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Théron A, Morera P, Resseguier N, Grisoli D, Norscini G, Riberi A, Collart F, Habib G, Avierinos JF. Long-term results of surgical treatment of secondary severe mitral regurgitation in patients with end-stage heart failure: Advantage of prosthesis insertion. Arch Cardiovasc Dis 2019; 112:95-103. [PMID: 30600216 DOI: 10.1016/j.acvd.2018.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 06/15/2018] [Accepted: 09/05/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Surgical treatment of secondary mitral regurgitation (SMR) is controversial. AIM To analyse outcome after undersizing annuloplasty (UA) and mitral valve replacement (MVR). METHODS Consecutive patients operated on for severe SMR, with left ventricular ejection fraction (LVEF)<40% and refractory CHF, were included. Endpoints were in-hospital mortality, mid-term cardiovascular (CV) mortality, evolution of LV variables and recurrence of mitral regurgitation (MR). RESULTS 59 patients were included (mean age 65±10 years, preoperative LVEF 36±6%; effective regurgitant orifice [ERO] 41±17 mm2), 41 with ischaemic disease: 12 underwent UA and 47 underwent MVR; only eight had concomitant coronary revascularization. In-hospital mortality was 3.3% (8.3% in UA group; 2.1% in MVR group). Eight-year CV mortality was 39±13% (40±18% in UA group; 27±10% in MVR group). Older age (hazard ratio 1.14, 95% confidence interval 1.07 to 1.22; P<0.001) and LV end-systolic diameter (hazard ratio 1.18, 95% confidence interval 1.09 to 1.27; P<0.001) independently predicted CV mortality. LVEF did not change between the preoperative and follow-up transthoracic echocardiograms in the MVR group (36±6% vs. 35±10%; P=0.6) or the UA group (36±5% vs. 31±12%; P=0.09). Conversely, LV end-diastolic diameter decreased significantly in the MVR group (64±8m to 59±9mm; P=0.002), but not in the UA group (61±7m to 64±10mm; P=0.2). Recurrence of significant MR occurred in 81% of patients in the UA group (mean postoperative ERO 19±6 mm2) versus none in the MVR group. CONCLUSIONS Surgical treatment of SMR can be performed with acceptable operative risk and mid-term survival in severe heart failure, even if there is no indication for revascularization. MVR is associated with significant reverse remodelling, and UA with prohibitive risk of MR recurrence.
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Affiliation(s)
- Alexis Théron
- Department of Cardiac Surgery, La Timone Hospital, AP-HM, 13005 Marseille, France
| | - Pierre Morera
- Department of Cardiac Surgery, La Timone Hospital, AP-HM, 13005 Marseille, France
| | - Noémie Resseguier
- Department of Cardiac Surgery, La Timone Hospital, AP-HM, 13005 Marseille, France
| | - Dominique Grisoli
- Department of Cardiac Surgery, La Timone Hospital, AP-HM, 13005 Marseille, France
| | - Giulia Norscini
- Department of Cardiology, La Timone Hospital, AP-HM, 13005 Marseille, France
| | - Alberto Riberi
- Department of Cardiac Surgery, La Timone Hospital, AP-HM, 13005 Marseille, France
| | - Frédéric Collart
- Department of Cardiac Surgery, La Timone Hospital, AP-HM, 13005 Marseille, France
| | - Gilbert Habib
- Department of Cardiology, La Timone Hospital, AP-HM, 13005 Marseille, France
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Nappi F, Avatar Singh SS, Santana O, Mihos CG. Functional mitral regurgitation: an overview for surgical management framework. J Thorac Dis 2018; 10:4540-4555. [PMID: 30174907 DOI: 10.21037/jtd.2018.07.07] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Functional mitral regurgitation (FMR) is one the most common complications of myocardial infarction (MI) in adults carrying a significant clinical and economic burden. Despite specific randomized controlled studies to address its treatment have been performed, there are still a number of questions remained unanswered. Outcomes of surgical repair of FMR are still hampered by a significant rate of recurrence of regurgitation and need for reoperation. Mechanisms underlying failure of repairs still need to be completely clarified and questions regarding the indications and optimal timing for intervention as well as the best suitable operative technique to be applied are still debated. This work will review the current knowledge on FMR including its pathogenic mechanisms, the available treatment strategies, the evidences from trials and observational studies and the potential future directions to address the issues related to its treatment.
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Affiliation(s)
| | | | - Orlando Santana
- Division of Cardiology, Mount Sinai Heart Institute, Columbia University, Miami Beach, FL, USA
| | - Christos G Mihos
- Division of Cardiology, Mount Sinai Heart Institute, Columbia University, Miami Beach, FL, USA
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Sündermann SH, Falk V. Chirurgische Behandlung der sekundären Mitralklappeninsuffizienz. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2017. [DOI: 10.1007/s00398-017-0147-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Yoshida S, Fukushima S, Miyagawa S, Nakamura T, Yoshikawa Y, Hata H, Saito S, Yoshioka D, Domae K, Kashiyama N, Yamamoto K, Shintani A, Nakatani S, Toda K, Sawa Y. Mitral Valve Structure in Addition to Myocardial Viability Determines the Outcome of Functional Mitral Regurgitation After Coronary Artery Bypass Grafting. Circ J 2017. [PMID: 28626146 DOI: 10.1253/circj.cj-16-1280] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Coronary artery bypass grafting (CABG) reduces functional mitral regurgitation (MR) associated with ischemic heart disease, although the predictive factors or mechanisms of reversibility of functional MR after CABG are not fully understood.We investigated whether mitral valve structure is associated with the outcome of functional MR after CABG.Methods and Results:From a consecutive series of 98 patients with mild-moderate functional MR preoperatively who underwent isolated CABG, we enrolled 66 patients who were followed up for >1 year postoperatively using echocardiography. The degree of MR was reduced in 34 patients (52%) postoperatively, in association with a lower rate of in-hospital treatment for cardiac failure in the long term, compared with the 32 patients (48%) with residual MR postoperatively. The patients with reduced MR postoperatively had longer estimated coaptation length and more anteriorly or centrally directed MR jets than those without reduced MR. On statistical analysis, the addition of estimated coaptation length and jet direction to the reported predictors (ejection fraction, left ventricular end-diastolic dimension, and tenting height) more accurately predicted changes in post-CABG MR than the reported 3 factors alone. CONCLUSIONS Residual MR was associated with the emergence of congestive heart failure in the long term after CABG. A specific mitral valve structure, such as large mitral leaflet size or predominant tethering of the posterior leaflet, was a predictive factor for the reversibility of post-CABG functional MR.
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Affiliation(s)
- Shohei Yoshida
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Satsuki Fukushima
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Teruya Nakamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Yasushi Yoshikawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Hiroki Hata
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Shunsuke Saito
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Daisuke Yoshioka
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Keitaro Domae
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Noriyuki Kashiyama
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Kouji Yamamoto
- Department of Clinical Epidemiology and Biostatistics, Osaka University Graduate School of Medicine
| | - Ayumi Shintani
- Department of Clinical Epidemiology and Biostatistics, Osaka University Graduate School of Medicine
| | - Satoshi Nakatani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
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Nappi F, Spadaccio C, Mihos CG, Fraldi M. Biomechanics raises solution to avoid geometric mitral valve configuration abnormalities in ischemic mitral regurgitation. J Thorac Dis 2017; 9:S624-S628. [PMID: 28740716 PMCID: PMC5505935 DOI: 10.21037/jtd.2017.05.63] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 05/09/2017] [Indexed: 11/06/2022]
Abstract
Ischemic mitral regurgitation (IMR) is a form of mitral insufficiency that is characterized by papillary muscle (PM) displacement, leaflet tethering, reduced closing forces, and different degree of annular dilatation. Treatment of this condition includes mitral valve replacement or mitral valve repair with restrictive annuloplasty. Recent evidences in mitral valve repair showed that addressing only the annulus and neglecting the subvalvular apparatus provides a suboptimal operation with poor long-term results. However, the complexity of the geometrical aberrances occurring in IMR demands for more accurate analysis also involving the biomechanics underlying the failing mitral valve and subvalvular apparatus. Finite element analysis (FEA) is a powerful tool in this context and we developed a biomechanical model of mitral valve and subvalvular unit using 3D geometry of the leaflets, annulus, chordae and PM. After the application of structural properties of materials to these elements and simulation of systemic pressure loading, FEA could be used to directly determine biomechanical changes and geometry variations. We believe this approach can provide valuable information to better address the surgical treatment of IMR and answer some of the questions still pending in IMR management.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, UK
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Christos G. Mihos
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Massimiliano Fraldi
- Department of Structures for Engineering and Architecture and Interdisciplinary Research Center for Biomaterials, Università di Napoli “Federico II”, Naples, Italy
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Chan V, Levac-Martinho O, Sohmer B, Elmistekawy E, Ruel M, Mesana TG. When Should the Mitral Valve Be Repaired or Replaced in Patients With Ischemic Mitral Regurgitation? Ann Thorac Surg 2017; 103:742-747. [DOI: 10.1016/j.athoracsur.2016.07.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 05/24/2016] [Accepted: 07/05/2016] [Indexed: 11/30/2022]
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Nappi F, Spadaccio C, Nenna A, Lusini M, Fraldi M, Acar C, Chello M. Is subvalvular repair worthwhile in severe ischemic mitral regurgitation? Subanalysis of the Papillary Muscle Approximation trial. J Thorac Cardiovasc Surg 2016; 153:286-295.e2. [PMID: 27773578 DOI: 10.1016/j.jtcvs.2016.09.050] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 09/15/2016] [Accepted: 09/16/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The symmetry of mitral valve tethering and regional left ventricle wall dysfunction are reported to play a fundamental role in the outcomes and long-term durability of surgical repair in ischemic mitral regurgitation (IMR). We recently demonstrated in a randomized clinical trial (the Papillary Muscle Approximation trial) the superiority of papillary muscle approximation (PMA) in combination with standard restrictive annuloplasty (RA) in severe IMR over annuloplasty alone in terms of adverse left ventricular remodeling and mitral regurgitation (MR) recurrence. This approach, however, failed to produce a survival advantage and was still plagued by a high incidence of reoperation. We therefore performed a subanalysis of the PMA trial on the basis of preoperative parameters to elucidate the value of subvalvular surgery in certain subcategories of patients with the aim of creating a decisional algorithm on the best operative strategy. METHODS We performed a subanalysis of PMA trial, evaluating 96 patients with severe IMR and eligible for myocardial revascularization randomized to PMA + RA (n = 48) versus RA alone (n = 48) in association with coronary artery bypass grafting. Endpoints included left ventricular remodeling, MR recurrence, overall mortality, reoperation, and a composite cardiac endpoint (cardiac death, stroke, reintervention, hospitalization for heart failure, or New York Heart Association class worsening). Stratification variables were preoperative symmetry of mitral valve tethering and regional wall motion abnormality. RESULTS PMA improved ventricular remodeling and recurrence of MR in both preoperative symmetric and asymmetric tethering and in case of inferior wall dyskinesia but did not produce an additional benefit in anterolateral wall dysfunction. CONCLUSIONS Preoperative symmetric and asymmetric tethering and isolated inferior wall dyskinesia are an indication for subvalvular apparatus surgery in IMR.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France.
| | - Cristiano Spadaccio
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Antonio Nenna
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Mario Lusini
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Massimiliano Fraldi
- Department of Structures for Engineering and Architecture and Interdisciplinary Research Center for Biomaterials, Università di Napoli "Federico II," Naples, Italy
| | - Christophe Acar
- Department of Cardiac Surgery, Hopital La Pitie Salpetriere, Paris, France
| | - Massimo Chello
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
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Timek TA, Lai DT, Bothe W, Liang D, Daughters GT, Ingels NB, Miller DC. Geometric perturbations in multiheaded papillary tip positions associated with acute ovine ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2015; 150:232-7. [PMID: 25998465 DOI: 10.1016/j.jtcvs.2015.04.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 04/12/2015] [Accepted: 04/18/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Novel surgical approaches are focusing on the "ventricular disease" of ischemic mitral regurgitation (IMR), to correct altered papillary muscle (PM) tip positions (apical displacement) and ameliorate leaflet tethering. Due to the anatomic complexity of the subvalvular apparatus, however, the precise geometric perturbations of the multiheaded PM tips associated with IMR remain uncharacterized. METHODS In 6 adult sheep, we implanted 3 markers on each PM. To specifically identify distinct PM tips, 1 marker was placed on the PM origin of the dominant chord to the anterior, posterior, and commissural leaflets. Nine markers were placed on the edge of the posterior mitral leaflet, and 5 on the edge of the anterior mitral leaflet. Eight markers were sewn around the mitral annulus. Animals were studied immediately postoperatively, with biplane videofluoroscopy and transesophageal echocardiography, before and during acute snare occlusion of the proximal left circumflex coronary artery, to induce IMR. Papillary muscle tip and leaflet edge geometry was expressed as the orthogonal distance of each respective marker to the least-squares mitral annulus plane at end-systole. In addition, the distance from each PM tip marker to the mitral annulus "saddle horn" was calculated. RESULTS Acute left circumflex occlusion significantly increased mitral regurgitation from a baseline of 0.7 ± 0.3 to 2.5 ± 0.5 (P < .05). The IMR was associated with posterior leaflet restriction near the central leaflet edge, with simultaneous prolapse of both leaflets near the posterior commissure. No apical displacement of PM tips was observed during IMR, although the posterior PM moved farther away from the midseptal annulus. CONCLUSIONS During acute ischemia, no apical displacement of any PM tip was observed. Posterior PM movement away from the annular saddle horn, and toward the annulus, was associated with IMR and leaflet prolapse near the posterior commissure, and with restriction near the valve center. These data may help guide development of surgical interventions aimed at PM repositioning.
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Affiliation(s)
- Tomasz A Timek
- Meijer Heart and Vascular Institute at Spectrum Health, Grand Rapids, Mich
| | - David T Lai
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Wolfgang Bothe
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - David Liang
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, Calif
| | - George T Daughters
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif; Department of Cardiovascular Physiology and Biophysics, Research Institute of the Palo Alto Medical Foundation, Palo Alto, Calif
| | - Neil B Ingels
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif; Department of Cardiovascular Physiology and Biophysics, Research Institute of the Palo Alto Medical Foundation, Palo Alto, Calif
| | - D Craig Miller
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif.
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Badescu GC, Kisslo J, Risum N, Glower DD, Swaminathan M. Dyssynchrony: A Different Kind of Mitral Regurgitation. J Cardiothorac Vasc Anesth 2013; 27:1421-3. [DOI: 10.1053/j.jvca.2013.06.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Indexed: 01/04/2023]
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