing demographic in North America is the elderly. Significant mitral regurgitation is present in more than 10% of this population. There are sparse clinical data to inform decisions regarding the optimal timing of operation and the appropriate operative intervention for this large population of patients with severe mitral regurgitation. RECENT FINDINGS Mitral valve surgery can be safely performed in most elderly patients with severe mitral regurgitation. The best outcomes occur when operative intervention is performed early, before advanced symptoms of heart failure develop. In elderly patients with mitral regurgitation, mitral valve repair is associated with superior early and late results compared with replacement. Survival after mitral valve repair among elderly patients is equivalent to a normal age-matched population. SUMMARY Elderly patients with severe mitral regurgitation should be referred for operation before significant symptoms develop. Mitral valve repair is favoured over replacement whenever feasible and is associated with satisfactory early and long-term results. If repair is impossible or the likelihood of durable repair seems low, valve replacement with a bioprosthetic valve should be performed. Further prospective clinical trials are essential to define the role of screening for this prevalent condition and to identify which subgroups of elderly patients will benefit most from early surgical intervention.
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Abstract
Mitral valve regurgitation (MR) is often diagnosed in patients with heart failure and is associated with worsening of symptoms and reduced survival. While surgery remains the gold standard treatment in low-risk patients with degenerative MR, in high-risk patients and in those with functional MR, transcatheter procedures are emerging as an alternative therapeutic option. MitraClip(®) is the device with which the largest clinical experience has been gained to date, as it offers sustained clinical benefit in selected patients. Further to MitraClip implantation, several additional approaches are developing, to better match with the extreme variability of mitral valve disease. Not only repair is evolving, initial steps towards percutaneous mitral valve implantation have already been undertaken, and initial clinical experience has just started.
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23
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Sri D. Is cardiac surgery getting more complicated? Indian J Thorac Cardiovasc Surg 2013. [DOI: 10.1007/s12055-013-0176-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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24
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Akins CW. Invited commentary. Ann Thorac Surg 2012. [PMID: 23176912 DOI: 10.1016/j.athoracsur.2012.05.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Cary W Akins
- Massachusetts General Hospital, Harvard Medical School, Cardiac Surgery-Cox 648, 55 Fruit St, Boston, MA 02114, USA.
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